Laser Therapy of Perforator Laser Therapy of Perforator VeinsVeins Michael F. Bardwil M.D.,F.A.C.S.Michael F. Bardwil M.D.,F.A.C.S.

Current Current Treatment of Treatment of

VeinsVeins

Saphenous Saphenous VeinsVeins

Laser AblationLaser Ablation

Varicose VeinsVaricose Veins

•PhlebectomyPhlebectomy•Foam SclerotherapyFoam Sclerotherapy

Telangectasia Telangectasia and Reticular and Reticular

Veins Veins SclerotherapySclerotherapy

Perforator Perforator VeinsVeins

Next area in treatment of Next area in treatment of veinsveins

Why does Vein Surgery Why does Vein Surgery Have Such a Bad Have Such a Bad

Reputation?Reputation? • Historically the procedures were Historically the procedures were

morbid morbid • High incidence of recurrence High incidence of recurrence

perceived as bad resultsperceived as bad results• Severe forms of venous insufficiency Severe forms of venous insufficiency

including refluxing perforators including refluxing perforators resulted in recurring stasis ulcers resulted in recurring stasis ulcers

Perforators Give Veins Perforators Give Veins A Bad NameA Bad Name

• Linton procedure had a reported Linton procedure had a reported 19% wound complication rate19% wound complication rate

Perforators Give Perforators Give VeinsVeins

A Bad Name A Bad Name

• Perforators are a more likely Perforators are a more likely source for recurrent varicose source for recurrent varicose veins than neo-vascularsationveins than neo-vascularsation

• Recurrence is perceived as bad Recurrence is perceived as bad resultsresults

Perforators Give Perforators Give Veins Veins

A Bad NameA Bad Name

• Severe forms of venous Severe forms of venous insufficiency including refluxing insufficiency including refluxing perforator veins resulted in perforator veins resulted in recurring stasis ulcers recurring stasis ulcers

Significance of Significance of Perforator VeinsPerforator Veins

• Source for reflux in the superficial venous systemSource for reflux in the superficial venous system• Reflux from perforator veins has been associated Reflux from perforator veins has been associated

with venous stasis ulcerswith venous stasis ulcers• Communication between deep and superficial Communication between deep and superficial

venous Systemsvenous Systems• Reflux from perforator veins can result in Reflux from perforator veins can result in

varicose veinsvaricose veins

Communication Communication Between Venous Between Venous

SystemsSystems• Not all badNot all bad• Allows patients to recover from vein Allows patients to recover from vein

insults such as injuries and DVT insults such as injuries and DVT • Allows us to perform vein ablative Allows us to perform vein ablative

procedures on the saphenous and procedures on the saphenous and other superficial veins other superficial veins

Communication Communication Between Venous Between Venous

Systems Systems

• Not all goodNot all good• Source for reflux in the saphenous veinSource for reflux in the saphenous vein• Associated with venous stasis ulcersAssociated with venous stasis ulcers• Reflux from perforators can cause non Reflux from perforators can cause non

saphenous varicose veinssaphenous varicose veins• Source for new and recurrent varicose Source for new and recurrent varicose

veins veins

Types of Types of PerforatorsPerforators

• HunterianHunterian• DoddDodd’’ss• BoydBoyd• CockettCockett’’ss• New NomenclatureNew Nomenclature

Hunterian and DodHunterian and Doddd ’’ss

Perforator Perforator

• Connect femoral and proximal Connect femoral and proximal popliteal perforators to the popliteal perforators to the saphenous vein saphenous vein

• Reflux from these perforator veins Reflux from these perforator veins results in varicose veins in the results in varicose veins in the middle and distal third of the medial middle and distal third of the medial thighthigh

• Stripping reportedly interrupts all Stripping reportedly interrupts all but 8%?but 8%?

BoydBoyd’’s s PerforatorsPerforators

• Perforator just distal to the kneePerforator just distal to the knee• Connects saphenous veins to popliteal Connects saphenous veins to popliteal

veinvein• Varicose veins medial leg upper thirdVaricose veins medial leg upper third• May appear as first place isolated May appear as first place isolated

refluxreflux• New nomenclature Paratibial New nomenclature Paratibial

perforators perforators

CockettCockett’’s s PerforatorsPerforators

• CockettCockett’’s I perforator posterior s I perforator posterior to medial malleolusto medial malleolus

• CockettCockett’’s II perforator 7-9cm s II perforator 7-9cm proximal proximal

• CockettCockett’’s III perforator 10-12 cm s III perforator 10-12 cm proximalproximal

• New nomenclature posterior New nomenclature posterior tibial perforators tibial perforators

Less Discussed Less Discussed PerforatorsPerforators

Indications for Indications for TreatmentTreatment

• Venous Stasis Ulcer associated Venous Stasis Ulcer associated with perforator vein 2-4 mm in with perforator vein 2-4 mm in sizesize

Indication for Indication for TreatmentTreatment

• Large perforator vein 3-4mm Large perforator vein 3-4mm noted at the time of saphenous noted at the time of saphenous ablationablation

• Refluxing perforator 2-4 mm Refluxing perforator 2-4 mm noted at saphenous ablationnoted at saphenous ablation

Indications For Indications For TreatmentTreatment

• Perforator veins refluxing into Perforator veins refluxing into varicose veins that are not varicose veins that are not associated with long or short associated with long or short saphenous reflux saphenous reflux

Indications forIndications fortreatmenttreatment

• Recurrent varicose veins that Recurrent varicose veins that appear to originating from appear to originating from refluxing perforatorrefluxing perforator

Indication for Indication for TreatmentTreatment

• Perforator veins refluxing into varicose Perforator veins refluxing into varicose veins that are not associated with long veins that are not associated with long or short saphenous vein refluxor short saphenous vein reflux

• Large perforator veins 2-4mm noted at Large perforator veins 2-4mm noted at time of saphenous ablationtime of saphenous ablation

• Recurrent varicose veins that appear to Recurrent varicose veins that appear to be originating from perforatorbe originating from perforator

• Stasis ulcers associated with perforator Stasis ulcers associated with perforator

HistoryHistory

• Standard questions regarding symptomsStandard questions regarding symptoms• Previous vein surgeryPrevious vein surgery• Stasis Ulcers and previous treatmentStasis Ulcers and previous treatment

ExaminationExamination

• Physical exam with attention to Physical exam with attention to pattern of varicose veinspattern of varicose veins

• Use the ultrasound as an extension Use the ultrasound as an extension of the physical examof the physical exam

• Photograph markings of perforator Photograph markings of perforator to be treatedto be treated

• Ulcers Ulcers • PPG to physiologically document PPG to physiologically document

venous insufficiency venous insufficiency

Problems with Problems with Perforator RxPerforator Rx

• Linton procedure problem with Linton procedure problem with wound healingwound healing

• SEPS general anesthesia required SEPS general anesthesia required inconsistent resultsinconsistent results

• Ultrasound guided foam multiple Ultrasound guided foam multiple sessions inconsistent results, non sessions inconsistent results, non approved solution no code for approved solution no code for reimbursement reimbursement

Future Meets Future Meets PastPast

• In office procedure to treat In office procedure to treat perforatorsperforators

• Less morbidLess morbid• Addresses non saphenous varicose Addresses non saphenous varicose

VeinsVeins• Addresses sources of recurrenceAddresses sources of recurrence• Addresses stasis ulcers Addresses stasis ulcers

Endoluminal Endoluminal Ablation Ablation

PerforatorsPerforators

Endoluminal Endoluminal Ablation of Ablation of PerforatorsPerforators• Minimally invasive proceduresMinimally invasive procedures

• Office basedOffice based• Local anesthesiaLocal anesthesia• VNUS ClosureVNUS Closure• Laser ablationLaser ablation• My experienceMy experience

VNUS ClosureVNUS Closure

• Device FDA approvedDevice FDA approved• Billing Code recommendationBilling Code recommendation• Recommended protocol using Recommended protocol using

ultrasound guidance and impedance ultrasound guidance and impedance to verify positionto verify position

Disadvantage Disadvantage VNUS ClosureVNUS Closure

• Device awkward and expensive, Device awkward and expensive, especially for add on perforator veins especially for add on perforator veins

• Protocol less effective than thoughtProtocol less effective than thought• Impedance less useful than flashImpedance less useful than flash• In general other closure procedures In general other closure procedures

have inferior results to laser have inferior results to laser

Laser PerforatorLaser Perforator

• Technically simplerTechnically simpler• Less expensive to perform; can treat Less expensive to perform; can treat

perforator at time of other veins and perforator at time of other veins and not incur increase procedural costs not incur increase procedural costs

• Results should be superior to closureResults should be superior to closure

Technical IssuesTechnical Issues

• VisualizationVisualization• Broad based neck Broad based neck • Multiple perforator necksMultiple perforator necks• Long Perforator necksLong Perforator necks

Technique My Technique My ExperienceExperience

• Micro puncture kitMicro puncture kit• Angio cath catheterAngio cath catheter• 18 gauge thin wall angiogram 18 gauge thin wall angiogram

needleneedle• 25 gauge 25 gauge ““finderfinder”” needle needle• 20 gauge needle with 400u fiber20 gauge needle with 400u fiber• 20 gauge needle with 600u fiber20 gauge needle with 600u fiber• Laser settingLaser setting• Use of foamUse of foam

Micro-IntroducerMicro-Introducer

• Advantage theoretically similar ElasAdvantage theoretically similar Elas• Disadvantage not enough room to Disadvantage not enough room to

place guide wire in far enough for place guide wire in far enough for introducerintroducer

Dr. Murphy technique use stiff end of Dr. Murphy technique use stiff end of guide wireguide wire

AngiocathAngiocath

• Advantage: Able to place without Advantage: Able to place without guide wireguide wire

• Disadvantage: Needle may be in, but Disadvantage: Needle may be in, but laser not. Work with VNUS device laser not. Work with VNUS device demonstrated proximity still only demonstrated proximity still only applies to horse shoes and hand applies to horse shoes and hand grenades grenades

18 gauge 18 gauge Angiogram Needle Angiogram Needle • Advantage: Direct access to veinAdvantage: Direct access to vein• Disadvantage: Still bulky, at times Disadvantage: Still bulky, at times

difficult getting fiber through needle difficult getting fiber through needle

20 Gauge Needle 20 Gauge Needle 400u Fiber400u Fiber

• Advantage: Easier to use technically Advantage: Easier to use technically to access vesselto access vessel

• Can access vessel at more than one Can access vessel at more than one spotspot

• Disadvantage: Inconsistent delivery Disadvantage: Inconsistent delivery of Energy if Laser system made for of Energy if Laser system made for 600u fiber 600u fiber

How I Do ItHow I Do It

• Always perform the venous duplex Always perform the venous duplex yourself yourself

• Mark the vein with patient standing Mark the vein with patient standing or sitting with feet dangling or sitting with feet dangling

• Strategically position patientStrategically position patient• Put the bed in reverse trendlenbergPut the bed in reverse trendlenberg

How I Do ItHow I Do It

• Re-map and mark patient in new positionRe-map and mark patient in new position• Use 25 gauge Use 25 gauge ““finderfinder”” needle needle• Place previously 2 inch stripped fiber Place previously 2 inch stripped fiber

through 20 gauge needle and mark with through 20 gauge needle and mark with steri-stripsteri-strip

• Access vein with 20 gauge needle, use Access vein with 20 gauge needle, use more than one needle if necessarymore than one needle if necessary

• Inject local anesthesia after you are in Inject local anesthesia after you are in veinvein

How I Do ItHow I Do It

• Laser setting 15 watts intermittent Laser setting 15 watts intermittent 1.5 sec duration, 1 sec rest1.5 sec duration, 1 sec rest

• Look for steam in vesselLook for steam in vessel• I usually deliver 200-300 joulesI usually deliver 200-300 joules• Steri strip applied. 4x4,kerlex, co-ban Steri strip applied. 4x4,kerlex, co-ban

Follow UpFollow Up• 1-2 days remove wrap and ultrasound1-2 days remove wrap and ultrasound• Low threshold to use foam at time of Low threshold to use foam at time of

this examthis exam

ResultsResults

• In progressIn progress