Laser Therapy of Perforator Veins
Michael F. Bardwil M.D.,F.A.C.S.
Current Treatment
of Veins
Saphenous Veins
Laser Ablation
Varicose Veins
•Phlebectomy
•Foam Sclerotherapy
Telangectasia and
Reticular Veins
Sclerotherapy
Perforator Veins
Next area in treatment of
veins
Why does Vein Surgery Have
Such a Bad Reputation?
• Historically the procedures were morbid
• High incidence of recurrence perceived
as bad results
• Severe forms of venous insufficiency
including refluxing perforators resulted
in recurring stasis ulcers
Perforators Give Veins
A Bad Name
• Linton procedure had a reported
19% wound complication rate
Perforators Give Veins
A Bad Name
• Perforators are a more likely source
for recurrent varicose veins than
neo-vascularsation
• Recurrence is perceived as bad
results
Perforators Give Veins
A Bad Name
• Severe forms of venous insufficiency
including refluxing perforator veins
resulted in recurring stasis ulcers
Significance of
Perforator Veins
• Source for reflux in the superficial
venous system
• Reflux from perforator veins has been
associated with venous stasis ulcers
• Communication between deep and
superficial venous Systems
• Reflux from perforator veins can result
in varicose veins
Communication Between
Venous Systems
• Not all bad
• Allows patients to recover from vein
insults such as injuries and DVT
• Allows us to perform vein ablative
procedures on the saphenous and other
superficial veins
Communication Between
Venous Systems
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Not all good
Source for reflux in the saphenous vein
Associated with venous stasis ulcers
Reflux from perforators can cause non
saphenous varicose veins
• Source for new and recurrent varicose
veins
Types of Perforators
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Hunterian
Dodd’s
Boyd
Cockett’s
New Nomenclature
Hunterian and Dodd’s
Perforator
• Connect femoral and proximal popliteal
perforators to the saphenous vein
• Reflux from these perforator veins
results in varicose veins in the middle
and distal third of the medial thigh
• Stripping reportedly interrupts all but
8%?
Boyd’s Perforators
• Perforator just distal to the knee
• Connects saphenous veins to popliteal
vein
• Varicose veins medial leg upper third
• May appear as first place isolated reflux
• New nomenclature Paratibial
perforators
Cockett’s Perforators
• Cockett’s I perforator posterior to
medial malleolus
• Cockett’s II perforator 7-9cm
proximal
• Cockett’s III perforator 10-12 cm
proximal
• New nomenclature posterior tibial
Less Discussed
Perforators
Indications for
Treatment
• Venous Stasis Ulcer associated with
perforator vein 2-4 mm in size
Indication for
Treatment
• Large perforator vein 3-4mm noted
at the time of saphenous ablation
• Refluxing perforator 2-4 mm noted
at saphenous ablation
Indications For
Treatment
• Perforator veins refluxing into
varicose veins that are not
associated with long or short
saphenous reflux
Indications for
treatment
• Recurrent varicose veins that appear
to originating from refluxing
perforator
Indication for
Treatment
• Perforator veins refluxing into varicose
veins that are not associated with long or
short saphenous vein reflux
• Large perforator veins 2-4mm noted at
time of saphenous ablation
• Recurrent varicose veins that appear to
be originating from perforator
• Stasis ulcers associated with perforator
History
• Standard questions regarding symptoms
• Previous vein surgery
• Stasis Ulcers and previous treatment
Examination
• Physical exam with attention to pattern
of varicose veins
• Use the ultrasound as an extension of the
physical exam
• Photograph markings of perforator to be
treated
• Ulcers
• PPG to physiologically document venous
insufficiency
Problems with
Perforator Rx
• Linton procedure problem with wound
healing
• SEPS general anesthesia required
inconsistent results
• Ultrasound guided foam multiple
sessions inconsistent results, non
approved solution no code for
reimbursement
Future Meets Past
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In office procedure to treat perforators
Less morbid
Addresses non saphenous varicose Veins
Addresses sources of recurrence
Addresses stasis ulcers
Endoluminal Ablation
Perforators
Endoluminal Ablation
of Perforators
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Minimally invasive procedures
Office based
Local anesthesia
VNUS Closure
Laser ablation
My experience
VNUS Closure
• Device FDA approved
• Billing Code recommendation
• Recommended protocol using
ultrasound guidance and impedance to
verify position
Disadvantage VNUS
Closure
• Device awkward and expensive,
especially for add on perforator veins
• Protocol less effective than thought
• Impedance less useful than flash
• In general other closure procedures have
inferior results to laser
Laser Perforator
• Technically simpler
• Less expensive to perform; can treat
perforator at time of other veins and not
incur increase procedural costs
• Results should be superior to closure
Technical Issues
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Visualization
Broad based neck
Multiple perforator necks
Long Perforator necks
Technique My
Experience
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Micro puncture kit
Angio cath catheter
18 gauge thin wall angiogram needle
25 gauge “finder” needle
20 gauge needle with 400u fiber
20 gauge needle with 600u fiber
Laser setting
Use of foam
Micro-Introducer
• Advantage theoretically similar Elas
• Disadvantage not enough room to place
guide wire in far enough for introducer
Dr. Murphy technique use stiff end of
guide wire
Angiocath
• Advantage: Able to place without guide
wire
• Disadvantage: Needle may be in, but
laser not. Work with VNUS device
demonstrated proximity still only
applies to horse shoes and hand
grenades
18 gauge Angiogram
Needle
• Advantage: Direct access to vein
• Disadvantage: Still bulky, at times
difficult getting fiber through needle
20 Gauge Needle
400u Fiber
• Advantage: Easier to use technically to
access vessel
• Can access vessel at more than one spot
• Disadvantage: Inconsistent delivery of
Energy if Laser system made for 600u
fiber
How I Do It
• Always perform the venous duplex
yourself
• Mark the vein with patient standing or
sitting with feet dangling
• Strategically position patient
• Put the bed in reverse trendlenberg
How I Do It
• Re-map and mark patient in new position
• Use 25 gauge “finder” needle
• Place previously 2 inch stripped fiber through
20 gauge needle and mark with steri-strip
• Access vein with 20 gauge needle, use more
than one needle if necessary
• Inject local anesthesia after you are in vein
How I Do It
• Laser setting 15 watts intermittent 1.5 sec
duration, 1 sec rest
• Look for steam in vessel
• I usually deliver 200-300 joules
• Steri strip applied. 4x4,kerlex, co-ban
Follow Up
• 1-2 days remove wrap and ultrasound
• Low threshold to use foam at time of this
exam
Results
• In progress