1. EVLT® Procedure
Step by Step

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

3. 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

4. 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.

5. 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

6. Pre-Operative Duplex, GSV

7. Multiple Varicosities

8. GSV Pre-Treatment

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

10. 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

12. Vein Diameter

13. 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

14. Pre-Operative Assessment

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

17. 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

18. 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”

19. Venous Access-Longitudinal

20. 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.

21. VenoSpasm

22. 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.

23. 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.

24. 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

25. 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

26. 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.

27. Tortuosity

28. Guide-Wire Advancement

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

30. Skin Stretch Maneuver
After
Before

31. Sheath Advancement

32. 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.

33. Fiber and Sheath

34. 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

35. Tumescent

36. 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

37. 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

38. 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