Office Based Vein Procedures: Ablation and Sclerotherapy Dr Office Based Vein Procedures: Ablation and Sclerotherapy Dr. Steven Abramowitz MedStar Washington Hospital Center Washington, DC

Steven Abramowitz, MD, RPVI   I have no relevant financial relationships

Venous Insufficiency Venous reflux disease develops when the valves stop working properly and allow blood to flow backward (i.e. reflux) and pool in the lower leg veins. Venous reflux disease is chronic and progressive. If left untreated, symptoms can worsen over time and could lead to chronic venous insufficiency (CVI) Reference: Medtronic

Reference: Medtronic

Reference: Medtronic

Risk Factors Risk increases with age Predisposing factors: DVT Multiple pregnancies Family hx – pattern suggestive of autosomal dominant inheritance with variable penetrance Both parents +  90% risk of varicose veins One parent +  25% risk male, 62% female No family hx  < 20% risk

Evaluation of Venous Insufficiency History: Symptoms – heaviness, fatigue, swelling, itching, aching Compression use DVT / hypercoagulability, personal or family Differential Dx: CHF, cirrhosis, renal failure, lymphedema, obesity, psoriasis, skin cancer Physical Exam: Tactile and visual exam for varicosities Assess for skin discoloration, swelling Assess distribution of varicosities to pinpoint site of venous dysfunction

Venous Imaging Imaging of choice = Doppler Ultrasound Delineates anatomy Mapping and planning therapy Assess reflux and visualize valves Assess for DVT, scarring, webs Assess perforator veins Can visualize nerves and surrounding structures MUST BE PERFORMED STANDING! Pic: http://www.sale-medical.com/products/GE-VINGMED-VIVID-7-ULTRASOUND-MACHINE-CARDIAC-VASCULAR.html

Ultrasound Testing Aggressive Identifications of reflux, measure diameter, reflux time, relationship to varicosities Anterior Accessory Small saphenous Duplicated saphenous Saphenous or other refluxing remnants after phlebectomy/stripping Deep Veins Map refluxing perforators > 3.5 mm in CEAP 4-6 patients

Indications for Intervention Failed Compression (20-30 mmHg x 3 mo) Dilation to > 5 mm Reflux time >0.5 sec GSV AAV SSV Perforators

Reference: Medtronic

Reference: Medtronic

Ablation Results • Prospective, multicentre, single-arm study. • Purpose: To evaluate long-term effects of RF segmental ablation of GSV using the CLF catheter • 326 patients (396 limbs) were treated with the ClosureFast™ catheter at 13 sites (8 Europe, 5 US) • Follow up: Patients were evaluated at 3, 6, 12, 24, 36, and 60 months post-procedure. 278 limbs followed to 5 years Results showed durable clinical efficacy rates through 5-years: High occlusion rate of 90.0% at 5 years Overall reflux-free rate of 93.7% at 5 years Low complication rate Dietzek A. RF Segmental ablation: 5-year data. Annual Symposium on Vascular and Endovascular Issues, Techniques, Horizons (Veith Symposium) New York City; November 19, 2013

Chemical Ablation Polidocanol or Sodium Tetradecyl Sulfate mixed with air or CO2 in office (physician compounded) Commercial prep (Varithena): 1% Polidocanol, O2, CO2 and trace nitrogen Labeled for GSV ablation Foam has lower vein closure rates than thermal ablation (70-80%) with repeated treatments No anesthesia required Able to treat tortuous or partially occluded veins Side effects: Migraine, visual disturbance, fainting, DVT, stroke

Mechanochemical Endovenous Ablation (MOCA):Non-Thermal, Non-Tumescent Self-contained unit consisting of wire abrasion combined with sclerosant ClariVein http://www.premierheartandveincare.com/vein-care/clarivein/

Position: Wire 5 cm from SFJ

Wire Agitation with STS Infusion http://www.premierheartandveincare.com/vein-care/clarivein/

MOCA GSV Results: Dutch Series 224 Patients (all GSV)* Closure: 95% 6 mo, 95% 1 year No nerve, skin injury or DVT 50 Patients (all SSV)** 1 year 94% closure VCSS decreased from 3 to 1 No DVT or nerve injury *Reijnen M et al. J Endovasc Ther 2011;18:328-334, update at Charing Cross 2014 **BoersmaD et al. Eur J Vasc Endovasc Surg. 2012

Cyanoacrylate Adhesive (CAA) - Anionic substances such as plasma or blood cause polymerization of the adhesive upon contact, leading to occlusion - Triggers an acute inflammatory reaction in the wall and surrounding tissues - Damages the vascular intima and induces immunologic response

CAA The VenaSeal® Sapheon Closure System (Medtronic)

Modern Venous Surgery Perform new stripping in the office 1-2 cm incision over proximal GSV Puncture distal end and place 8F sheath Use Pin stripper and pull out vein Wrap immediately No need to stop anticoagulation or aspirin Invagination of proximal stump and ligation with permanent suture may reduce neovascularization Microstab phlebectomy has minimal scarring Phlebectomy of large varicosities (7 mm) has faster healing than injections

3 wks post-op incisions Pre-Op

Clinical Outcome Comparisons Randomized study of 500 legs. Compared: Post op pain: RF and Foam less pain initially Complications: 1 PE w/ foam, 1 DVT w/ stripping > 30% of foam retreated at 3 years (P < .01) No difference QoL Immediate Occlusion Recanalization - 3yrs New Veins - 3yrs EVLA 94% 6.8% 20% RFA 95% 7% 14.9% Foam 80% 26.4% 19.1% Stripping 96% 6.5% 20.2% Rasmussen et al Br J Surg 2011 Rasmussen et al JVS 2013

Sclerotherapy Ensure no superficial reflux with ultrasound Injection of polidocanol or STS directly into vein Solution irritates vein, causing it to collapse Over time, the vessel scars https://www.laserlipoandveins.com/before-after-pictures/veins/

Side Effects DVT Larger veins that have been injected may become lumpy and hard; may require several months to dissolve and fade. Staining may appear at the vein site. Neovascularization may occur at the site of sclerotherapy treatment. https://www.laserlipoandveins.com/before-after-pictures/veins/

Conclusion Lots of good choices for Venous Disease Excellent safety profiles Easy to use, tolerate Expect patients to have improved QoL Better outcomes than ever before Educate that venous disease is lifelong, and lifestyle changes may be needed