Endo-venous laser ablation of small saphenous vein By Dr. Sohiel M.Ayman 2016

Agenda Introduction Aim of the study Patients & methods Procedure Results Conclusion Discussion

Introduction Small saphenous vein (SSV) reflux is an important and often overlooked cause of superficial venous insufficiency. It is present in about one-sixth of patients with superficial venous insufficiency. And its manifestations are often confused with reflux in the great saphenous vein (GSV).

Anatomy of superficial veins of the lower limb

Small Saphenous Vein (SSV) Courses from lateral aspect of the ankle up to posterior aspect of the calf muscle. Terminates in popliteal fossa at Saphenopopliteal Junction (SPJ) Variable confluence with Popliteal Vein (PV) Proximal portion lies between superficial & deep fascial layers SPJ Pop V SSV

ANATOMY Knowledge of the precise anatomy of an incompetent pathway is crucial to the success of its treatment. Sural nerve runs adjacent to the SSV at the inferior border of the gastrocnemius muscle and is more caudal, lateral and deeper than the SSV above this level.

Treatment The goal of small saphenous ablation techniques is the same as great saphenous ablation: “ permanent closure of the vein without complications.” Course, Anatomic landmarks, Draining veins, Branches, and surrounding Nerves are unique and clearly different than the GSV. These unique aspects make thermal ablation of the SSV different as well.

Aim of the study The aim of this ablation procedures is to damage the inner vein wall without causing thrombosis nor a full-thickness burn and nerve damage.

Patients & methods 18 patients admitted to military hospital and minister of health hospitals with 1ry varicose veins involving small saphenous vein. From May 1st 2014 – June 30th 2016.

Patients & methods All patients were subjected to: History Clinical examination Duplex evaluation EVLT of small saphenous vein using “1080 Diode laser” Follow up (clinical & Duplex)

Inclusion criteria Preoperative ultrasound evaluation Reflux > 0.5 seconds in superficial venous system Assess SSV, noting: Vein depth and maximum diameter Presence of tortuous or aneurysmal segments Other significant anatomy Duplicate systems Large side branches Incompetent perforators or tributaries

Exclusion criteria Venous Thrombosis

Pre-op Ultrasound Assessment Map and mark Maximum diameter Tortuous segments Aneurysmal segments Areas where vein is very close to skin Large branches or perforators Potential access sites

Vein Mapping Make indentations in skin using a straw Remove US gel from leg Connect marks on leg with marker to identify pathway of vein and important anatomy

Procedure The entry is usually at the level where the last incompetent tributary vein joins the SSV and below this point the SSV is normal in caliber and regains competence.

Procedure 2. Guide wire passage 3. 6Fr sheath insertion over the wire 4. Laser Catheter insertion through The 6 Fr sheath 5. Locating Position (The distal tip of the catheter should be Positioned 10 -15 mm below the SPJ.) Procedure

Infiltration Technique Image courtesy of Carolyn Menendez, MD Using 1% diluted Lidocaine. We do not leave any vein segments unprotected Re-scan to ensure: >10 mm distance between skin surface and vein wall Circumferential black “halo” appearance in fascial compartment Perivenous vs. subcutaneous infiltration During endovenous ablation procedure, if patient experiences discomfort, energy delivery can be stopped and additional tumescent fluid can be administered – as long as within patient’s dosage limits – and the procedure resumed If dosage limit has been met, plain injectable saline may be used in place of tumescent anesthesia

After Relocating our position we start FIRING BANDAGE is a must

Results

Demographics Age: Range : 24 – 48 years X : 30.06 + 1.01 years Gender: Male / female : 11 / 7 Side: Right : 5 limbs Left : 13 limbs Vein affected: Small Saphenous vein only : 15 LIMBS Great & small saphenous veins : 3 LIMBS.

Pre-Operative Duplex Assessment Reflux is present with retrograde flow lasts for at least 1 sec. in all patients. Range : 1- 1.6 sec. X : 1.21 ± 0.04

Detection of reflux Before After No reflux in all patients One day post operative Non significant reflux in 2 patients 11 % 3 months post operative Significant reflux in one patient 5.5% “ “ “ “

Complications DAY 90 DAY 1 TYPE 2 patients Hematoma Thrombosis Burn 2 patients Hematoma Thrombosis Burn One patient Dysesthesia Infection Swelling Pigmentation

Duration of the procedure Length of the treated vein segment The average laser administration time was 77.2±24.8 seconds for SSV treatments (ranging from 25 to 122 seconds), Length of the treated vein segment The average length of vein treated was 16.1±5.1 cm for SSV treatments (ranging from 8 to 25 cm)

Energy The average total energy in joules (J) delivered per treatment was 1,080.9±347.7 J for SSV treatments (ranging from 350 to 1,708 J) The laser fiber was withdrawn at an average rate of 2.2 mm per second.

CONCLUSIONS The SSV has anatomical relationships that make evaluation and management decisions more complex when compared to the GSV. -Treatment goals are similar: eliminate reflux from its highest possible point and then eliminate the varicose outflow tracts to maximize clinical benefit and durability. -Endo-venous thermal ablation is a preferred technique because it is efficient, highly successful and very safe. - Thermal ablation of the SSV is similar to GSV treatment with some minor modifications based on the anatomy.

August 2009Volume 38, Issue 2, Pages 199–202

The prevalence of thrombosis and paresthesia is very low. April 2009Volume 49, Issue 4, Pages 973–979.e1 Conclusion Endo-venous laser ablation of the SSV has excellent early and midterm results. The prevalence of thrombosis and paresthesia is very low. Symptom relief is very good.

Thank you for your attention