EVLT® Procedure Step by Step

Ultrasound Settings Standard duplex Scanner with probe frequency 7.5 MHz or greater Set the Color and Doppler to optimize flow velocities between 50-100cm/s Maintain a shallow depth during the procedure to optimize resolution Utilize zoom mode for guided procedures, for example, percutaneous vein access.

Pre-Operative Duplex Assessment Patient in reverse trendelenburg (feet are tilted low and head is high). Patient can also be standing Leg position Knee flexed Leg rotated outward

Ultrasound Transducer Transverse: The Transducer is perpendicular to the Vein. Vein is easier to see but the view is limited to one spot Longitudinal: The Transducer is parallel to the vein. Difficult to get in correct plane but once there, the image is more complete.

Pre-Operative Duplex Assessment Perform scan of GSV from SFJ to below the knee. Identify and mark: SFJ Min and max vein diameters Aneurismal segments Tortuous segments Vein depths that are less than 10mm from surface Other important anatomy such as large branches, duplicate saphenous, etc Optimal Access points Confirm reflux of vein segment to be treated

Pre-Operative Duplex, GSV

Multiple Varicosities

GSV Pre-Treatment

GSV,CFV,ALV Images courtesy of Olivier Pichot, MD

Terminal Valve Incompétence: Sagittal section at the groin - CDU CFV/GSV termination Reflux generated from the Common Femoral Vein through the entire section of the Sapheno Femoral Junction

Vein Diameter

Pre-Operative Marking Use a betadine swab or surgical marking pen to outline the GSV, -Or- Use a straw to make skin depressions before mapping the vein The vein depressions or betadine remain visible after the gel is wiped off The leg is ready to mark

Pre-Operative Assessment

Vein Access Vein Access can be achieved with any of the following methods: Percutaneous Ultrasound-guided Stab Incision and Phlebectomy hook Small hook

Venospasm Venospasm is a major concern when attempting percutaneous access of the GSV Causes of Venospasm Cold room Cold patient Nervous patient Multiple needle sticks Extended access time

Percutaneous Vein Access Localize the GSV in cross-Section using B-Mode. Position the vessel at the center of the transducer For small veins, use micro-puncture set As little local as possible Hold needle at a 60 degree angle, bevel up. Deliver the vein as quickly as possible without collapsing the vein. Look for vein wall to dimple in as the needle approaches, then perforate vein with a firm “dart”

Venous Access-Longitudinal

Percutaneous Vein Access Remove the transducer from the access site as the sheath is placed. Position the transducer at the SFJ as the physician flushes the sheath, verifying that the “flush” has entered the Femoral Vein via the GSV. Remain at the junction as the guide wire is placed, confirming the position in the femoral vein.

VenoSpasm

Vein Access Problems Difficulty visualizing the access needle. Look for Proximal Vein Wall to Dimple. If needle is not visualized longitudinally, rotate transducer to x-section view and re-center vessel. Be sure transducer is “square” on vessel and not angled obliquely.

Monitor vessel size and alert physician if vein appears smaller. Vein Access Problems Venospasm caused by multiple needle sticks. Monitor vessel size and alert physician if vein appears smaller. Avoid causing entire vessel to spasm May be necessary to choose a more proximal access site or perform a “cut down” for access.

Vein Access Problems Needle looks to be in vessel but no flash seen Needle may be positioned against vessel wall If you think the needle is in, it probably is Rotate needle to bevel angle is reversed and draw back for “flash” If still no flash, needle may have pierced posterior vein wall. Try retracting syringe while simultaneously drawing back

Guidewire and Catheter Advancement Troubleshooting Guide wire or Catheter does not advance easily after access is achieved. Use ultrasound to follow path from sheath and identify tip of catheter or wire. Measurements can be done to Confirm placement Have “glidewire” available and use if necessary

Guidewire and Catheter Advancement Assess area for presence of aneurysm, branch or perforator. If present, retract catheter or guidewire distally then advance slowly while applying probe pressure to occlude branch or decrease diameter of vein. If catheter or wire cannot be advanced at level of prolapsed valve, perform calf compression. Augmented flow into vein may reverse position of valve while simultaneously advancing catheter or wire.

Tortuosity

Guide-Wire Advancement

Guidewire and Catheter Advancement Troubleshooting Skin Stretch Maneuver Straightens the vein to make wire and/or catheter advancement easier.

Skin Stretch Maneuver After Before

Sheath Advancement

Fiber Placement Insert fiber once introducer sheath is in position in the SFJ. Insert fiber into sheath to first “bead” or marking. While holding fiber stationary, withdraw sheath to the second bead. Under Ultrasound guidance, withdraw fiber and sheath simultaneously to starting position. Final position can be confirmed with laser aiming beam.

Fiber and Sheath

Tumescent Infiltration Idea is to circumferentially compress the vein so that it surrounds the fiber uniformly. Described as a tubular anesthetic affect along the course of the vein. Injections with a long 22+/- gauge needle every 2+/- cm. Must be done with Ultrasound Guidance, Must be in Perivenous space

  Tumescent

Confirmation of Starting Point Confirm on Ultrasound that the fiber tip is slightly below SFJ Check with aiming beam keeping in mind Laser Safety Check with test fire with Ultrasound in place Create sectional markings as a guide to achieve 3-4mm/sec Remove fiber and sheath simultaneously

Pull-back Lock Fiber and sheath together with a steri strip Go to Ready on Laser when all is set Check aiming beam and confirm starting position Depress foot pedal and remove fiber and sheath simultaneously at 3-4mm/sec

Post-Op Compression bandage and stocking for first 24hours then for one week when not sleeping Anti-Inflammatory if needed Exam 1 week, 1 month Follow-up procedures, as needed