Chapter 155 - Varicose veins endovenous ablation sclerotherapy

Question 1

Number of valves in the GSV

Answer 1

7-10 mostly at SFJ

Question 2

Anterior accessory GSV incidence

Answer 2

14%

Question 3

SSV number of valves

Answer 3

7-10

Question 4

Reticular veins define

Answer 4

1) Thin walled blue venules within superficial compartment 2) diameter 1-3 mm 3) connect to saphenous vein from lateral subdermic venous system (LSVS) 4) feeder vein to telangiectasias

Question 5

Telangiectasia define

Answer 5

1) dilated venules, capillaries or arterioles 0.1-1.0 mm 2) flat and red if from arterial side 3) raised and blue if from venous side 4) appear in thigh near LSVS in 88% of the time

Question 6

Concurrent ambulatory phlecbectomy in EVA

Answer 6

no clear evidence controversial

Question 7

Contraindication to RFA

Answer 7

1) SVT 2) DVT 3) venous aneurysm 4) ABI < 0.9 5) ? pacemaker?

Question 8

RFA techniques by step

Answer 8

1) 10cm below popliteal area is the most distal extent 2) 1cm minimum separation from skin needed 3) 21 gauge needle for access 4) 0.018 wire and 7Fr sheath 5) ClosureFAST inserted 6) position 2-2.5 cm from SFJ 7) tumescence to create 1 cm diameter around vein 8) trendelenburg before treatment 9) 2x20sec cycle at SFJ then single segment for most 10) double segment again if large vein 11) 30-40 mmHg stocking for 1 week (controversial) 12) 72 hr post-EVA U/S to determine EHIT

Question 9

Safety of tumescent lidocaine dose

Answer 9

35 mg/kg body weight

Question 10

Limit of cycles for RFA per segment

Answer 10

3

Question 11

Temperature and heating speed for RFA

Answer 11

Reach 120C within 5 sec if cannot then need to do again

Question 12

Complication of RFA

Answer 12

1) perforation 2) thrombosis 3) PE 4) phlebitis 5) EHIT 6) infection 7) nerve injury 8) skin burns 9) discoloration

Question 13

3 year data of ClosureFAST RFA

Answer 13

occlusion rate 92.6% Improved VCSS CEAP improvement in 74%

Question 14

Category of wavelengths used in EVLT

Answer 14

1) Hemoglobin-specific laser wavelengths 2) water-specific laser wavelengths

Question 15

Trends in wavelengths for EVLT

Answer 15

higher wavelength lasers has less pain and bruising

Question 16

Laser tip in bruising for EVLT

Answer 16

jacket tipped better than bare tipped

Question 17

EVLT procedure

Answer 17

1) 21 gauge needle, 0.018 wire, microsheath 2) 0.035 guidewire, long sheath to 2-2.5 cm from SFJ 3) EVLT fiber passed and used

Question 18

LEED is

Answer 18

linear endovenous energy density LEED and treatment efficacy correlated higher LEED = higher success but more nervous injury

Question 19

Currently used LEED for EVLT

Answer 19

50-80 J/cm

Question 20

AVF after EVA where

Answer 20

external pudendal artery to GSV stump asymptomatic

Question 21

EVLT closure long term rate

Answer 21

92.3% at 1 year 86.9% at 2-3 years

Question 22

Absolute contraindication to sclerotherapy

Answer 22

1) allergy 2) acute cellulitis 3) acute respiratory or skin disease 4) severe systemic disease 5) phlebitis migrans 6) acute superficial thrombophlebitis 7) pregnancy 8) hyperthyroidism 9) bedridden status

Question 23

Relative contraindication to sclerotherapy

Answer 23

1) asthma 2) DM 3) hypercoagulable state 4) leg edema 5) advanced PAD 6) CKD

Question 24

Classes of sclerosing agents and specific types

Answer 24

OSMOTIC 1) hypertonic saline (23.4% NaCl) 2) Sclerodex (hypertonic 10% saline + 25% dextrose) ALCOHOL 3) chromex (chromated glycerin 72%) 4) nonchromated glycerin DETERGENT 5) Scleromate (sodium morrhuate) 6) Sotradecol (sodium tetradecyl sulfate)/ tromboject 7) Varithena (polidocanol 1%)

Question 25

General differences between sclerosing agent classes

Answer 25

Strength: detergent \> osmotic \> alcohol Alcohol has low risk hyperpigmentation, necrosis and allergic reaction osmotic = hurts to inject detergent cause matting of telangiectasia but almost no pain

Question 26

Osmotic sclerosant action

Answer 26

dehydration of endothelial cells through osmosis

Question 27

Alcohol sclerosant action

Answer 27

Destruction of endothelial cells on contact

Question 28

Detergent sclerosant action

Answer 28

Aggregating on endothelial wall disrupting membrane and thrombosis

Question 29

Sclerotherapy STS dosing

Answer 29

TABLE 155.3

Question 30

Liquid sclerotherapy key points

Answer 30

1) 30 gauge needle 2) largest diameter treated first 3) if significant pain then stop (paravascular injection) 4) anaphylaxis possible 5) delivered in 2-3 cm intervals 6) compression stocking up to 3 days 7) typically 10-20 injections per visit

Question 31

Amount of liquid sclerosant based on vein size

Answer 31

Varicose vein \< 1ml Reticular vein 0.25-0.5 ml Telangiectasia 0.1-0.2 ml

Question 32

Ultrasound-guided foam sclerotherapy developed by

Answer 32

Tessari 1999

Question 33

US guided foam sclerotherapy bubble size

Answer 33

\< 100 micron

Question 34

Ratio of liquid to air in foam sclerotherapy

Answer 34

one liquid to 4-5 air

Question 35

Formula to calculate how much foam sclerotherapy

Answer 35

V = pi x D/2

Question 36

Preparing foam sclerosant

Answer 36

Rapid back and forth 20 cycles with 3 way stopcock

Question 37

Complication of sclerotherapy

Answer 37

1) hyperpigmentation 10-30% 2) telangiectatic matting 15-20% 3) pain 4) urticaria 5) never injury 6) superficial thrombophlebitis 7) anaphylaxis 8) DVT/PE 9) arterial injection 10) cutaneous necrosis

Question 38

VANISH 2 study looked at

Answer 38

Polidocanol endovenous microfoam vs vehicle for the treatment of saphenofemoral junction incompetence

Question 39

HASTI score

Answer 39

heaviness achiness swelling throbbing itching

Question 40

Mechanicochemical ablation (MOCA) key points

Answer 40

1) rotating wire from catheter 2) mechanical damage of endothelium and spasm 3) sclerosant deposited can use in tortuous veins and SSV

Question 41

VenaSeal key points

Answer 41

n-butyl cyanoacrylate 1) glue polymerize with ionic compound 2) 5cm from SFJ 3) 3 cm intervals 4) no need for tumescence