Chapters Transcript Video Left Refluxing Perforating Vein Ablation with Venclose Maven™ Perforator Catheter Featuring: Dr. Jeffrey Carr; Duration: 13 minutes A 46 year old man who has had a very long standing chronic disease of very very strong family history. And he came to me uh complaining of years and years of heaviness, aching, tired, fatigue in his legs, the throbbing and restless legs and cramping. And not to mention, he had over 12 episodes of recurrent thrombophlebitis in both legs. The left leg was worse than the others uh than the right. Um He underwent laser ablation therapy 15 years ago by another provider just of the thigh portion of the great sinus vein, but really did not achieve really any significant improvement over the ensuing years. On his initial duplex ultrasound, we showed closure of that thigh portion of the great sinus vein, but pathologic reflux of bilateral great sap anus and small sinus veins as well as a very large left distal calf perforator of 5.8 centime millimeters and 1942 milliseconds of reflux. Now, he had focal pain over the site of this distal calf perforator that persists despite treatment of his left great sinus vein. And so that's the focus of our intervention today. Uh In addition, because of his recurrent thrombophlebitis is at high risk uh for additional episodes, they've been very painful. Um And he has many superficial vars as well. Uh, that had drained into the superficial system that we will plan on tackling later with phlebectomy. We wanna look at our treatment length that we think we can adopt from that distal end. Yeah, you come, come back, do five. Ok. Just stay right there. That's good. That's good. Ok. So that's do not cross mark that, that's our, that's our safety distance. And now we're gonna move from there to the entrance. We believe that where we think we're gonna angle in on access right about a little more. OK? So just over 22 centimeters or 20 millimeters, this is a five millimeter coil. It's important not to overdo the lidocaine your wheel. Uh These veins are very vasal reactive. So you gotta be very careful, come up very easy and just put a little wheel there and not too much, just enough so that they don't feel the skin neck again. He has a soft, softer skin. The key is to not to move too much with the sonography and just to find it, you can see the tip. Now, I'm not on the edge of the show me the good lumen, the black lumen. There you go more, a little more. So I'm just about to pierce it. I'm gonna poke, poke through a little bit. No looking real. I think I just grabbed some tissue there. How about now? It feels like it. Anybody see. Ok, I am in the vessel. I'm gonna hold really still. I like my assistant to put that in because I'm focusing on not moving an iota and now you say I landed the plane, not at the beginning of the runway, but you know, maybe 1/4 of the way and in Korea just put the wire down and it made it to the edge and it actually made the turn. So it's a looped. It's a little loop. No, it's not loop. It's perfect. It's in the PT. So I'm in the vessel. I'm gonna take my wire out, gonna make a little incision, not my wire, my needle out and then I'm gonna keep that wire right there. We don't wanna lose that position because we, we're pretty pleased that it went in where we hoped I'm gonna make a little skin nick because I don't want resistance when we put the sheath in to pull my wire out. So just a little 11 blade skin nick. And then can you load the space so she'll load this on. I'm just really focusing on not moving that wire and then notice the dilator the distance of the dialer to the sheath. Ok? Because the key is to get the sheet in the dialer is gonna go into that vein, but we're gonna make sure the sheath does. So I'm holding my wire, Casey's gonna show me approaching it. Ok. So we have the dilator in the vein, we have the wire around into the poster tubule. But you can see it's very challenging to know where the sheath begins. And then what's where the sheath and the dilator are in relation on the ultrasound. So that's why it was important to look at how much I'm going to anchor the dilator now. Ok. That's a great view. You can see the double density. I'm gonna just try to advance the sheath in over the dilator here without pushing the dilator and, and that's it. So now my sheet is in and I'm pulling the dilator out and we have that wire in a good position. So I think we can pull everything out, right? We're going to OK. And then we have feedback that we're in the lumen. Wonderful little flesh, please. I'm gonna jiggle just a little. So here I am to the right. I'm not even in it yet. I gotta shallow. My angle of it. Oh, there it is. Right. OK. We're coming into the top into that tributary. Now, you can see the truck, the needle, but I'm off plane. So she's gonna open up the lu in there. I'm not moving right there. I wanna see, I'm gonna aim for her target right there. So I moved laterally and I think right there, I'm in a good position as I enter in. Can you flush that real quick. Just a light little flush. We're going to just flush that again. That's our feedback. It's very challenging. But I think when we flush, we'll be able to see, um, see the tip of the catheter, just light little flush. Ok. That's good. And you see the bubble, so we know where tip is really at the edge of our right where that turn was. So we're in really good position. I'd rather be too far forward than not in the vein. So now we're inserting the maven which has markings on it and the five millimeter tip, I'm anchoring this very firm not to pull back. And I'm really just wanna come in with the maven. You can see it coming in now and I'm gonna go right to that edge and I think that's right where we initially preplanned pretty close. I'm gonna pull back now with the sheath, I'm gonna remove the sheath completely. Very careful not to let the maven come back. It's very lubricious, slippery and it can easily come out if you're not anchoring it. Yeah. So make sure you got dry hands and catheter that we're in good position. I like to note on the skin where we are, you have a number there four on the skin. So it's about, it's just under four and now we're gonna check our distal tip just like we did on the pre and we're gonna try to locate the coil and I could see this many wants to come and point to it, please. So the tip, the plastic tip is right at the junction. Correct, right down there. It's very hard to see it, but it's right there. And 3.5 millimeters from there to, to the coil is the beginning of the coil. So it looks like the coil starts right there. Go ahead and measure that. And that's confirmatory. Yeah. 3.5. We're perfect. So we're very confident that dense white is the beginning is the five millimeter coil. Can you measure the coil itself just to show that we're all on the same page. This is so important to take your time and make sure you know exactly what it is because so I'm gonna put it in there. I'm gonna show I'm pushing it in just to show the coil five millimeter coil. There it is OK. So take that off. So a little pinch here, fill some burn. So you can see my needles perfect. It's going right to the tip and I'm pushing the posterior tibial vein away from my treatment location. Again, I'm gonna pull back before I heat here. I'm a little distal and again, I'm kinda going on all sides of this thing. I'm gonna come back a little bit a lot more just to get this point here. We also want to stay away from the skin is another hazard, five millimeters or greater. Here we go first treatment. So we're getting feedback from the generator. But at the same time, it's important to look at the ultrasound and see if you're getting treatment affect where you think, where you believed it was occurring. So we're exactly where we hoped and thought you could see the e echo density occurring. Often. You'll see a little scintillating or bubbling, boiling of the blood. And this is our second treatment cycle. 22nd cycles. Target is about 100 and 30 °C. You don't feel anything, not a thing. He's enjoying the ride and we're starting to see some echo density, meaning we have treatment effect. We're getting coagulum, we're denuding the endothelium of the vein to destroy it on and create inflammation. So I'm very pleased with this location at the deep and we're well enough away from the posterior tibial vein there. From experience to date. We have, we've been able to inform ourselves about this. We early on in the original study. Um the ID E trial, we worked from one treatment per location to six. We found safety at either one of those uh strategies, but we saw a few pas early on when it was just a one and done uh location. Um I think there are a lot of variables that go into it. Um I believe if you're in the lumen and are absolutely certain, you know, you're gonna deliver the therapy. But uh we've been practicing and recommending up front the six So I'm gonna stop here. We did six. We're gonna recommend six per location up front to get clo the best chance for closure. So I'm gonna be staring down here to pull back five and my and Casey's gonna be looking to see if it matches up what we think on the screen. So here I go, I'm pulling back and that's in the middle of the next one. So we think that's five. You agree? Yeah, there could be, there could, there could be plaques. I'm sorry, there could be slack stored in the catheter. You may not be pulling back. Exactly five. So just kind of be aware of that. You see the poster tibial head flow and you see that's the closed perforator there, you can see it to the top left here where it drained in and we see complete closure uh from the, from the treatments today. And then now I just show the posterior tibial really try to line that out and we have flow. There you go. Now we're really laying it out and it's hard when there's compressed images. So uh do your best. Uh the best is to follow up with these patients. Published December 13, 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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