1. Endovenous Radiofrequency Ablation
Of Varicose Veins in an Asian Centre
Zhiwen Joseph LO, Pravin LINGAM, Ryan Jun-Yi TAN, Glenn Wei Leong TAN
Thank you chairman and big thank you to ____ and the scientific committee for accepting my study. 1

2. No potential conflict of interest2

3. Ligation/stripping >> sclerotherapy >> EVLT >> RFA
Varicose veins are as old as Hippocrates.
Venefit: segmental RFA
RFITT: bipolar RFA
Ligation/stripping >> sclerotherapy >> EVLT >> RFA
Van den Bremer. Historical overview of varicose vein surgery.
Ann Vasc Surg (3):426-32 3

4. 4

5. Segmental (Venefit) vs bipolar (RFITT) vs monopolar (EVRF)
A Double Blind Randomised Controlled Trial of Radiofrequency Thermo-ablation Treatments of Great Saphenous Varicose Veins: Venefit (Closurefast) vs. Radiofrequency Induced Thermal Therapy (RFITT) vs. Endovenous Radiofrequency (EVRF) - NCT
By Worchestershire NHS
Primary Outcome Measures:
Percentage of participants with 100% ablation of the previously treated vein segment [ Time Frame: 6 months ] [ Designated as safety issue: No ]Duplex confirmed absence of recanalisation of the ablated

Secondary Outcome Measures:
Pain score on the visual scale [ Time Frame: 7 days ] [ Designated as safety issue: No ]Percentage of patients scoring pain in each category for the three treatments
Quality of life measured by SF36, Euroqual 5D and Aberdeen varicose veins questionnaire [ Time Frame: 12 months ] [ Designated as safety issue: No ]
A double blind RCT of RFA treatments of great saphenous varicose veins:
Segmental (Venefit) vs bipolar (RFITT) vs monopolar (EVRF)
Assessments by visual pain scores, duplex ablation and quality of life questionaires 5

6. EVRF CR45i As compared to VNUS segmental radiofrequency ablation
The EVRF system (F-Care, Belgium), which utilizes monopolar radio frequency energy, was introduced in
The central unit works with CR45i and CR30i catheters
The maximum heating power of the probe is 15W. It can be preset individually according to vessel lumen diameter and its location relative to skin surface.
The 120cm long CR45i catheter of 1.5 mm diameter, is inserted into the vein through the 6F needle.
Thermoablation is performed using the 1-25W continuous impulse.
The exposure time for each 5mm segment is approx. 5 seconds.
The 5mm working electrode generates the temperature of oC within the vein.
It effectively denatures vascular endothelial cells and vascular wall collagen, so that the vein shrinks and becomes fibrotic.
### Variable energy 20 – 25 W >> 25 W above knee & 22 W at level of knee and below
### Less expensive 6

7. Ultrasound EVRF console Tumescence
A Double Blind Randomised Controlled Trial of Radiofrequency Thermo-ablation Treatments of Great Saphenous Varicose Veins: Venefit (Closurefast) vs. Radiofrequency Induced Thermal Therapy (RFITT) vs. Endovenous Radiofrequency (EVRF) - NCT
By Worchestershire NHS
Primary Outcome Measures:
Percentage of participants with 100% ablation of the previously treated vein segment [ Time Frame: 6 months ] [ Designated as safety issue: No ]Duplex confirmed absence of recanalisation of the ablated

Secondary Outcome Measures:
Pain score on the visual scale [ Time Frame: 7 days ] [ Designated as safety issue: No ]Percentage of patients scoring pain in each category for the three treatments
Quality of life measured by SF36, Euroqual 5D and Aberdeen varicose veins questionnaire [ Time Frame: 12 months ] [ Designated as safety issue: No ] 7

8. SFJ
EVRF tip
EVRF tip
(pre-tumescence)
EVRF tip
(post-tumescence)
Variable energy: 20-25W
25W above knee
22W below knee

9. 1st long black mark Withdraw sheath 2nd long black mark Stop ablation
Able to burn very short segments of vein with the same catheter as burning tip only 5 mm
Useful for treating short saphenous vein and anterior thigh vein 9

10. Buddy-wire Long sheath LSV & ATV cannulated
Very rarely unable to pass CR45 catheter up to SFJ as catheter is flexible and lower profile
Techniques to overcome tortuous vein
Terumo glidewire as “buddy wire” to straighten vein
Use of long 35 cm sheath 10

11. Study Design Retrospective 2013 – 2014 1,400-bed tertiary hospital
Single surgeon
Pilot 50 patients, 80 limbs
Factors investigated
Demographics
BMI
Co-morbidities
Previous venous interventions
CEAP classification
Venous duplex
RFA treatment energy and time
Post-op complications
6-month clinical surveillance
- First Asian centre report for EVRF monopolar RFA
BMI: Body Mass Index ;
CEAP: clinical, etiology, anatomical, pathophysiology ;
RFA: radio-frequency ablation 11

12. Results Demographics Study population Study period Male : Female
Chinese : Malay : Indian : Others
Mean age (range)
Mean BMI (range)
Right : Left :
50 patients, 80 limbs
2013 – 2014
51% : 49%
79% : 5% : 11% : 5%
59 (27-75) years old
28 (20-39) kg/m2
Co-morbidities
Type 2 DM
Peripheral arterial disease
Previous venous surgery
10 (20%)
3 (1%)
CEAP classification C1 C2 C3 C4 C5 C6
0 (0%)
30 (38%)
16 (20%)
21 (26%)
13 (16%)
DM: diabetes mellitus 12

13. Results Venous duplex SFJ incompetence LSV reflux SPJ incompetence
SSV reflux
Deep veins reflux
ATV present
61 (76%)
80 (100%)
12 (15%)
1 (1%)
15 (19%)
Post-op complications
Saphenous neuralgia
Phlebitis
DVT
Recurrence
5 (6%)
7 (9%)
0 (0%)
ATV: anterior thigh vein ; DVT: deep vein thrombosis ; LSV: long saphenous vein ; SFJ: sapheno-femoral junction ; SPJ: sapheno-popliteal junction ; SSV: short saphenous vein 13

14. Conclusions
EVRF is a feasible endovenous modality for varicose veins with low complication rates
Benefits include:
Lower profile with need for only 6Fr sheath
Variable energy level hence allowing for below knee cannulation
Shorter active tip hence allowing for treatment of shorter vein segments (e.g. anterior thigh veins or short saphenous veins)
Less expensive catheters
Further analysis of 1174 varicose veins treatment from , with comparison between monopolar RFA versus segmental RFA will be undertaken 14

15. Thank you 15

17. Disadvantages of Venefit
Less flexible, large profile (7 Fr)
3 or 7 cm ablation tips
Working port usually occludes after first ablation rendering it unusable
If unable to cross the tortuous vein, then need 018 wire (costly at $180 with risk of vein wall perforation)
Unable to adjust the temperature according to level of ablation (option to reduce the temperature for SSV and below knee LSV ablation reducing risk of neuralgia)
- First Asian centre report for EVRF monopolar RFA 17

18. Disadvantages of Clarivein
Risk of ulceration on contrast extravasation
Will need double puncture as clarivein catheter shorter and unable to reach SFJ from ankle
Skin staining and pigmentation
Pain when spinning tip of clarivein catches on side-branch
DVT risk increased
- First Asian centre report for EVRF monopolar RFA 18