In this case presentation, Dr. Jeffrey Carr demonstrates left great saphenous vein ablation using the Venclose™ RF Ablation Catheter with mid-calf access. The video highlights procedural setup, access strategy, and key clinical considerations in performing endovenous ablation for venous insufficiency.
patient is a retired school teacher of 30 years and coach on his legs for a lot of his career and came to me after years of pretty much all the symptoms of chronic venous disease with heaviness, aching, tired, fatigue, burning, stinging, itching, throbbing, and notably edema. He thought it was his heart. And so he came to me as a cardiologist thinking oh maybe my heart's failing. Of course his echocardiogram was normal. It was not heart failure. We reassured him about that, but with a venous duplex scan, we confirmed chronic venous insufficiency venous hypertension, that was pretty advanced. We call him the CP 3. If you look down here, you can see the edema on his left leg. He drove 4 hours today to get here for the procedure. It's probably 2+, not terrible. The right leg was 3 or 4+, I think when you met me. They were almost elephant type of legs. They were pretty bad. We've already treated his right great saphenous a few weeks ago. He's doing well from that. But today we're going to tackle his left great saphhous. So what we like to do first is what I call a preview. And this is a good pattern of habit to get into because a lot of patients might be waiting from your from the time you get your original diagnostic study, and there might be an interval of acute DVT that you didn't know about and you certainly wouldn't want to take out a superficial vein in the setting of an acute DVT on the same vein. Him driving 4 hours is a good example of that. And so here Casey is just doing a quick, it really just takes seconds just to find that deep vein, do some compression, and so she just demonstrated that on the ultrasound. So now we want to look at the course of the great saphanus. We do a quick sweep up just to make sure we know if there are any hazards. We see if there's any anatomic variants, and you can see this great saphenous vein runs right in that saphenous space pretty much the whole way. About mid-thigh there is, or distal thigh, there is a branch that comes off right there, that tributary going up underneath the skin, something to know about if you had a big varicose vein here, I might note that if there was a large area in that dilated there, I might do a double treatment there, but for the most part this looks like a pretty straightforward, great saphenous vein running in the saphenous space. What we do now is we like to look at where we're going to enter in, and I like to say go as distal as you can or want or the best place. That doesn't mean where you enter and access is not where you need to terminate therapy, but if you start really high in the leg and you miss, you start moving up the leg and your treatment section opportunities are more limited. So I advise as you're starting, if this is your first cases, it's probably best just to be just below the knee. It's pretty consistent where that gray saphendu is. It's contained by fascia usually, but for those that are familiar with it, I tend to go mid calf, sometimes even more distal, depending on the type of seat class and what we're really after. But since he's a seat 3, I'm thinking about a mid-calf here, and you can see Casey had just shown nicely a really good spot. Your sonographer can also put a surgical pen on there if they're waiting for you to come in and to X marks the spot, even to map out the course of the vein, especially if it's tortuous. This can be really helpful if you're just starting out when you have some variations about where to go, because it can be a little challenging if you're not used to holding the ultrasound probe about how to follow up with me. Casey is pointing out with that arrow now on the ultrasound a branch of the saphenous nerve, and actually this is probably a pretty sizable branch right there, and these are sensory nerves, but this is also the reason why thermal injuries to nerves are more common from the mid-calf down to the ankle. So we always try to hunt for it. More often than not, we don't see nerves, the saphenous nerves here. We'll talk about the sal nerve on the small saph cases, but if you think it's a nerve, I say it is a nerve. Just treat it like a nerve. It's always safe to do that. And if you don't see it, if your mid-calf or distal, assume that they're small nerves you don't see approximating very closely to this great saphenous. So what I like to do is I go into transverse. Some people go longitudinal or sagittal views, but I do a transverse. You try to keep the probe as vertical as you can to the skin. So right as perpendicular to the skin here. And I like to put that great sapfa directly in the middle of my field, so I do this every time. Sometimes you get in a hurry or you're over here to the side like this. It can be hard to hit it. So if you set yourself up the same way every time with access, it becomes much more reproducible. And so because I'm right in the center there and I try to pick a nice kind of a nice open, more dilated location like that. Then at about a 45, I'll make a little wheel here and you can see it just really just want to go under the skin with lidocaine, not too much, but just enough to make an incision and put the sheath in where it doesn't hurt. You talk about venal spasm in a bit, but you can't if the vein is really close to the surface, you might, you might cause spasms. So here's the introducer needle. You can do it with or without a syringe. I like the 3 cc syringe because I have tactile feedback about this. There's also a visual with blood return, and you can see the little marker on the needle shows that there's a bevel up, and I would highly recommend going bevel up as you enter into this so you don't target that wire entry into the back wall. And so now at a 45 degree angle, bevel up, I try to come in. And I don't rush this. I just kind of come right and approach the vein, and you can see now I can pick up the tip of the needle and I'm kind of dancing. I call it dancing right on the top of it. Let me see if I can get a little bit more pressure. I'm dancing on the top of it there to line it up and I want to be right in the middle and then I'll do a quick jab. And it looked like it went off to the side, but it didn't because I've got returns, so I just jabbed right through that. I make these transitions really slowly and carefully. I try to be very still. I like watching And so those people are incredible trying to keep their heart rate and their bodies still when they're shooting. But it's the same thing. Just little movements can move you right out of that vein. So what we like to do, you can see it went in very smoothly. A lot of times it won't. You'll hit a wall, but I have the wire. It actually is looped in there, but she's followed it up, and I believe it's important to follow that up so you don't inadvertently put that sheath into a tributary. So I would like to visualize this as we go. You don't have to, but I make a little skin incision. I think it heals a little better when you have a skin incision rather than a blunt. Um, you know, sheath going in. It's a stylistic thing. And then just simply put that in. You have some tumescent, or a little lidocaine here, so you shouldn't feel that. You OK? Yeah. Doing good? Great. Excellent. Um, when you're starting out, I'd recommend you just get feedback from, uh, aspiration and flushing that catheter. You should have no air in here, but you can see we're in the lumen because we have blood return, and we're just going to flush that through. All right, so we have access. The next step is to um deliver or to place the Vlod catheter inside the great saphenous vein to our target beginning location. And then Rhoda's going to unsheathe this for me, and this is the, I know you've seen this in the course there, but for those remote, and you can see there's a 10 centimeter coil with markers, black band markers at 2.5 centimeters, so there's 4 of them to make that. And as we know, this device is unique in that it will Default to the 10 centimeter and with a tap of a button on the generator you can only deliver energy at the distal 2.5 centimeters, so a really nice feature. You also notice the nice curve that's already in here that's very helpful. It's a 6 French device, so as we get into tortuosities or branches or maybe a stuck valve, a fixed valve, you can steer away from it really nicely without having to use a wire, but you could use a wire if needed here. Also note the warning tracks. There are two sets of warning tracks here, and these are 2.5 centimeter divisions, the solid lines followed by the X lines, and we'll get into that in a minute. With a gap in between, so we're going to deliver the catheter. I like to watch this go up with the ultrasound probe, again, making sure we don't divert down into a perforator. We've actually had that happen. We had to come back and it would go down a perforator to the femoral or a deep vein and then back out a perforator. If you weren't watching, you potentially could burn a deep vein. You certainly would never want to do that. So just adopt a practice that you get comfortable with for safety. So what we do now is we check with ultrasound. The Location, the anatomy here and it's important you can see the femoral vein down below, the big black space and this great saphenous vein enters in just to the left of that screen to the sahaofemoral junction, the SFJ. We're gonna pull back 2 to 3 centimeters from the SFJ that's in the IFU, but for my practice and many others, I like to use the epigastric vein, the superficial epigastric vein. Can you demonstrate that, Casey? It's to the left there, the lower left. It's it's a passive drain from the abdominal wall. It's very consistently present in this location within 1 centimeter of the SFJ, and it just feeds and drains the front portion of that. I like to do that and preserve that, to see it and preserve it, because I think it's just like having a little garden hose that's always on, it's always dripping to bathe the front end of what's going to heal here. And so that's a practice I do and many others here, but either way, we're still more than 2 to 3 centimeters from the SFJ. So locating it can be difficult depending on the anatomy, the tip of the catheter, and just show that again, Casey. And you can see here, it helps to even jiggle the catheter a little bit to know your position. On certain patients, they might have a lot of fibrosis and striations, connective tissue, and ultrasonography. You might get fooled. You might think it's the tip of the catheter. It's linear, it looks just like a catheter, and it's really fascia. Or connective tissue and so moving it can help. Turning it can help, and then reorienting to the device. You can see the coil is there and you can't quite see it here, but usually the tip, if you magnify it, it has two lines on the tip of it with ultrasound. Maybe Casey can, this is a little harder to show on this one right at the very tip. There's a plastic ending, a polymer ending, and it shows up as two lines instead of one. You also see the corrugations, if you will, of that coil, so we know that that's the device. It's very obvious on this one, but in many other cases. Certainly obese patients, it might be really difficult to see that, but it's really vital. I stress this point because you certainly want to know where you're burning. You can't turn back. So we'll measure twice at this point by 2 to 3 centimeters. She's going to do one more time here. We're going to be 2 to 3 centimeters from. The SFJ or the epigastric vein, superficial epigastric vein. And then if you show down here. OK, so she. It can be challenging for sonography to get this. Again, it depends on the patient's shape because this great saphenous will curve in in posterior, so there's an angle of your probe that takes a little getting used to, even for a new vascular technologist to get this anatomy. We have this classic Mickey Mouse appearance that she just showed you there. Where it's the great saphanous, the common femoral and the femoral veins right there at the lower left, the Mickey Mouse appearance, and the great saphenous drains right there at the nose, and you can see some bubbling there as well. So that's a really good landmark to pick everything up here. And um go ahead one more time, show the tip, and then we're going to get, get on this. I'm just stressing this point on this very first case. We'll go quicker on the subsequent cases, but I think it's very helpful because the most challenging portion from a thinking side and how you work through a case is the start point and the end point. of your thermal ablation. Now, I, I just wanted to highlight that my sheath was in all the way. We know our start point was there. I'm going to anchor here in what I call indexing or just calibrating right here. You see, I'm going to a marker, so I know that is my spot. And we'll come back to that. So wonderful. So now the next step is to deliver the tumescence. And We have a foot pedal to my right down here. We have and you can use a three-way syringe, a stopcock. I did that once for one case. I'll never do it again. My thumbs won't forgive me for that. My joints again, the same needle that we use, and we have a pump on the table over there that is delivering the temescence that's mixed up in a bag. Um And I'm going to take the probe. I think it's helpful. You can certainly have an assistant hold the probe if you'd like. In a sagit view, that's very challenging, I think, for two different operators. For me, it always helps to have it in my hand just for stereotaxis in your brain because this is a three dimensional issue here, and some are better than others. Some brains are more geometry focused than algebra. Um, and so they're better, you know, your visual spatial skills, but this is where it comes in here. And so I like to go up and deliver the teescence in a sagual view. So you'll see the probe is this orientation. I'm already numb here, so I go right to that same numb point, the, uh, uh, the anesthetized location, so he doesn't feel it. Uh, I tell, I tell the patient, we, we usually distract the patient. We have all these cameras here. We're distracting you, right? Yeah. But we want to get their minds off of it because if you focus on the pain, it tends to intensify. But you'll see as I work my way up here, I'm tapping on the pedal here just to kind of get a sense, is it really hurting or not. I want to make this as comfortable as I can for the patient because this is what they'll remember and talk about. It's not the treatment, it's the anesthesia that they feel. So I'm working my way up here. Starting above this, you can go either above or below. I'm going to advance below it. Now I'm behind it, but the goal is to deliver the teescence within the saphenous fascia, within that saphenous space. So that we get good what we call haloing or 360 degree coverage of the temesins completely surrounding the vein. I'd like to work my needle in as far as it will go because that will limit the numbers of skin sticks. Again, the worst part of the procedure, people say. And So I'm just advancing that needle, watching, and I like to go this sagittal because I get to see how far that tumescence, that black water, basically, saline. Will travel. I want to get the most mileage out of it, and you see also a mounding on the surface here that also is a good cue of where your temescence is. So I'd like to go at the end of that. If you wait a little bit of time, it's going to be numb, and so it'll help with that little skin. Did you feel that? Is it bad? No. So he's not feeling it. Some people scream with that. Other people are sleeping, don't even know you're doing it. It's just everybody's brains are different with their nociception. And so here you see I'm right on top of the needle. I'm on top of that vein, and again the goal is to collapse the vein. Onto the catheter onto the device so that we get Really surface to surface contact or conductive heating. This is how this whole procedure works is through conduction through that coil and just like you're pushing a burger or a piece of chicken on a skillet and pushing it down to brown it, you want to do the same thing here. You don't have chicken legs though, but you know it's the same, it's a good analogy. And so you want that's the idea here when you're when you're, we want to press down and you see when we start treating it, we're going to put some pressure on it and again to evacuate blood out of the vein. So that we can have uniform heating, that uniformity we believe really helps with permanent closure. And makes this efficacious long term. And And so here you see going above the vein again this is. I always say it's difficult to deliver too much to muscles for comfort for the patient. I usually confine myself to this 500 cc bag. You can deliver too much lidocaine from a toxicity standpoint if you deliver above a certain amount per patient's body weight, but for the most part, I'm very liberal with the tins because I just don't want any. Buddy going out, you know, leaving, going, boy, I'll never do that again because it was so painful. And if they're, if you're delivering 120 °C with an unanesthetized area, they're going to remember it. And so I just don't want that experience, so I go above and below. And just taking time to work our way down. It could go a little faster here, but again for the first one, just wanted to demonstrate. Where we are here. So, kind of coming up to the mid-thigh, you can see there's the end of the teescence there. So I put that at the end of my probe, or the, the probe right here, so I know that that's where I need to pick up and, and hit again. So I'm going to come in here like that and you can see. There's the needle coming in right to the edge of where I previously delivered the temes. And just working, and what's nice is there is a saphenoussac uh all the way up here. That contains this great saphanus, a lot of patients won't have one, or there'll be uh variations where the great saphenous will come out of the saphenous fascia and run right under the skin. With no fascia to contain it, and then the temes can be more difficult to deliver. It can dissipate and migrate really quickly, so just be aware of that. I'm going to swing around here just because my wingspan has been exceeded. And just to finish off at the end, again, this is just stylistic. I just don't like turning my neck. My partner will stand at the bedside here on one side and he'll do the temescence turning his head, and I just, you have to figure out what works for you just in terms of standing by the patient. Um And here we go, a little bit more. You have a dial on the pump, so if it's going too slow for you, you can dial it up. And make this a faster transmission, but then it might be a little more uncomfortable if you're too fast. So, just be aware of that. You see, I'm going below it here, posterior. Going to come, see if I can come a little more anterior. And we're getting near the end of the line and we're near the end of the temesin bag, so we try to budget how much we deliver, but the great saphhodu is coming and coursing and torsioning around a little more anterior here. Here's a pinch. And we're just about there. Mm, OK. All right, we're coming up and now it should be picking up. The tip of the catheter pretty soon. There it is right there, the tip of the catheter. This tends to be just the most challenging part from an imaging, but also if you have a large patient, it can be physically challenging just to be able to get there. But you see I'm moving the needle past the tip of the catheter. I call this bullnosing, like your bull you have a bullnose countertop where it wraps around the tip even though the heat is. Delivered axially. Perpendicularly to the catheter, there can be some forward heat transmission, especially if you're on the curve. So I'm getting a little warning I'm at the end here. So I think I did really well with the tip, and now we're going to check this transverse. I'm going to let Casey jump in and do the check. So I went up the leg in a sagittal view to deliver it, but we always check it in the opposite plane, 90 degrees from that. So we'll go a short axis, a transverse view. To make sure we get 360, go ahead and do that first and then come on back all the way first. So we want to make sure we get 360 degree coverage. We see really nicely haloing around that catheter and the vein. The vein has collapsed. We're underneath the inside the fascia really well, looking good still. If you take a long time or go out for coffee doing this, it might dissipate out, so you just want to get on it. You don't want to just. You know, dawdle here. Uh, we want to look at that sapens nerve right at the very end. We can do that when we're down there just to decide, and that'll be a good little decision-making point about where we stop. So where we start is right now. Um, You know, in woodworking, you always measure twice and cut once in vain closure work. You measure 3 times and burn once. OK, so, uh, Casey noticed that the catheter was now 3.3. We had 3.0, so just a little bit back, it's better to come back, but this also shows you why it's so important to check a third, I say a third time, um, because you can't go back. So I'll jiggle the catheter again. We want to make sure she doesn't cut with ultrasound, cut it obliquely, because you can see the end of the catheter, but it's actually because the catheter is not lined perfectly with the with the line of the coil, you might miss where the tip really is. So we always have to agree that's our safety mechanism. And if one doesn't, they have to convince the other about it before we burn. So we're ready to burn. We'll come back to this. She's showing the nerve at the end. So this is the start point again. This is where your brain goes into gear, like where do I want to start? I'm going to take the handle and we're going to burn here as she's putting even pressure on the device, on the coil, pressing down. This will help eliminate blood. If you're starting, I highly recommend you can even put the vein, put the patient in reverse Trendelenberg to start to get access, and then flip your table back to Trendelenberg to drain. That's a good thing to do if you're early on in your experience. She's putting pressure here. We did 122. Treatment cycle, we're doing a 2nd, so we do a double treatment. At the initiation location here of the great Saphanus, and you can see the evidence that it's working. You can see the boiling of the blood, the bubbling, and we also see that we're delivering on the console. Uh, the, the 22nd treatment. I'm going to pull back now. We'll come back, yeah, and show the, the generator. So I'm gonna pull back now. You can see there's 2.5, 5. 7.5, 10 centimeters. So right there we get right back on it, hit the button, and the generator with the algorithm within 5 seconds will deliver 120 °C and the algorithm there of changing the wattage to the right. Watts per centimeter is to keep an even temperature at 120 for 20, for a full 22nd cycle. So you're getting about 15 seconds where it's actually at 120. We're going to pull back again, 1234. I anchor that sheath as I do that. We just don't want any movement. We know precisely where we are. Again, Casey, you can see she's got even pressure. Sometimes the sonographers, you might put heel pressure on it in tow, and that might force the tip up near the skin. Those are some key tips, so try to avoid that. You want that nice even pressure. The other thing to note is you want to be a safety distance away from the skin. Uh, we want to be 1 centimeter away from the skin, and you can see on the right side of the ultrasound, we're almost at 2 centimeters. There's 11 or 1.5 or more away from the from the dermis. At the top, and remember it's the dermis, right, not the epidermis, right? The bottom. So really be vigilant about staying away from what I like to call hazards, you know, skin, arteries, bone, nerves. You want to be a centimeter away with this device because we know that the 234, we know that the. Thermal injury decline is to negligible at 1 centimeter away. So I just showed that we came to our first warning track and my catheter was here and I pulled it back again to I call it indexing where I am, so I have another new reference, but I know exactly where I am. The coil is up in this region here, so we're still a good ways away. some ways away from the mid-calf and further where we start having to think about. Concern for thermal injury. Avoiding it. OK, so now I'm going to pull back again 10 centimeters. I'm going to anchor the sheath. I'm going to pull back 1234. I see my second warning track. Now I'm going to anchor the catheter here to expose the coil, because I want to know exactly what's coming out of the skin. And I'm going to anchor here, pull the sheath all the way out. And as I do that, you can see that the coil is now exposed and out of the skin. If I didn't change anything, I'm going to burn potentially a permanent hole in the skin there. Nobody would want that. It should never happen. But if you don't pull that sheath back, you can still be delivering through that and not see it. So it's important to expose it once you get to that warning track. There's no harm in just letting a little blood leak back here like this. But what we do now is we're going to convert. On the console, generator console to a 2.5 distal tip treatment location. I like, and then we're going to watch again, see if we're far enough away from the skin, we are, and the nerve and the nerve. We know we're getting near that saphenous nerve down further, but we're we're, are we 1 centimeter from that? Yes, so you look at the top you can see where exactly centimeter. We're right at 1 centimeter here, um. I'm going to show you what I would do. Let's say, so that's right on the borderline, so let's not take any risk. I'm going to take the temescence back. And I'm going to demonstrate what we can do in this situation where let's say you're concerned, we should be concerned 1 centimeter or less, so we're right on the borderline. So we put it in this short axis, the transverse view, and I go just like I'm getting access for GSV. You can see my needle tip now is right between the coil and what we think might be the nerve. Again, it may not be a nerve, but we're treating it as if it is a nerve. And now I'm just putting it right in between and it pushed it away. I don't know if you saw it move laterally to the left on the screen, and I'm just really put in, I call this a little more just insurance. To keep a really safety distance away. Now, scan in transverse, come down all the way to my fingers. We want to see if it comes back. Yeah, really stays away, right, and let's just go right there too. Come on down a little further, right there. I'm just going to give a touch up because remember we started here and I've been talking so much and taking so much time that it might have rebounded and recoiled a little bit right at the very end. And this is, again, the start and the end points. is where I think you've got to think through a lot and it's less than 1 right here, yeah, so Casey's pointing out that right here this is the entrance site we're probably less than 1 centimeter, so that means we're not going to burn this area, but I haven't moved the catheter. I've been anchoring it. Let's go to our distal tip. I don't know if you can see, but I'm going to hold the coil here. I like to do this. I've just adopted it from the very beginning of Venlo's use, because if there's some malfunction or somebody didn't hit the button, I'm going to feel the heat at the same time he is, and boy, I'm going to be right on that button, right? So I'd rather know myself rather than him screaming and having some delay to turn it off. So here we go. I'm going to. Now we're treating just the distal portion, the distal 2.5 centimeters. Can you see it at the end? Maybe you're a little low. Yeah, here it is. There you are. She's right on it. She's so good OK, for his case as a CP 3, I see no reason to go any further distal here. So I'm going to terminate the procedure here and show you where we ended. So it was sticking out about that much. So that's right at mid-calf, maybe a little bit lower than mid-calf. OK, so that's the end of the first case. We are going to put a little bandage on here and a little pressure, localized pressure here just to keep it from oozing. And then put his hose on.
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