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Diagnostic and Interventional Devices for Varicose Veins Available devices to treat superficial and perforator vein disease. By Steven Elias, MD, FACS, FACPh This discussion is limited to available devices to treat superficial venous disease: saphenous veins, perforator veins, and branch varicosities. The nondevice options for the management of superficial pathology such as sclerotherapy and microphlebectomy are not covered because they employ specific techniques rather than significant specialized technology. Other devices for pathologic conditions of the deep venous system are also not discussed because they could be a section unto themselves. These other devices include pharmacomechanical technologies for DVT and balloons/stents for proximal venous obstruction. In the Tips & Tricks section, I cover certain aspects of techniques and technology that can enhance your results when treating superficial venous disease. VESSELS TREATED
Endovenous Laser
The laser wavelength does not seem to affect occlusion/recanalization rates. Procedural technique does seem to affect occlusion/recanalization rates and complication rates (see Tips & Tricks). Radiofrequency and laser demonstrate similar occlusion/recanalization rates if technique is perfect. Perforator devices and ablation technique (percutaneous ablation of perforators [PAPS]) have a longer learning curve than saphenous treatment. PAPS with laser or radiofrequency has similar early success rates. It is crucial to choose a device and perfect your technique to attain acceptable endpoints. Sclerotherapy agents and techniques can be used in certain clinical settings to treat saphenous veins, branch varicosities, and perforators.  Tips &Tricks: Techniques and Technical Information for Treating Varicose Veins Tumescence (tumescent infusion) is key before, during, and after varicose vein treatment. Tumescence plays a role in saphenous treatment, perforator treatment, and branch varicosity treatment. Because tumescence is used so often, I like to infuse it with some type of peristaltic infusion pump similar to that used for liposuction (Figure 1). This pump gives a steady infusion and saves your hands for other parts of the procedure. Of course, tumescence can be infused by hand, and many practitioners utilize this technique. The cost is approximately $1,500 to $2,000, and I think it is well worth the investment. Tumescence is used for anesthetic purposes, but more importantly, its role in vein exsanguination is paramount. The ability to attain good vein exsanguination is perhaps the main difference between good results and excellent results. All devices used for endovenous ablation ultimately damage the vein wall architecture itself by getting enough energy to the vein wall to destroy it. There is debate as to whether direct vein wall contact or near vein wall contact is the mechanism. What is clear is that all device techniques require good, direct tumescent placement. No device company advocates minimal, haphazard tumescent infusion. Tumescence should concentrically envelop the treating catheter. I often say, "The catheter should be floating in a sea of tumescence" (Figure 2A). If viewed longitudinally during infusion, a "wave" of tumescence can be seen traveling cephalad (Figure 2B). Placement of the infusing needle should be within the saphenous sheath. Pressure in this closed space allows for adequate exsanguination of the target vein. This enhances vein-wall contact or near-vein-wall contact with the treating catheter so that enough energy can reach the vein wall. Tumescent infusion leads to vein exsanguination from outside the vein (exovenous). The second tip for adequate exsanguination is to utilize endovenous exsanguinations, which can be accomplished by aspirating on the sidearm of the introducer used to place the endovenous catheter (Figure 3). Aspiration can be done by placing a 10- or 20-mL syringe on the sidearm, aspirating, and locking it in place with a clamp. I term this the Mackay maneuver because it was first demonstrated by Edward Mackay, MD, a vascular surgeon from Florida. This maneuver requires a longer introducer, with a distal end close to the treating portion of the catheter. Therefore, with larger veins (>8 mm in diameter), I will place a 25-cm sheath through which the treating catheter can be passed, which is especially necessary when using the radiofrequency devices because a very short sheath is usually placed. Most laser devices already have a long sheath for placement. I believe there is better vein wall coaptation against the treating catheter with the Mackay maneuver of endovenous exsanguination than without this maneuver. Exovenous and endovenous exsanguination improve results because the thermal energy is better directed toward the target organ, the vein, and not the nontarget organ, the blood. Failures can be attributed to many things, but one of the primary causes is not getting enough energy to the vein wall. If you are heating a significant amount of residual intraluminal blood, you are wasting energy—energy that should be directed to the vein itself. Exsanguination is a key component of a good outcome. Exovenous and endovenous exsanguinations are reliable techniques that help to achieve this endpoint. Steven Elias, MD, FACS, FACPh, is the Director of the Centers for Vein Disease at Englewood Hospital, New Jersey, and Mt. Sinai Hospital, New York, and is Associate Professor of Surgery, Mount Sinai School of Medicine. He has disclosed that he holds no financial interest in any product or manufacturer mentioned herein. Dr. Elias may be reached at (201) 894-3252; veininnovations@aol.com. |
