1. Retrograde Injection Technique for Endovenous Chemical Ablation of Varicose Veins, A Case Study
Steven T Deak, MD, PhD, FACS
Hungarian Medical Association of America
Sarasota, Florida
October 27, 2016

2. Treatment of Varicose Veins
Surgical Ablation
Thermal Ablation
Chemical Ablation

3. Albucasis described multiple vein ligation and external stripping thus preceding contributions by Charles Mayo by 900 years
Albucasis 1050

5. Varicose Veins: Indications for Intervention
General appearance
Aching pain
Leg heavines
Easy leg fatigue
Superficial thrombophlebitis
External bleeding
Ankle hyperpigmentation
Lipodermatosclerosis
Atrophic blanche
Venous ulcer

6. Standard Varicose Vein Surgery
Standard open varicose vein surgery has been used to treat uncomplicated varicose veins for over 100 years.
The essential aim of the operation is to ligate and disconnect the great saphenous vein (GSV) or short saphenous vein (SSV) at its junction with the deep venous system has remained constant.

7. Inversion Stripping of Saphenous Vein
      Complications
Wound complications
Thigh hematomas
 Nerve injury Saphenous n 7-39%
                     Femoral n - rare
                     Common peroneal n 2-4-%
                     Sural n -  20%
Vascular Injury
Venous  Thromboembolism
DVT 1:200
PE   1:600
Recurrence  60% at 11 years
Neovascularization
Perkins,JMT Phlebology 2009;24 Suppl 1:34-41

8. Neovascularization
Prominent recurrent varicose veins with venous ulcer in a 32-year-old man who underwent comprehensive saphenofemoral junction ligation and stripping of the great saphenous vein above the knee 8 years earlier.

9. Neovascularization
Diagram of neovascularization of the groin after ligation of the great saphenous vein (GSV) and all its tributaries at the saphenofemoral junction without stripping the greater saphenous vein.
 A new vein is bulging at the anteromedial side of the common femoral vein (CFV) and continued downward as a very tortuous vein, connecting again with the retained GSV trunk.
 If the above-knee GSV has been stripped it may connect with any other superficial vein remnant

10. Neovascularization
Vascular cast of recurrent refluxing saphenofemoral junction specimens showing the connecting network of vessels in both specimens there are abundant tortuous vessels. Cast injected from the saphenofemoral junction and distally.
J Vasc Surg :

16. Endovenous Laser Ablation for varicose veins EVLA
EVLA involves insertion of a laser fiber into the incompetent truncal vein (usually greater saphenous vein) with subsequent thermal ablation of the vein. 
This should achieve the same affect that saphenofemoral ligation or popliteal ligation together with stripping of the truncal vein.

18. The treatment of large superficial varicose veins requires a two step approach:
The incompetent greater saphenous vein is closed with endovenous thermal ablation
Followed by ambulatory phlebectomy of the residual varicose veins, either at the same time or at a later date
I would like to show you an improved technique for treating the incompetent greater saphenous vein and the associated varicose vein tributaries at the same time with a single access site using endovenous chemical ablation with 1% polidocanol injectable foam

19. The GSV is accessed with 5 Fr micropunture catheter in distal thigh, leg 45* the GSV is thrombosed polidocanol1% SFJ compressed to protect the deep system
2nd injection is administered through the same catheter and directed distally in retrograde fashion thhrough the incompetent vv to the calf dorsiflex foot to prot. deep

20. 38 year old male presents with varicose veins for many years with heavy feeling in both legs.
Severe reflux in the greater saphenous vein 500 msecons in duration
GSV measures 11 mm in diameter
Varicosities at the knee 8 to 11 mm
The GSV was thrombosed with 3 mLs of polidocanol injectable foam 1%
The remaining varicosities in the distal leg were then treated with an additional 5 mL of polidocanol injectable foam 1% through the same micropuncture catheter in the distal thigh for a total foam volume of 8 mL

21. Pre-Op
2 Weeks Post-Op

22. 1% Polidocanol Injectable Foam
Physician Compounded Foam

23. Retrograde Ablation of Venous Valvular Reflux in the Treatment of Venous Valvular Reflux with 1% Polidocanol Injectable Foam