In this interactive case, Dr. Jeffrey Carr demonstrates treatment of a medial ankle perforator vein using the Venclose Maven™ Perforator Catheter. This case highlights a horizontally oriented perforator, requiring a modified access strategy with wire and sheath support.
Um, I'm Jeff Carr. I'm an interventional cardiologist here in Tyler, Texas. We welcome you, uh, from around the country. Uh, so you'll have to do, uh, to pull that full screen up. So when we're referring to an ultrasound, uh, feature, an image on the ultrasound, please click on the ultrasound so you can get a much bigger view of that, uh, cause this is a lot of what we do. Of course, uh, a lot revolves around excellent, uh, and good ultrasound scanning. Uh, to make this successful, and she's had previous, uh, great staphis, uh, vein ablation in another institution years ago, uh, but she has, uh, C4C disease or so. I don't know if you can zoom in down on her, uh, physical findings down here. Just go ahead and let that, let off. So she's, you can see the hyperpigmentation. She's got, uh, corona phlebictatica. And, but she continues to have focal pain really right over these sites of these two perforators that we're going to demonstrate to you. And after several years of conservative management and compression therapy and all that, she's not happy. Are you happy with it? The pain, I'm not happy with the pain, very unhappy. So again, we're talking here about a quality of life issue as far as the indication to do this. We, we know the first thing to really do is to demonstrate the perforator in a sagile or longitudinal view the best you can. And uh OSI is trying to lay out this distal calf perforator, the right uh distal cap perforator, uh, on our original ultrasound was 5.2 millimeters, so it's greater than equal to 3.5 and it had 742 milliseconds of reflux back on the original diagnostic study that we had some time ago. And you can see it's really horizontal, um, and you have a pointer there. The key things to look at when you're lining up and evaluating these perforators is to look for the, the drainage pattern and find the deep system. So Osi down there to the right is showing you the posterior tibial vein that it drains into. And we want to identify our fascial planes. You can see the deep fascia, which he's gonna show you with the line. You go ahead and pop open your ultrasound, uh, panel, if you will. And you can see right there with the plus mark, the deep fascia, you can see that perforator. By definition, it pierces through the deep fascia to drain to the deep system right there. So this is one of our main focus or foci or targets, if you will, of where we want to deliver our thermal energy. Now, having said that, we have to be very careful, uh, most careful about safety. And we want to make sure we don't cause a thermal injury and a deep vein thrombosis. So we want to avoid the the deep vein system. We want to avoid, avoid arteries, bones, and nerves. So those are what I call hazards. Um, we want to keep a safety distance from delivering the 130 °C thermal injury to those hazards. So we Put a safety distance because we know the temperature drops off at 5 millimeters. Why don't you put color on next. So you can see, um, I'm gonna do a little calf squeeze there or a foot squeeze. To show that reflux, you'll see, you'll see the blue is the reflux, so there's quite a bit of reflux there in that uh distal cap perforator here. It's almost an ankle perforator. It's right on that border, but we're looking for arteries. We don't see any. Pulsation here yet and we're gonna really confirm there's the artery. Remember, these are paired with the vein, we have paired tibial veins. So the tibial vein is large right there as it drains in right above that, right? Do you agree? But we want to talk about angles of getting into this perforator. Um, and so if you see to the lower left, it's really kind of, you go ahead and point to that. I can't see you pointing there you go. You know, so we're coming in from the top here and how would you approach this, I guess is the question. Would you, we would be to try to treat as a longer, uh, a length of a segment, the longest segment that you can. And that's the really distinct and unique advantage of the um MAVEN device is it's a 5 millimeter coil, so you can do pullbacks along the length of the treatment section. So if you get intraluminal early, you have a much greater opportunity to treat a longer segment. So I liken, and you'll hear me this with this other cases, I liken an analogy to an air uh airport runway. We find the runway, we want to land our plane, meaning get into the lumen as quickly as we can on the runway, right when the runway starts, if you can, so you have a lot of run room to go. And also, if you don't hit the vein, if you miss it. You can move up, right? If you start further down at the end of the runway, then if you miss it, you're done. You know, you, you don't have any room for error. We have two options on access. One is a 12 gauge angioca, which has a very rigid procar. Uh, we'll talk about that in a little bit. And we have a just a standard uh needle introducer, an over the wire technique where you put in a sheath. And for this case, I think I would adopt the over the wire, the standard wire case, so we can get the wire to be, to come down. And the one thing you want to do if you're going to use the wires, you need to make sure the wire can go down far down the vessel into the deep vein system so you have what we call purchase. You can deliver a sheath. Into it. If the wire doesn't go very far, it's gonna be really hard to deliver a sheath to where you want it to go inside the lumen or false. So we wanna be really careful about this one again because the deep fascia is really close to that poster tibial vein, right? So often, show us where you believe the poster tibial vein. It is, it's that large round one, right? OK. Now, how can you prove that? Because it looks like, well, why wouldn't it be the one above that, right? Well, you can go flip it 90 degrees and go agile and you can see it run up the leg. So do that. This is really good technique. This is really important to show. And you can put color on it. You see that drainage there? Beautiful. You see that drain going right and that's all reflux, so you just or you flipped it, I guess. It would be nice, I think I'm gonna try to get my needle in the fattest part of that vein right in the middle here. Try to open that up. Right there and see if my wire will slip and make that curve. OK? You think it's gonna go? All right. And I've had a couple of cases where I kicked myself because as soon as I put the, the lidocaine in, it spasmed down the vein and we're, you know, we had to wait it out. So I come back a little further. Uh, from where I am. And remember, the edge of the probe is your marker from the edge of the screen. So I'm wanting to come in at this angle at a 45. And so I'm gonna start a little further back here. Sorry, pinch there, dear. And I, I like to watch on an ultrasound and make sure I'm not overdoing it. Just create a little wheel. You're, it's really just that skin. Skin nick there and it's already starting to affect that vein, so. All right. And um for this one, I don't usually make an eleven-blade nick, you know, creating wood. For the angio cath, I will, I'll talk to you about that if we do an angioca case. But of course, double up. You zooming in pretty good here. OK. Everybody can see that remotely pretty well. So bevel up and I'm gonna uh see if you can open it up a little bit more. Before I do that, I'm sorry, before I'm ready to go, I'm gonna shape my wire right in line with your ultrasound, OK? And so I line everything up. These are the external markers because it's all a 3D deal here, as you know. You there. Did I already go? Sorry, dear. OK, I think I'm a little off here. So one more stick here. Sorry about that. So I'm gonna try to come in flat, little. And now you can start seeing my needle come in. And I just, I don't, I like to not get too aggressive. I mean, you, it's, the tendency is to be really anxious and just like, oh, there it is, go for it. I like to really know as I move my hands back and forth that I'm in plane. Uh, and I'm gonna come in a little bit deeper. And Do I have flow return? It feels like it. It's not. So I'm not inflamed. It looked good, but I'm not in vessel. How about there? Yes. So I have visual. I like assistant to tell me. I can feel it, but it's much better and you can see on the overhead camera that we've got some blood return. I may not be fully in. Well, sometimes I will grab the tissue, it'll grab that wall. They're so thin and flexible and pliable that, that, um, I'm gonna need some help. These, uh, we change these wires out sometimes. And this one's really a little too flexible. But we'll see if we can really gentle coming in. So I'm not sure I'm fully in the loin. But I am, you can see the wire there. And we're gonna turn it down. I shaped it, and let's see where it's going. Is it going? It's going very smoothly, and you can see my wire is following that poster tibial out. This is also a good way to know for sure where the poster tibial is, right? If you're not sure. 7 centimeter sheath, and you can see the dilator with the sheath there. You zoomed in pretty well. OK, good. And just anchoring that back and watching as we go here. I'm sorry, dear, it's gonna hurt a little bit so the challenge is to know how deep it goes. Uh, because you have a dialer in there, right? So it's hard to say. I see a double lumen here. I don't think I'm pierced through the skin yet. I'm through the vein yet. Do you agree? OK, so a little harder hurt, a little hurt. Oh, I'm sorry, dear. OK, now it looks like I see. Double lumen. Now I see I see here, but I can't point, but you can see the lumen of the catheter is really right close to that bend where it bends out and I've got blood return. So I'm going to be very careful. I believe the wire down might take a dialer out just in case I'm wrong. And no, I think I'm good, right? Y'all agree? We got, we're in the lumen, so I'm gonna take everything out. And this also is gonna try to demonstrate the sheet. You can get feedback. Can you open up? I'm anchoring it here. Um, I just don't want anything to, and we've seen blood return. So we have really good confirmation. We're in the loin. OK, go ahead and put that up. OK, now time for the May. And you can see the coil is 5 millimeters. That's the business end. And you have a pointer. You can give me separate pointer. And then I want you to see the dead space at the tip, and it's 3.5 millimeters. It's a different color here. So you see the silver coil and you see the plastic, um, part or the, you know, the. The tip that basically just secures the catheter from an engineering standpoint, you have to have it. It's 3.5, but it's important because that's inert, that's not delivering energy. So you can't assume, you can't say, oh, there's the tip. I think that's what you're treating. Yeah, you have to come back 3.5 millimeters. Uh, this may not be echogenic, but we'll do that on the ultrasound screen to show you. But I really wanted to demonstrate this before we put it in. We've got these markers here, the two double X's, which is the do not cross zone, the danger zone here, and then these markers that it's a warning track I call it for a centimeter when you combine these two. So we want to stay 5 millimeters from every hazard. So 5 millimeters is that point. So if I start seeing the X's when I'm bringing it out of the skin, I know I'm in danger for burning the skin. OK. This is a 40 centimeter shaft length, and I'm just gonna simply insert it in here and we're gonna watch it come out and we're gonna try to locate. That first, here comes. Can you help me with that? OK, just give me a little more sec. That's good. OK, and so we're coming out and we're coming right to the corner. Of the perforator, it looks like to me. Can you show that also? And I'm at the warning trap, which means the coil is just outside of the 7 centimeter sheet, OK? Like if I'm here, it's in the sheet. So, um, I've got 5 millimeters distal to the sheep at this point. So I'm gonna pull the sheet back a little bit because I think I'm, uh, just show that tip if we can. Again, you're on the other side. So, OK, I'm gonna go deep. And now I'm under the perforator. I'm under the deep fascia. You see that to the lower right? And so I'm gonna come back. And I wanna be just on top of that fashion, so I'm kind of right on the edge of it. To be, it's, I call it tumescent, but it's not tumescence. It's just lidocaine to numb it up. You don't need tumescents like you would with a small or great sap, but let's like, look at the overhead, uh, here. OK. So if you look on the overhead, um, you're gonna feel another pinch. This is to numb it up. Now, I'm way down deep, so I come, you know, pretty far down here, and this is where the tip of the catheter is. So pinch, pinch there, dear. And I try to get my needle right on top of that thing. And I'm, I'm very liberal with, you see I'm to the right of the screen there. As I'm putting in the lidocaine, yes. OK. And we're using 1.1%. You can use 2%. We're using 1 here and again, we're gonna use a lot here. And you can see uh my goal here is to push away the uh um the push for tia bay, but actually we're starting to actually get better uh visualization of the tip of the catheter. Um, as we bring in that liquid density, the water density, so we can get more transmission of the ultrasound. So I'm just gonna I'm in here. And I'm just gonna first kind of treat all the way above and below. So basically, just like you would do a GSV SSV and a Sara face or whatever, go above and below, surround it, that's nice right there, right on the side and it also have the effect of Of um Clasping that perforator on the device, right? And you can see the vein on top of right in the middle of the screen. Looks like we're getting a good compression. We can take the tourniquet off too. Mm. Um, We started putting tourniquets on everyone early on because everybody's, you know, you just hate it when they're not, you know, they come in with their hose or something and the, the vein is way smaller than you thought or that you knew it to be. So this is one of our tips, but now we don't want the pressure. So I'm gonna do one more lidocaine and now we're getting some really good visualization of the tip. I'm gonna jiggle it here and the echo density, go ahead also to show the coil. Super important if you, you know, to try to locate the tip of that catheter, right? So, um, In the transition, you can see, you get a hint of the plastic there, but that density there is 5 millimeters, and I'm sorry, we can't measure that, but we usually say, oh, I think that's the tip, and if it comes out 5, we know it's the tip. So that's another tip, trick here. And one more, I'm just gonna push the, uh, push your tibial further away. And I'm gonna just come in right to the edge again, right to the back edge. Now, remember when we set it up, we said 5 millimeters, but you can also push it away if it will stay with your tumesis even further than 5. I'm sorry, dear. I know it's hurting, and I think we're ready to go. This, you know, I like to say this is a miniature version of a DSE SSE with banks. That's how we designed, how it was designed, and, um, so you don't have to learn too many new things about it. We also have a foot pedal down here. I'm just gonna use this for now this table. We have a foot pedal, which is really nice in case you kind of get your hands, so you can do either one. The foot pedal is right down there, guys. OK. All right. And we're right at the edge. I'm jiggling. I'm triple checking here, and we're ready to go. And so I hit the button. It's a 22nd cycle of 130 °C. And I'm holding rock steady here, not moving. That's on. So I'm gonna index the sheet if you can see on the overhead. Where I'm not quite on my mark, so I'm gonna Pull the sheet back, keeping the device there perfectly right there. And now I'm gonna pull back 5. So it's 1 division here and we're gonna be looking on the screen and also looking, I'm gonna be looking here, I'm just gonna look on the, you all can see on the ultrasound, I'm gonna pull back 5. If you see it come and so that's a tandem. And we're gonna be here. Sometimes I found depending on the patient, there might be some slack in the system, so you might be pulling it back hard, but it doesn't move the catheter. That's why I like to look on the screen too, just to have that other confirmation that it's really doing what you believe it is. And I'm always, we're always checking to say, is that the coil? Is that the coil? You can see it's a little fuzzy there. It's hard to tell. That's 6. So that's the 2nd 6. We're gonna pull back to our third location. I'm gonna look here, you look there. And right there. OK, just a little bit more. So this is our last. Treatment cycle and you were saying you're watching the jewel, the wasp per centimeter vary, so it varies to maintain the 130 °C. So that's gonna go up and down. So you're saying if it's going higher, then it's a good sign that you're getting coagulation, right? That's a good observation. OK, um, just to double check, we're gonna come out. So I'm gonna pull this out. And I'm just gonna pull it out together so you see how far you can see it on the screen, and you see where the device was in relation to the 7 of your cat sheath, the catheter. So why don't we go look down on it. OK, it's good, OK. And so you see the warning track right here. And the warning track, do you see that well? The warning, it's just like you mimic the same thing as the larger Ben posts. And you see the beginning of the warning track. If you're at the beginning of the warning track, then you've got a full 1 centimeter before the coil. If you're halfway through, right at the edge of the warning track, now you've got that 5 millimeter safety distance, and that's why X's are there. Do not cross, right? Don't cross into the X's. If you see X's, you know you're gonna, you know, get something in trouble. You're gonna burn the sheep or you burn a hazard, OK? All right, so now I'll, I'll switch with you and you, uh, it's still open and you know that up front or you can't see it and we, so we wanna show efficacy, meaning we've got closure of the, of the target vein and we've got patency, the deep system and arteries. So Do you? Yeah. And that We do it. So one of the questions is, do you give any anticoagulants or any platelet therapy or anything different? And the answer is no, uh, nor do we stop any anticoagulant antiplatelet therapy. That's the beauty of it too. You don't have to change anything for the patient. There's no data. In fact, we showed a slide last night about a study looking at If they were on anticoagulant therapy, does that affect patency? It does not, in a retrospective series of different modalities. So just don't stop it. No, don't stop it. So if they had stents in their heart, is that what you're saying? Oh stents in their legs and their arteries. Yeah, keep them on the dual antiplatelet therapy, whatever they're on, keep them on it. Don't change anticoagulants or dual antiplatelet, any antiplatelet therapy, any anticoagulant, continue. It's not going to affect your, your efficacy by the data that we have. That's the posterior tibial vein. Yes, sir. Is it pulsating, pulsing. No. So we have a posterior tibial vein that's patent. We see the deep fascia, show the deep fascia, which we did not cross. We came right to the top of it. We believe we started right on the edge of it. Again, to keep that 5 millimeter safety distance. Now show the perforator going back. To the left. And this is all color, so we should see color if there's flow, we see no flow. You gotta put color on, on these afterwards, not just the 2D because you'll never know, right? So we don't see any flow. You see nice coagulation there, a beautiful result, I would say, you know, if, if I'm looking at this, it's great. I'm really, really pleased with that. Um, and so we're very happy we've got PC the deep system and efficacy on our target area.
Content on this site is intended for United States Healthcare Professionals Only
