CHOOSING THE APPROPRIATE TRUNCALVEIN CLOSURE DEVICE

Steve Elias MD FACSDirector, Center for Vein Disease

Director, Wound Care CenterEnglewood Hospital and Medical Center NJ

THE ANSWER:

• The one that works

• The one you are familiar with

• The one you own

• The least expensive

• None of the above

CONSIDERATIONS:

• Size – big, small• Length - short• Location – AK, BK, Suprafascial• Multiple veins – GSV, SSV, AAGSV• Disease state – C5, C6, SVT• Patient type – fat, thin, anxious, friend, foe• Special – MD, spouse of MD, attorneys

Choices: 2014

• 810 nm• 940 nm• 980 nm• 1320 nm• 1470 nm• Radiofrequency• Polidocanol Endovenous Microfoam • Mechanochemical – MOCA• Cyanoacrylate glue• Steam• V Block

Occlusion Devices: Two Categories*

• TT (Thermal, Tumescent)

• NTNT (Non Thermal, Non Tumescent)

*Elias S. Emerging Endovenous Technologies. Endovasc Today. March 2014.

Thermal Tumescent: TT

• Laser – HSLW, WSLW, radial/jacketed, etc

• Radiofrequency

• Steam – not in US

Non Thermal, Non Tumescent: NTNT

• Mechanochemical

• Cyanoacrylate glue

• Polidocanol Endovenous Microfoam

• V Block

Modern Era of Endovenous Ablation: MEEVA

• Percutaneous, outpatient, local anesthesia

• TT:• RF/Laser - >90% ablation rate @ 4yrs• Steam - >90% at 1 year (Europe)

• NTNT : • MOCA – 95% ablation at >2 years• Foam – 85% at 2 years• Glue – 95% at 1 years• V Block – 100% at 4 months

SIZE

• Big (>12mm) – TT

• Small – NTNT or TT

• Really big – TT, SFJ/SPJ ligation?

• Really small – NTNT or “should I do this?”

LENGTH

• Short segment – RF 3 cm, laser, foam, MOCA

• Short – maybe not CAG (cost?)

• Long - anything

LOCATION

• AK – anything

• BK GSV and SSV – NTNT before TT

• Suprafascial – MOCA, TT but consider skin/ cord, hyperpig

DISEASE STATE

• C5, C6 – AK GSV & BK GSV – TT or NTNT

• C5, C6 – BK GSV residual – retrograde NTNT and foam ulcer bed (MOCA) tumescence an issue

• Previous SVT – TT – need more energy

PATIENT TYPE

• Fat – TT over NTNT

• Thin – NTNT over TT

• Anxious, Nervous – NTNT over TT

ANTICOAGULATION

• INR 2.0 – 2.5 – anything

• INR > 2.5 - TT

SPECIAL SCENARIOS

• MD or Spouse – RF, MOCA

• Friend – RF, WSLW (1470), MOCA

• Foe – HSLW (810/980) or stripping

• Attorney – 810/980 with 150 joules/cm and no tumescence

CONCLUSIONS

• Need one TT and one NTNT

• Tailor the technique to the situation

• All veins are not the same