endovenous laser treatment (evlt™)amt always in pursuit of innovative the procedure technologies...

AMTAlways in pursuit of innovative

technologies

EndoVenous Laser Treatment

(EVLT™)

AMTAlways in pursuit of innovative

technologies

Greater Saphenous Vein Reflux

• Treatment Aims

• Inclusion Criteria for EVLT

• Exclusion Criteria for EVLT

AMTAlways in pursuit of innovative

technologies

Treatment Aims

• Eliminate source of reflux- Incompetent saphenofemoral or saphenopopliteal

junction

- Incompetent perforator connections to the above

• Ablate incompetent venous segments

• Offer an alternative to traditional treatment

– ligation & stripping

AMTAlways in pursuit of innovative

technologies

Inclusion Criteria• Varicose veins due to SFJ/SPJ incompetence

and GSV/SSV reflux as demonstrated by bi-

directional continuous wave doppler and duplex

ultrasound imaging

• At least 18 years of age

• Either gender

• EVLT chosen by patient over surgery or other

MIS techniques

AMTAlways in pursuit of innovative

technologies

Exclusion Criteria• Concomitant peripheral arterial disease

• Inability to ambulate

• Deep venous thrombosis

• Pregnancy or breast feeding

• General poor health

AMTAlways in pursuit of innovative

technologies

EndoVenous Laser Treatment

AMTAlways in pursuit of innovative

technologies

Step-by-Step Guide

• Pre-operative examination

• The Procedure

• Post-operative care

• Follow-up

AMTAlways in pursuit of innovative

technologies

Pre-operative Examination

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technologies

Pre-operative Examination• Patient describes symptoms

• Physical exam of extremities

• Ultrasound exam using duplex scanner

• Transverse measurements of GSV/LSV

• Photography of legs for comparison

• Patient signs consent form

AMTAlways in pursuit of innovative

technologies

The Procedure

AMTAlways in pursuit of innovative

technologies

The Procedure• Patient Placed on Treatment Table

• Head-up (Reverse Trendelenberg)

• Sterile Prep and Drape leg

• Anaesthetise entry point with local

• Make small skin nick at entry point*

• Needle entry into GSV under U/S control*May be done after Guide Wire inserted but before sheath

AMTAlways in pursuit of innovative

technologies

The Procedure• If difficult access use Micro Introducer Kit

• Guide wire passed through needle and up GSV

• Remove needle from patient/guide wire

• Load dilator into sheath avoiding kinking

• Sheath/dilator passed over guide wire

• Remove dilator and guide wire

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technologies

The Procedure

• Aspirate via side arm to check for venous

blood and flush sheath with saline

• Insert fiber into sheath up to first mark

• Position tip of sheath & fiber using

ultrasound (1-2cm below SFJ/SPJ)

• If epigastric vein enters GSV near the

junction position sheath tip below this

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technologies

The Procedure

• Hold fiber still and withdraw sheath over

fiber back to 2nd marker

• Confirm fiber tip position with U/S (1-2cm

below SFJ/SPJ or epigastric vein entry point)

• Secure fiber to sheath with friction lock

• Pass proximal end of fiber to assistant for

attachment to Laser

AMTAlways in pursuit of innovative

technologies

The Procedure• Patient placed head down (Trendelenberg

Position)

• Anesthetise length of leg along the line of

the GSV with tumescent solution

• This should be done under U/S control to

ensure anaesthetic surrounds the GSV

• Anaesthetic compresses vein over the

fiber tip and provides cooling + analgesia

AMTAlways in pursuit of innovative

technologies

The Procedure• Issue safety glasses to ALL people in

treatment area including the patient

• Activate the laser

• Check the patient for transillumination of

the aiming beam at the groin*

*NOTE: The aiming beam is not a substitute

for Ultrasound in confirming fiber position

AMTAlways in pursuit of innovative

technologies

The Procedure• There are two alternative treatment

modes:

– Pulsed and Continuous

• For Pulsed technique:

– Set Laser in ‘repeat pulse’ mode:

• 12 Watts

• 1 second pulse

• 1 second pause

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The Procedure• Turn down room lights

• Fire laser and withdraw fiber & sheath:

– Deliver 5 – 7 pulses of laser energy per cm of

vein treated

– Ideally deliver ~70 Joules of energy per cm of

vein treated

• Check the above parameters were met

AMTAlways in pursuit of innovative

technologies

The Procedure

• For Continuous technique:

– Set Laser in ‘continuous’ mode:

• 14 Watts Power

• Turn down room lights

• Activate the laser

AMTAlways in pursuit of innovative

technologies

The Procedure

• Withdraw fiber & sheath in a continuous

action:

– Withdrawal rate of 4 – 6 seconds per cm of

vein treated

– Ideally deliver ~70 Joules of energy per cm of

vein treated

• Check the above parameters were met

AMTAlways in pursuit of innovative

technologies

The Procedure

AMTAlways in pursuit of innovative

technologies

Post-operative Care

+

Bandage Compression

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technologies

Post-operative Care• Dress leg with compression bandage:

• Variety of types used

• Personal preference of Clinician

• Class II compression stocking:• Must be fitted correctly

• Not worn at night

• Up to a 20 minute walk before leaving

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technologies

Post-operative Care• Resume normal activities:

• Light exercise recommended

• Avoid hot baths

• Avoid vigorous gym workouts

• OTC non-aspirin analgesics for any pain:• Pain usually after 3 – 4 days

• Some clinicians give prophylactic anti-inflammatory

drugs for ~I week post op.

AMTAlways in pursuit of innovative

technologiesFollow-up

Duplex Ultrasound

AMTAlways in pursuit of innovative

technologiesFollow-up

• Examinations done with ultrasound to

confirm vein staying closed:

– At one week

– At one, three and six months

– Yearly thereafter

AMTAlways in pursuit of innovative

technologiesFollow-up

• Additional treatment as needed

• Phlebectomy:• Usually done at the same time as EVLT

• Usually under GA but can be done under local

• Sclerotherapy• Done as separate treatment after 4-6 weeks

• Only treats vein which are still visible

AMTAlways in pursuit of innovative

technologies

EndoVenous Laser Treatment

• The Results

• Combined Results

• Long Term Results

• Potential Advantages

• Conclusions

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technologies

Pre-EVLT 2 Wks Post-EVLT

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technologies

EVLT The Results

• 195 GSVs treated in 172 patients

• 100% technical success

• Well tolerated by all patients under

strictly local anesthesia

AMTAlways in pursuit of innovative

technologies

EVLT The Results

126 Women 46 Men

Range: 23-77 yrs Mean: 42 yrs

Gender

Age

Side

Diameter

Length

110 Left 85 Right

Range: 4.4-28 mm Mean: 10 mm

Range: 15-48 cm Mean: 36 cm

AMTAlways in pursuit of innovative

technologies

EVLT The Results• 187/195 (96%) of GSVs successfully closed

following initial EVLT

• 7/195 (4%) GSVs closed following re-treatment with EVLT

• 190/195 (97%) GSVs remain closed at 1-21 month f/u with duplex ultrasound (+color doppler) evaluation

• There have been no skin burns, paresthesias, or other adverse reactions

AMTAlways in pursuit of innovative

technologies

EVLT The ResultsFollow-Up

(Months)

Ratio Closed

(% Closed)

% Reduction

In Diameter

1

3

6

9

12

18

21

195/195 (100%)

158/160 (99%)

114/115 (99%)

72/74 (97%)

59/59 (100%)

43/43 (100%)

19/19 (100%)

30%

52%

73%

> 85%

> 85%

> 85%

> 85%

AMTAlways in pursuit of innovative

technologies

EVLT The ResultsCombined Results (Min, et al.)

• > 1000 GSVs treated with endovenous

laser

• Up to 21 month follow-up

• > 97% of GSVs have remained closed

• Bruising & mild tenderness (< 2 wks)

• No other minor or major complications

AMTAlways in pursuit of innovative

technologies

EVLT The Results

Long Term Results (Min & Khilnani, 2005)

• 1000 GSVs treated with endovenous laser

• Up to 60 month follow-up

• > 98% Success rate

• Ecchymosis resolved in all cases(< 4 wks)

• No other minor or major complications

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technologies

Pre-Treatment Post-Treatment

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technologies

Potential Advantages• Safe in-office procedure

• Well-tolerated with local anesthesia

• Non-scarring with minimal access site

size

• Immediate return to daily activities

• Lower treatment costs compared to

surgery

AMTAlways in pursuit of innovative

technologies

Conclusions• Extremely favorable long-term results with

EVLT

• Appears to be a very safe and well

tolerated in-office procedure

• Effective closure of incompetent GSV

segments

• The future looks bright