Servier – Phlebolymphology

XIII. Non thermal non tumescent (NTNT)
ablation methods

Why does the combination of sclerotherapy and mechanical vein injury works better?
Mark Whiteley (UK)
Thermal ablation requires transmural damage of the vein wall for fibrosis and long-term ablation. Unlike thermal ablation, sclerotherapy cannot affect deeply located layers of the venous wall, meaning that the success of great saphenous vein ablation after 1 year is no higher then 75%. The combined usage of sclerotherapy throughout the process of mechanochemical ablation (MOCA) should increase the depth of exposure to the vein wall and lead to transmural fibrosis. To prove this hypothesis, a comparison of sodium tetradecyl sulfate (3%) alone with MOCA on the wall of the extrafascial segment of the great saphenous vein was made by studying the histological and immunohistochemical properties of the vein wall. The exploration showed that MOCA resulted in deep media damage, shear damage from mechanical rotation. Immunohistochemisty revealed the exact location of the deepest injury of the vein wall with MOCA. As such, MOCA enhances sclerotherapy damage to the vein wall in both the endothelium and media layers. The effect in the media appears to be via mechanical shearing of the layers, allowing ingression of sclerosant deeper into the media.

Mechano-chemical saphenous ablation by Flebogrif®
Tomasz Zubilewicz
Given the results of treatment, where 200 procedures were performed in cases of great saphenous vein/small saphenous vein incompetence using the Flebogrif catheter. The clinical success, anatomical success, safety of Flebogrif®, and technical features/ advantages were studied. The closure rate was 96% after 3 months, 93% after 6 months, and 92% after 1 and 2 years. There were 15 cases of recanalization (11 for the great saphenous vein and 4 for the small saphenous vein). There was 1 major complication, ie, deep vein thrombosis due to thrombophilia. In 32% of cases, there were minor complications: 1 case of prolongation pain, 35 cases of thrombophlebitis, and 26 cases of discolorations. There were no sclerosant-related side effects (allergic reaction etc). The technical features and advantages of the procedure included no anesthesia, no tumescence, short procedure time, no need to invest in additional medical devices, no hospitalization, catheter available in two lengths (60 and 90 cm), and clearly visible by Doppler.

Infra malleolar access for endovascular treatment of venous insufficiency ulcers
Michael Tal (US)
Michael Tal presented his experience using inframalleolar access to treat venous ulcer patients. Mechanochemical ablation allows treatment below the ulcers because it is characterized by a minimal risk of nerve injury (over 180 000 cases performed worldwide and no reports of nerve damage). A retrospective enrollment and review of 103 patients (89 with active chronic venous ulcers and 14 with healed ulcer) who were treated with mechanochemical ablation using inframalleolar access using a micropuncture with 16G peripheral surgical catheter and local anesthesia showed that closure was observed in 62 great saphenous veins, 22 small saphenous veins, and 19 great saphenous veins/ small saphenous veins. The average surgery time was 40 minutes; 55 patients received low-molecular weight heparin during the procedures and 47 received antibiotics; 44 patients had debridement during the procedure and 3% had postprocedural phlebitis. A decrease in pain from 4 points to 1 on day 5 postprocedure was observed. A reduction in ulcer size was recorded in 52% of patients after 1 week, in 80% after 1 month, and in 98% after 3 months. Therefore, inframalleolar venous access is feasible and safe, it enables treatment of the underlying vein, and appears to enhance venous ulcer healing. Inframalleolar access should be considered as the preferred access point when treating venous ulcers.

Limitation of the current technology – glue
Nick Morrison (US)
Adhesive ablation has some clinical advantages in the treatment of the below the knee portion of the great saphenous vein and the small saphenous vein, especially in case of cranial extension of the small saphenous vein and perforators. However, the method has some limitations. Strong contraindications are acute deep or superficial vein thrombosis, active skin infection, significant arterial insufficiency (ankle brachial index <0.6), uncontrolled significant medical illness (asthma, malignancy, etc), and lipodermatosclerosis. The weak negative recommendations are the cases of treatment of a very thin patient or a very superficial vein (because a “cord” may be palpable and may irritate the patient), pregnancy, adhesive or chemical sensitivity, autoimmune disease, or compromised immune system. Moderate negative recommendation for use of glue includes patients with very limited mobility, cases of a tortuous saphenous vein, previous great saphenous vein thrombophlebitis, and small diameter vein (<3 mm).