In this interactive case, Dr. William Harris demonstrates left great saphenous vein ablation using the Venclose™ RF Ablation Catheter. This case features a slightly posteriorly positioned GSV, requiring thoughtful access planning, with sheath access obtained at the level of the knee.
OK, that's great. So what we're doing is um. Uh, we're going to start off with a radio frequency ablation. This is a gentleman, we've already operated on his right leg, um, and, uh, we'll attack his left greater saphenous vein. He has significant reflux all the way through. We did, um, uh, closure on the right side with radio frequency ablation on the top and vain on the bottom, and today we're going to look at his um. His left greater saphenous vein, so you can see it on ultrasound now. I've got it kind of highlighted, it's a pretty good picture of it. I'm at the knee, we've already tracked it down from the saphenofemoral junction. Um, his one's a little bit posterior, but it's not bad. You can see it dumping into the saphenofemoral junction there and running along the course of the leg. So I like to start kind of at the knee sort of around the knee region if and uh localize them stick and a burn 123 stick. I like to not give them too much time to anticipate. So we'll access his vein, you can see the. Saffron being, um, we do a fair number of these here. And uh can you make the ultrasound a little bit more superficial? Oh, no, I got it. Never mind, it's all right. Uh, you can see the tip of my needle inside the vein. Bouncing kind of on the top of it. Not there. Then I moved it. They make it a little more superficial, wouldn't you? That's good. And you can see it's gone, um, in this case, the GSB has gone a little bit superficial, but we'll access it. See the tip of my needle. This access kit that comes with the the BD uh provides with the Venclos is really uh fantastic. The needle you can see very well on ultrasound, um, and it's really a good setup. So it's a 6 French system. For those of you not familiar with it, we've gotten into the vein wires advanced. And then this is the six-inch sheath that comes with the setup with the pack. And it's a pretty stiff sheath, but it's slides into the vein very, very well. And so we advanced the catheter in. This is the Van Gogh closed catheter for those of you not familiar. You've got a 10 centimeter treatment length. There's a 2.5 centimeter segment right here, which is kind of a protective segment that you'll see us pull out at the end. And then this is kind of your last run that the, the markers here. And so Hopefully you can see and I'm sliding the catheter up. And so we will look for it at the saphenofemoral junction, so you can see the tip of the catheter is already up there. So we like to go approximately 3 centimeters caudal to the saphopins. It's better to be more caudal from the saphofemoral junction than closer to the femoral vein to prevent your chance of, you know, being hit at the end of the case. So there's the tip of the catheter right there. We'll move it up just a little bit. And you see that bright white tip on ultrasound. Right in the middle of the screen. And you can see it running in between the fascial planes, and so we'll take tumescence solution, and I like to start at the top. Some people start at the bottom, but I like to start at the top. Stick and a burn, sir. Turn up the Tees. And we have a, a, a pump, fluid pump, which allows us to put this in pretty rapidly. Now we like to surround the catheter. Circumferentially with the tumescent solution to prevent it from burning. So we're injecting uh saline with sodium bicarbonate as well as lidocaine to numb the area and insulate the space and protect it from the saphenous vein. So we're injecting circumferentially around the vein here. It's a really good picture. You can see the temein solution going around the vein. Now it's really important, you can see the fascial planes on the top and the bottom of the ultrasound screen. It's really important to get in between those fascial planes. Um, I've seen it before and even, you know, when I started off doing this, I didn't really appreciate. Often how much you have to really sneak in underneath those fascial planes and get them separated uh off the vein to get adequate insulation. To be efficient, I can start the closure right now. And so Wendy's gonna hit the button. So you can hear the numbers going now. The, the temperature on the catheter is getting to 120 degrees. That's an appropriate temperature. That's where we want it to be. If I started to hear a giddy up or it wasn't reaching 120 degrees, then I would have concern that there wasn't contact with the catheter with the vein wall. One thing also about using the tumescent solution, yeah, you can hit it again. Is it, it closes down the vein and puts pressure on the surrounding vein to get more contact with the surrounding area. Total treatment length is 40 centimeters. And so like I said, I usually start from the top down and that allows us to be pretty efficient, so I can start the burning process pretty early. We do 2 cycles up top typically unless there's poor contact. We also look at the resistance, and that's the 3rd screen with the lightning bolt to make sure that goes to less than 2, and I pull it back 10 centimeters at a time per treatment length. We're down to the 30 centimeter mark. You can see here. That we're looking at the common femoral vein. Can you go a little deeper on the ultrasound? Increase the gain just a little bit. So there's a common femoral vein sitting next to the common femoral artery. It's completely compressible, so we don't have any clot in there. We always want to check that at the end, and you can see the vein is totally ablated in that case. So, I pull it back another. So you can see the catheter here, we're pulling it back to the 20 centimeter mark. I de-sheath it fairly early on. Um, I take the sheath out of the equation. Yeah, you can go ahead and hit it. Um, you know, there's minimal bleeding around the area. Um, you've got the catheter still in like I said, it's a six inch system. And so, Works pretty well. So you can see the catheter here. And so we'll pull it back again to its last segment. Now, when we've got it in, there's the 5 centimeter marker or the 2.5 centimeter marker sitting up, that gives you another 2.5 centimeters before the coil part that heats up. Go ahead and hit it one more time. If you feel any burning, let me know, sir. This is the final treatment. You see the catheter doing its magic right there. And you can also see here the resistance getting down below 2 on the right hand side. The temperature is up to 120 degrees and the treatment time. Is 20 seconds for that segment and then you're done. So pretty quick and efficient. So. And then what Wendy will do is wrap the leg. Um, sometimes we use compressive stockings for a big leg like this. Are you going to use an ACE wrap or we're going to use a stocking. We're gonna use, we have a big stocking, so we'll get that going and put them in a stocking. We usually do a follow up ultrasound within 5 to 7 days postoperatively, and we get that set up, um, out here. Uh, sometimes that involves them coming in on a Saturday. We have ultrasonographers who work on Saturdays to check and make sure they don't have a postoperative DVT. But the incidence of DVT, if you do it like this is exceedingly low, so. And we'll get the next patient going.
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