Servier – Phlebolymphology

XII. Thermal tumescent (TT) ablation
methods

Wavelengths, fibers or way of procedure performance for successful laser ablation? Lessons learned
from 15 years of experience
Uldis Maurins (Latvia)
Laser energy is mainly absorbed by water in the vein wall and water content in the blood. The level of absorption of laser energy with a 1470-nm wavelength laser is 40 times higher than a 980-nm wavelength laser and 40 times lower with the new 1940-nm wavelength laser. The radial fiber, which replaced the bare fiber that heats up to 700°C to 800°C, at a linear endovenous energy density 60 J/cm, heats up to 100±10°C and it is often accompanied with carbonization and loss of effectiveness. The introduction of a 2-ring fiber into practice has improved the procedure due to a reduced and softer sticking potential of reduced side effects. We now have different fibers: (i) radial slim 2-ring fiber (d=1.3 mm), radial Swift 1-ring fiber (d=1.6 mm), and classic radial 2-ring fiber (d=1.9 mm) for different situations for effective closing of different veins of any diameter. Usage of these new fibers with local tumescent anesthesia provided with a pump will help improve treatment results. Today, it is possible to conduct laser ablation without using compression stockings. Integrated use of these principles will help achieve complete resorption of treated great saphenous veins in 96% of cases at the 1-year follow-up (average diameter, 9 mm; linear endovenous energy density, 73 J/cm; endovenous fluence equivalent, 31 J/cm²). The modern trend is a wish to leave the shortest possible great saphenous vein stump in order to decrease the number of relapses.

The future of the endovenous ablation
Lowell Kabnick (US)
Today, endothermal ablation methods with laser and radiofrequency ablation are the gold-standard treatments of varicose veins. The current studies show no differences in efficacy between radiofrequency ablation and laser ablation. All endovenous treatments are safe, with low complication and morbidity rates. Interventions resulted in significant and clinical improvements in symptoms and signs. All interventions result in significant improvements in quality of life. Nonthermal nontumescent methods are a modern alternative to treat varicose veins. Today, the recommended vein diameter should not be bigger than 12 mm (mechanochemical and glue ablation) and 10 mm (foam ablation). Quality of life improvements and an occlusion rate greater than 90% are similar for both nonthermal nontumescent and thermal ablation methods. On the other hand, thermal treatment is associated with discomfort during tumescent infiltration (not the ablation part of procedure itself). Thermal treatment with radiofrequency or endovenous laser ablation is the mainstay of varicose vein treatment at present. All procedures appear to be in clinical equipoise among the ablation procedures because no perfect device is available currently for superficial venous disease.

Thermal ablation of saphenous and non-saphenous varicose veins by steam
Rene Milleret (France)
The first-generation steam machines were available in 2006, with the second-generation being available in 2016. Steam allows even heating of the vein wall, can cross the tortuosities, heat veins close to the skin, does not heat deep veins, and does not induce inflammatory reactions or allergic complications. Steam is efficient and safe for saphenous trunks, even in 10 mm and more. Recurring varicose veins are more tortuous than saphenous trunks and more difficult to catheterize with laser fibers or radiofrequency catheters, but steam will go through the bends and, from one entry point, can treat up to 8 cm of the vein. Perforators are often tortuous, with branches that can be surrounded by sclerotic tissue. Steam is a good option, as, in the deep veins, only droplets of hot water will be released, they are diluted in the fast-flowing blood without risk of deep vein thrombosis. Popliteal perforators are often seen as recurrences after small saphenous vein surgery. Steam can close even large perforators with a small catheter under echo guidance. Steam can heat up to 600 J/cm without damaging tissues; therefore, it can be useful for malformation treatment. Combined with foam for superficial lesions, steam allows less aggressive treatment of these venous malformations. Radiofrequency and laser are the references for thermal endovenous techniques. For teams who perform advanced venous surgery, steam opens up more indications and saves time and trouble.

UGLA – ultrasound guided laser ablation
Peter Dragic (Germany)
Traditionally, the pullback speed of fiber and the amount of energy was based on the calculation of linear endovenous energy density or endovenous fluence equivalent. Ultrasound-guided laser ablation (UGLA) changes this approach. The sense of UGLA is that, based on information obtained from the ultrasound probe about vein wall thickness and the ablation at that place, the pullback speed can be determined to optimize the amount of energy needed for successful ablation. UGLA provides an increased percentage of occlusion and a lower chance of recanalization. The foundation of UGLA is an assumption that vein wall thickness is not always proportional to its diameter and increasing vein diameter is not always followed by increasing its thickness. Sometimes aneurysms of 20 mm or larger have the thinnest wall of the entire vein, but sometimes it is the opposite where a tiny vein has thicker walls than veins with a larger diameter. It is this assumption that can lead to inadequate ablation. Traditionally, a normal vein, a varicose vein, and a vein after postthrombotic syndrome with the same diameter are going to have different thickness. In these cases, UGLA provides an increased percentage of occlusion and a lower chance of recanalization.

Thermal ablation in the extrafascial location – is it safe?
Igor Zolotukhin (Russia)
Endovenous thermal ablation for extrafascial veins is the safest procedure (no pulmonary embolism/deep vein thrombosis), but complications, such as skin injury (burns, retraction), nerve injury, and hyperpigmentation, occur. There are only a limited number of papers about the subject. Igor Zolotukhin reported the data from a pool of members of the Russian Phlebological Association. The questions were sent out to 163 practicing phlebologists, 94 of them participated in the poll (58%), where 87 (53%) practice thermal ablation, of which 17 (20%) do not use thermal ablation for extrafascial veins, 35 (40%) infrequently perform, extrafascial thermal ablation, and 35 (40%) frequently perform extrafascial thermal ablation. Among the 70 doctors who practice thermal ablation for extrafascial veins, 51 (73%) preferred laser, 7 (10%) radiofrequency ablation, and 10 (14%) both methods. Observed adverse events and complications were reported by 57 (71%) doctors. Hyperpigmentation was observed by 46 (66%) doctors and 36 reported that the mean time to resolve the hyperpigmentation was 6 to 12 months, where 3 doctors reported that it took longer than 12 months. The feeling of a tensed cord under the skin was observed by 43 (61%) phlebologists, skin retraction was observed by 16 (23%), phlebitis by 12 (27%), pain by 23 (33%), and the need for pain killers by 10 (14%). Of the 57 extrafascial thermal ablation users, 1 to 5 adverse events were reported by 39 (68%) users, 6 to 10 adverse events by 7 (12%), and ≥11 and more adverse events by 6 (11%). The procedure does not lead to life-threatening adverse events, but it does not seem to be free from complications.

Hybrid procedures in varicose vein treatment
Aleksandra Jaworucka-Kaczorowska (Poland)
Some patients seek treatment because of symptoms, fears about future harm, but the majority seeks treatment because of cosmetic appearances. From 14% to 55% of patients have reflux with multiple origins. Endovenous laser therapy alone for the proximal great saphenous vein does not address the multiple sources of clinical reflux. Concomitant treatment can be used effectively in below the knee saphenous veins, tributary varices, and perforating veins. Above the knee great saphenous vein endovenous laser therapy improves the symptoms of chronic venous disease, but persisting below the knee reflux appears to be responsible for residual symptoms; some patients even return with persistent reflux and worsening symptoms. From 30% to 99% of patients, secondary treatment of residual varicosities is required. Advocates of delayed phlebectomy cite “over-treatment” as a primary concern, but “under-treatment” and its sequelae leads to worse outcomes in those patients needing further treatment and in a time of austerity, the additional treatment is not economical, so it is better to do it in a single procedure. Compared with endovenous laser therapy alone, endovenous laser therapy with concomitant sclerotherapy was, on average, 5 minutes longer and endovenous laser therapy with concomitant phlebectomy prolonged the procedure time by 20 minutes. A one-stage treatment reduced the need for secondary procedures, significantly improved quality of life, significantly improved the severity of venous disorders, and reduced the cost.

Aleksandra Jaworucka-Kaczorowska reported on her own experience with endovenous laser therapy and concomitant sclerotherapy. Of 576 patients (508 primary, 40 recurrent, and 28 with previous superficial vein thrombosis of the affected vein), 87 (15%) were multiple origin, 212 (37%) had perforating veins, and 558 (96%) had visible varicosities below the knee. A combined hybrid procedure was used: endovenous laser therapy for the great saphenous vein, small saphenous vein, and accessory saphenous vein (1470 nm, radial fiber) and ultrasound-guided foam sclerotherapy was used for incompetent perforating veins and tributaries. The vein occlusion rate was 100% at the 1-week follow-up, 96.5% at the 6-month follow-up, and 91.8% at the 12-month follow-up. For truncal veins (great saphenous vein and small saphenous vein), the occlusion rate was 99.2% after 1 year, additional sclerotherapy was required in 32 (5.6%) patients, and 184 (31.9%) patients wanted additional sclerotherapy due to C₁ status. After 1 month, complications and side effects occurred in 22.5% of patients (hyperpigmentation, 13.9%; superficial thrombophlebitis, 4.7%; paresthesia, 1.7%; skin necrosis, 0.7%; visual disturbance, 1.5%), and 98.3% of patients (566/576) said they would have this procedure again. So, a onestage treatment is not only for patient preference, but it is also valid for many medical indications. A hybrid approach does increase the treatment possibilities and its efficacy with an acceptable increase in procedure risk.