Radiofrequency ablation of varicose veins using bipolar device: A step by step approach

Transcription

1 Radiofrequency ablation of varicose veins using bipolar device: A step by step approach Poster No.: C-1152 Congress: ECR 2013 Type: Educational Exhibit Authors: V. Kasi Arunachalam, M. K. yadav, K. P. Vellam, R Renganathan, P. Mehta, M. P. Cherian ; Coimbatore, 2 3 Tamilnadu/IN, coimbatore/in, Coimbatore, Ta/IN Keywords: Varices, Ablation procedures, Ultrasound, Veins / Vena cava, Vascular DOI: /ecr2013/C-1152 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 21

2 Learning objectives Varicose veins are one of the most common problems encountered in day to day clinical practice. It has a range of clinical presentations from being asymptomatic on one end and causing severe limb edema with ulceration and bleeding on the other. Various therapies have been in practice since long including Trendelenberg procedure, stripping and SEPS. The recent pin hole modalities of treatment include radiofrequency and laser ablation. The basic objectives of this poster are: 1. To learn about the bipolar radiofrequency ablation device 2. To study about the slection of patient and the technique of doing RF ablation for varicose veins using bipolar device. 3. To describe the possible complications associated with RF ablation of variocse veins. Background Varicose veins can be either due to reflux from sapheno femoral / sapheno popliteal junction or from incompetent perforators. The most common site for reflux is great saphenous vein (GSV). The causes for varicose veins are Primary - Valvular insufficiency, most commonly at Sapheno femoral junction(fig.1) Secondary - Most commonly due to deep venous thrombosis. The following are the risk factors to develop varicose veins: Female Obese and Tall individuals Pregnancy Occupation - associated with long duration of standing Heredity Constipation The standard management for GSV reflux is surgical ligation of the sapheno-femoral junction (SFJ) and stripping of the GSV. In the recent past there has been a radical shift towards minimally invasive techniques, one of which is radiofrequency ablation (RFA). We present a step-by-step approach for the use of bipolar probes in RFA of the GSV. Page 2 of 21

3 Radiofrequency ablation of varicose veins: RFA was first used to treat the varicose veins in After that it is continously modified till date. Principle: The basic principle of RFA is to pass the current with the frequency >100 khz into the dilated veins, which causes agitation of ions within the blood and induces the heat. This heat causes thermal coagulation which leads to tissue destruction and shrinkage of the blood vessel(fig.2). Muscle and nerve stimulation secondary to passage of current will not occur at this frequency.they usually occur at the frequency < 10 khz. Monoploar and bipolar configuration: The previously used RFA devices are of monoploar configuration. In Monoplolar configuration, grounding pad is required as it acts as a neutral electrode(fig.3). But the disadvantages are a. grounding pad related injuries like skin burns. b. not safe to use in patients with metallic implants. This is overcome by using bipolar RFA device(fig.4). In bipolar device both the electrodes are in the same probe with an insulator between the electrodes(fig.5) and there is no need for grounding pad. So bipolar RFA probes can be safely used in patients with metallic implants. Radio frequency geneartor unit (CelonLab POWER, Celon AG Medical Instruments, Teltow, Germany) in our institute has a maximum power output of 250 watts. The total length of the RF applicator (CelonProCurve) is 120 cms. In the applicator, the diameter and length of active portion is 1.8mm and 15mm respectively and it fits in a 6F Sheath(Fig.6) Images for this section: Page 3 of 21

4 Fig. 1 Fig. 2 Page 4 of 21

5 Fig. 3 Page 5 of 21

6 Fig. 4 Page 6 of 21

7 Fig. 5 Page 7 of 21

8 Fig. 6 Page 8 of 21

9 Imaging findings OR Procedure details Selection of patients for RF ablation of varicose veins: Inclusion Criteria: Incompetent junction with reflux into the adjacent superficial vein for >0.5 seconds (Fig 7, Fig 8). Exclusion criteria: 1. DVT 2. Deep vein reflux 3. Inability to ambulate 4. Pregnancy 5. Grossly dilated superficial venous system in preprocedure USG RF ablation technique: The steps in radiofrequency ablation of dilated GSV are as follows: Step 1: With USG guidance, mark the diseased GSV in the skin and Local anesthetic cream is applied along its course. Step 2: Place the patient in Reverse Trendelenburg's position(fig. 9) -> Pooling of blood within the dilated venous system -> easy to puncture the dilated vein. Step 3: Under USG guidance, GSV is accessed using the Seldinger technique. Step 4: Long 6F sheath is positioned with its proximal end 4cm distal to the SFJ(Fig.10). The long sheath is useful when Sometime the charred tissue are adherent to the tip of the probe. The probe has to be withdrawn and should be clenaed. If a long sheath is used, then it will be easy to take the probe out and keep it back after cleaning at the point where the procedure is stopped. Step 5: The radiofrequency applicator is inserted through the sheath and positioned 2 cm below the SFJ and it is confirmed with USG / Fluroscopy. Step 6: Perivenous tumescence : Under USG guidance, perivenous tumescent fluid (a mixture of 300 ml of normal saline and 30 ml of 1% Xylocaine ) is injected(fig.11). The perivenous tumescence reduces treatment related pain and it decreases the diameter of Page 9 of 21

10 vein, which increases the contact between the vein and the probe. It also protects the perivenous tissue from heat damage. Step 7: Position of the patient: Trendlenburg's position (Fig.12) Step 8: Mild intravenous sedation (Fentanyl and Midazolam) given. Step 9: The radiofrequency applicator along with the sheath is steadily pulled out with continuous delivery of RF waves. Step 10: The procedure is terminated when the wider mark on the shaft of the applicator is visible at the puncture site. Post procedural care: Immediate: Single dose of 60mg low-molecular-weight heparin is injected subcutaneously. Application of Creep bandage from the foot to the groin. Mobilization of the patient within 1 hour after the procedure. After 24hrs : Compression stocking for 3 weeks A class II (30- to 40-mm Hg gradient) compression stocking is used and it reduces the post procedural bruising and tenderness. It also reduces the risk of venous thromboembolism Follow up: All patients are advised to come for follow-up after 7, 21, 90, and 180 days. In all these follow ups, Patient's symptoms are recorded. Clinical and Doppler examinations are also done to rule out the extension of thrombosis into the deep veins and to look for any recanalisation of thrombosed superficial veins(fig.13). Complications: The common complications associtaed with RF ablation are Page 10 of 21

11 Bruising and tenderness Skin burns Extension of thrombus into deep veins(fig.14) Thrombophlebitis Injury to the adjacent nerve Images for this section: Fig. 7 Page 11 of 21

12 Fig. 8 Page 12 of 21

13 Fig. 9 Page 13 of 21

14 Fig. 10 Page 14 of 21

15 Page 15 of 21

16 Fig. 11 Fig. 12 Page 16 of 21

17 Page 17 of 21

18 Fig. 13 Fig. 14 Page 18 of 21

19 Conclusion Endovenous radiofrequency ablation is a safe, effective and preferred alternative to the surgical procedures in the treatment of the varicose veins. Among the endovascular ablation procedures, RFA is well tolerated and accepted by the patients with insignificant side effects. Images for this section: Fig. 15 Page 19 of 21

20 Fig. 16 Page 20 of 21

21 References 1. Sybrandy JE, Wittens CH. Initial experiences in endovenous treatment of saphenous vein reflux. J Vasc Surg 2002;36: Zierau UT, Lahl W. The endovenous RFITT-treatment of varicose veins, a new method of interventional phlebology. Technique and first results. Phlebologie 2009;38: Roth SM. Endovenous radiofrequency ablation of superficial and perforator veins. Surg Clin North Am 2007;87: Kasi V, Kalyanpur TM, Narsinghpura K, Chakravarthy D, Mehta P, Cherian M. Bipolar radiofrequency-induced thermotherapy of great saphenous vein: Our initial experience. Indian J Radiol Imaging 2012;22:86-8. Personal Information Page 21 of 21