Robert J. Min

Endovenous laser treatment of saphenous vein reflux: long-term results.

PURPOSE To report long-term follow-up results of endovenous laser treatment for great saphenous vein (GSV) reflux caused by saphenofemoral junction (SFJ) incompetence. MATERIALS AND METHODS Four hundred ninety-nine GSVs in 423 subjects with varicose veins were treated over a 3-year period with 810-nm diode laser energy delivered percutaneously into the GSV via a 600- micro m fiber. Tumescent anesthesia (100-200 mL of 0.2% lidocaine) was delivered perivenously under ultrasound (US) guidance. Patients were evaluated clinically and with duplex US at 1 week, 1 month, 3 months, 6 months, 1 year, and yearly thereafter to assess treatment efficacy and adverse reactions. Compression sclerotherapy was performed in nearly all patients at follow-up for treatment of associated tributary varicose veins and secondary telangiectasia. RESULTS Successful occlusion of the GSV, defined as absence of flow on color Doppler imaging, was noted in 490 of 499 GSVs (98.2%) after initial treatment. One hundred thirteen of 121 limbs (93.4%) followed for 2 years have remained closed, with the treated portions of the GSVs not visible on duplex imaging. Of note, all recurrences have occurred before 9 months, with the majority noted before 3 months. Bruising was noted in 24% of patients and tightness along the course of the treated vein was present in 90% of limbs. There have been no skin burns, paresthesias, or cases of deep vein thrombosis. CONCLUSIONS Long-term results available in 499 limbs treated with endovenous laser demonstrate a recurrence rate of less than 7% at 2-year follow-up. These results are comparable or superior to those reported for the other options available for treatment of GSV reflux, including surgery, US-guided sclerotherapy, and radiofrequency ablation. Endovenous laser appears to offer these benefits with lower rates of complication and avoidance of general anesthesia.

Endovenous Laser Treatment of the Incompetent Greater Saphenous Vein

PURPOSE To assess the safety and preliminary efficacy of endovenous laser treatment (EVLT), a novel percutaneous technique for occlusion of the incompetent greater saphenous vein (GSV). MATERIALS AND METHODS Ninety GSVs in 84 patients with reflux at the saphenofemoral junction (SFJ) into the GSV were treated endovenously with pulses of laser energy and evaluated in a prospective, nonrandomized, consecutive enrollment multicenter study. Patients were evaluated at 1 week and at 1, 3, 6, and 9 months to determine efficacy and complications. RESULTS Eighty-seven of 90 GSVs (97%) were closed 1 week after initial treatment with endovenous laser. The remaining three GSVs were closed after repeat treatment. Eighty-nine of 90 GSVs (99%) remained closed for as long as 9 months according to serial duplex ultrasonography. Sonographic evaluation demonstrated 73% reduction in GSV diameter at 6 months (61 patients) and 81% reduction in GSV diameter at 9 months (26 patients) after EVLT. One patient developed a transient localized skin paresthesia. There have been no other minor or major complications. CONCLUSIONS EVLT of the incompetent GSV appears to be an extremely safe technique that yields impressive short-term results. Long-term follow-up is awaited.

Reporting Standards for Endovascular Treatment of Lower Extremity Deep Vein Thrombosis

Suresh Vedantham, MD, Clement J. Grassi, MD, Hector Ferral, MD, Nilesh H. Patel, MD, Patricia E. Thorpe, MD, Vittorio P. Antonacci, MD, Bertrand M. Janne d’Othée, MD, Lawrence V. Hofmann, MD, John F. Cardella, MD, Sanjoy Kundu, MD, Curtis A. Lewis, MD, MBA, Marc S. Schwartzberg, MD, Robert J. Min, MD, and David Sacks, MD, for the Technology Assessment Committee of the Society of Interventional Radiology

Multi-society consensus quality improvement guidelines for the treatment of lower-extremity superficial venous insufficiency with endovenous thermal ablation from the Society of Interventional Radiology, Cardiovascular Interventional Radiological Society of Europe, American College of Phlebology and Canadian Interventional Radiology Association.

Neil M. Khilnani, MD, Clement J. Grassi, MD, Sanjoy Kundu, MD, FRCPC, Horacio R. D’Agostino, MD, Arshad Ahmed Khan, MD, J. Kevin McGraw, MD, Donald L. Miller, MD, Steven F. Millward, MD, Robert B. Osnis, MD, Darren Postoak, MD, Cindy Kaiser Saiter, NP, Marc S. Schwartzberg, MD, Timothy L. Swan, MD, Suresh Vedantham, MD, Bret N. Wiechmann, MD, Laura Crocetti, MD, John F. Cardella, MD, and Robert J. Min, MD, for the Cardiovascular Interventional Radiological Society of Europe, American College of Phlebology, and Society of Interventional Radiology Standards of Practice Committees

Duplex Ultrasound Evaluation of Lower Extremity Venous Insufficiency

Physicians unfamiliar with venous insufficiency, particularly disorders of the superficial venous system, often underestimate the complexity of the problem and the importance of proper evaluation before initiating treatment. In addition to a directed history evaluation and physical examination, additional evaluation with use of a variety of noninvasive diagnostic instruments, including duplex ultrasound, may be necessary when determining the cause, severity, and best treatment options available for a particular patient. After such evaluation, the treating physician should have a precise map of the patients pathways of venous insufficiency, including sources of reflux (eg, saphenofemoral junction, saphenopopliteal junction, perforators), tributaries, vein size, and vein morphology.

Temperature changes in perivenous tissue during endovenous laser treatment in a swine model.

PURPOSE To conduct a pilot study to measure temperature at the outer vein wall during endovenous laser treatment (EVLT). METHOD Temperature at the outer vein wall was monitored during EVLT in a live pig ear vein (8 W: 1.0 and 2.0 seconds pulse duration; 10 W: 1.0 and 1.5 second pulse duration; 12 W: 0.5, 1.0 and 1.5 second pulse duration) and exposed hind limb vein (8 W: 0.5, 1.0, 1.5 second pulse duration; 12 W: 0.5,1.0, 1.5 second pulse duration with perivenous tumescent fluid (TF); and 15 W: 0.5 second pulse duration without and with TF, 1.0 second pulse duration with TF). RESULTS Peak temperatures, near the outer vein wall in an ear vein of a live pig, with laser fluence at 8 W were 40.8 degrees C and 48.9 degrees C (pulse durations of 1.0 and 2.0 seconds, respectively). At 10 W, peak temperature was 47.1 degrees C and 49.1 degrees C (pulse durations of 1.0 and 1.5 seconds, respectively). At 12 W, peak temperature ranged from 37.9 degrees C (0.5 second pulse duration) to 49.1 degrees C (1.5 second pulse durations). In an exposed hind limb vessel, at 8 W, peak temperature ranged between 34.6 degrees C to 38.5 degrees C (0.5, 1.0 and 1.5 second pulse durations). At 12 W and 0.5 to 1.5 second pulse durations, with TF, peak temperature ranged from 35.6 degrees C to 39.4 degrees C. At 15 W and 0.5 second pulse duration, peak temperature was 44.0 degrees C without TF and 34.5 degrees C with TF. At 15 W and 1.0 second pulse duration, with TF, pulse duration peak temperature was 37.0 degrees C. CONCLUSIONS In the model studied, peak temperatures of perivenous tissues generated during endovenous laser seem unlikely to cause permanent damage to these perivenous tissues. The peak temperature generated is reduced with the use of perivenous tumescent fluid.

Endovenous laser treatment of saphenous vein reflux.

Readily available noninvasive diagnostic tests now allow physicians to accurately map out abnormal venous pathways and identify sources of reflux. In recent years, minimally invasive alternatives to surgical treatment of saphenous vein reflux, the main contributor to most cases of symptomatic varicose veins, have been developed with promising results.(1-8) The latest percutaneous technique developed to treat incompetent saphenous veins is endovenous laser, which allows delivery of laser energy directly into the vein lumen to cause collagen contraction and denudation of endothelium. This stimulates vein-wall thickening with eventual fibrosis of the vein. These modern percutaneous techniques now provide patients with alternatives to ligation and stripping for treatment of significant sources of venous reflux without many of the potential complications associated with surgery.

Cyanoacrylate Adhesive for the Closure of Truncal Veins: 60-Day Swine Model Results

Background: The introduction of cyanoacrylate (CA) within a blood vessel triggers polymerization, followed by an inflammatory reaction. Methods: A sheath was positioned 2.0 cm caudad to the junction of the superficial epigastric and abdominus rectus veins in 2 swine, followed by ultrasound-guided injection of 0.16 mL of CA glue. After glue delivery, the catheter was pulled back 3 cm, compression was applied to the treatment site, and the process was repeated for the entire length. At 60 days postimplantation, the veins were harvested surgically and examined histologically. Results: The histologic changes were consistent with a chronic foreign-body-type inflammatory response. Venous closure, segmental wall thickening, and fibrosis were observed. Conclusion: Injection of CA is feasible for closure of superficial veins in animal models. Vein closure is achieved via an inflammatory process which ultimately leads to fibrosis.

Recommended Reporting Standards for Endovenous Ablation for the Treatment of Venous Insufficiency: Joint Statement of the American Venous Forum and the Society of Interventional Radiology

Sanjoy Kundu, MD, FRCPC, FCIRSE, FASA, Fedor Lurie, MD, Steven F. Millward, MD, FRCPC, FSIR, Frank Padberg Jr, MD, Suresh Vedantham, MD, Steven Elias, MD, Neil M. Khilnani, MD, William Marston, MD, John F. Cardella, MD, FSIR, FACR, Mark H. Meissner, MD, Michael C. Dalsing, MD, Timothy W.I. Clark, MD, FSIR, and Robert J. Min, MD, MBA, FSIR, Toronto and Peterborough, Ontario, Canada; Honolulu, Hawaii; Newark and Englewood, NJ; Saint Louis, Mo; New York, NY; Chapel Hill, NC; Springfield, Mass; Seattle, Wash; and Indianapolis, Ind

Transcatheter Duplex Ultrasound-Guided Sclerotherapy for Treatment of Greater Saphenous Vein Reflux: Preliminary Report

Background. Surgical ligation and stripping of the greater saphenous vein has been the gold standard for treatment of saphenofemoral junction incompetence for several years. Although sclerotherapy of the greater saphenous vein has also been advocated by some phlebologists, the procedure can be technically challenging and has resulted in inadvertent nontarget injection. Objective. The purpose of this study was to assess the effectiveness and safety of transcatheter duplex‐guided sclerotherapy for the treatment of varicose veins due to saphenofemoral junction reflux. Methods. Fifty‐one greater saphenous veins in 50 patients were treated with transcatheter sclerotherapy. Using local anesthesia and ultrasound guidance, the greater saphenous vein was entered 15–45 cm below the saphenofemoral junction. An infusion catheter was placed over a guidewire and positioned under ultrasound guidance, and 3% sodium tetradecyl sulfate was administered below the saphenofemoral junction and along the course of an “empty” greater saphenous vein via the catheter. Results. Catheter placement and treatment was possible in all patients, with 2–5 ml of 3% sodium tetradecyl sulfate administered per session. At the 24‐hour and 1‐week follow‐ups, all treated greater saphenous vein segments were closed following initial treatment, with no flow detectable by continuous wave or color Doppler interrogation. No patients required re‐treatment, with all veins remaining closed at 2‐ to 12‐months follow‐up. There have been no adverse reactions. Conclusion. Transcatheter duplex ultrasound‐guided sclerotherapy should improve both the safety and efficacy of treatment compared to conventional ultrasound‐guided sclerotherapy and offers an alternative to surgical ligation and stripping for those patients wishing to avoid surgery.