In this interactive case, Dr. Lina Vargas demonstrates left great saphenous vein ablation using the Venclose™ RF Ablation Catheter. This case highlights a straightforward procedural approach with sheath-based access to the target vein.
OK, so it's a beautiful junction. You saw that Mickey Mouse. Everyone's familiar with Mickey Mouse. OK, so one thing we wanted to look at though on this one is that that inferior epigastric. Because there's definitely uh some, you know, like it's there's a little bit of variability as far as like the distance we talk about 2 to 3 centimeters from the junction some people want to like on purpose leave that um inferior epigastric patent, right? So you know, most times I find that obviously there's a lot of variation as far as the anatomy, but in most people I think I don't worry too much about it because um. A lot of times it'll be within those 2.5 centimeters so I don't look for it on purpose, but it's something that is worth mentioning and so on this one, like you can see the inferior, uh, the inferior epigastric is coming right there right next to the junction so obviously it'll be but yeah so. Some people may actually for whatever reason like the patient has an anatomy where the inferior epigastric is like uh just a rise you know or coming in uh just a little bit distal whether you want to. I personally don't worry too too much about it. I think most people have it within those 2.5 to 3 centimeters anyway, uh, but that was when you go to.5 from the epigastric? No? What was that? If, if it, yeah, I think so, but honestly, I never see it. I, I, I don't worry too much about the inferior epigastric patency at all, yeah. So then yeah it's tracking it down obviously staying within the fascia I think you know a few times like you'll see uh great softness veins that come out of the fascia you can still treat it with laser like there it's doing something interesting it's kind of staying there but giving you like a like a larger tribe. Um, You can treat it when it's outside of the fascia, we just wanna make sure that you are at a safe distance from the skin, OK? So, um, you definitely want to make sure that you do enough toescence to where you're pushing it down and giving you that cushion to protect the skin from the heat that's generated inside of the vein if it's outside of the fascia, potentially running right under the skin, OK? So, you can call me when, like, Just one. That's good. All right. Here it goes, OK? You're gonna feel a poke, a little burning from the numbing medication. Just take deep breaths for me. In through your nose, out through your mouth. 123, ouch, ouch, ouch. Good. Breathe, breathe, breathe. This is uncomfortable, but we'll feel better soon. I'm happy about your hair, cause you're really I don't mind, you know, so. properly. Just like off to the side, so. I need to see if I can really get on. Maybe go on longitudinal. That's another thing you can do there. So let me shows you that I'm like past it there. There we go. Let me just a little. I did get a flush, yeah, mhm. There and I felt it, yeah, so that's perfect. OK. How long does it take for it to take effect? Um, so I'm going to actually be giving you more. Um-hum. Uh, numbing medications. So it's actually going to feel, feel better, OK? OK. So I'll give you, I feel a little discomfort here, OK? Yeah. Just bear with me. It's all very normal. OK. Yeah. So, You're doing amazing, by the way. Thank you. Yeah, you're doing great. Everything's going fantastic. Just kind of get that going, so here we'll see if we need any resistance in those branches that we saw. So far it's going nice and easy. I know I'm gonna be up there. Suspect I'm gonna be um out there, yeah, I'm already there. So I just move my little donut there. It's right there at the end of the sheet ready to go. So, um, I'm just gonna wait for Doc to get his measurement. Oh, I took it out and took it back. Oh, see, this is what happens, OK? So if we don't pull the thing, it doesn't do anything, OK. Except I took it out and. There we go. See, I'm like accustomed to him pulling, so I wasn't even thinking about pulling it, but that's just one thing, yeah, so he's gonna get me my 2.5 measurement. I like that. We know that that inferior epigastric is, uh, within that zone. That's my tip, and you can always verify on like transverse if you feel like maybe you're not getting like the full view of the vein. So you have that's your proximal and there's nothing there and then we should see epigastric there's inferior epigastric coming in and as he's moving distally we should see the tip. There. There it is. OK. You guys see it? The top, yeah. Uh-huh. OK. Perfect. So, what, what, how much, what's the diameter of that vein? So, it's like a larger vein. It's. Is it three? It was. So, still do two cycles? Yeah. So, I think it was on our three, on, on the mapping, it's actually like 11 millimeters. So, it's like larger than a centimeter worth potentially doing three cycles. So, we'll do that on her. It's probably a little smaller now just from manipulation, but I think it's still like a decent sized one where, you know, we'll see. Obviously we do two mess and it's all gonna go down, but just from your pre it was a larger vein, OK. So what we're gonna start doing now is we're going to start giving you lots of fluid with numbing medication all the way from the bottom here of your thigh all the way up to your groin. This is the part that's going to be most uncomfortable, but it's not going to take us very long. Once we're done with this, you shouldn't feel anything else, OK? Just giving you a little bit of. Um, everyone feels differently. Some people say that it's like more pressure than pain. Um, just kind of breathe through it. It won't take very long, OK? I'm hoping this doesn't really bother you much. I'm just kind of preparing for. You know, things that you may feel, but hopefully it's, it's easy for you, OK? OK, so that's important, you know, when you're, when you're using boxing, you know, just being mindful that you don't want air to go here. So just be mindful if someone's, if someone's, if you, if you have no one around, just be mindful if you have someone they'll let you know when you're getting to the end so that we can switch the back, OK? Here comes the pressure, OK? Just deep breaths. You for most I fear your ma. OK. So then I just try to reposition my needle. To try to use that same, uh, access point without bugging her too much. That's recognizes that they keep moving up, see how that's traveling. here. How are you doing? OK. Yeah. You, you can think of better things to be doing right now, huh? All right. Here comes for numbing, OK? Don't hit me. Just deep breaths. 123. Ouch, ouch, ouch. Good. Yeah, you're doing amazing. You are doing amazing. And if it's not like super tracking like I want it, it's crazy how everyone's like uh soft tissues are different. Like some people they it just travels and if you just see it, some others it's like. It's not the same, so I'm just gonna stay here. I'm gonna wait for that and I'm just gonna stop because I don't, it's not worth getting any bubbles, so I'll give her a minute to change that back. I'm just getting ready with my needle here. Uh, she's gonna let me know if there are any bubbles there. Sometimes when you change, like there's bubbles, I, we don't see anything, so we're just gonna go. If we get any, then it'll be a good. Yeah. Maybe we'll. So, there's no need to take it out and just flush it again? Yeah, no. Um, if you see needle, if you see bubbles, then for sure, but otherwise if you don't see anything, So see how I'm kind of like readjusting my needle as I go so that I get the most out of that poke instead of like poking her a million times. um Think we've made it up to. There, so, almost there, OK? OK. Here comes one more. Don't hit me. 123, ouch, ouch, ouch. OK. And just a little wheel. Um, you're doing great. Almost done. It's like, I don't know. Tell you when we're done. Let's see what's going on, OK. That's nice to see how it's like pushing the wall. George. So in here, do the same. I'm just gonna come back, go a little bit more superficial so I can get a little bit further up there. Let's make sure that I'm aligned with you. Sometimes I, if I get lost, like I'll have him find me. You just get on top of on top of the catheter that's it, right? On top of like there I just went a little bit posterior, did a little bit on the back. Look at that wall how it's collapsing. That is beautiful. That's the tip. You see the vein proximal to the tip and it's collapsing nicely. I'm looking at my temperature, it's less than 25, so from all accounts I would say this is really good, very good opposition, way past the tip, good temperature. Yeah, we're good. So you could check for flow there if you wanted just, you know, for the sake of being. Um, I've decided that I'm going to do three cycles there just because it was a larger vein to begin with. Let, let's see if you want to do less than 2020 cycles. You can turn off the thing in between. If you wanted to do a shorter one. Yeah, shorter you can stop it before, but I don't see why. I understand. Yeah, I'm just. Yeah. You could. It's an option in this. Oh, yeah, for sure. Yeah. OK? So, you're just gonna hold some pressure like up there at the top and. You just push a button. I don't know. I think we, it may, I don't know. OK. Did we lose, I just want to double check because here's junction there and then 2.5 would be about right there. I think we may have slid back just a bit. Oh, OK. Let me. We have the donut in place, but let's measure. It's always good and, and you always want, I encourage my techs to always tell me or anyone if there's anything that needs to be, let's just, Double check. Yeah. You know, he feels that we may have come back and, you know, that, that I, I think that's a reasonable thing to check and we'll check. Yeah, that's Should I, I am feeling some pressure further south. Yeah. OK. Um-hum. Yeah, your leg, your leg is going to feel. Yeah. Yeah. Above the knee, kind of mid. Yeah thigh. You're going to feel a centimeter, maybe. Yeah, maybe, maybe a centimeter or two, yeah. OK. Uh, it just looked a little, At a screen, so I just wanted to double check. So OK. But we have Temesin to here, so I'll just compress it. We just have. Um-hum. Let's, we can give more. Um cause this is all Temesa here. OK. So, um, let's go back and check. Sorry, I wasn't paying attention when you guys talked at that again. I was talking to her. Yeah, so there's. So let me just come with the catheter. Let me just, yeah, let me just come to with the catheter there. Yep. And then back just a tiny bit. OK. So, I think it's worth doing more fluid there. I really think it's worth doing more fluid there. OK. So, um, I'm going to give you just a teeny tiny bit more lidocaine. So, what I was trying to say is, yeah, it's super normal right now for your leg to feel heavy. Um-hum. Uh, maybe a little numb. We've given you lots of numbing medication. Um-hum. That is all completely normal. It'll start feeling better, you know, in a, you know, after we're done and within the next few hours, OK? OK. It's all super normal, OK? Good. I just wanted to point it out. Yeah. Perfect. Thank you so much for letting me know. Yeah, but I love that. I mean, double checking and triple checking things like, you always want to do that, OK? 123. OK, this should be the last poke, OK? I know I said that before, but. Well. You can blame this one on me. Yeah, from one person to another, but definitely within you, let me just align myself there. I, yeah, yeah. Just on different days you can have, uh, your veins, you know, your veins can really become really small. Uh-huh. When, uh, it's cold. OK. When you're dehydrated, when you're scared, when somebody's doing what I'm doing. Right. Uh shrinking, but then if you're happy you're out in the sun, you've had a couple of juicy days. So, absolutely, OK? So I think it's nice we checked that we did more medicines were less than 24, even better, so I'm happy with all of this, OK? So at this point you really shouldn't feel much of anything aside from what you're feeling right now and some pressure up here, um, as far as discomfort goes, you should be pretty comfortable. So, um, When I, one of the things that I hated about the laser, has anyone ever done laser like at, at that time, like you had to pull, like have this constant pull and it had like markings every essentially half the mirror and you would have to like. Really concentrate and like right now I can let loose, we can talk. Your tech can even start cleaning the leg to move things along. Right now we're not doing it because you know obviously we're not rushing or anything, but just as far as optimizing time like he could be cleaning the leg. We could be doing other stuff just moving things along because there's. Really nothing that we need to do as long as cycles are going, we're keeping track of how many cycles, so we've done 2, we're gonna do a 3rd 1, so if you look at the number on the screen on the bottom left, it won't jump to 3 until we're, we've completed the 3rd cycle, OK? If I were to stop right now, it's like I've done 2 cycles. So, um. Just takes it 20 seconds. It'll give you the audible cue. So it'll go to 3. So we've done our 3. We're gonna pull back. So we did 10. We're gonna pull 10. So 1234. I have my X marks. I'm still safe because I have a 7 centimeter sheath, right? If you have a longer one, you have to be mindful of that and just maybe pull back at that point if you're not sure. 7 centimeters, you're good to go if you're seeing the, the X marks. Um, So from here on we're just gonna do 11 cycle for you could do 2 if you wanted, but I don't think it was like crazy big everywhere else so that's our 4th cycle so we're gonna do so that's 1234, no, it's not going to, it's not going to hurt. So if you wanna be safe then you'll do 2. So here I'm seeing X marks. I'm just going to advance, push it in on my safe, uh, line sign. So let's have a 10 centimeter she makes 10 centimeters. So you just have to, you just have to, so if this is a 7 and you know that these ones are 2.5, so you would have to at least be at the half of the. Of this segment here or just completely pull it out and before and just be safe. And that's it, we're done. So here if you have like a pen.
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