Chapters Transcript Video Superficial Venous Treatment and Clinical Outcomes Back to Symposium So again thank you very much we look forward to a great day of education we're gonna start this morning with Doctor Erin Murphy superficial venous treatment and clinical outcomes. Green button. Thank you. Alright, good morning, everybody. Uh, you're a bit late, so actually he's wrong. You don't get lunch. Um, no kidding, um, we're, we're gonna start off with, um, superficial venous disease this morning and then transition pretty quickly into deep venous disease. Um, I'm gonna start off with an overview. We're gonna go through some cases after and see how, you know, we can apply these and hopefully pick up some tips and tricks. So, um, we have multiple options for our patients with superficial disease, um, some with more data than others and more history than others, um, so again, a quick overview here just to get us started, um, the, the treatment options that we have are divided, um, between those that are used regularly for axial closure and those that are just adjunctive procedures. So the ones above the line, uh, the blue, the navy blue line are our definite, you know, and. Selective axial closure procedures. So thermal ablation, RFA, EVLT, we have our non-tumescent, non-thermal closure, which is cyanoacrylate, and then we have MCA and claravene, which is clara vein on the other side, followed by our varahena chemical ablation, which are more selectively used. Um, below that adjunctive, it's either concomitant or staged phlebectomy, sclerotherapy, ultrasound guided sclerotherapy, um, and of course our conservative measures. So we're gonna go through these briefly RFA EVLT, um, this is endothermal, you know, injury from heat which causes fibrosis and venous closure. This is the longest track record we have, um, a lot of data on this. We've used it for many years. It's predictable. Um, it does require tumescent, but I will tell you, I don't know how many of you have had tumescent now that I've had it, I'm a little less sympathetic, uh, because it's really not so bad, um, and then, but there is some discomfort with it. There is a risk of nerve injury. With this, so that's real. So, um, if you, we may talk about it in some of the other, uh, discussions, but if you have, um, you're treating the SSB, I always find the nerve. Um, you wanna stay above the nerve and make sure you have a good distance between that and the vein you're, you're, um, treating for the GSB. I don't go below midcalf. Um, this is best suited for locations above the nerve, um, and for patients who can tolerate needle sticks and those who have large diameter veins, this is probably your best treatment option. They have shown kind of over and over in multiple trials that RFA and EVLT have pretty similar outcomes. Um, the one that I wanted to point out that the only one that's really different is, um, this review that was done. They said, well, maybe laser might have a little bit higher efficiency. It was about 3% higher, um. But these patients have um a little bit prolonged recovery. They have more bruising. If you use the technology, you can kind of feel the vein, you know, burst, um, which causes some of that bruising and postoperative pain after they are subtle differences. Both do work. Um, the next definitive closure option is venous cele. This one has been a bit controversial, um, you know, in the recent years just because it has a different set of complications than we're used to handling. Um, but basically you're putting the catheter up, you're inserting liquids of glue, uh, holding pressure, and then going to the next segment and gluing the vein closed. Um, there are some advantages to this that you don't have needle sticks, that you don't need to mess in. The patient can just get up and go. You don't need to wrap their leg. There's no compression. Um, but the risks are real and they can be uncomfortable to deal with, um, and they're a little bit unpredictable. Uh, you can have phlebitis-like reactions more commonly. You can have foreign body reactions. Um, there is definitely a higher cost, um, and we don't have really long term data. They're kind of sorting through that still and trying to, to get some review data out there. Um, this is good for needle stick. patients, you wanna make sure the vein's deep enough that you are, um, that you're not going to feel the cord because it is a permanent implant. So patients who have, you know, your older patients who are needle stick afraid but have really thin skin and it's right under the skin, you're gonna feel that vein. You need to tell them that or not use this, um, and, uh, again, long straight veins, you do have to get that catheter all the way up. Um, the closure rates for this are pretty good. The, uh, VClose trial showed 1 year, 97%, um, was not inferior to RFA. They had similar clinical improvements in this and the 5 year extension, which also showed non-inferiority to RFA, but also there was not, it was not a superiority, uh, outcome. Um, so for our selective closures, Verena is the one that people use more often. Again, no heat, no temescent, minimal discomfort, but closure rates are a little bit more variable. You may have to treat more than once, um, again, because you're injecting something into the vein. Blood's not always properly displaced. You can wind up with some phlebitis. You can have some post-op pain. This is good for residual recurrent disease. This is good for like your tortuous ASV that you can't get a straight catheter through, um, or for stage treatment below the knee where you're having it, you're using it adjunctively to your RFA because you want to treat that small segment that's below, uh, closer to the nerve. Vanish one and vanish two trials, um, showed that there is consistent improvement in the patient's outcomes. Um, vanish one. So a 75% closure with one treatment vanished too. It was higher, 85%, but with two treatments, so not quite as high as we're seeing with our thermals or the cyanoacrylate, um, but the outcomes are relatively safe. They're effective, um, in certain pop in populations. I would not use this in extremely large veins. Um, MCA is our other option. Has anyone here used it? OK, yeah, a couple, um, so it's not super common and they've also had some reimbursement issues, I think when they originally coded, um, but it is another non-thermal, non-sumescent it is a bit operator dependent for your outcomes, um, it does have lower long term closure rates that are pretty well established when you're looking at the tech. Technology across the board you can see roughly they're, they're similar when you're looking at those definitive closures across the top with RFA EV uh UVLT, um, the standard acrylate. The ones at the bottom a little bit more unpredictable, which is why I said they're more, uh, used selectively. Um, the AVF guidelines, basically what we're looking at the 4.1s categories here say that they recommend endothermal ablations over, uh, stripping in all of these cases. Um, when you're getting into the 4.2s, I think those are the, uh, yeah, so using the thermals above the nerve, uh, so an SSV above the nerve and that GSV above, um, the calf, um, and then, you know, basically the. They're all kind of what we just talked about. We're getting into the fives where, um, yeah, the below knee segments, then treating those preferentially with non-thermal, the one that were close to the, uh, close to the nerve. Um, ESBS made kind of a nice, uh, decision making tree. They prioritized for the truncal veins using the, um, endothermal therapies the. It is a class 1 recommendation. Class 2 recommendations were actually high ligation and stripping, which they still do a bunch, um, and the satin acrylate and using the others as a, uh, class 2B. Um, phlebectomies can be done with or, uh, in a staged fashion. The cost-effectiveness trial done by Davies I thought was interesting. Um, he, because he found not only that EVLT and RFA were the only cost effective options in that system, but, um, also that in the list of non cost effective included conservative care. Um, it also included, uh, stripping, so, um, they recommend, um, that symptomatic varicose veins are treated, uh, as a cost saving measure. So in summary, when you're looking at your where your hit points are, the highest closures are with your thermals and your standard acrylate. Your least discomfort is with the non-thermals. Most durable, most data is probably with RFA, um, and your complex anatomy, um, more the chemical ablations we can't get our catheters through, um, but match your needs to your patient. But I would say that for my practice and for most practices, RFA is the cornerstone. It's predictable. It's where we have our consistently safest, highest results. Um, and, and can tell the patient what to expect and stand by it, um, with that, uh, Venclose is the newest RFA technology. There was a long period of time where there really wasn't any innovation in this, um, which is surprising for how many we do, and, um, this is 6 French. It's, it's, it's more agile. It's, um, a little bit more flexible. It has a little bend on the tip if you've not used it. And so between pressing on the tissue and turning it, you can get through a lot of it without a wire and through the valves if there are any. Um, it has dual heating elements, so you can either treat 2.5 centimeter segments or 10 centimeter segments with the same catheter. Um, you just have to, you know, press, press the button to change it between the two. So if you have an ASV and a GSV and you want to treat one with a 2.5, 1 with a 10, you can do that. The postmarket trial had 7 sites that include 100 patients, um, in the GSV and SSV cohort. This was a prospective multi-center trial. The, uh, briefly with the results, the occlusion rate was 95%. The, uh, primary safety endpoint, there was no DVT or PE at that one month point. You can see there's improvement and, uh, baseline to mean, um, one week and one month VCSS scores and also. So in the quality of life measure, um, freedom for recantalization 100%, um, and there was one case of a E hit. Um, so in summary, this was, you know, safe device. It, it, it does have some technical improvements over prior generations. It's, it is my preferred, um, RFA catheter now. The, um, one other catheter to be aware of with this device is the Maven catheter. Has anybody used this one? Yeah, OK, um, I actually, you know, the older RFA, um, stylettes were very, you know, stiff, difficult to use. This is an RFA for perforators that, um, uses the same units. You don't need any other capital equipment. Has a 0.5 centimeter heating element that's 0.5 from the tip, so you stay 1 centimeter back from your deep vein. Um, and I can show you just briefly. This is the picture on the, uh, left side of your screen is the sheet that I put in. You go into Longview. This took me a couple of cases to get used to. Once I got used to it, it's, it's pretty straightforward technique. Um, and then the middle is the catheter with some. Messing around it after removing the sheath, and then you're going to treat 6 cycles, uh, pull it back 0.5, 6 cycles, pull it back 0.5. Ideally, you're going to treat below, at above fascia if the distance from the deep vein allows you to do so. Um, but I've had really good results with this. Published Created by
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