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Great Saphenous Vein Ablation | For Patients

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you are at first cause cardiovascular

Institute today and we're gonna be

showing you a procedure called great

saphenous vein ablation will be using

very a laser for this we have in my team

today Jason Roberts to my right Dana on

my left and spoke orally is that's me

our patient today is the lady with the

symptomatic severe venous insufficiency

of the right lower extremity as part of

her workup we have already done venous

insufficiency ultrasound on her and she

happens to have severe reflux and she is

symptomatic so we will be showing you

today how to access the great saphenous

vein under ultrasound guidance and how

to proceed with the procedure after that

and then once we complete the procedure

we'll show you what the post-op care

involves and how the patient should

comply with that so we'll begin a

procedure Jason

so let's take our positions

so first thing what's gonna happen is

that Jason is going to visualize this

great saphenous vein under ultrasound

guidance so you can see on the screen

there and Jason will point with where

the gsv in fact is so what we're going

to be doing its first and foremost we

need to follow the great saphenous vein

up the thigh and make sure that we got a

good clear run assessed for any branches

or any type of inter luminal material or

phlebitis or anything like that we have

a pretty good run all the way up to the

common femoral vein we can also see the

great saphenous vein here as it empties

into the common femoral vein the typical

sacrum junction yes and can you point

for them where the great saphenous vein

is coming in and where it goes into the

deep system absolutely so you can see

the great saphenous vein coming in from

the top here it actually drains down

into the common femoral vein which is

here and here's your traditional Mickey

Mouse right here here's your two years

and the common femoral vein itself and

the actual staff M Junction is here so

we'll open it up just a little bit kind

of take a look at the anatomy itself we

have a really nice run as you can see

coming in from here dumping into the

common femoral vein and then you can see

that gastric vein emptying in to the

same Junction as well we definitely

would like to preserve that so in

staging the case we're going to come

back probably two centimeters behind

that actual gastric vein so I think we

got a pretty good run so now the

assessment is for dr. Olle is do we want

to come below the knee or do we actually

want to access a little bit above the

knee either which way is I believe the

vein is a sizable enough for either

which way yes so in this patient guys we

have already done an ultrasound and she

has had previous ablation as well so her

below the knee gsv is partially closed

so we're going to try to access it just

above where it recognizes and then our

hope is to go ahead and go do a

successful ablation of the rest of the

vein so we'll begin our procedure now so

here is just a hypodermic needle and I'm

going to be numbing up the skin just

above the

and you can see the very top of the

screen that little I'm gonna compress

her right here so you can see it kind of

winking at you this one's a little bit

more superficial so it's gonna take a

little bit more technical ability to

grab this one but I got good confidence

in dr. Ali over here thank you so what I

do generally guys is I press it with my

finger to see exactly where I'm going to

be accessing it and you can see the

depression on the screen so now I'm

going to give a little numbing your

honey a little bit of pinch coming up

for you okay here's my lighter can so

you don't want to give too much because

then you lose where the the vein

actually is going on if you can focus on

this needle and show them how I'm trying

to just access a little pinch here so on

the screen you guys see my needle so I

will there I'm going in now and that's

the needle

and that's moving nice and smoothly so

that tells me that I'm in the vein but

again this Wayne is being treated before

such the wire sort of hangs up in the

walls which is which can happen so now

I'm in there and yes and you can show

them you know how the wire went smoothly

so this was good for you guys to to see

typically it's very easy to access the

vein and you can advance the bar without

any problem but issues like this can

happen as well especially in previously

tweeted great saphenous veins that are

partially thrombosed so you may have

some technical challenges and then again

so what you typically do is ask your

scenographer to scan the vein a little

bit more cephalad

and then find a spot that is nice and

free of any previous rhombus and then

you can advance of are free and then we

confirm our by position Jason can you

show them that sure you can see it here

this is the transverse shot so you can

actually see the bright echogenic wire

inside the vein and it's good to look at

it in two views just make sure it stays

inside the vein and it doesn't exit and

then you can also get a better shot of

it along here so you can see on this on

the picture here you can see how

tortuous the actual vein is and the wire

inside of it so this will actually grab

the wire like dr. Olle said and it'll

give you a little bit of resistance so

you know you know on a scale of one to

ten I think the access was definitely a

nine you know and then understanding the

anatomy is the best part of it so and

then we like I said one more time that

you can take a look at it and long you

can see the wire inside the vein as it

goes up so we got a pretty good run so

once we actually put the dilator in

it'll straighten out we'll actually

straighten out this little area here and

give us probably hopefully a good smooth

run Jason will now load this catheter on

this show them if you can paid yes he

loads them on this on this 45 wire so

this isn't over the wire system and in

the case like this I think you really

want to have a wire handy especially

since we knew that we were actually

getting into a procedure that had been

previously of a bladed and it was

actually a tortuous vein so I just

basically advanced it on this and

sometimes you can have an issue with the

skin being a little bit thick

but this went in very smoothly as you

notice this catheter is marked so it's a

60 centimeter catheter and it has

markings at every centimeter so we are

about where we need to be so now Dana's

going to attach the fiber to the actual

pulse generator wonderful are you doing

all right any okay very good

let me go ahead just hold it here for

now once this sheath is in position what

we want to do is we want to take one

more additional check because the actual

fiber sticks out of the front of the

catheter two centimeters so basically

what we're gonna do is we're gonna look

at again and we're going to confirm one

more time our position and let me just

find everything so as you can figure it

please focus on the screen where you can

see the most echogenic structure in the

middle is the fiber is the laser fiber

itself and what Jason is doing is he's

putting these two muscles around the

parameter space so to sort of create an

insufflation around the vein so patient

will not experience any discomfort

during this procedure it is hydrophilic

right catheter itself yeah so it will

slide so just double check we have

plenty of room so you want to be about

two centimeters distal to the Safin

ephemeral junk there's the junction

we're a little over two centimeters

would you safer because if you do have

if you do oblate close to that what

you're trying to avoid is a formation of

a sail of a blood clot and then

potentially having a blood clot go to

your lungs so all right so we're ready

to go so it's very important to see once

I start and when I once I activate the

laser that you can actually see the vein

being collapsed behind the catheter what

actually is happening is there is

denaturation of the protein in the wall

of the vein so basically that's what

we're trying to achieve so we're ready

to go and you can actually see the laser

catheter firing and the vein closing in

front of your eyes right behind the cap

that's the catheter actually close in

the vein so I'm doing a very nice slow

pullback and I've already timed it to

what I need to be and you know you can

keep a good a good little compression on

with pro pressure on to the vein to make

sure you really have a good adherence to

the beam itself onto the catheter that's

what the tumescence does as well but you

can also apply a little bit of pressure

on the way out and that's generally the

recommendation

so now we just sit back and we just do a

nice slow pullback now there are some

automated pullback catheters available

as well that are on a rail but we tend

to use the man will pull back which is

worked very fine

very nicely for us so we're getting very

close to our exit point yeah so once

you're at these little tiny markers that

tells you that you're at the end of the

catheter and I am pretty much out and I

will stop right here and then Jason

holds manual pressure and then so this

concludes our laser procedure from the

stick to the end what we do now is we

will wrap this leg in a clean dressing

and then what patient goes home six

hours later they can remove that

dressing and then put a compression

stocking on which they're going to use

for two weeks we do tell them that they

should avoid taking a bath or getting

into a tub within the first 24 to 48

hours of the procedure because we would

like the access point to heal also as

our protocol we bring the patient back

after 48 hours for a repeat ultrasound

of the leg because we want to make sure

that they don't have a DVT now the risk

of that is very very low but again like

I as I pointed to you guys that it's

definitely a possibility

besides that we encourage your patients

to walk because the more they walk the

better the healing is we can also give

them some anti-inflammatory

post-procedure that they can use if they

experience any pain so little bit of

bruising is expected sometimes some

redness and erythema and we have used

Jason in the past some antibiotics if

you get superficial flu virus or sort of

an infection around the skin area which

is all those things are very rare and I

would say the incidence is less than 5%

so if you can direct your attention

towards Jason now he's going to wrap

this leg up and you can see it's not

bleeding which is a good closure

hemostasis should be actually pretty

quick since we actually did a thermal

on the way out so hemostasis should come

pretty quick I'm not saying that they're

all this quick but I'm saying it should

be relatively expedient post procedure

so as you can see and then as you can

see here this is all that's really left

here's the hole access point from the

actual procedure it's no bigger than a

pencil lid so we closed

you know the whole entire side with

about a pencil lid okay let's wrap bro

so basically it's just a bulky dressing

it's no big deal some institutions

outfit them with their stockings I don't

really think that we need to do that I

think we put a nice wrap on it so we're

gonna start in the ankle and then we're

gonna come up gonna keep this here like

I said we have hemostasis so we're

pretty much good with that but like I

said we're not gonna fit her in her

stockings right now so I'm gonna put a

good bulky wrap underneath here we put

the tumescence in the leg it's going to

come out there's nothing to stop that we

found that if we keep them in their

stocking when they leave it tends to get

wet and soggy and you know nobody

generally likes that so we're gonna wrap

her up nice and send her home and in the

morning she can cut this one off and put

her stocking on so hang on let me get

this going

so we'll do the same thing so not too

tight but enough that it gives a little

good good support around exactly and if

any any point feels tight to the patient

they can actually cut it off remove it

depend unique then you just relax on

okay yeah okay let's pick it up one more

time okay let me have one more yeah I'm

gonna get all this out of the way so we

go like this

almost I'm going to wrap it back up a

little bit higher

you're gonna do additional wrapping yeah

I'm just gonna wrap it up can you bend

any honey bend it there you go good yeah

okay guys so this concludes our

procedure and thank you very much Jason

and thank you Dana for assisting me in

this procedure and thank you very much

from goodbye from Jacksonville Florida

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