1. Steve Elias MD FACS FACPh Director, Division of Vascular Surgery Vein Programs Columbia University and Medical Center, NY Assistant Professor of Surgery Columbia University

2.  Vascular Insights LLC – Advisory Board  Covidien Inc. – Advisory Board

4.  Combination – endovenous mechanical and chemical  Mechanical – wire > rotates > intimal damage  Chemical – liquid > penetrates > scar  End result – venous occlusion

8.  Percutaneous ultrasound guided  4 fr. micropunture sheath  18 gauge IV access  No further wires or larger sheath exchange

11.  Pullback 1.o – 1.5 mm. per second  Inject during pullback  Sodium tetradecyl sulfate 1.5% liquid (or equivalent sclerosant)  Volume dependent on size/length

17.  30 limbs  GSV only  C2 – 24 C3 – 2 C4 – 4  Avg. 55 years  Treat GSV only (no treatment VV or IPV)  1 yr. follow up to complete trial  No tumescence or sedation *Elias S, Raines JK. Mechanochemical tumescentless endovenous ablation: final results of the initial clinical trial. Phlebology;27:67-72.

18.  GSV size – 8.1 mm.  GSV length treated – 36 cm.  GSV treatment time – 5 min.  Overall treatment time - 14 min

19.  All closed except 1 st patient – btw 3-6mos  6 month – 29/30 (96%)  12 month – 29/30 (96%)  24 month – 27/28 (96%) ( 1 died, 1 no US yet) *Elias S, Raines JK. Mechanochemical tumescentless endovenous ablation: final results of the initial clinical trial. Phlebology;27:67-72.

20.  Subcutaneous ecchymoses – 3 pts.  Side branch tear?  No DVT  No nerve injury  No skin injury

21.  224 GSV’s  C2 (13%)C3 (67%) C4 (20%)  GSV diameter 7 mm  GSV length 41 cm  treatment time 16 min Ramon RJP, van Eekeren MD et al. Endovenous mechanochemical ablation of great saphenous vein incompetence using the ClariVein device: a safety study. J Endovasc Ther 2011; 18:328-334.

22.  6 weeks – 182/185 closed 98%  6 months – 40/42 closed 95%  No nerve/skin/DVT

23.  6,000 cases worldwide (GSV/SSV)  > 90% occlusion rate – various intervals  Chaloner – 92% at 1 yr.  QoL – improves as any successful EVA  DVT - < 1%  No nerve/skin injury  No tumescence – longest part of short procedure

24.  Rotate 1 st (spasm/vortex) then inject slow  Catheter ON = Catheter MOVING  Two handed technique – 1 pulls – 1 injects  Tendency: Pull too fast, inject too slow

25.  Volume originally 12 cc (1.5%STD) for all  Volume now based on diameter/length  Volume tends to be less  Table available  GSV – 6-10 cc SSV – 2-4 cc PPV – 1cc

26.  Stronger is better  STD 1.5% - 2% 93-96% 1% < 90% (Chaloner UK)  PLD – 2 – 3 % (volume based on weight)  Lower volume, maximum concentration

27.  Slower contraction and scarring  No flow but appears sponge like (color flow)  Can take up to 1 year for contraction  If some flow – reimage 3 months

29.  No thermal injury – nerves, skin  SSV, BK GSV, PPV  Ulcers – retrograde  Eliminates tumescence – patient and MD

30.  It works, It is safe – 96% at 2 years  Learning curve - 5 – 8 cases  No tumescence – the future, only one now  Glue, PEM, TAHOE (RF)  Another good option for ablation (95% pts.)

31.  Respect the elders,  Embrace the new,  Encourage the improbable and impractical  Without bias