Milleret Rene MD
Steam ablation of small saphenous vein and popliteal perforators
AUTHOR: Rene Milleret
Introduction: We have been using since 2008 a thermal technique based on the heat generated when water vapor condensates back to liquid: The Steam method. The ability of pressurized steam to flush through bends and tortuosity is a significant advantage over more rigid fibers or catheters.
Material and methods: The steam device comprises a generator, a heating hand-piece and a dedicated catheter. Steam temperature is 110 °C.
Surgical technique is similar to other thermal methods.
Ultra sound guided vein entrance is obtained by puncture with a 16 G, 48 mm Venflon®. When treating a Small Saphenous trunk the entry point is just above the medial posterior perforator to avoid heating the gastro cnemian vein
The catheter can be safely pushed up to 2 cm from the sapheno popliteal junction. If a common trunk with the gastro cnemian vein is found, we place the tip 1 cm from the junction of the two veins.
Tumescence is then applied around the vein under echo-guidance using Klein’s solution (1). A gaze soaked in cold saline is applied around the catheter at the entry point to cool down the skin and avoid any burn.
300 Joules are delivered on each of the first centimeter’s marks. Then the energy delivered In the vein depends on its pre-operative diameter measured on the patient standing.
Treating recurrences and Popliteal Fossa perforators may imply several punctions as it is usually not possible to negotiate sharp tortuosities.
Post operative care: All patients are treated for at least 1 week with a Low Molecular Weight heparin , expect those who are already under anti coagulation .If this is the case the treatment is not discontinued .
Patients with a personal and/or family history of thrombo-embolic disease are treated for 20 days. Venous trunks which have presented with a superficial venous thrombosis are not a contra-indication for the treatment but we wait for 18 months before ablating the vein with steam.
Results: We have treated 670 Small Saphenous Veins and 243 Popliteal Fossa Perforators between 2010 and 2016.
98 % of the patients have been controlled at 3/6 weeks to detect complications and check that the vein was closed. All the vein were closed on Duplex examination.
Complications were few:
— 3 cases of Deep Vein Thrombosis localized to a calf vein without pulmonary embolism,
— Paresthesia of the sural nerve was detected in 3,5% of the patients, it was long lasting in only 0,5% (still present at the 1 year control).
— No infection was reported.
— Skin burns at the entry point were seen in 2% of the patients but were superficial and healed spontaneously in 2 or 3 months.
Long term closure rates are: 94% at 1 year, going down to 88% at 3 years, 65% of patients
being followed up at this delay.
In Conclusion; Steam Ablation spares the patient and the surgeon the incision and dissection
of the Popliteal Fossa, which can be challenging in case of Redo Surgery.
Dr. Milleret is a vascular surgeon with a training in electronics .
He built his own Doppler machines since 1971 and used them to develop new techniques in Phlebology.
He performed the first deep vein valvuloplasty in Europe (1978), introduced Cryo-fibrosis and Cryo-stripping for ablation of Saphenous trunks. When endovenous surgery appeared he devised a Steam Ablation technique which allows thermal ablation of tributary veins perforators.
His current research is focused on Transcutaneous Ultrasonic methods to treat refluxing veins Non invasively, and on Prosthetic venous valves for deep venous insufficiency .