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Disclosure Lowell S. Kabnick, M.D., FACS,
FACPh,RPhS
I disclose the following financial relationship(s):
•Research Grant: BTG
•Ownership Interest: AngioDynamics, Vascular Insights
•Consultant/Advisory Board: AngioDynamics, BSN Jobst, Vascular Insights
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Small Saphenous Thermal
Ablation Lowell S. Kabnick, MD, RPhS, FACS, FACPh
Director, NYU Vein Center
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Courtesy JL Gerard
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Tibial nerve
Common Peroneal
Gastrocnemius nerve
SSV
Courtesy JL Gerard
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Anatomic Variations
• SSV joins the popliteal vein
at the Saphenopopliteal
Junction (SPJ) and joins
deep veins at a higher level
through its cranial extension
of the SSV or joins GSV via
the vein of Giacomini
Cavezzi A, Labropoulos N, Partsch H, Ricci S, Caggiati A, Myers K, Nicolaides A, and Smith PC. Duplex Ultrasound
Investigation of the Veins in Chronic Venous Disease of the Lower Limbs- UIP Consensus Document. Part II. Anatomy. Eur J
Vasc Endovasc Surg 2006; 31:288-299
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2nd Anatomic Variation
• SSV continues upwards
as the cranial extension
of the SSV or vein of
Giacomini but also
connects with the
popliteal vein through an
„anastomotic‟ tiny vein
Cavezzi A, Labropoulos N, Partsch H, Ricci S, Caggiati A, Myers K, Nicolaides A, and Smith PC. Duplex Ultrasound
Investigation of the Veins in Chronic Venous Disease of the Lower Limbs- UIP Consensus Document. Part II. Anatomy. Eur J
Vasc Endovasc Surg 2006; 31:288-299
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3rd Anatomic Variation
• SSV has no
connection to deep
veins- it continues
upward as the
cranial extension of
the SSV or vein of
Giacomini
Cavezzi A, Labropoulos N, Partsch H, Ricci S, Caggiati A, Myers K, Nicolaides A, and Smith PC. Duplex Ultrasound
Investigation of the Veins in Chronic Venous Disease of the Lower Limbs- UIP Consensus Document. Part II. Anatomy. Eur J
Vasc Endovasc Surg 2006; 31:288-299
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Other Veins
• Gastrocnemius veins may join the popliteal vein, proximal SSV, or their confluence at the SPJ
• SSV may merge with the gastrocnemius veins before joining the popliteal vein (10-30%)
Cavezzi A, Labropoulos N, Partsch H, Ricci S, Caggiati A, Myers K, Nicolaides A, and Smith PC. Duplex Ultrasound Investigation of
the Veins in Chronic Venous Disease of the Lower Limbs- UIP Consensus Document. Part II. Anatomy. Eur J Vasc Endovasc Surg
2006;31:288-99
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Incompetent Giacomini Vein
• Transmits reflux from
GSV or thigh
perforators and pelvic
veins to SSV through
the intersaphenous
anastomosis (IA)
Georgiev M, Myers K, and Belcaro G. The thigh extension of the lesser saphenous vein: From Giacomini‟s observations to
ultrasound scan imaging. J Vasc Surg 2003;37:558-63
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Cranial Extension of the SSV
• Continues straight up into the gluteal area as a single vein or divides in many deep and superficial branches
• Joins the deep femoral veins as a posterior or posterior lateral thigh perforator
• Connects to the posterior thigh circumflex vein which then passes to the GSV in the medial thigh (vein of Giacomini)
Caggiati A, Bergan J, Gloviczki P, Jantet G, Wendell-Smith C, Partsch H. Nomenclature of the veins of the lower limbs: An
international interdisciplinary consensus statement. J Vasc Surg 2002;36:416-22
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Saphenopopliteal Junction (SPJ)
• Most often 2-4cm
above the knee
crease
• Higher in 25-30%
• Rarely below knee
crease
Myers,Ken: Making Sense of Vascular Ultrasound, a hands on guide, 2004
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21 gauge Needle Insertion
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Micropuncture sheath
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Laser 4 Fr Sheath / RFA 6Fr
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Tumescent Anesthesia
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Tumescent Anesthesia
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“Walking the Line”
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Laser Fiber / RFA Catheter
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Placement of Sheath and Fiber
Fiber/RF placed
just before the SSV
“dives” to the popliteal
vein
2-3cms from the
Junction
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Let‟s Look at the SSV Literature
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Eur J Vasc Endovasc Surg 2009
Eur J Vasc Endovasc Surg 2009
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• 810 laser
– 14w @70J/cm
• 169 limbs
• Avg age 57
• 100% Closed at 3 months
• 1.3% sural nerve paresthesia
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J Vasc Surg. 2009 Apr;49(4):973-979.e1.
• Laser 980
• 226 SSV closure rate
98.7%
• Paresthesia rate
2.5%
• No EHIT2 (LMWH)
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• J Endovasc Ther 2009;16:500-505
• 940nm
– 14 w pulse 80-90j/cm
• 269 SSV
• 6.7% initial failure and 15% long term
• No parethesia reported
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980nm
210 limbs
Concomitant GSV reflux was present in
156 limbs (74 %), and these limbs
underwent EVLT of both the SSV and
the GSV
4% failure avg 4 month f/u
1.6% parasthesia
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88 (43 %) had type A anatomy
69 (33%) had type B anatomy
52 (24%) had type C anatomy.
EHIT 2 RATE
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EHIT 2
5.7 % EHIT 2
No clots present @ 2 to 11
months
Incidence of EHIT2 is higher
for the SSV than the GSV
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NYU VEIN CENTER
SSV
September 2007-December 2010
Total SSV 367
EHIT2 1.1%
SSV failures 2.72%
AVG US Follow up 145 days
Preliminary Data
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Volume 53, Issue 1,January 2011
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Steam Pilot Study
• 3 refluxing symptomatic SSV
• PROCEDURE
• 16 g needle USG into the SSV
• steam catheter (1.2-mm diameter) was
passed through the needle into the vein
until positioned 3 cm below the junction
• 1-2 puffs/cm steam generated at 120 C
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• 3/20 were SSV of the 20 axial veins
• All closed at 6months
• Pain score1/10
• No DVT etc
• Median satisfaction score 9.25/10
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Treating the Small Saphenous Vein AUGUST 2008 I ENDOVASCULAR TODAY
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Key Points
• 1. Harder than the GSV
• 2. Know the anatomical variations and
relationships
• 3. Endothermal Ablation is preferred in US
– Great outcomes
– Minimal morbidities