Chapters Transcript Video Right SSV Ablation with Venclose™ RF Ablation Catheter Featuring: Dr. Jeffrey Carr; Duration: 18:00 minutes He has a 69 year old man who has ischemic cardiomyopathy and peripheral vascular disease that's very stable. Uh He does not have any significant p ad in terms of claudication but does have some proven disease below the knee. He presented to me uh complaining of many years if not decades of heaviness and tiredness, fatigue in his legs. He's had cramping and restless legs along with a lot of itching. Uh He has swelling in his legs as well. We did a duplex ultrasound, a venous duplex, ultrasound of his legs uh several months ago, confirming pathologic bilateral great and small sass vein reflux. He has already undergone uh radiofrequency ablation with the Venlo device of bilateral great uh sinus veins and now returns today uh to take on his right small sahan vein uh on the ultrasound. The size the diameter of his right small sinus was 5.1 millimeters and it displayed 2, 2742 milliseconds of reflux. He had no deep vein thrombosis and he did have a perforator and a tributary that had reflux that we are not planning on treating today, but, but discovered and we know about. He has sep four disease and a V CS S score of 10. And we will begin by touring you through the ultrasound anatomy. Uh One of the most important things we do after we prep a patient is we tour through the anatomy with the ultrasound for several reasons. One is to identify the course of the vein to see if there are any an atomic variants. Um but also to see if there's any interval changes from our diagnostic ultrasound. And as you can see on the ultrasound, it's very straightforward. There's a small sinus vein in the center of the screen. It's encompassed by fascia, uh the superficial and deep fascia. Um It has that kind of classic uh cleopatra's eye appearance right there, that Casey's showing you and this is the small Sahan. We also want to look for the deep veins. So Casey show us uh how uh the deep veins look first to make sure we don't have any deep vein thrombosis. So I just do a quick compression of the vein to make sure that there's no obstruction. And you can see the popliteal vein that she's compressing midway through the ultrasound there in the middle of the field, it compresses nicely. So no indication of a of a fresh interval thrombus. And so I'm going to give a little bit of a wheel here. It's hard to see with the gel and you wanna be careful when you're numbing the leg that you don't induce spasm right at the spot where you wanna enter. And you can see I'm just going pretty slow. Um So that I don't go too deep and get into the vein itself. It is there, these veins are very uh vaso reactive and so they can, you can induce spasm quite readily. So then I have the introducer needle, there's an indicator showing the bevel up um on this. And so we always want the bevel up to help uh advance the wire in. I want to put my probe in the ultrasound. And the image of the target of that small Sahan is directly in the middle of the field because then I'll pick right in the middle of the probe and use a 45 degree angle for my approach in. And so I've got it numb, I'm gonna kind of stab through the skin. And as you see on the ultrasound, I'm trying to poking through on the front wall of the small Sains. And I'm intentionally just showing this to you where I like to have the needle right in the middle of the bo the circle. If you will the globe, if you're off to the side, it can bounce off. But you can see I'm really well positioned here and then I just make a quick little stab like that as I aspirate and to see if I am through and I don't have return. So I think there's catching the front wall a little bit and now I did and that's a little, that's an instructive uh point there you could see on the ultrasound, it looks perfect, but it's actually was grabbing the front wall of the endothelium of the vein. I have, I looked to see if I have confirmation of Venus return and I do and then bring in the wire, go ahead and look at it and I, this is a, a tactile and a visual way of knowing if I'm in the center of the vein. And you can see I'm advancing, it, it feels very smooth. I have no resistance. And Casey is scanning up following me as I go. We like to do that routinely to watch where the wire goes because often it may divert off the off path into a side branch, uh four by four. OK. So then we take the introducer needle out. I like to make a small little incision for cosmesis. So it can heal very uh very well. Don't have to. And then we thread the micro introducer sheath um over the wire and into the wing. It's good practice to make sure you can aspirate and flush you can if it's a small vein and there's spasm on the vein, it may be very difficult to, to, to aspirate back. But you can see it's pretty easy to flush the catheter and we know we're intraluminal and she hands off the device to me and you can see the, the catheter is a six French catheter that has a natural curve, um which is very helpful as you negotiate through anatomy. You do don't typically have to shape this at all. Um And of course, we have a 10 centimeter uh heating element and coil and three divisions that mark off 2.5 centimeters which we'll get to about converting this to the distal tip function. There's a warning track here. I call it with X's uh at 2.5 centimeters and another with lines to show that you're getting near the end when you're inside the body. So these are very important markers uh to, to know and then we have this the, the back end markers that match to the length of the sheath. Um So that when it exits here, you'll know where the proximal end of the coil is positioned in the vein. So we put the catheter into the vein. And again, we like to watch the, the transfer I'm feeling and I actually found some resistance pretty early on here. And I'm gonna, I just torqued the catheter because of the shape and it's just nicely got past that little resistance that might have been a valve or a side branch and it just slipped in right past that. So it's important not to just ram this through uh to kind of feel and have that tactile uh response here. So, you know, if there are any barriers to transmission. So Casey has positioned the ultrasound right at the mid papa space. We know that our termination is a probably a deep vein, the femoral vein where it's going down. Um And so we're bringing this back and we want to demonstrate now on ultrasound that we know exactly where the sheath where the um the device tip is. And this is a very nice demonstration on ultrasound where you will see the echo density, the linear echo density, you can actually see portions of the coil. Um there's the tip and you see where it almost looks like two with that, that extra density there, we know that's the tip. One of the I the tips here is to move your and jiggle the catheter gently. And you can prove to yourself in the stenographer uh that the tip is where you think it is and we actually have. So this is in, in perfect position. Um And we're gonna, I'd like to index once I know it's in position. I like to look at the next marker here and I will anchor the catheter in my hand and pull the sheet back right to that marker. And then I know that's my start point for my Pullbacks. The next stage is to administer the two me to miss anesthesia is um hanging in the bag on the IV pole. And this is a mixture of, for us, we use R ringers lactate. Uh We use epinephrine and we use lidocaine that is administered around the vein to anesthetize it and also protect it from surrounding structures. So here I come in, I'm gonna enter in where it's already numb on the skin. On the first wheel. I have it bevel up. I'm putting my ultrasound uh or probe in the sagittal view, laying out the catheter and the vein. And you can see as I'm working, working through here with the pedal administering the TSC which shows up black on the ultrasound, the fluids the water in it will be very, very echolucent. So it's dark, it's a fluid and you can see me pushing down the vein um and pushing it away from the skin. We want to keep a safety distance all the way through the treatment away from the skin of at least five millimeters. I'm sorry, at least a centimeter. The and we are at the tip and you could see that nice shadowing, you know, the tip because of the, you see these three shadows, acoustic shadows and that's really tell tale uh to know that that's the cat, the coil. Um Again, he this imaging is very good, but other patients might have a lot of fibrosis and is very easily to be fooled and you really vital that you know exactly where your catheter tip is when you're in my history in the heat. So we wanna move pretty quickly once we have the two essence in just so it doesn't dissipate. And it's very important to triple check your position at the top and where you're gonna be initiating because you might have inadvertently pushed the catheter in the patient moved. And you certainly, uh, you know, you can't turn back once you hit the button, you're, you're heating. So I'm just gonna jiggle a little bit. I always confirm with my sonographer, uh, so that we have um two opinions on that. And if we disagree, we have to convince each other where the tip is. So it's vital. We see that marker. We're very confident we're in perfect position. And now I'm gonna take um the handle and gonna activate uh the van close. And so I push the button and we see very quickly the heat uh is heating up within five seconds. The target is 100 and 20 °C. There's an algorithm to maintain that temperature, uh varying the energy that is being delivered uh to the coil and there are 22nd cycles. And so we're gonna treat twice at the uh first location uh for both the small sins and we do the same usually uh at the Great Gray saps as well. So that's our second 22nd treatment cycle. And now we're gonna pull back and do a tandem treatment. And so I have my marker here. And so that's my start point. I'm gonna use the hub to help me that's one. So that's 2.5 centimeters, five centimeters 7.5 and 10. So that's the length of the coil. And now this is tandem and we're also right at the end, it happened to work out perfectly that this is where the end of the sheath, um is a safety distance away from the beginning of the coil. So you're not heating the sheath. We also like to watch the ultrasound to show that we're seeing treatment effect. We see scintillating or bubbling if you will or boiling of the blood uh to know that we're delivering the energy. So several different ways of getting feedback that you're delivering um the treatment. So I'm gonna pull back again because we treated that and we did 1234, that's 10. So that's the same. And now it's very important as you get past this warning track that you don't treat without seeing your coil. So I like to anchor the catheter and then pull the sheath out of the body without moving the catheters without moving the catheter position. So now I have the sheath out of the body and I see the, the other uh warning landmarks and I have the double X. So I know that the end of the catheter is right here. It's very, very close. And so that's too far down to treat because we know we start getting approximating the sural nerve branches in this area and it is very close quarters to muscles and tendons. Uh even though we did transmission. So typically we like to terminate on a small Sahan just cepal add to that bifurcation of the gas truck and away from that seal nerve that I was demonstrating to you earlier. So we're gonna switch the catheter and do one more because this is right just above where we saw the sural nerve and we can verify here with the ultrasound. And so Karina is gonna switch the catheter and just a simple put uh push of the screen, you can see it went from a 10 centimeter co uh co treatment length to 2.5 centimeters. And we have an audible feedback where the tone changes to know that is doing that. Um I like to hold my hand if I see the coil out of the skin, I put my hand there so that it will burn my hand if there's a malfunction or we didn't hit the button. I just use that as a safety precaution. Um And then we activate it. Once we're certain about this, it will still deliver the 22nd treatment, but you can hear the pitch uh from the generator is at a higher level. Um And we can also see that we're just having on ultrasound, the 2.5 centimeter treatment length right at the distal tip of the catheter. So the decision to be made now is if we're done or we want to do one more. I'm anchoring this again. So I have a landmark. So I know exactly how much I'm pulling back and I'm gonna pull back one more 2.5 centimeters right to there. Now, as you can see the coil is outside the skin, it's outside the body again. If we were on the 10 and didn't switch, we would be burning a hole at the skin, uh, not advised. And so we uh also know that we switched it to 2.5 and we're down a little lower here. And so this is where um it's just above that area, the seal nerve and we wanna stay a safety distance away. And so I believe we will stop here uh again, to preserve a safety for that seal nerve. So I'm gonna take this out and simply put pressure on the entrance site and we're done. So the color is on right now. So if we had patency of the vein and we would see a little ribbon of flow, it's not unusual to see that uh whether you're treating a great or small sinus vein. Um because we, we take out the device, the tool, there's a little void where the catheter was. Um And without a lot of pressure, you might see a little patency um as it's as immediately afterwards, I don't be surprised by that. Um If you given the treatment and the therapy you're creating the intense inflammation and injury to the wall and over time that's gonna fibrose and certainly with thrombose in the near term, it looks great. Ok. Published December 13, 2024 Created by Related Presenters Jeffrey Carr, MD, FACC, FSCAI Interventional Cardiology, Cardiovascular Disease, Internal MedicineCHRISTUS Trinity Clinic View full profile
Content on this site is intended for United States Healthcare Professionals Only