In this interactive case, Dr. Jeffrey Carr demonstrates left great saphenous vein ablation using the Venclose™ RF Ablation Catheter. This case highlights a superficial, extra-fascial segment of the left GSV, requiring careful technique to ensure safe and effective treatment. The video also demonstrates tumescent anesthesia administration to support optimal vein compression and thermal protection, along with key procedural steps, access strategy, and energy delivery considerations.
Uh, but we have, uh, here who's, and, um, I, I treated. Uh, right grade saphenous vein just a few days ago on Friday, and he's back for the left. You've been having a lot of problems with your legs, right? Um, I think you mentioned to me that you're stumbling even in your house because of this, the heaviness in the legs and the aching, itching, tiredness, fatigue, restless legs, right? And some cramping at night, and you've worn the hose, it's not getting better, um, and that's leading to our treatment today. Excuse me. So we have a left right saphenous vein and also it's gonna tour us through that. I'll go ahead and get ready. And uh we also have some below the knee tributaries we'll look at. But the GSV is our main uh goal for, for now. So here's the great saphenous vein, and we're kind of the mid lower leg here and you see it runs in the fascia. In the esophagus fascia, it does, does that split there? There's a little, um, well, I think there's a small split in the small, uh, perforator. OK. And then as it comes up to the left there, does it stay in the fascia all the way? Uh, no. It just gets really. It exits. It exits and it stays on. And it. Superficial. Actually this is a pretty good case, although many of you, most of you are performing these treatments already in the great Saphanus, um, again. Uh, you can get varying anatomy that makes, makes things a little more challenging, and you think through how you approach because we have a lot of different options. I'm gonna go ahead and get access here just to kind of speed things along. He does have C4C disease. He's got hyperpigmentation down here. Uh, can you zoom in on that Scott down at that ankle? So, and he's got corona phlebicstatica, uh, going on at the ankles a little bit. Uh, but mostly his symptoms, he's got edema, and we're gonna, I like to say, find the most distal location for your access that's favorable to you. And again, you don't have to treat this low, and certainly we wanna be careful when we're doing thermal ablation this low down in the leg to avoid nerve injury, but here's a good spot you're gonna feel a bee sting, a pinching or some burning here. But access is not necessarily where you end treatment, so we have plenty of options, but as we all know, access is key, uh, for a successful procedure here. And sometimes the most challenging, usually the most challenging part of it. So, um, I'm gonna, what I like to do on these is really put it right in the center and you see me with my needle, I'm a little off plane instead of being vertical, but I like to go right to the center of the. Of the vein is before I commit fully and I jab at it, poke right to get through the front wall, often go through the back wall and pull back, but no big deal, usually with a great, let's see here. I'm a little resistant, so I'm probably grabbing that back wall. You see, I'm going fast, but I'm really, really, um, not coming in with my needle vertical, um, but let's see, I am on the back wall. Show me that a little bit more there, the needle tip. And maybe the side, so I'm just gonna pull back and reorient as I'm just kind of feeling. The needle and I'm getting like everything else, and everybody else, I got some spasm. And now I'm through. I pulled back further. I kept hugging that back wall and just feeling that tactile feedback and the visual feedback, and I like to also see the course of that wire, did it go up into that, you know, side branch or a perforator go down to the deep system. OK, just kind of grabbing, grabbing some of that skin, but fortunately it's numb. You don't feel that, right? Great. OK, so we've got the 10 centimeter. Coil And the then closed the devices. Talk to me. Sorry. Oh, I was just moving your hand back. It wasn't coming in. Sorry, OK. And um. I'd like to follow this up too with ultrasound. And one, it can just veer off path again and go down a perforator and through the deep vein, the femoral vein, and back out of a up a perforator, and then you'd be ablating a femoral vein, which you never wanna do. And if you just do it the same way every time, you just minimize some of this variant anatomy and mistakes. Um, so we're going up all the way to the groin here. And we're ready for tumescence. So this is the first check of of positioning the catheter. um, you can see at the left is the common femoral vein, the sainofemoral junction. Uh, right the lower left where that great saphenous joints, and you see the superficial epigastric vein coming in right there, the little blue, right there, the circular blue area is the superficial epigastric vein. You see it enters in and drains really close to the SPJ or SFJ staphenofemoral junction, and my catheter is right to it. So I'm going to pull back from the IFU on this device says 2 to 3 centimeters from the SFJ. But I use the epigastric vein as my landmark. Um, and I like because I just really wanna make sure I'm not flirting with that edge there, so I'll come back 2 to 3 centimeters from the saphenofemoral, I'm sorry, from the superficial epigastric vein. I'm kind of on the high side of 3 there. On larger patients, I'll probably, uh, come back even a little further, uh, because it's very hard to get compression afterwards for them, um, and I just, I just think there's more of a risk for some propagation. And uh a potential for EI. Get the bubbles out. We're good. OK, so we're just trying to move along as quickly as we can now. Um, but acknowledging that this, usually when you have this variant anatomy where the great saphenous will course outside of the saphenous space, it could be pretty challenging putting the tumescence in and really keeping it a good 1 centimeter away from the skin and other vital structures. So. Um, What I like to do on these first, especially when they're coming up this close to the skin, is really see, make sure I can push it down. Nathan, you were talking about that on the other case of going above it first, right? You, you like, we like to go, you see that just under the dermis, and that's a better look at it now. And this is where it exits. You see that the catheters coming out of the sap of space, so it's now right about here it's running right under the dermis, but I'm getting good deflection there and pushing away from the skin. You see on the right of the screen, the grid is 1 centimeter for the ultrasound, and we like to make sure when we're burning that we're 1 centimeter or greater away from that dermis. And so we'll double check that. Let's just keep moving along here so we can. Get this all covered first, and then we'll come back and I, I like to do touch-ups, uh, as needed. If I start seeing rebounding, where that tumescence just dissolve, you know, diffuses away uh from this because there's nothing to contain it in, in the superficial area, superficial compartment outside of the saphenous space. Um, You're doing OK? Great. We're moving along. We'll be done before long here. Now you can see that it's right up against the dermis there. And so I'm gonna try to separate it. Um, I, I like to go up sagittal when I'm with my great small snaus. I'd like to see how far I can go with one needle insertion, because of course we all know the needle sticks are the most uncomfortable for this procedure for patients. And so the fewer needle sticks I get or I do, I think I'm more successful, you know, for the patient's sake, um. My partner started out going transverse. He he liked to see go in the south of space. There's nothing wrong with that, Nathan. What do you do? Do you go up sagual longitudinal, or do you go up transverse plane here when you're delivering here it's more satisfying going that way. You go this way, yeah, yeah, yeah. I think it's more efficient too. You know, it's, it's easier to hit the spot in a transverse plane where you're gonna ride around the catheter. But it's easy to get. A little deeper superficial, and you're not going to be really getting it to travel all the way up cephalide like this. So we're getting, Close to the end here and it's really traversing nicely. I still think we're, we're pretty close to the skin. So is this some, is this a case you would use this device with or would you go with a non-thermal, an NTNT device, Nathan, for here? I do non-thermal, but you know, it just depends, right? Right. Yeah, there's nothing, there's no, there's not a right answer in. It's good to have multiple tools in your toolbox. But there's a lot of different ways of doing this safely with a good outcome, and so. Um you're getting a really good dissection. Are you using a spinal needle? Um-hum. No, not a spinal needle, just a regular. Comes in a pack. Comes in a pack. OK. And we're gonna get right, right, thank you. Right on top of that, we need to get that posterior wall a little better. There we go. And actually you can see the wall of the vein there. If you see right around the catheter, the catheter is the linear white, and we're getting into the coil real soon here, but you can actually see the vein wall. The imaging is really good. He's very thin up here, so it's nice, and we get this. See that you see some of that, the corrugations or that coil that um so we know we're in that heating coil area. I'm gonna go a little more posterior here. And let me try, I just exceeded my wingspan, so I'm gonna swing, swing around here. Excuse me, and we'll finish off with the. Very important tip. Right up in here. And another pinch And I'm getting below it first. And I'll finish off above it. You can see I'm going to go with the needle past the tip, even though the heat is transferred conductively in a radial fashion or axial manner, you still can get forward transmission of heat from the tip itself. And I found that, especially up in here where you get the natural bend in the great saphenous, if you're poking right into that, that bend and you don't cover the tip, that's where the patients will say, ouch. Or more. Um, and so I like to do what I call tip coverage, really good tip coverage, like you're bullnosing a countertop, you go past it to make sure you get it past it. So I take a little extra, just a little extra time. And then I double check it all in a transverse plane. You can see I'm coming really close. I rebounded here and I'm really close to the skin. It's underneath that centimeter, so I would not burn in that area. But down in here, variable, I'm going to have to do several touchups. So I'm going to reserve a lot. I'm gonna just do maybe to mid-thigh so we can go and then I'll stop and pause and I'll do some touch up with the teescence. So right in this area, we wanna touch that up. I'll do this in a transverse plane. Sorry about the, the dizziness on that holding the probe here, um, because now I'm pushing it back down now to our centimeter safety distance all the way up. So I'm just gonna get on this right here and then we're gonna stop. Here and just kind of work our way back down as it rebounds. Let's get on it and so we're gonna triple check the top here to make sure we're that 2 to 3 centimeters away. Real fast if we can because I know now that temeinide delivers just diffusing out you measure you can see the top markers are centimeters, so we're nearly 4 so I'm gonna start it here you feel any burning, OK? Let us know if it burns. If you feel any heat or burning. Let us know. All right. Feel anything? You good? I'm good. Awesome. Going to do a double treat here. This is a convention. Um, we know that there's patency of a great saphenous vein, it's most likely near the saphenofemoral junction, most likely location. And I'm gonna pull back 10 centimeters here with 1234, and double check to make sure we're not within a centimeter. One of the tips also is that, you know, just from the pressure on the ultrasound, you can force the skin within that centimeter. You can see we're over 1 centimeter, so we're totally safe in this location. But if Ossi was really pushing hard on that, we would get within that 1 centimeter and it's all about distance when it comes to the thermocline I like to call it, just one treatment here, pulling back another 10. And let's double check to be is this safe to do? Remember this is the area I touched up. What if you let one thing you can do is let off on it and see if it drops down. Go ahead, let off, let off all the way. It dropped. It dropped past 1 centimeter. So I'm actually gonna blindly just treat this without using the ultrasound because I want to protect that 1 centimeter margin. OK, now this next area, we're probably gonna go ahead and take a look. I'm gonna pull back now. 1234, that's 10 centimeters. We have a centimeter, we need to do some touch-ups. I think we need to do a little touch up, that's a little too close for my comfort level as it rebounds again up in here, let's see, where's the tip? Where's the tip of the catheter? That's treated, right? So that's tip. So we're just under 1 centimeter. We'll just go right above it again. And just do some touchups to push that back down. There we go. Now you can see, you can see I'm pushing the catheter back down more than 1 centimeter. There's the tip of the cat. Oh, this is the coil right close up here actually. It's up higher in it. Yeah, yeah, I think that's the coil. Yeah, you can get a little confused, the coil, so you're not sure you can jiggle the catheter or 1 centimeter there. We have already pulled back. I'm gonna do treatment here. We're gonna keep that handy. We might have to just do this all the way down. Nothing wrong with electing to do a non-thermal technique here. But I've had really good success even with thermals with these kind of variant anatomies where they're really close to the skin and of course. Uh, we're gonna pull back 1234. That's 10 centimeters. We're gonna touch up down here. Where do you think it is right there? Oh, it came back pretty far, huh? We're already at the knee. Yeah, we're already down near the knee. And remember, this is kind of that last part where it was really near the surface and you can see it rebounded again. So I'm gonna. And push it away again. I could get on a plane. There we go. All right, we're past the centimeters. See that there? There's the tip. You know it's the tip because of that double line. That's a great illustration of that plastic termination portion there on this larger catheter. You always see the double. You know it's not the coil, but it's the plastic tip. Um, No Well, the polymer tip, I should say more. Medical and just gonna give that extra, extra boost we're gonna treat here. be. Um, even though I'm protecting it, I'm very confident that we're not gonna cause a direct thermal injury to the skin in this situation because I've deflected away enough. When all the tumesin wears off and now you've got a rebounded natural position of the great saphenous, it's gonna heal. And the healing is gonna bring in a ton of inflammatory, a lot of inflammation, 2341234, and my warning track, I'm gonna index that catheter back. This is about mid-cap where I said I was gonna stop. Um, so I think, and we're in the saphenous space. I'm gonna go here. I think we're still safe enough away from those saphenous branches and just even give another little touch up here because it's taken me a little while, you can see now I'm getting really good temescence around this again. Act as a A heat sink for the energy, but also to protect the adjacent structures and we're really not gonna go this low, but I'm just gonna. Just be extra cautious. It's hard to deliver with one bag, it's, it's kind of impossible to get too much to me in my view. And so, um, I'm gonna treat this as my last location. Doing OK? So I'm, I'm treating to right about here. In my termination spot. One of the things that's off label that I've done too, if I'm really close to something, I might, I'd shorten my treatment cycle. If I'm worried Are you feeling something? OK, and then we're gonna take this out. jerking. Oh, you're jerking. OK, he's jerking. Just some my clonic jerks or something. So we're done with the ablation.
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