In this case presentation, Dr. Jeffrey Carr demonstrates left great saphenous vein ablation using the Venclose™ RF Ablation Catheter. This case highlights a mid-calf access approach, along with key procedural steps, access strategy, and clinical considerations in performing endovenous ablation for venous insufficiency.
A 67-year-old man who presented to me with non-healing wounds in both of his feet, on the right toes and also in the left heel and dorsum of his left foot. He's a truck driver and had a 3 pack per day smoking history but quit years ago, and he said that his symptoms in his wounds started with the initiation of bites. He had fire ant bites. And he just never has been able to heal those, so he's in wound care, and they've had very slow healing despite aggressive conservative management. He also complains of heaviness, aching, edema, stinging, burning, itching. Tiredness and nocturnal cramping. He has normal ABIs and so we always want to think about concomitant peripheral artery disease in addition to venous disease. On his duplex ultrasound done in September 23. We confirmed bilateral pathologic great and small saphas vein reflux. He has significant pathologic reflux in below the knee perforators. And he has a right distal calf perforator that's dilated to 3.5 millimeters, 714 milliseconds of reflux. So today we are tackling his left great and small saphenous veins. His left great saphenis vein was maximally dilated at 7.4 millimeters with 1,438 milliseconds of reflux. His left small saphas vein. Was 2.2 millimeters with 788 milliseconds of reflux. He has no deep vein thrombosis or superficial uh thrombosis as well. So the plan for him after he has failed aggressive conservative management with wound care and compression hose therapy is to treat his left great and small saphenous veins. The distribution of his ulcers in his feet are not classic for vein leg ulcers, but he certainly has other symptoms and he has other advanced C class findings. You can see the marked hyperpigmentation in his legs showing evidence that he's had venous hypertension for many decades. And in addition to all of his symptoms, we felt that treatment was indicated for him. So, now we're going to scan the great saphenous vein, the target of our therapy today, up front just to show the pathway, so you're looking for any variants. Any diversions and see if it stays within the saphenous space and you can see it where the arrow is pointing on the ultrasound. So you see it stays within the saphenous space. And come on down and we're gonna trace this down. To find her and you can see it bifurcates there and stays in the space and goes out of the space for a tributary, but it comes more interior here. And Casey is going to locate kind of our best. Um, access location. So, excuse me, there's a nerve right there. Yep, saphenous nerve is very helpful. You don't often see them. Here, but she's pointing to the sa a tributary of the saphenous nerve. Or a branch of the saphenous nerve, I should say, and a nice big um anterior located great saphenous vein. I think we can check the tribs after we're done because we're going to mess no matter what. Oh, yeah, that's great, so go, we can go pretty low here with him, so. I suggest one. Probably just below midcalf. I don't want to go too low. We can, we can fall. The rest, cause we're going to do foam anyway, so that'd be good. Kind of foam a distal G. Get rid of this. I can see better. All right, so, next, I'm going to, Utilize, um, the ultrasound and in short axis view, transverse, I'm going to go just a little bit below mid, mid calf here at a really nice location. I'm going to make a little wheel with my lidocaine. You can see just a little bit. You want to be careful not to cause spasm of the vein. With the bevel up, I have my introducer needle. No shape. No shape. Sorry, a little pinch here. Yeah. And you can see, Uh, I'm getting through. OK, right there I'm on it. I went through it. I'm gonna come back. And we're feeling and looking for. Yes. Right there. It just popped off that back wall. And now you can see I'm in that. Great saphenous. We're looking for a little blood return. Sometimes you don't get it and I'm feeling, I feel resistance. I'm probably on that back wall. So, I'm going to lower my needle a little bit. And as I pull back. Can you, yeah, what do you think back wall. Yeah. So it's kind of compressing. You can see it's spasming that. What's that? Um-hum. He's getting dizzy. Take some deep. OK, I'm in come on up now, Casey. And So a little better or. He's got really thick skin, so sometimes it's, you just got to make an incision to help get your catheter in. How's he feeling? I don't want No, not, not much. So, you're doing OK? OK. We are in. Come on up. So we like to track the device as we go. I hold, I hold it loose, but I kind of, I just go smooth and right there he felt that. So I'm going to use the angle here. We kind of hit the end. We're probably right at the end. Where the great esophagus vein angles down right there you can see it and you can see on the ultrasound. The tip really well and we're going to measure. A safety distance back of 2 to 3 centimeters from the SFJ. Um, I like to use the superficial epigastric. Vein as a landmark rather than SFJ and she's putting that cursor onto the angle there where this, the superficial epigastric vein drains. So you can see we're over 3 centimeters. There's the tip. You just really want to make sure you verify the tip. So we're good and we indexed right here on that mark so we know that's our position and we're going to go ahead and start our two misses. You're gonna feel a series of pinches and some burning as this goes in. I'm going to go right to where it's numb, and then you're gonna feel some pressure as this goes in. How are you doing? I'm fine. OK, just gonna work our way all the way up and surround this vein with the numbing fluid. I can see this vein is really tortuous and coursing over. OK. Doing all right? Yeah, I'm fine. Oh. I'm sorry about that. Yeah. Mhm. It used to stab and poke lately. At the wound care center? There and then, I've been going to the skin doctor and. Oh, yeah. And that's a really good demonstration there on the ultrasound about putting it right in that cephenous space above and below that vein in the catheter, collapsing the catheter collapsing the vein on the catheter with using the temesin. So, it's really nice there. OK, we're moving along here. Oh. All right. Right. Sometimes. How are we doing on the tumescentda? Yeah, I'm doing great. I. OK. Yes, I see it. Thank you. Um There we go. Get back on board here. And it's easy to have the needle divert down below the fascia, and you can kind of see that right in that location, posterior. To To this infinite space. And if you're not sure, then you can just flip it like this, and you can see the surface space really well that way. You can see I'm below it on some of that. So that's a nice little teaching point here. And we'll just go up the rest, well, we'll just be consistent. We'll go longitudinal for this one. We can show another case where we go up transverse. And didn't check it longitudinal. I might need to roll. I will need to roll. Hm. OK, my wingspan. So I'm going to swing it around to get this last section here. And if you get lost, just go transverse. I'm doing great. Mm, so you can see it's, it's really right superficial up there, isn't it? Right up on that. So this was where it helps to, to switch your planes. I was getting lost a little bit with the. Location of the tumescence and then then this is really much easier here. We've got plenty of tumescence, right? We're not going to be shorting. Yeah, great. So You know, another stick, another stick there. Sorry. I'm you know, poking you a few times here, but we're almost done with the pokes. OK, really good. And let's see if we can go back to the longitudinal. There we go. And this really shows that nicely how we want to get coverage all the way around the tip. The catheter, especially that posterior wall, this is an area where if you don't do it well enough, they commonly will feel it right there because that tip kind of digs into that posterior wall as it bends around. Naturally, the following the path of that great saphanus and so that's, I like to really do enough at the at the very end here to make sure I've got that fully covered. We're going to demonstrate with ultrasound the um. To mess us in a different plane, in a transverse plane to make sure we've got 360 degree coverage. And that we're far enough away from the hazards. And we're going to measure again. To make sure. To make sure that we're a good 2 to 3 centimeters away and she's measuring from the epigastric vein there. Yeah. And we're three. We're perfect there. That's a really good distance away. Now, you can show the handle if you want to show this. Um, this is where we, the only time we use it. So, we're checking all the way down by ultrasound. Looks good. Remember we had that saphenous nerve down there, but we look good there, right? Yeah, it's good. Yeah. OK. All right, now that we've triple checked it, we're going to go ahead and initiate therapy after she puts steady, even horizontal pressure on that. We like to see that the, um, catheter is really even with the skin, ready to go. So I hit the button. And we now see the generator. Delivering the therapy. The just put it. We're going to show this on here, one. 23. 4. Perfect. And then I hit that again. All right, you can go back quiet. Got it. Yeah. I what What Uh, Yeah yeah. They got me that way. That. Yeah. And Here we go. We did another pullback. We can see this pulling back on. OK, he's focusing on this, so yeah. 12, here we go. Using a ton of to get to that. Did you see this? Yeah, I can see. So, now I'm going to do this. All right, pull back an index, and now I'm going to do this. Are you, oh, you're letting off? Well, because of that nerve, because it's already down here. And so in this one she let off because it was closer to the skin and we didn't want to, uh, push the skin toward the device. What's he feeling? OK, here we go, uh, um. So, are we ready? tight. OK. So, I'm going to, hold it there. 12, 34. You see the warning track here. And, so, now I'm going to hold this here and anchor this back. Watch, yeah, yeah, there you go. You can see the coil there. So, now we're going to go ahead and convert to 2.5. OK. You shouldn't, No. OK. OK. And we're going to. That's where it was one time I seen you. But I. Is that OK? I can get this out. Uh, maybe, Is he feeling that? OK, we're going to do this again now. OK, I'm gonna just hold it right there and we're gonna pull this back to here. So, now we have two here. We're going to get one more treatment out of that. So I'm going to anchor it. We're verifying that we're on 2 1/2, and this will be our last treatment. Treatment zone Let me just show that we're. The marker is right at the skin. It's the halfway marker, which is 5 centimeters. And now we're gonna, can you wipe that real fast, Rhoda? Take it off. Take it off. And now we're gonna show on the skin. Where the last treatment. Location was right there. So we had this much safety margin. OK.
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