In this case presentation, Dr. Jeffrey Carr demonstrates treatment of a medial ankle perforator vein using the Venclose Maven™ Perforator Catheter. This case highlights an alternative access approach utilizing a 12-gauge Angiocath™ IV Catheter to support effective entry into the target perforator.
The patient is a 76-year-old male with a venous clinical severity score of 24 and a Cp classification 5 clinical score. Symptoms include leg heaviness, fatigue, numbness, and restless leg syndrome. The small saphenous vein and great saphenous vein have been treated with radio frequency ablation. The incompetent perforator vein is located 15 centimeters from the heel and 5.5 centimeters from the tibia. The diameter is 3.7 millimeters with reflux time of 810 milliseconds. Use duplex ultrasound to obtain a clear view of the incompetent perforator vein at the level of the deep fascia and deep venous system. Line up the perforator to the corner of the ultrasound screen in longitudinal view. Mark where the perforator and ultrasound probe is located prior to treatment and ensure the probe is perpendicular to the skin. Administer local anesthesia to the access site. Make a skin, Nick. If using an angiocah IV catheter, insert the angio IV catheter until flashback appears and confirm position with ultrasound. If using an introducer sheath, insert the wire and compatible introducer sheath over the wire. Verify intraluminal position in transverse view if using an angiocah IV catheter, remove the needle. The fascia layer is the white line here, so everything above this line is superficial tissue and everything below is deep tissue. It is recommended to place the catheter heating element right below or at the fascia line. The posterior tibial veins are located here and here, and the posterior tibial artery here. Veins are compressible. The posterior tibial veins are close to the angiocah IV catheter. So in this case you will need to push the post tibs away with tumescent after placement of the catheter. Insert the Venclose Maven perforator catheter and advance the tip to the desired treatment start location under direct ultrasound visualization to ensure that the catheter is positioned appropriately. Pull back the introducer sheath or angio IV catheter to visualize catheter markings at the skin. It is recommended the catheter heating element be placed at or below the deep fascia. Administer local anesthesia, then inject tumescent anesthesia adjacent to the vein wall to create a layer of fluid around the vessel. Ensure the distal tip of the catheter is at least 0.5 centimeters from the skin, deep system, and adjacent arteries. The catheter tip can be visualized here, and the posterior tibial vein is located here. The artery is here, and you can see the calcification on the posterior tibial artery wall. Measure to verify distance from the posterior tibial veins and arteries. Administer additional tumescent anesthesia to protect the posterior tibial veins and arteries. Measure again to determine adequate distance. Ensure good vein wall apposition with the heating element by applying external compression. Deliver treatment by pressing the button on the handle or stepping on the optional foot pedal. 22nd treatment cycle at a set temperature of 130 °C begins. Multiple heating cycles can be performed at each segment based on anatomy and physician discretion. If multiple treatment segments are planned, pull the catheter back 0.5 centimeters and repeat treatment. When treatment is administered near the fascia level, you should consider delivering additional tumescent anesthesia on top of the catheter to protect the skin. Deliver another treatment. Once treatment is complete, remove the catheter. Confirm occlusion of treated vein, and confirm patency of deep veins with ultrasound. Apply external compression.
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