small saphenous thermal ablation

Disclosure Lowell S. Kabnick, M.D., FACS,

FACPh,RPhS

I disclose the following financial relationship(s):

•Research Grant: BTG

•Ownership Interest: AngioDynamics, Vascular Insights

•Consultant/Advisory Board: AngioDynamics, BSN Jobst, Vascular Insights

Small Saphenous Thermal

Ablation Lowell S. Kabnick, MD, RPhS, FACS, FACPh

Director, NYU Vein Center

Courtesy JL Gerard

Tibial nerve

Common Peroneal

Gastrocnemius nerve

SSV

Courtesy JL Gerard

Anatomic Variations

• SSV joins the popliteal vein

at the Saphenopopliteal

Junction (SPJ) and joins

deep veins at a higher level

through its cranial extension

of the SSV or joins GSV via

the vein of Giacomini

Cavezzi A, Labropoulos N, Partsch H, Ricci S, Caggiati A, Myers K, Nicolaides A, and Smith PC. Duplex Ultrasound

Investigation of the Veins in Chronic Venous Disease of the Lower Limbs- UIP Consensus Document. Part II. Anatomy. Eur J

Vasc Endovasc Surg 2006; 31:288-299

2nd Anatomic Variation

• SSV continues upwards

as the cranial extension

of the SSV or vein of

Giacomini but also

connects with the

popliteal vein through an

„anastomotic‟ tiny vein

Cavezzi A, Labropoulos N, Partsch H, Ricci S, Caggiati A, Myers K, Nicolaides A, and Smith PC. Duplex Ultrasound

Investigation of the Veins in Chronic Venous Disease of the Lower Limbs- UIP Consensus Document. Part II. Anatomy. Eur J

Vasc Endovasc Surg 2006; 31:288-299

3rd Anatomic Variation

• SSV has no

connection to deep

veins- it continues

upward as the

cranial extension of

the SSV or vein of

Giacomini

Cavezzi A, Labropoulos N, Partsch H, Ricci S, Caggiati A, Myers K, Nicolaides A, and Smith PC. Duplex Ultrasound

Investigation of the Veins in Chronic Venous Disease of the Lower Limbs- UIP Consensus Document. Part II. Anatomy. Eur J

Vasc Endovasc Surg 2006; 31:288-299

Other Veins

• Gastrocnemius veins may join the popliteal vein, proximal SSV, or their confluence at the SPJ

• SSV may merge with the gastrocnemius veins before joining the popliteal vein (10-30%)

Cavezzi A, Labropoulos N, Partsch H, Ricci S, Caggiati A, Myers K, Nicolaides A, and Smith PC. Duplex Ultrasound Investigation of

the Veins in Chronic Venous Disease of the Lower Limbs- UIP Consensus Document. Part II. Anatomy. Eur J Vasc Endovasc Surg

2006;31:288-99

Incompetent Giacomini Vein

• Transmits reflux from

GSV or thigh

perforators and pelvic

veins to SSV through

the intersaphenous

anastomosis (IA)

Georgiev M, Myers K, and Belcaro G. The thigh extension of the lesser saphenous vein: From Giacomini‟s observations to

ultrasound scan imaging. J Vasc Surg 2003;37:558-63

Cranial Extension of the SSV

• Continues straight up into the gluteal area as a single vein or divides in many deep and superficial branches

• Joins the deep femoral veins as a posterior or posterior lateral thigh perforator

• Connects to the posterior thigh circumflex vein which then passes to the GSV in the medial thigh (vein of Giacomini)

Caggiati A, Bergan J, Gloviczki P, Jantet G, Wendell-Smith C, Partsch H. Nomenclature of the veins of the lower limbs: An

international interdisciplinary consensus statement. J Vasc Surg 2002;36:416-22

Insertion?

Saphenopopliteal Junction (SPJ)

• Most often 2-4cm

above the knee

crease

• Higher in 25-30%

• Rarely below knee

crease

Myers,Ken: Making Sense of Vascular Ultrasound, a hands on guide, 2004

Procedure

ssv

Laser Kit

DUS SSV

Skin Anesthesia

21 gauge Needle Insertion

018 wire

Micropuncture sheath

Upsize 035 wire

Laser 4 Fr Sheath / RFA 6Fr

Tumescent Anesthesia

Tumescent Anesthesia

“Walking the Line”

Laser Fiber / RFA Catheter

Placement of Sheath and Fiber

Fiber/RF placed

just before the SSV

“dives” to the popliteal

vein

2-3cms from the

Junction

Let‟s Look at the SSV Literature

Eur J Vasc Endovasc Surg 2009

Eur J Vasc Endovasc Surg 2009

• 810 laser

– 14w @70J/cm

• 169 limbs

• Avg age 57

• 100% Closed at 3 months

• 1.3% sural nerve paresthesia

J Vasc Surg. 2009 Apr;49(4):973-979.e1.

• Laser 980

• 226 SSV closure rate

98.7%

• Paresthesia rate

2.5%

• No EHIT2 (LMWH)

• J Endovasc Ther 2009;16:500-505

• 940nm

– 14 w pulse 80-90j/cm

• 269 SSV

• 6.7% initial failure and 15% long term

• No parethesia reported

980nm

210 limbs

Concomitant GSV reflux was present in

156 limbs (74 %), and these limbs

underwent EVLT of both the SSV and

the GSV

4% failure avg 4 month f/u

1.6% parasthesia

88 (43 %) had type A anatomy

69 (33%) had type B anatomy

52 (24%) had type C anatomy.

EHIT 2 RATE

EHIT 2

5.7 % EHIT 2

No clots present @ 2 to 11

months

Incidence of EHIT2 is higher

for the SSV than the GSV

NYU VEIN CENTER

SSV

September 2007-December 2010

Total SSV 367

EHIT2 1.1%

SSV failures 2.72%

AVG US Follow up 145 days

Preliminary Data

Volume 53, Issue 1,January 2011

Steam Pilot Study

• 3 refluxing symptomatic SSV

• PROCEDURE

• 16 g needle USG into the SSV

• steam catheter (1.2-mm diameter) was

passed through the needle into the vein

until positioned 3 cm below the junction

• 1-2 puffs/cm steam generated at 120 C

• 3/20 were SSV of the 20 axial veins

• All closed at 6months

• Pain score1/10

• No DVT etc

• Median satisfaction score 9.25/10

Treating the Small Saphenous Vein AUGUST 2008 I ENDOVASCULAR TODAY

Key Points

• 1. Harder than the GSV

• 2. Know the anatomical variations and

relationships

• 3. Endothermal Ablation is preferred in US

– Great outcomes

– Minimal morbidities

Thank You

Reported SSV