1. Non Thermal, Non Tumescent Ablation: How and When To Cool It Down
Steve Elias MD
Director, Center for Vein Disease
Englewood Hospital and Medical Center NJ

2. Disclosures Medtronic Inc. – Scientific Advisory Board
Vascular Insights LLC – Scientific Advisory Board
LeMaitre Vascular – Consultant
Hancock-Jaffe Labs - Consultant

3. “SO WE BEAT ON, BOATS AGAINST THE CURRENT, BORNE BACK CEASELESSLY INTO THE PAST”
F. SCOTT FITZGERALD “THE GREAT GATSBY”

4. How and When How has been discussed many times
How can be learned at our hands-on workshops
When is more important now
When to consider NTNT or TT?

5. EVA: Categories* TT (Thermal, Tumescent)
NTNT (Non Thermal, Non Tumescent)
TNT (Thermal Non Tumescent) - new
NTT (Non Thermal Tumescent) - new
*Elias S. Emerging Endovenous Technologies. Endovasc Today. March 2014.

6. Thermal Tumescent: TT Laser – HSLW, WSLW, radial/jacketed
Radiofrequency – Closurefast, RFITT
Steam – SVS, Veneti

7. Non Thermal, Non Tumescent: NTNT
Mechanical Occlusion Chemical Assisted – Vascular Insights LLC
Cyanoacrylate glue – Medtronic Inc
Polidocanol Injectable Microfoam – BTG
V Block – VVT Medical

8. ADVANTAGES DISADVANTAGES MOCA CAE V BAS PEM No foreign body left
Longest follow up of all NTNT Tortuous veins – angled wire
Perforators – PAPS
60,000 cases worldwide
* Only one with a code
Need to pullback/inject simultaneously
Longest learning curve
Compression 5 days
CAE
Segmental ablation
Pullback rate variable eliminated
Second longest follow up
# cases in hundreds
No post procedure compression
Perforators – PAPS ?
Foreign body left
Phlebitic reaction
Tortuous veins - difficult
V BAS
Uses approved liquid or foam sclerosant
# cases <100
Shortest follow up
Smallest number treated
Compression 7 days
PEM
Tortuous veins – foam traverses
Treat branch varicosities, PPV
Requires 2 people for procedure
IFU – 2 weeks compression
Not indicated for SSV
Need 3 pts within 1 week/1 month

9. NTNT – Recent Literature
They all work with similar safety/efficacy
They all improve QoL
NTNT non inferior to TT
NTNT probably less discomfort during/after
MOCA – Dedicated code and valuation
PEM – some carriers have on policy (not Medicare)
CAE – self pay currently
Successful EVA helps patients

10. Should We Do This?
SVS/AVF Guidelines – 1B recommendation for EVA, compression if not a candidate for EVA
NICE Guidelines (UK): EVAFoamSurgeryStockings
Good data based on: efficacy, safety and QoL
A closed/ablated superficial axial vein is good no matter how it is accomplished

11. What’s In A Name? It is not really about the name of the vein
Technique and technology choices depends on:
Size – small, medium, large
Length – short, long
Location – AK, BK, Suprafascial
The Neighbors – nerves, skin, LDS or ulcer
Disease state – C5, C6, SVT
Patient type – fat, thin, anxious
Special – MD, MD spouse, friend, foe, barrister

12. Rules To Live By: When Deciding What To Use When
Treat to lowest point of incompetence
Use whatever is “safest” to achieve above
Consider cost – to patient and health care system
Tailor technique/technology to the clinical setting
Need to have TT and NTNT in armamentarium

13. Size, Length, Tortuosity
Size – Large >12 mm, Medium 5-10 mm, Small <5 mm
Large – TT before NTNT
Medium – NTNT before TT or dealers choice
Small – NTNT or Should you be doing this?
Length – Long – anything, Short – cost CAE, PEM - expensive MOCA/RF/Laser - good
Tortuosity – PEM, MOCA then others (guidewires)

14. Location: AK or BK (Nerves)
AK – GSV, AAGSV, Intersaphenous (Giacomini)
BK – GSV, SSV, PPV, VV
AK – anything as long as it is in fascia and straight
BK – GSV/SSV – NTNT>TT, VV – PEM, Phlebec
PPV – Laser>MOCA> Foam (artery) CAE?

15. BK GSV – Saphenous Nerve

16. Sural Nerve

17. Proximal Nerves: Tibial/Peroneal

18. LOCATION: Fascial/Suprafascial
AK Fascial – anything
BK GSV and SSV – NTNT (MOCA>PEM>CAE) before TT
Suprafascial – MOCA> Inversion stripping> PEM> TT (skin/cord, hyperpig)>CAE(phlebitis)

19. ADVANCED DISEASE STATE: C 4-6
C5, C6 – AK GSV to mid calf – TT/NTNT
C5, C6 – GSV/SSV to ankle – NTNT (LDS or ulcer difficult tumescence)
C5, C6 – BK GSV residual – retrograde NTNT and foam ulcer bed (MOCA/PEM)
Previous SVT – TT – need more energy

20. BK GSV

21. BK C5, C6

22. PATIENT TYPE Fat – TT over NTNT Thin – NTNT over TT
Anxious, Nervous – NTNT over TT

23. SPECIAL SCENARIOS MD or Spouse – RF, MOCA
Friend – RF, WSLW (1470), MOCA
Foe – HSLW (810/980) or stripping
Attorney/Barrister – 810/980 with 150 joules/cm and no tumescence

24. ANTICOAGULATION INR 2.0 – 2.5 – anything INR > 2.5 – TT
Rarely stop it

25. RETREATMENT AFTER FAILED EVA
If used NTNT > use TT If used TT > use alternate TT If TT fails > inversion stripping with tumescence

26. CONCLUSIONS Need one TT and one NTNT
More advanced disease, the lower to go -NTNT
Tailor the technique to the situation
All veins are not the same – either by name but more importantly by size, location, disease state

27. TREATMENT OF REFLUX IN THE SUPERFICIAL VEINS TREATMENT OF PATIENTS WITH REFLUX IN THEIR VEINS

28. “THE FUTURE OF NON THERMAL ABLATION: IS THE FUTURE OF ENDOVENOUS ABLATION”

29. Don’t Worry, Be Happy Vein Disease Is An Incurable Disease