Q&A

1-3 mrn/sec. I would recommend 1 mm/sec for the first 12 cm, 2 mm for the next part of the vein and 3 mm/sec for the lower part of the vein, any superficial vein or the majority of the SSV. Delivery of the thermal energy is best discussed as the number of joules deposited per cm of treated vein. It has been shown that an average delivery of 70 ]/cm results in successful closure in all cases. In most cases, following endovenous laser the tributary varicosities will shrink by 4 weeks and subsequent ambulatory phlebectomy or sclerotherapy are made easier. Ambulatory phlebectomy may also be offered at the time of the endovenous laser. However, with a significant number of tributary varicose veins this prolongs the procedure and may increase the risk of deep vein thrombosis. It has been observed that the larger untreated tributary varicosities are at a higher risk of spontaneous thrombosis following ablation of the inflow truncal incompetence in spite of GCS use. It is reasonable to consider concurrent treatment of these larger tributaries (8-10 mm in diameter), particularly those in the thigh. Others defer treatment of all tributaries suggesting the phlebectomies of these veins are easier after they shrink in size. Post procedurally, patients are placed in a class II GCS (30-40 mmHg) for 1-4 weeks depending on the size of their tributary varicosities. Longer duration GCS use is recommended for the larger untreated tributary varicosities to minimize the risk of spontaneous occlusion with a significant amount of blood. Patients have essentially little or no down time after this procedure. Ambulation of at least 1 hour a day for the first week is recommended and the patients are asked to avoid only very strenuous exercise, hot tubs and long hot showers. A moderate amount of bruising, last up to 2-3 weeks, probably related to the tumescent anesthesia delivery, is present in most cases. Some soreness over the vein in the first 24 hours after the procedure is normal and palliated with Tylenol and GCS. About 1 week after the procedure the patients usually feel a pulled muscle feeling as the vein cicatrizes both circumferentially and longitudinally. This is also palliated with ambulation, stretching, GCS and Advi!. Several cases series have been published in the literature or presented at recent meetings reviewing the success of endovenous laser. The reported clinical success of this procedure at 12 month follow up, defined as lack of flow within the treated portions of the great saphenous veins (GSV) range from 90-99%. (2-6) Pooled data demonstrate a low complication rate with no DVT or skin burns and a 0.25% risk of transient parasthesia. The data for endovenous laser are remarkable when compared with historical controls for surgery. The cumulative success of the endovenous laser at two years using pooled data is 94%. At 2-year follow-up, the failure rate for surgery is already 25% and at 5 years 28% (7-9). Given the fact that most of the laser failures occur < 1

year and that most of the surgical recurrence have occurred by 2 years it is certain that the success of the endovenous laser is at least as good and probably superior to ligation and stripping.

References 1. Khilnani NM and Min RJ. Imaging of Venous Insuffi-

ciency. Seminars of Interventional Radiology. Accepted; anticipated publication Fall 2004/Spring 2005. 2. Min RJ, Khilnani NM and Zimmet S. Endovenous laser treatment of saphenous vein reflux. ]VIR 2003; ]4: 991-6. 3. Proebstle TM, Gul D, Lehr HA, eta!' Infrequent early recanalization of GSV after endovenous laser treatment. J Vasc Surg 2003; 38:511-6. 4. Todd K Fronek H, Isaacs M, Mackay E and Oearson D. Endovenous laser treatment: a twelve month evaluation of 291 patients. J Vasc Intery Radiol 2004:S144 5. Roisental M. EVT for the incompetent greater and lesser saphenous veins. J Vasc Interv Radiol 2003: 211 6. Mackay E. Transcatheter greater saphenous vein ablation with endovenous laser and ultrasound guided tumescent anesthesia. IVAC 2004. 7. Blomgren L,Johansson G, Dahlberg-A, eta!' Recurrent varicose veins: incidence, risk factors and groin anatomy. Eur J Vasc Endovasc Surg 2004; 27:269-74 8. Sarin S, Scurr JH, Coleridge Smith PD. Stripping of the long saphenous vein in the treatment of primary varicose veins. Br J Surg 1994; 81: 1455-8 9. Dwerryhouse S, Davies B, Harradine K and Farnshaw JJ. Stripping of the long saphenous vein reduces the rate of reoperation for recurrent varicose veins; 5-year results of a randomized tria!' J Vasc Surg 1999; 29: 589-92.

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Q&A 9:00 a.m.

Sclerotherapy: Principles and Techniques Steven Zimmet, MD Zimmet Vein and Dermatology Clinic Austin, T.X Sclerotherapy has been relatively widely practiced in Europe, especially in France, Germany and Switzerland, since the 1940's. Interest in the United States has increased significantly, in part due to the revolution in non-invasive diagnostic techniques, over the last 15 years. Sclerotherapy is used to treat telangiectasias, reticular veins and bulging varicose veins. Incompetent perforators and saphenous veins can be treated using ultrasound-guided sclerotherapy 0,2). The aim of sclerotherapy is to obliterate incompetent veins in order to improve appearance, symptoms and/or complications of venous disease. Treatment that is too

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