Disclosure Steve Elias M.D.

I disclose the following financial relationship(s):

•Consultant/Advisory Board: Covidien Inc,

Vascular Insights LLC

Steve Elias MD FACS FACPh Director, Vascular Surgery Vein Programs NY Presbyterian Hospital Columbia University Medical Center Assistant Professor of Surgery Columbia University NY

“The Treachery of Images”: Rene Magritte

Veins Sources of problems

Occlusion is goal

Thermal, mechanical, chemical

Anatomy

Pathophysiology

Treatment technique

Complications

Access points Positioning at SPJ Tumescence placement Distal points of treatment Avoid Injury - nerves, skin, DVT

1.Giacomini’s vein

2.Profunda

Femoris vein

3.Perforating veins

from lateral thigh

4.Anterior lateral

branch of the

GSV

1. GSV

2. Giacomini’s

vein

3. Calf plexus

4. SSV

5. communicating

Variable termination vs. GSV Popliteal fossa - 70% time Femoral vein - 25% Below popliteal fossa - 5% Intersaphenous vein - branch to GSV Thigh Extension (TE) of SSV – no

popliteal connection

Cavezzi A et al. Duplex ulrasound investigation of the veins

In chronic venous disease - UIP Consensus Document.

Part II. Anatomy. Phlebology 2006;21:168-179.

Gibson KD et al. Endovenous laser treatment of the short

saphenous vein: Efficacy and complications. JVS 2007;

45:795-803.

VV - Calf (SSV) and medial thigh

varicosities (GV) or TE of SSV

Diameter – Elias 5.8 mm

- Kontothanassis 6.4 mm*

VV - due to SSV 20% of the time**

**Gibson KD et al. Endovenous laser of the short saphenous

vein: Efficacy and complications. JVS 2007;45:795-803.

*Kontothanassis et al. Endovenous laser ablation of SSV. JVS. April 2009

Distal access - sural nerve

Proximal positioning - nerves and PV

Skin and nerve concerns

*King, T. Can saphenous and sural nerve

parathesia be prevented during ELT. Abstract

EVF 2010

Sciatic nerve divides into the tibial and common peroneal nerves, proximal to the knee

Peroneal crosses posterior to lateral head of gastrocnemius, and becomes subcutaneous behind head of fibula

Tibial Nerve Anatomy

Popliteus muscle

Gastroc heads

Soleus muscle

Plantaris muscle

Sural nerve - Kontothanassis – 2.2%

- Gibson - 1.6%

- Wang - 2%

- Huisman - 1.3%

- King – 0%

Inferior border gastroc and tumescence

Kontothanassis D. et al. Endovenous laser treatment of the

small saphenous vein. JVS April 2009

Huisman et al. Endovenous laser ablation of SSV:

Prospective analysis 150 patients. VascEndovasc Surg 2009

Tibial nerve injury - plantar “push”

Runners, jump etc. walking OK

Visualize tibial nerve

Higher nerve injury with open tx

SPJ - Fascial curve (2-3cms avg.2.8 cm)

Tumescence to push SPJ/Nerves deeper

Range - 0% - 5.7%

Ravi - 0% *

Elias - 0.8%

Kontothanassis – 0%

Gibson - 5.7% (close to junction?)

VV Surgery - 5.3% *

*Ravi R et al. Endovenous ablationof saphenous veins:a large

single center experience. J Endovasc Ther 2006;13:244-8

*Van Rij et al. Incidence of deep vein thrombosis after varicose

vein surgery. Br J Surg 2004;91:1582-85

Distal - inferior border of gastrocnemius muscle (sural nerve) ZOC

Proximal - “fascial curve”2-3 cms. SPJ (2.8 cm)* Perivenous tumesence - push sural nerve

and tibial nerve away

Skin protection - 1-2 cms. Energy - same as GSV

*Wang XJ, Elias SM. Small saphenous vein ablation:

Reasons, risks,results. Poster session, AVF Annual

Meeting 2/07; San Diego , CA.

15 - 20 % of all litigation cases involve nerve injury

Even MIVS can cause nerve injury

Temporary or permanent

Nerve injury - tumescence and anatomy

awareness Nerve injury – not treatable and can be

permanent DVT - lower occurrence with proper

technique DVT - Treatable and temporary All may change with non thermal techniques Chemical, MOCA, Cyanoacrylate glue