Cranial Tributary Ablation of the Saphenofemoral Junction during Laser Crossectomy of the Great Saphenous Vein.

Online December 7, 2021 doi: 10.3400/avd.oa.21-00066 Ann Vasc Dis Vol. 14, No. 4; 2021; pp 355–361 Original Article Cranial Tributary Ablation of the Saphenofemoral Junction during Laser Crossectomy of the Great Saphenous Vein Tsuyoshi Shimizu, MD, PhD,1,2 Yoshio Kasuga, MD, PhD,3 and Takeshi Shimizu, MD, PhD2 Objectives: Anterior accessory saphenous vein (AASV) insufficiency is one of the most common causes of recurrent varicose veins after endovenous thermal ablation (EVTA) for great saphenous vein (GSV) insufficiency. The purpose of this study was to evaluate the efficacy and safety of cranial tributary ablation (CTA) during laser crossectomy (LC) of the GSV. Methods: We reviewed 182 limbs in 171 patients undergoing EVTA aiming for LC with a 1470-nm diode laser. In the CTA group, either the superficial circumflex iliac vein or the superficial epigastric vein was directly ablated during LC. The result was compared between the CTA (n=63) and control (n=119) groups using follow-up duplex ultrasound performed for 6 months after EVTA. Results: Initial success rate of CTA was 69%. The AASV occlusion rate (90% vs. 63%, p<0.001) and the flush GSV occlusion rate (68% vs. 30%, p<0.001) at 6 months were better in the CTA group. No major adverse events were observed. Conclusion: CTA during LC of the GSV is a safe and effective approach to achieve better flush or AASV occlusion rates after EVTA. It is occasionally technically demanding but can be a feasible option. Further investigation is needed to confirm our results. 1 Department of Cardiovascular Surgery, Nagano Matsushiro General Hospital, Nagano, Nagano, Japan 2 Cosmos Nagano Clinic, Nagano, Nagano, Japan 3 Department of Surgery, Nagano Matsushiro General Hospi- tal, Nagano, Nagano, Japan Received: May 27, 2021; Accepted: October 21, 2021 Corresponding author: Tsuyoshi Shimizu, Cosmos Nagano Clinic, 380 Oshimada, Nagano, Nagano 381-2212, Japan Tel: +81-26-285-2654, Fax: +81-26-285-2732 E-mail: ©2021 The Editorial Committee of Annals of Vascular Diseases. This article is distributed under the terms of the Creative Commons Attribution License, which permits use, distribution, and reproduction in any medium, provided the credit of the original work, a link to the license, and indication of any change are properly given, and the original work is not used for commercial purposes. Remixed or transformed contributions must be distributed under the same license as the original. Annals of Vascular Diseases Vol. 14, No. 4 (2021) Keywords: varicose veins, endovascular procedures, catheter ablation, endovenous laser ablation, recurrent varicose veins Introduction Long-term results of endovenous thermal ablation (EVTA) for great saphenous vein (GSV) incompetence are still controversial1); however, neoreflux in incompetent tributaries, such as the anterior accessory saphenous vein (AASV), is one of the most common causes of recurrence after EVTA.2,3) On the other hand, this type of recurrence is less,2,4) and neovascularization5) is more common after high ligation and stripping because all saphenofemoral junction (SFJ) tributaries are generally ligated (flush ligation) at the time of surgery. Therefore, flush occlusion of the SFJ or the proximal GSV after EVTA can be associated with better long-term results without increasing the risk of neovascularization. Laser crossectomy (LC), in other words flush ablation or high ablation, is a promising approach; however, flush occlusion or AASV occlusion rates after LC are not always satisfactory. AASV flow was occasionally restored after flush occlusion of the GSV. Flow restoration or recanalization in the AASV developed either subsequent to or simultaneously with flow restoration in the cranial tributaries, such as the superficial circumflex iliac vein (SCI) or the superficial epigastric vein (SEV). Therefore, we believe that cranial tributary ablation (CTA) of the SFJ during LC could be associated with better flush occlusion rates or better AASV occlusion rates. The purpose of this study is to investigate the efficacy of this new approach. Methods Study design We retrospectively analyzed 182 limbs in 171 patients undergoing EVTA aiming for LC of the GSV with a 1470-nm diode laser (ELVeS Radial 2 Ring™, Biolitec GmbH, Wiesbaden, Germany) since Jan 2017. Patients who underwent direct AASV ablation were excluded. Patients were 355 Shimizu T, et al. Fig. 1 Positioning of the fiber tip during endovenous thermal ablation and flush occlusion. (A) Duplex ultrasound shows the fiber tip positioned close to the saphenofemoral junction (SFJ) proximal to the superficial epigastric vein (SEV) for laser crossectomy. (B) Duplex ultrasound shows the fiber tip inserted into the superficial circumflex iliac vein (SCI) for cranial tributary ablation. (C) Duplex ultrasound shows flush occlusion of the great saphenous vein obstructed just at the SFJ 3 months after laser crossectomy with concomitant superficial circumflex iliac vein ablation. (D) The great saphenous vein remained occluded at the SFJ 6 months after endovenous ablation (C and D are images from the same patient). divided into two groups based on the treatment performed on their limbs: the CTA group (63 limbs), which underwent CTA during LC, and the control group (119 limbs), which underwent LC alone. Patients in whom CTA was attempted but unsuccessful (28 limbs) were classified into the control group. Follow-up examinations using duplex ultrasound were performed for 6 months after EVTA, and the results were compared between the groups. LC technique The target GSV and the SFJ, including its tributary distributions, were assessed using duplex ultrasound before EVTA. The fiber was delivered into the GSV and advanced to the SFJ. Ablation was commenced at about 5 mm from the SFJ (Fig. 1A). High energy (300–500 J/cm) was applied to the proximal portion (1–2 cm) of the GSV with the femoral vein (FV) compressed in the Trendelenburg position. CTA technique The fiber was delivered into the GSV and advanced up to the SFJ. Under ultrasound guidance, the fiber tip was introduced into the SCI or the SEV. To visualize the SEV, 356 the GSV, and the fiber in the same longitudinal plane, the probe was tilted laterally. To visualize the SCI, the probe was tilted medially, and the fiber was directed laterally. The operator held the probe with the hand and manipulated the fiber with the other hand from the body surface to direct the fiber tip toward the orifice of the SCI/SEV. The assistant advanced the fiber approximately 10 mm into the SEV/SCI (Fig. 1B). The time for fiber cannulation into the SEV/SCI was limited within approximately 5 min. After tumescent local anesthesia, the tributary was directly ablated with 50–100 J. Subsequently, the fiber tip was taken out to the proximal GSV and advanced toward the SFJ, and the proximal GSV was ablated close to (5 mm) the SFJ using the crossectomy technique as described previously. Initial success of CTA was defined as the target tributary (...truncated)