Combined techniques : How to

ablate varices during endovenous

surgery ?
R.Milleret , D.Valean , M.Fodor
 To treat During or After ?
• Conflicting studies but a majority
is in favor of simultaneous treatment .
• It’s true that tributaries directly connected
to the trunk will shrink, but we have no
predictive technique which could be
applied to an individual patient.
 Treating Saphenous Tributaries
• 4 techniques available :
Invasive :
--- Mini-Phlebectomies
--- Cryo-Phlebetomy
Non Invasive :
--- Foam sclerotherapy
--- Steam Phlebectomy
 Methods
• Mini – Phlebectomies :
--- Tumescent anesthesia
--- Needle puncture
--- Hook grasping
--- Sub cutaneous dissection ,
Varady spatula
--- Suture or no suture ?
 Cryo-Phlebectomy
• 1,5 mm rigid probes
• 10 to 15 cm length
• Incision with N°11 blade
• Tumescent anesthesia
• Catheterization when possible
• OR extraction by external freezing
 Foam sclerotherapy
• Less concentration than usual , 0,5%
to 1% Aetoxy .
• Echo guided , from the thigh to the ankle
• Catheter delivered if straight segments
• Compression Tumescence after injection
• ( Start technique , AA Ramelet )
 Steam Phlebectomy
• Steam will travel through the tortuosities
• All introducers in place before heating
• General anesthesia or sedation more adapted
• Cooling tumescence before and after steam
injection : compression of the vein .
* Large veins can be treated
Catheter in the 17 G Venflon
 Results
• NO STUDIES ABOUT RE OPENING OF VEINS
3 TO 6 MONTHS AFTER :
--- Foam Sclerotherapy
--- Mini Phlebectomies
--- Cryo-Phlebectomy

* Thousands of papers on Saphenous Trunks …

 Steam : Trib vein study
• 3 centers : Nicolini , Hartung , Milleret
• 30 members on 26 patients

• Age : 54 +- 13 years
• Sexe : 55,2% women
• Anesthésie : General = 67,9%
 Material
• 92 tributaries
• Diameters 6,4 +- 3,1 mm
• Length 8 cm+- 5,1
• Pulse/cm 2,3 +-0,9

• Entry Points : 4,9 +6 2,4

If Phlebectomies 13,1 +- 6,4 (P<0,0001)
 Results
• Post Op Pain : 0,7/10
• Occlusion :
95,7 % 3 months
95,7 % 6 months
• Patient’s evaluated cosmetic results :
92 % 3 months
100 % 6 months
 Randomized study of Steam
Phlebectomy versus Foam obliteration
of superficial tributaries
 Material
• 2 groups of 20 patients each,randomized .
• Location of varices : Anterior Accessory ,
Internal Calf
Posterior Calf
* Diameter of varices : 3 to 10 , mean 6 mm .
 Methods
• Foam : 1% Polidocanol ,
Tessari tourbillon technique,
6 to 10 cc in one session (Tegernsee)

• Steam : 3 to 6 pulses/location
3 to 6 18G / 20 G infusion catheters
* Eccentric compression .
 Post Op at 8 days
Foam Steam

Inflammation 6/20 0/20

Pain ( scale of 10 ) 2,4 0,5

 Results at 1 month
Foam Steam

Blood extraction 12/20 6/20

Pigmentation 12/20 4/20

 Results at 6 months
Foam Steam

Pigmentation 4/18 2/19

Cosmetic result 10/18 15/19

(patient’s evaluation
Good/very good)
 Elements of choice
• Young woman , thin legs :
Mini-Phlebectomies / Cryo phlebectomies

Because risk of pigmentation with foam ,

Vein still palpable for some months after
steam .
 Opposite case
• Man with big bulging varicose veins

Steam best option , painless , no diameter

limit .
Phlebectomies can be added as these veins
are quite resistant and we can ablate
long segments through one incision
 Foam
• Combined with phlebectomies when all the
veins cannot be removed : Accessory
Anterior Saphenous trunk for intance .
• Foam then Tumescence then Phlebectomy
• Thus excess foam is removed through the
phlebectomy incisions = less risk of
pigmentation .
 Specific problems
• Lipodermatosclerosis : avoid incisions ,
Steam = less inflammatory reactions
can obliterate perforators
• Superficial thrombosis : phlebectomy
thrombectomy
but trunk can be treated by heating
technique .
 V Box : 1 Box , 2 techniques
• Segmental Radio-Frequency ablation
for Saphenous trunks ,

• Low Pressure Steam for Tributaries

• Just plug in to the mains , and connect

the RF catheter or the Single Use Steam
hand-piece
THE V box single use hand piece
 Conclusion
• Choice of technique depends on the
availability of the equipment : cryo , steam .
• Phlebectomy combined with Foam
offers a cheap way to treat these veins .
• Scientific studies are far behind in this area
as compared with Saphenous vein ablation.