Mechanical-Chemical Ablation Mechanism of Use … NCVH/5-30-Sat/0910_Ariel...
Transcript of Mechanical-Chemical Ablation Mechanism of Use … NCVH/5-30-Sat/0910_Ariel...
Mechanical-Chemical Ablation Mechanism of Use with Venous Ulcers
A R I E L D . S O F F E R , M D , FA C CA S S O C I AT E C L I N I C A L P R O F E S S O R O F M E D I C I N E F L O R I D A I N T E R N AT I O N A L U N I V E R S I T Y
• Fellow of the American College of Cardiology since 1998 with training at Cedars-Sinai, Beverly Hills, USC/UCLA, and Harvard Business School.
• Professor at Florida International University School of Medicine. Published the first article on the importance of venous insufficiency in the cardiovascular practice, Endovascular Today, 2007.
• Founder of "Soffer Vein & Vascular" (Cardiovascular-Based Multi-Specialty private practice with 8 offices throughout South Florida), and the Vein Experts Training Academy (www.vetavein.com)
• Co-Founder of AppwoRx™ - Patented clinical photography applications used heavily in the venous space.
Dr. Ariel David Soffer-BioNCVH Vein Forum
Relevant Disclosures
BTG Paid Consultant
Sigvaris Paid Consultant
Alma Lasers Paid Consultant
3
Venous Ulcers
Venous ulcers, or stasis ulcers, account for 80% of lower extremity ulcerations.
Less common etiologies for lower extremity ulcerations include:
• arterial insufficiency
• prolonged pressure
• diabetic ulcers and neuropathy
Venous Ulcers
1-2% of the world population.
Debilitating for patients.
The financial burden of venous ulcers is estimated to be $2 billion per year in the United States.
Treatment options
Limited• Compression
• Stripping/Thermal ablation of proximal refluxing veins
• Foam sclerotherapy
• Hyperbaric Chamber
Historically poor healing and high recurrence.
Ulcer effect on the patient
Devastating condition• Infection
• Foul smell
• Chronic pain and swelling
• Depression
• Disability
Diagnosis
Clinical• Shallow, painful ulcer located over bony
prominences, particularly over medial malleolus. granulation tissue and fibrin present
Ultrasound• Venous insufficiency evaluation a must
• GSV, SSV, perforators, Deep system
Pathophysiology of venous ulcers
Controversial:1. Venous hypertension causing activation of
inflammatory process• Leukocyte activation, endothelial damage, platelet
aggregation, and intracellular edema contribute to venous ulcer development.
2. ISCHEMIC. High venous pressure in the venoules below the ulcer bed prevents adequate arterial supply.
Treatment of the ulcer bed venules/venous pools is essential!
Mechanical-Chemical Ablation
Largely painless
Distal access (Foot/retrograde)
No nerve damage
Ability to treat below ulcer
Unique mechanism-collateral damage
11
MOCA™
12
MOCA™
Typical ulcer case
The Mechanical Chemical Ablation treats the tributaries, venous pools and venules below the ulcer
Ultrasound
Ulcer bed before treatment Ulcer bed immediately after treatment
Mechanical Chemical Ablation Recent Trial
• MARADONA Trial (Mechanicochemical endovenous Ablation verses RADiOfrequeNcy Ablation)
• Netherlands study with 460 Patients • Endpoint was comparability to RFA
with less discomfort
• Showed equal results at 1 year with less procedural and post-procedural pain
15
Typical case #1
• 79 y.o. male with greater than 20 year history of bilateral skin discoloration below the knees
• Recurring right ankle ulcer for 4 years
• Previously treated by primary care, dermatology, vascular surgery, podiatry and wound care
• Referred by wound care center
• Has difficulty with transportation
Case #1
Case #1
• Venous duplex ultrasound – bilateral GSV reflux distal thigh to ankle. Right greater than left
• Right GSV coursed below the ulcer
• Retrograde approach from distal thigh to ankle
Post treatment (10/23/12)• Pre-treatment (11/3/11)
Case #2
• 65 y.o. male with history of DM
• Former smoker
• History of right heel ulcer for 2 years with pain.
• History of right 2nd toe ulcer and discoloration for 6 months
SSV reflux
Pre treatment (9/26/11) Post treatment 5 mo Post treatment 9 mo
Case #3
68 y.o female with 16 year history of ulcers
Described instances of “ruptured veins”
Constant pain with limited mobility
Cannot drive due to the pain
Used to be very social and “wants to go dancing again”
Had been told that she would have to “live with this for the rest of her life”
Case #3
SSV insufficiency with tributary to ulcer
GSV normal
Treated SSV in with Mechanical Chemical Ablation
Case #3
Pre-treatment Post 6 months
Case #4
59 y.o. Male with a history of LLE persistent ulcer(s) since 2003
Prior history of EVLT in 2004 and phlebectomies
Multiple failed skin grafts in 2005
Being treated by wound care center
Duplex still shows patent and refluxing left GSV and SSV
RFA left GSV and SSV 2010
Case #4
2011 Duplex US demonstrates patent and refluxing left GSV below the knee to the ankle
GSV courses below ulcer
Case #4
Pre –treatment Post 11 mo
Summary
Venous ulcers are a big public health problem with limited treatment options.
Mechanical Chemical Ablation offers a unique mechanism that seems to be beneficial in the treatment of venous stasis ulcer amongst other possible indications.
Closing Remarks / Thank You
Mechanical-Chemical Ablation Mechanism of Use with Venous Ulcers
A R I E L D . S O F F E R , M D , FA C CA S S O C I AT E C L I N I C A L P R O F E S S O R O F M E D I C I N E F L O R I D A I N T E R N AT I O N A L U N I V E R S I T Y