Juan Terre and Nelson Chavarria Division of Cardiology, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, NY, USA Management of symptomatic chronic venous insufficiency is complex and varies with disease severity [1–4]. In the following series, we describe the use of minimally invasive treatment modalities employed when venous duplex ultrasound imaging confirms the diagnosis and identifies specific segments of venous incompetence [5–7]. Thermal techniques including radiofrequency (RF) ablation and endovenous laser therapy will be discussed, as well as an emerging technology that does not use tumescence or healing elements, mechanico‐chemical ablation (MOCA) [8, 9]. Two current methods used to achieve ablation of the great or small saphenous veins involve the use of a RF catheter and an endovenous laser ablation (EVLA) procedure utilizing a laser‐fiber catheter, both requiring their own respective generators. The primary difference between the two techniques is the heat source. RF ablation utilizes RF waves to produce steam bubbles and heat to damage the endothelium and denature the collagen matrix of the vein wall. Eventually leading to inflammation and fibrosis. The EVLA method utilizes a laser fiber to directly deliver laser energy to the vein wall causing endothelial damage and subsequent fibrosis. Both modalities require tumescent anesthesia to compress the vein around the catheter and insulate the surrounding tissue from thermal injury. Below we describe step‐by‐step techniques of these treatment modalities. Step 1. Access to the refluxing superficial vein is first obtained at its lowest point of incompetence under ultrasound guidance (evaluation in short‐ and long‐axis views advised [Figure 17.1]) with a 21G introducer needle and 0.018‐in. wire under local anesthesia (1% lidocaine). Utilizing a modified Seldinger technique, a 4 Fr micropuncture sheath is advanced into the vein over the 0.018‐in. wire. Techniques employed to increase first puncture success include reverse Trendelenburg positioning, continuous IV hydration, rubber band ligation above the access point, or placement of a warming pad. Figure 17.1 Steps in accessing the saphenous vein under ultrasound guidance (a) in short (b) and long‐axis views (c), ultrasound guided vein puncture (d). Figure 17.2 Steps in catheter positioning and tumescent anesthesia administration. Catheter advanced and then retracted 2.5 cm from the saphenofemoral junction (a). Injection of tumescent anesthesia under ultrasound guidance (b) creating a “thermal sink” and collapsing the vein around the catheter (c). Step 2. Once access is secured, the 0.018‐in. wire is exchanged for a 0.035‐in. guidewire. The 4Fr micropuncture sheath is then exchanged for a 5 Fr introducer sheath. Intraluminal position within the vein is confirmed by aspirating non‐pulsatile venous blood and visualization under ultrasound. Step 3. The RF ablation catheter (Covidien ClosureFast™, Medtronic, MN, USA) is then slowly advanced in the saphenous vein under ultrasound guidance and placed at least 2.5 cm distal of the saphenofemoral junction (Figure 17.2a). Advancing the catheter may sometimes prove difficult when making turns. Pressing the overlying tissue to direct advancement is often helpful. Step 4. Once the catheter is in place, local tumescent anesthetic solution (450 ml 0.9% normal saline, 35 ml 0.1% lidocaine, and 15 ml 0.8% sodium bicarbonate [10]) is injected under ultrasound guidance in the perivenous space of the saphenous vein (Figure 17.2b,c). Tumescent anesthesia can be administered either manually with serial injections utilizing a 20 cc syringe and 21G needle or with a filtration pump (HK Surgical Klein Infiltration Pump™, HK Surgical Inc., San Clemente, CA, USA), which can deliver high volumes of anesthesia through pressure tubing. Aside from providing anesthesia, tumescent fluid serves to separate the vein from perivenous structures, creating a “thermal sink” to dissipate peak temperatures and compresses the vein to maximize treatment to the endothelial wall. Step 5. The RF generator is then activated, providing heat energy of 120°C for 20 seconds through the 7 cm copper coil segment of the ablation catheter. Once the treatment cycle is completed after 20 seconds, the catheter is simply withdrawn to the new adjacent venous segment and the generator is activated once again to give another 20 seconds treatment cycle. The steps are repeated in sequence to treat the entire length of the vein. Step 6. At the end of the procedure, the catheter and sheath are removed. Hemostasis is achieved with manual compression at the site of venous access. Compression bandages and stockings are applied on the treated leg for one to three days to reduce postprocedure bruising and tenderness. Patients are encouraged to walk after the procedure. Follow‐up protocols vary by institution [11]
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Catheter‐Based Therapy for Varicose Veins
Introduction
Thermal Techniques
Radiofrequency (RF) Ablation
Follow‐Up
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