Chapters Transcript Video Left GSV Ablation with Venclose™ RF Ablation Catheter Featuring: Dr. Jeffrey Carr; Duration: 20:00 minutes A 67 year old man, uh, who presented to me with non healing wounds in both of his feet on the right toes and also in the left heel and, uh, dorsum of his, of his left foot. He's a truck driver and had a three pack per day smoking history, but quit years ago. And he said that his symptoms in his wounds started, uh with the initiation of um, of bites. He had fire ant bites and he just never has been able to heal those. So he's um in wound care and they've had very slow healing despite aggressive conservative management. Um, he also complains of heaviness, aching, edema, stinging, burning, itching, tiredness and nocturnal cramping. He has normal A bis. Um And so we always want to think about um, concomitant artery disease. In addition to Venus disease on his duplex ultrasound, done in September 23 we confirm bilateral pathologic great and small saha vein reflux. He has significant pathologic reflux in below the perforators and he has a right distal calf perforator that's dilated to 3.5 millimeters, 714 milliseconds of reflux period. So today we are tackling his left great and small sahan veins. His left great saha vein was maximally dilated at 7.4 millimeters with 1438 milliseconds of reflux. His left small surface vein was 2.2 millimeters with 788 milliseconds of reflux. He has no deep vein, thrombosis or superficial uh thrombosis as well. So the plan for him after he has failed aggressive conservative management with wound care and compression of therapy is to treat his left great and small Samphan veins, the distribution of his ulcers and his feet are not classic for vein leg ulcers, but he certainly has other symptoms and he has other uh advanced c class findings. You can see the marked hyper pigmentation in his legs, um showing evidence that he's had venous hypertension for many decades. And in addition to all of his symptoms, uh we felt that treatment uh was indicated for him. So now we're gonna scan the great sinus vein, the target of our therapy today up front just to show the pathway. So you're looking for any variants, any diversions and see if it stays within the sap of space. And you can see it where the arrow is pointing on the ultrasound. So you see it stays within the sinus space and come on down and we're gonna trace this down to find her and you can see it bifurcates there and stays in the space and goes out of the space for a tributary, but it comes more interior here and Casey is going to locate kind of our best um access location. So, excuse me, there's a nerve right there. A Sahan nerve is very helpful. You don't often see them here, but she's pointing to the SA A sa a tributary of the SAF nerve or a um branch of the Sahan Nerve, I should say. And a nice big um interior uh lo located Great Sahan Vein. I think we could check the trips after we're done because we're going to mess no matter what. Oh Yeah, that's great. So go, we can go pretty low here with him. So I would suggest one just below me. A cap. I don't wanna go too low. We can, we can foam the rest because we're gonna film anyway. So that'd be good kind from a distal g. Get rid of you see better. All right. So next, I'm gonna utilize um the ultrasound and in short axis view, transverse, I'm gonna go just a little bit below mid mid calf here at a really nice location. I'm gonna make a little wheel with my lido cane. You can see just a little bit. You wanna be careful not to cause spasm of the vein with the bevel up. I have my introducer needle. No shape, no shape. Sorry. A little pinch here. Yeah. And you can see mm I'm getting through OK. Right there. I'm on it. I went through it. I'm gonna come back and we're feeling and looking for right there. It just popped off that back wall. And now you can see I'm in that great sinus looking for a little blood return. Sometimes you don't get it. And I'm feeling, I feel resistance. I'm probably on that back wall. So I'm gonna lower my needle a little bit. And as I pull back, can you? Yeah. What do you think? Casey? The back wall, it's kind of compressed so you can see it spasming that take some deep. OK. I'm in. You come on up now, Casey and he's got really thick skin. So sometimes it's, you just gotta make an incision to help get your catheter in. How's he feeling the morphine? Is he doing? Ok. OK. We are in, come on up. So we like to track the device as we go. I hold, I hold it loose but I can I just go smooth and right there. He felt that. So I'm gonna use the angle here. We kind of hit the end. We're probably right at the end where the great sap of vein angles down and right there you can see it and you can see on the ultrasound, the tip really well and we're going to measure safety distance back of 2 to 3 centimeters from the SFJ. Um I like to use the superficial ep gastric vein as a landmark rather than SFJ. And she's putting that cursor on to the angle there where this, the superficial IP Gasser vein drain. So you can see we're over three centimeters. There's the tip. You just really want to make sure you verify the tip. So we're good and we indexed right here on that mark. So we know that's our position. We're gonna go ahead and start our two E. You're gonna feel a series of pinches and some burning as this goes in. I'm gonna go right to where it's numb. Then you're gonna feel some pressure as this goes in. How are you doing? OK. Just gonna work our way all the way up and surround this vein with the numbing fluid. You can see this vein is really tortuous and coursing over. OK? Doing all right. Oh I'm sorry about that. OK. Getting used to stabbing hopefully at the wound care center and I've been going to Oh Yeah. And that's a really good demonstration there on the ultrasound about putting it right in that Cetus space above and below that vein in the catheter, collapsing the catheter, collapsing the vein on the catheter with using the tsin. So it's really nice there. OK. We're moving along here. All right. Minute. Awesome. How we doing on the Two Essence, Rhoda. OK. Yes, I see it. Thank you. Yeah. There we go. Get back on board here and it's easy to have the needle divert down below the fascia and you can kind of see that right. In that location posterior to, to the s space. And if you're not sure, then you can just flip it like this and you can see the surface face really well, that way you can see I'm be below it on some of that. So that's a nice little teaching point here. And we'll just go up the rest. Well, we'll just be consistent, we'll go longitudinal for this one. We can show another case where we go up transverse and check it longitudinal. I might need a roll. I will need a roll. OK. Mm OK. My wingspan. So I'm gonna swing around to get this last section here and if you get lost, just go transverse, I'm doing great. Mm So you can see it's, it's really right superficial up there, isn't it right up on that? So this was where it helps to just switch your planes. I was getting lost a little bit with the location of the Tess and then then this is really much easier here. We got plenty of tess, right? We're not gonna be shorting. Yeah, great. So another stick, another stick there. Sorry, you know, poking a few times here, but we're almost done with the pokes. OK. Really good. And let's see if we can go back to the longitudinal. There we go. And this really shows that nicely how we want to get coverage all the way around the tip, the catheter, especially that posterior wall. This is an area where if you don't do it well enough, they commonly will feel it right there because that tip kind of digs into that posterior wall as it bends around naturally, the following the path of that great staffs. And so that's, I like to really do enough at, at the very end here to make sure I've got that fully covered. We're gonna demonstrate with the ultrasound, the, um, to essence in a different plane in a transverse plane to make sure we've got 360 degree coverage and they were far enough away from the hazards. And we're gonna measure again to make sure, make sure that we're a good 2 to 3 centimeters away and she's measuring from the epigastric vein there and we're three, we're perfect there. That's a really good distance away. Now, you can show the handle if you want to show this. Um This is where we, the only time we use it. So we're checking all the way down by ultrasound. Looks good. Remember we had that Saffin Nerve down there, but we look good there. Right. I, yeah, it's OK. All right. Now that we've triple checked it, we're gonna go ahead initiate therapy after she put steady even horizontal pressure on that. We like to see that the um catheter is really even with the skin ready to go. So I hit the button and we now see the generator delivering the therapy be over. OK. You put it. OK. It we're gonna show this on here. One 23 four and then I hit that again. I can go back quiet. Got it. Yeah, I know. Yeah, I uh uh and that are you not at work? Yeah. OK. Right. Here we go. We did another pull back. We can see this pulling back on. OK. He's focusing on this. So yeah, 12, here we go. Did you see this? So now I'm going to do this. All right. Pull back an index and now I'm gonna do this. Are you oh You're literally letting off here and so on this one, she let off because it was closer to the skin and we didn't want to uh push the skin toward the device. What's he feeling? OK. Here we go. Uh r so are we ready? OK. So I'm gonna hold it there. 12, 34. You see the warning track here? And so now I'm gonna hold this here and anchor this back. Yeah. Yeah, there you go. You can see the coil there. So now we're going to go ahead and convert to 2.5. OK? And we're gonna Yes, but that it sounds good. Is he feeling in that? OK. We're gonna do this again now. OK. I'm gonna just hold it right there and we're gonna pull this back to here. So now we have two here. We're gonna get one more treatment out of this. I'm gonna anchor it. We're verifying that we're on 2.5 and this will be our last treatment treatment zone. Just show that we're a marker is right at the skin, the halfway marker, which is five centimeters and now we're gonna ST it. Can you wipe that real fast? Rhoda, take it off, take it off. And now we're gonna show on the skin where the last treatment location was right there. So we had this much safety margin. Ok? Published December 12, 2024 Created by Related Presenters Jeffrey Carr, MD, FACC, FSCAI Interventional Cardiology, Cardiovascular Disease, Internal MedicineCHRISTUS Trinity Clinic View full profile
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