endovenous laser treatment (evlt™)amt always in pursuit of innovative the procedure technologies...
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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
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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
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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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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
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The Procedure
AMTAlways in pursuit of innovative
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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
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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
AMTAlways in pursuit of innovative
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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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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
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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
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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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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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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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Pre-EVLT 2 Wks Post-EVLT
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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
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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
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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
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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
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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
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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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Pre-Treatment Post-Treatment
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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