Non Thermal Non Tumescent Ablation How and When
Non Thermal, Non Tumescent Ablation: How and When To Cool It Down Steve Elias MD Director, Center for Vein Disease Englewood Hospital and Medical Center NJ
Disclosures • Medtronic Inc. – Scientific Advisory Board • Vascular Insights LLC – Scientific Advisory Board • Le. Maitre Vascular – Consultant • Hancock-Jaffe Labs - Consultant
“SO WE BEAT ON, BOATS AGAINST THE CURRENT, BORNE BACK CEASELESSLY INTO THE PAST” F. SCOTT FITZGERALD “THE GREAT GATSBY”
How and When • How has been discussed many times • How can be learned at our hands-on workshops • When is more important now • When to consider NTNT or TT?
EVA: Categories* • TT (Thermal, Tumescent) • NTNT (Non Thermal, Non Tumescent) • TNT (Thermal Non Tumescent) - new • NTT (Non Thermal Tumescent) - new *Elias S. Emerging Endovenous Technologies. Endovasc Today. March 2014.
Thermal Tumescent: TT • Laser – HSLW, WSLW, radial/jacketed • Radiofrequency – Closurefast, RFITT • Steam – SVS, Veneti
Non Thermal, Non Tumescent: NTNT • Mechanical Occlusion Chemical Assisted – Vascular Insights LLC • Cyanoacrylate glue – Medtronic Inc • Polidocanol Injectable Microfoam – BTG • V Block – VVT Medical
ADVANTAGES DISADVANTAGES No foreign body left Longest follow up of all NTNT Tortuous veins – angled wire Perforators – PAPS 60, 000 cases worldwide * Only one with a code Need to pullback/inject simultaneously Longest learning curve Compression 5 days Segmental ablation Pullback rate variable eliminated Second longest follow up # cases in hundreds No post procedure compression Perforators – PAPS ? Foreign body left Phlebitic reaction Tortuous veins - difficult V BAS Pullback rate variable eliminated Uses approved liquid or foam sclerosant # cases <100 Foreign body left Shortest follow up Smallest number treated Tortuous veins - difficult Compression 7 days PEM Pullback rate variable eliminated Tortuous veins – foam traverses Treat branch varicosities, PPV Requires 2 people for procedure IFU – 2 weeks compression Not indicated for SSV Need 3 pts within 1 week/1 month MOCA CAE
NTNT – Recent Literature • • They all work with similar safety/efficacy They all improve Qo. L NTNT non inferior to TT NTNT probably less discomfort during/after MOCA – Dedicated code and valuation PEM – some carriers have on policy (not Medicare) CAE – self pay currently Successful EVA helps patients
Should We Do This? • SVS/AVF Guidelines – 1 B recommendation for EVA, compression if not a candidate for EVA • NICE Guidelines (UK): EVA Foam Surgery Stockings • Good data based on: efficacy, safety and Qo. L • A closed/ablated superficial axial vein is good no matter how it is accomplished
What’s In A Name? It is not really about the name of the vein Technique and technology choices depends on: • • Size – small, medium, large Length – short, long Location – AK, BK, Suprafascial The Neighbors – nerves, skin, LDS or ulcer Disease state – C 5, C 6, SVT Patient type – fat, thin, anxious Special – MD, MD spouse, friend, foe, barrister
Rules To Live By: When Deciding What To Use When • Treat to lowest point of incompetence • Use whatever is “safest” to achieve above • Consider cost – to patient and health care system • Tailor technique/technology to the clinical setting • Need to have TT and NTNT in armamentarium
Size, Length, Tortuosity • Size – Large >12 mm, Medium 5 -10 mm, Small <5 mm – Large – TT before NTNT – Medium – NTNT before TT or dealers choice – Small – NTNT or Should you be doing this? • Length – Long – anything, Short – cost CAE, PEM - expensive MOCA/RF/Laser - good • Tortuosity – PEM, MOCA then others (guidewires)
Location: AK or BK (Nerves) • AK – GSV, AAGSV, Intersaphenous (Giacomini) • BK – GSV, SSV, PPV, VV • AK – anything as long as it is in fascia and straight • BK – GSV/SSV – NTNT>TT, VV – PEM, Phlebec • PPV – Laser>MOCA> Foam (artery) CAE?
BK GSV – Saphenous Nerve
Sural Nerve
Proximal Nerves: Tibial/Peroneal
LOCATION: Fascial/Suprafascial • AK Fascial – anything • BK GSV and SSV – NTNT (MOCA>PEM>CAE) before TT • Suprafascial – MOCA> Inversion stripping> PEM> TT (skin/cord, hyperpig)>CAE(phlebitis)
ADVANCED DISEASE STATE: C 4 -6 • C 5, C 6 – AK GSV to mid calf – TT/NTNT • C 5, C 6 – GSV/SSV to ankle – NTNT (LDS or ulcer difficult tumescence) • C 5, C 6 – BK GSV residual – retrograde NTNT and foam ulcer bed (MOCA/PEM) • Previous SVT – TT – need more energy
BK GSV
BK C 5, C 6
PATIENT TYPE • Fat – TT over NTNT • Thin – NTNT over TT • Anxious, Nervous – NTNT over TT
SPECIAL SCENARIOS • MD or Spouse – RF, MOCA • Friend – RF, WSLW (1470), MOCA • Foe – HSLW (810/980) or stripping • Attorney/Barrister – 810/980 with 150 joules/cm and no tumescence
ANTICOAGULATION • INR 2. 0 – 2. 5 – anything • INR > 2. 5 – TT • Rarely stop it
RETREATMENT AFTER FAILED EVA If used NTNT > use TT If used TT > use alternate TT If TT fails > inversion stripping with tumescence
CONCLUSIONS • Need one TT and one NTNT • More advanced disease, the lower to go -NTNT • Tailor the technique to the situation • All veins are not the same – either by name but more importantly by size, location, disease state
TREATMENT OF REFLUX IN THE SUPERFICIAL VEINS TREATMENT OF PATIENTS WITH REFLUX IN THEIR VEINS
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