This document discusses thermal ablation as an alternative to surgery for treating great saphenous veins. It notes that randomized trials show thermal ablation is at least non-inferior to surgery for procedural success and clinical outcomes, with improved patient quality of life. The advantages of thermal ablation are outlined as being totally outpatient, avoiding sutures and reducing risks of infection, lymphatic damage, and limitations from anticoagulation. Key steps for performing thermal ablation are described, including patient selection, setting, ultrasound use, catheter placement skills, tumescent anesthesia, and ensuring sufficient heat delivery to the vein wall for durable success. Various technologies for heat delivery are mentioned, and segmental ablation is noted to allow faster patient recovery compared

1. Great Saphenous Vein
Thermal Ablation
Thomas M Proebstle

2. Disclosure
Thomas M. Proebstle, M.D.
I disclose the following financial relationship(s):
•Consultant/Advisory Board: Sapheon

3. Background
for Thermal Ablation of Great Saphenous Veins
- High ligation and Stripping was a brilliant idea
more than 100 years ago
- Today, numerous prospective randomized trials
comparing thermal ablation to surgery show at
least non-inferiority for procedural success and
clinical results, but improved periprocedural QoL

4. Background
for Thermal Ablation of Great Saphenous Veins
- High ligation and Stripping was a brilliant idea
more than 100 years ago
- Today, numerous prospective randomized trials
comparing thermal ablation to surgery show at
least non-inferiority for procedural success and
clinical results, but improved periprocedural QoL

5. Advantages (personal selection)
of Thermal Ablation of Great Saphenous Veins
- Totally Outpatient
- No sutures to be removed
- Infections only sporadically reported
- No lymphatic damage in the groin
- Even Coumadin can stay at an INR of 2.0 – 2.5
- Immediate return to normal Life

6. Checkpoints
for Thermal Ablation of Great Saphenous Veins
- Indication
- Appropriate Outpatient Setting
- Ultrasound Technology available throughout
intervention
- Catheter and Local Anesthesia Placement Skills
- Heat Delivery Technology and Technique
- Post Tx Care, LMWH, Stockings as required

7. Indication
for Thermal Ablation
of Great Saphenous Veins
Pathological reflux in the GSV
linked to Venous Disease related
Clinical Signs or Complains
 CEAP / VCSS

8. Thermal Ablation of
Great Saphenous Veins
Appropriate Outpatient Setting
- Minor OR providing Air Condition
- Tilt Table for Trendelenburg and reverse position
- Laser Safety if necessary
- Dimmable Lights for Ultrasound exams
- Organized Office staff, on-call phone numbers

9. Thermal Ablation
of Great Saphenous Veins
Ultrasound Technology must be
available during intervention
- 8 to 12 MHz or more Linear Scanner
- Color Duplex and PW-Mode
- Sterile Drapings for Probe and Ultrasound-Keyboard

10. Thermal Ablation of
Great Saphenous Veins
Catheter and Local Anesthesia Placement Skills
 all injections to be performed ultrasound-directed
- Puncture Skills !!!
- placement of catheter or laser fiber at the SFJ not too
ambitious, today 2 cm distance recommended !!

11. Thermal Ablation of
Great Saphenous Veins
Tumescent Local Anesthesia
Saline with 0.05% Lidocaine
1 mg epinephrine per 1000 cc, 10cc bicarbonate 8.4%
- Pain Control
- Collapsing the GSV around the heat source
- Thermal insulation of the surrounding tissue

12. Rule #1
for Thermal Ablation of Saphenous Veins
durable success is linked to
sufficient dosing of Heat Energy
to the Vein Wall

13. Recanalization 12 months after thermal ablation
of the GSV with respect to the administered EFE
940 nm laser – bare fiber
Proebstle TM et al: Reduced recanalization rates of the great saphenous vein after
endovenous laser treatment with increased energy dosing: definition of a threshold for
the endovenous fluence equivalent. J Vasc Surg (2006) 44:834-9.

14. Question #1
for Thermal Ablation of Saphenous veins
How gentle can Heat Energy
be delivered to the Vein Wall ?
Which is the best System ?

15. Thermal Ablation of
Great Saphenous Veins
Heat Delivery Technology and Technique
> 10 years: RF old style
810, 940, 980 nm diode lasers
1064, 1320 nm Nd:YAG lasers
< 5 years: RF-Segmental
1470 nm diode lasers
pressurized overheated steam
New Fiber Tips: spherical, covered, radial
Hb H2O

16. 8 W, 1 mm/s control 5 W, 0.5 mm/s
20 mm 13 mm 8 mm
control 15 W 30 W
940 nm1320 nm
Thermal Ablation of Great Saphenous Veins
Water versus Hemoglobin absorbed Laser Wavelengths

17. Covered Fiber Tips
ceramics bare fiber tip
metal
radial

18. RA Weiss, Dermatol Surg (2002) 28:56
RFA 1st generation versus 810 nm Diode Laser

19. Thermal Ablation of Great Saphenous Veins
Prospective Randomized Trials on Patients´ Recovery
Almeida JI et al. Radiofrequency endovenous ClosureFAST versus
laser ablation for the treatment of great saphenous reflux: a
multicenter, single-blinded, randomized study (RECOVERY study).
J Vasc Interv Radiol. 2009;20:752-9.
Shepherd AC et al. Randomized clinical trial of VNUS ClosureFAST
radiofrequency ablation versus laser for varicose veins.
Br J Surg 2010;97:810-8.
Segmental Thermal Ablation shows faster recovery
compared to 980 nm bare fiber ablation proven by
VCSS and QoL instruments

20. Disclosure
Standard Error below 1% at all times
95.7%

21. Disclosure

22. future Questions
for thermal Ablation of the Great Saphenous Vein
How does Segmental Ablation compare to
- water absorbed laser wavelengths ?
- Latest laser fiber tip technology ?
There are new concepts arriving:
is the end of the Age of Heat already in sight?
Will we turn to become gluers instead of burners?