A radiofrequency generator delivers high
frequency alternating electromagnetic energy
(radiofrequency) to the electrodes located at
the end of the catheter. There is a central
electrode surrounded by an outer group of
collapsible electrodes or tufts that make
contact with the vein wall. The radiowaves do
not conduct the heat but it is the resistance to
these waves in the surrounding tissue, causing
excitement of the molecules in the tissue that
cause resistive heating. The injection of
tumescence anesthesia to collapse the vein
ensures good contact between the vein wall
and outer electrodes. The vein is typically
heated to 850 C and a thermocouple in the tip
allows for accurate monitoring and automatic
maintenance of this temperature. The heat
induces venous spasm and collagen shrinkage,
damaging the vein wall, leading to occulsion.
Catheter pullback speeds are relatively slow
compared with laser, which heats the vein to
much higher temperature. However, a new
RFA catheter has been intriduced that has an
active element lenght 7 cm, allowing for rapid
treatment of sequential segments, and it is
possible that this will supersede the original
design (Dietzek , 2007).
Endovenous Laser Therapy
Laser (light amplification by stimulated
emission of radiation) creates high energy
bundled light that is monocromatic (all
wavelenght) and releases direct thermal energy
that heats both the blood and adjacent vein
wall, causing destruction of the cells in the
vein wall ( Van de Bos et al, 2008). The tip
reaches temperatures in thr region vein
increases the contact surface area. The term
fluence refers to the total amount of energy
applied per unit area and is measured in J/cm 2.
The laser energy deliveres to the veins
depends, amongst other factors, on the output
setting of the device and the pullback speed of
the catheter. The quicker the pullback
speed, the less energy is delivered to the
surface area of the vein. The energy produced
by the laser is sufficient to vaporize the blood,
crating bubbles that can be seen the ultrasound
image.
Ultrasound Equipment
Almost all modern ultrasound scanner used for
imaging peripheral venous disease should be
suitable for guiding endovenous procedures.
This also includes most portable scanners,
providing they have a large enough screen.
Typically, flat linear array tranducers with a
frequency in the range of 5 12 MHz are
suitable for guidance, providing good images
of wires and catheters. High frequency probe
can provide excellent resolution of the main
superficial venous trunks but may provide
suboptimal images of the SFJ or
saphenopopliteal junction in larger patients
and in certain cases could lead to problems in
the precise positioning of the catheter tip
relative to a junction. To ensure sterility of the
procedure, the tranducer can be placed in a
sterile probe cover containing ultrasound gel
with a sterile sleeve covering the transducer
cable.
The Procedure
A video showing key ultrasoun image of the
procedure is included on the DVD. A
pretreatment scan should have been performed
to ensure the vein are suitable for endovenous
treatment. In most case, the main trunk of the
GSV or SSV is treat other veins providing they
fulfill treatment criteria (Table 13.3). The
following detailed description is for EVLT
treatment of the GSV.
The patient should be in a supine position on
the treatment table. Prior to vein puncture, the
GSV should be scanned to identify the
optimum site for catheter access. Ideally for
the GSV, this is aroundthe knee level where
the vein is usually superficial and nerve injury
is less likely to occur. It is also useful to image
the SFJ to ensure that good images of the
junction can be obtained. This is also allows
operator to optimize the gray-scale image
controls for guiding the procedure. As the the vein. For patients undergoing a local
procedure is commenced, the operating table is anesthetic procedure, some local anesthetic
tilted in a foot down position to distend the can be injected into the skin at the
vein for easier identification and puncture of