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Min J, Hwang JH, Park SW, Hwang JJ, Kim JS, Lee SA, Chee HK. Radiofrequency ablation for the treatment of great saphenous venous insufficiency using a newly developed VENISTAR catheter: A preliminary study. Vascular 2024:17085381241250112. [PMID: 38662409 DOI: 10.1177/17085381241250112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
OBJECTIVES This study was aimed to assess the preliminary outcomes of radiofrequency ablation (RFA) using a newly developed catheter (VENISTAR) for the treatment of incompetent great saphenous veins (GSVs). METHODS In this prospective observational study, endovenous RFA using a VENISTAR catheter was performed on 16 saphenous veins in 12 patients between August and November 2019. Patients' pre- and post-procedural data were recorded. Doppler ultrasound imaging and clinical evaluation were performed at 1 week and 1, 3, and 6 months to determine the efficacy and safety of the treatment. RESULTS Technical success and complete closure of the targeted GSVs immediately after the procedure were observed in all 16 limbs (100%). However, one patient (one limb) was found to have partial occlusion without significant reflux after 1 week of follow-up. Kaplan-Meier analysis yielded a complete occlusion rate of 93% at 6 months of follow-up. The Venous Clinical Severity Scores at the time of all follow-up were significantly lower than those at baseline (3.3 ± 1.1 at baseline to 0.6 ± 0.6, 0.3 ± 0.6, 0.1 ± 0.4, and 0.2 ± 0.4 at 1 week and 1, 3, and 6 months, respectively) (p < .001). Mild post-procedural pain was noted in 7 and 4 limbs at 1 week and 1 month, respectively. Grade 1 ecchymosis over the ablated segment was noted in 5 (35.7%) of 14 limbs at 1-week follow-up. CONCLUSIONS Endovenous treatment of GSV insufficiency using a new VENISTAR radiofrequency catheter has been shown to be feasible, effective, and safe throughout the 6-month follow-up.
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Affiliation(s)
- Jeeyoung Min
- Department of Radiology, Konkuk University School of Medicine, Seoul, Korea
| | - Jin Ho Hwang
- Department of Radiology, Konkuk University School of Medicine, Seoul, Korea
| | - Sang Woo Park
- Department of Radiology, Konkuk University School of Medicine, Seoul, Korea
| | - Jae Joon Hwang
- Department of Thoracic and Cardiovascular Surgery, Konkuk University School of Medicine, Seoul, Korea
| | - Jun Seok Kim
- Department of Thoracic and Cardiovascular Surgery, Konkuk University School of Medicine, Seoul, Korea
| | - Song Am Lee
- Department of Thoracic and Cardiovascular Surgery, Konkuk University School of Medicine, Seoul, Korea
| | - Hyun Keun Chee
- Department of Thoracic and Cardiovascular Surgery, Konkuk University School of Medicine, Seoul, Korea
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Nielsen AG, Croucher AA, Muschamp SD, Losty E, Worthington T, Kiely MJ, Whiteley MS. Linear endovenous energy density (LEED) should always be quoted with the power used in endovenous thermal ablation - results from an in-vitro porcine liver model study. Phlebology 2023; 38:172-180. [PMID: 36749579 DOI: 10.1177/02683555231156015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Linear Endovenous Energy Density (LEED) is the energy used per cm of vein in endovenous thermal ablation (EVTA) but does not include time. This study examines the effect of time during EVTA. METHOD EVTA was performed in a previously validated porcine liver model. LEEDs of 40, 60, 80 and 100 J/cm, using different powers were repeated 5 times each. Thermal spread, tissue carbonisation and device-tissue sticking during treatment were recorded. RESULT LEED positively correlated to thermal spread and carbonisation of the tissue. Power was correlated with carbonisation but not thermal spread. Pullback had no correlations with thermal spread or carbonisation. Catheter sticking found occurred in powers >= 15 W or LEED >= 80 J/cm. CONCLUSION LEED is a good measure of EVTA but does not include time. Power, which does include time, correlates with carbonisation and with device-tissue sticking. The power used must be quoted with the LEED.
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Pannier F, Noppeney T, Alm J, Breu FX, Bruning G, Flessenkämper I, Gerlach H, Hartmann K, Kahle B, Kluess H, Mendoza E, Mühlberger D, Mumme A, Nüllen H, Rass K, Reich-Schupke S, Stenger D, Stücker M, Schmedt CG, Schwarz T, Tesmann J, Teßarek J, Werth S, Valesky E. S2k guidelines: diagnosis and treatment of varicose veins. DER HAUTARZT; ZEITSCHRIFT FUR DERMATOLOGIE, VENEROLOGIE, UND VERWANDTE GEBIETE 2022; 73:1-44. [PMID: 35438355 PMCID: PMC9358954 DOI: 10.1007/s00105-022-04977-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/23/2022] [Indexed: 11/29/2022]
Affiliation(s)
- F Pannier
- Praxis für Dermatologie und Phlebologie, Helmholtzstr. 4-6, 53123, Bonn, Germany.
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4
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Whiteley MS. Current Best Practice in the Management of Varicose Veins. Clin Cosmet Investig Dermatol 2022; 15:567-583. [PMID: 35418769 PMCID: PMC8995160 DOI: 10.2147/ccid.s294990] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/27/2022] [Indexed: 12/01/2022]
Abstract
This article outlines the current best practice in the management of varicose veins. “Varicose veins” traditionally means bulging veins, usually seen on the legs, when standing. It is now a general term used to describe these bulging veins, and also underlying incompetent veins that reflux and cause the surface varicose veins. Importantly, “varicose veins” is often used for superficial venous reflux even in the absence of visible bulging veins. These can be simply called “hidden varicose veins”. Varicose veins usually deteriorate, progressing to discomfort, swollen ankles, skin damage, leg ulcers, superficial venous thrombosis and venous bleeds. Patients with varicose veins and symptoms or signs have a significant advantage in having treatment over conservative treatment with compression stockings or venotropic drugs. Small varicose veins or telangiectasia without symptoms or signs can be treated for cosmetic reasons. However, most have underlying venous reflux from saphenous, perforator or local “feeding veins” and so investigation with venous duplex should be mandatory before treatment. Best practice for investigating leg varicose veins is venous duplex ultrasound in the erect position, performed by a specialist trained in ultrasonography optimally not the doctor who performs the treatment. Pelvic vein reflux is best investigated with transvaginal duplex ultrasound (TVS), performed using the Holdstock-Harrison protocol. In men or women unable to have TVS, venography or cross-sectional imaging is needed. Best practice for treating truncal vein incompetence is endovenous thermal ablation. Increasing evidence suggests that significant incompetent perforating veins should be found and treated by thermal ablation using the transluminal occlusion of perforator (TRLOP) approach, and that incompetent pelvic veins refluxing into symptomatic varicose veins in the genital region or leg should be treated by coil embolisation. Bulging varicosities should be treated by phlebectomy at the time of truncal vein ablation. Monitoring and reporting outcomes is essential for doctors and patients; hence, participation in a venous registry should probably be mandatory.
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5
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Ielpo B, Pueyo-Périz EM, Radosevic A, Andaluz A, Berjano E, Grande L, Sánchez-Velázquez P, Burdío F. Clinical case report: endoluminal thermal ablation of main pancreatic duct for patients at high risk of postoperative pancreatic fistula after pancreaticoduodenectomy. Int J Hyperthermia 2021; 38:755-759. [PMID: 33941013 DOI: 10.1080/02656736.2021.1917703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
PURPOSE Multiple attempts have been made to manage the pancreatic stump and the pancreatic duct in order to reduce the rate of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD), however radiofrequency-based technologies could help to achieve this goal. Previous encouraging clinical and experimental results support the use of endoluminal thermal ablation (ETHA) of the main pancreatic duct to reduce pancreatic exocrine secretion and hence POPF. We here describe our initial clinical experience with ETHA of the main pancreatic duct in two cases at high risk of POPF. METHODS Two cases underwent PD for malignancy with a high risk of POPF (adenocarcinoma, obese patients, surgical difficulties with heavy intraoperative blood loss, soft pancreas or walled-off pancreatitis and a tight small pancreatic main duct). In both cases, ETHA of the main pancreatic duct was conducted intraoperatively just before Blumgart-type pancreatic-jejunal anastomosis using a ClosureFast catheter (Medtronic, Mansfield, MA, USA) normally used for varicose vein treatment (therefore an off-label use). RESULTS Although a clear radiological POPF was detected in the second case, the clinical postoperative course in both cases was uneventful. Little pancreatic fluid collected in the abdominal drainage with low levels of amylase enzyme, confirming low exocrine pancreatic function. No other procedure-related complications were detected. CONCLUSION Endoluminal thermal ablation of the main pancreatic duct may be a feasible and safe technique to reduce the adverse effects of POPF after PD.
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Affiliation(s)
- Benedetto Ielpo
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Eva M Pueyo-Périz
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | | | - Anna Andaluz
- Departament de Medicina i Cirurgia Animals, Facultat de Veterinària, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Enrique Berjano
- BioMIT, Department of Electronic Engineering, Universitat Politècnica de València, Valencia, Spain
| | - Luis Grande
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Patricia Sánchez-Velázquez
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Fernando Burdío
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
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Barnat N, Grisey A, Gerold B, Yon S, Anquez J, Aubry JF. Vein wall shrinkage induced by thermal coagulation with high-intensity-focused ultrasound: numerical modeling and in vivo experiments in sheep. Int J Hyperthermia 2021; 37:1238-1247. [PMID: 33164625 DOI: 10.1080/02656736.2020.1834626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Varicose veins are a common disease that may significantly affect quality of life. Different approaches are currently used in clinical practice to treat this pathology. MATERIALS AND METHODS In thermal therapy (radiofrequency or laser therapy), the vein is directly heated to a high temperature to induce vein wall coagulation, and the heat induces denaturation of the intramural collagen, which results macroscopically in vein shrinkage. Thermal vein shrinkage is a physical indicator of the efficiency of endovenous treatment. High-intensity focused ultrasound (HIFU) is a noninvasive technique that can thermally coagulate vein walls and induce vein shrinkage. In this study, we evaluated the vein shrinkage induced in vivo by extracorporeal HIFU ablation of sheep veins: six lateral saphenous veins (3.4mm mean diameter) were sonicated for 8 s with 3MHz continuous waves. Ultrasound imaging was performed before and immediately post-HIFU to quantify the HIFU-induced shrinkage. RESULTS Luminal constriction was observed in 100% (6/6) of the treated veins. The immediate findings showed a mean diameter constriction of 53%. The experimental HIFU-induced shrinkage data were used to validate a numerical model developed to predict the thermally induced vein contraction during HIFU treatment. CONCLUSIONS This model is based on the use of the k-wave library and published contraction rates of vessels immersed in hot water baths. The simulation results agreed well with those of in vivo experiments, showing a mean percent difference of 5%. The numerical model could thus be a valuable tool for optimizing ultrasound parameters as functions of the vein diameter, and future clinical trials are anticipated.
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Affiliation(s)
- Nesrine Barnat
- Physics for Medicine Paris, Inserm, ESPCI Paris, CNRS, PSL Research University, Paris, France.,Theraclion, Malakoff, France
| | | | | | | | | | - Jean-François Aubry
- Physics for Medicine Paris, Inserm, ESPCI Paris, CNRS, PSL Research University, Paris, France
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Dabbs EB, Riley MI, Davies CE, Bishop OH, Whiteley MS. Pattern of thermal damage and tissue carbonisation from endovenous radiofrequency ablation catheter - Using an in vitro porcine liver model. Phlebology 2020; 36:489-495. [PMID: 33308029 DOI: 10.1177/0268355520975539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Successful endovenous thermoablation relies on transmural vein wall ablation. We investigated the pattern of thermal spread and tissue carbonisation from RadioFrequency-induced ThermoTherapy (RFiTT) at different powers and pull back methods, using a porcine liver model. METHODS We used a previously validated in-vitro porcine liver model. Different powers from 5-25 W were used to administer 150 J. We compared continuous and pulsed energy delivery. Length, lateral spread, and total area of thermal damage, together with any tissue carbonisation, was measured using digital analysis software. RESULTS All experiments used 150 J total energy. Total thermal damage area was smaller with lower power and pulsed energy. Continuous energy caused more tissue carbonisation than pulsed except at 25 W. CONCLUSION Reduced thermal damage with lower power or pulsed energy results from cooling due to increased time of treatment. Increasing the power increases tissue carbonisation. Optimal treatment is determined by the highest power used continuously that does not cause tissue carbonisation.
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Affiliation(s)
| | | | | | | | - Mark S Whiteley
- The Whiteley Clinic, Guildford, UK.,Faculty of Health and Biomedical Sciences, University of Surrey, Guildford, UK
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8
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Barnat N, Grisey A, Gerold B, Yon S, Anquez J, Aubry JF. Efficacy and safety assessment of an ultrasound-based thermal treatment of varicose veins in a sheep model. Int J Hyperthermia 2020; 37:231-244. [PMID: 32133898 DOI: 10.1080/02656736.2020.1734672] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Purpose: Varicose veins are a common pathology that can be treated by endovenous thermal procedures like radiofrequency ablation (RFA). Such catheter-based techniques consist in raising the temperature of the vein wall to 70 to 120 °C to induce vein wall coagulation. Although effective, this treatment option is not suited for all types of veins and can be technically challenging.Materials and methods: In this study, we used High-Intensity Focused Ultrasound (HIFU) as a non-invasive thermal ablation procedure to treat varicose veins and we assessed the long-term efficacy and safety of the procedure in a sheep model. In vivo experiments were first conducted on two saphenous veins to measure the temperature rise induced at the vein wall during HIFU ablation and were compared with reported RFA-induced thermal rise. Thermocouples were inserted in situ to perform 20 measurements during 8-s ultrasound pulses at 3 MHz. Eighteen saphenous veins of nine anesthetized sheep (2-2.5 % Isoflurane) were then exposed to similar pulses (85 W acoustic, 8 s). After treatments, animals recovered from anesthesia and were followed up 30, 60 and 90 days post-treatment (n = 3 animals per group). At the end of the follow-up, vein segments and perivenous tissues were harvested and histologically examined.Results: Temperatures induced by HIFU pulses were found to be comparable to reported RFA treatments. Likewise, histological findings were similar to the ones reported after RFA and laser-based coagulation necrosis of the vein wall, thrombotic occlusions and vein wall fibrosis.Conclusion: These results support strongly the effectiveness and safety of HIFU for ablating non-invasively veins.
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Affiliation(s)
- Nesrine Barnat
- Physics for Medicine Paris, Inserm, ESPCI Paris, CNRS, PSL Research University, Paris, France.,Theraclion, Malakoff, France
| | | | | | | | | | - Jean-François Aubry
- Physics for Medicine Paris, Inserm, ESPCI Paris, CNRS, PSL Research University, Paris, France
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9
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Sevil F, Colak A, Ceviz M, Kaya U, Becit N. The Effectiveness of Endovenous Radiofrequency Ablation Application in Varicose Vein Diseases of the Lower Extremity. Cureus 2020; 12:e7640. [PMID: 32399372 PMCID: PMC7216314 DOI: 10.7759/cureus.7640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We aimed to determine the outcome, complications, and quality of life effects of radiofrequency ablation (RFA) in the treatment of superficial venous insufficiency. A total of 134 extremities from 100 patients were evaluated in this retrospective study performed at the Cardiovascular Surgery Department of Atatürk University Faculty of Medicine. Treatment success was determined by occlusion. The clinical, etiologic, anatomic, and pathophysiologic (CEAP) and venous clinical severity score (VCSS) scores of patients were assessed pre- and postoperatively to evaluate clinical outcome and quality of life. The pain was assessed with the Wong-Baker score. Complications and their frequency were assessed and recorded. Treatment success, as measured by occlusion rate, was 99% percent. Prior to treatment, the CEAP clinical score was C2 (81.0%), while after treatment, it was C0 (54.0%) (p<0.001). The pretreatment median VCSS score was 5 (min-max: 1-9) while the post-treatment median was 1 (min-max: 1-3) (p<0.001). The mean pain score was 1.34; only one patient reported a score of 6 while the minimum score was 1. A total of 15 complications occurred; only one was a major complication (deep vein thrombosis or DVT) while the remaining 14 were minor complications. While longstanding surgical treatments still provide significant success, the RFA technique not only surpasses them in success rate but also in terms of pain, complications, and better patient satisfaction. The results of our study indicate that RFA is an effective and safe option for the treatment of superficial venous insufficiency.
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Affiliation(s)
- Fehimcan Sevil
- Cardiovascular Surgery, Afyon Health Sciences University, Afyon, TUR
| | - Abdurrahim Colak
- Cardiovascular Surgery, Ataturk University School of Medicine, Erzurum, TUR
| | - Münacettin Ceviz
- Cardiovascular Surgery, Ataturk University School of Medicine, Erzurum, TUR
| | - Uğur Kaya
- Cardiovascular Surgery, Ataturk University School of Medicine, Erzurum, TUR
| | - Necip Becit
- Cardiovascular Surgery, Afyon Medical Sciences University, Afyon, TUR
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Agrawal S, Saber W. Venous Ablation. Interv Cardiol Clin 2020; 9:255-263. [PMID: 32147125 DOI: 10.1016/j.iccl.2019.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Chronic venous insufficiency is a common and a highly prevalent vascular disorder, that occurs as a result of venous reflux owing to defective venous valves, which in turn causes venous hypertension with significant symptom burden that can interfere with quality of life. Therapeutic strategy involves lowering the venous pressure by lifestyle changes, compression therapy, and conventional catheter-based thermal ablation and novel nonthermal, nontumescent techniques of ablating the affected veins.
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Affiliation(s)
- Sahil Agrawal
- Warren Clinic Cardiology of Tulsa, Saint Francis Hospital, 6161 South Yale Avenue, Tulsa, OK 74136, USA
| | - Walid Saber
- Interventional Vascular Services, Non-invasive Vascular Lab, Landmark Medical Center, Woonsocket, RI, USA; Brown University, Providence, RI, USA; Oceanstate Cardiovascular & Vein Center, 191 Social Street, Suite 100, Woonsocket, RI 02895, USA.
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Pérez JJ, Ewertowska E, Berjano E. Computer Modeling for Radiofrequency Bipolar Ablation Inside Ducts and Vessels: Relation Between Pullback Speed and Impedance Progress. Lasers Surg Med 2020; 52:897-906. [DOI: 10.1002/lsm.23230] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2020] [Indexed: 12/18/2022]
Affiliation(s)
- Juan J. Pérez
- BioMIT, Department of Electronic Engineering Universitat Politècnica de València Valencia Spain
| | - Elżbieta Ewertowska
- BioMIT, Department of Electronic Engineering Universitat Politècnica de València Valencia Spain
| | - Enrique Berjano
- BioMIT, Department of Electronic Engineering Universitat Politècnica de València Valencia Spain
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12
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Nyamekye IK, Dattani N, Hayes W, Harding D, Holloway S, Newman J. A Randomised Controlled Trial Comparing Three Different Radiofrequency Technologies: Short-Term Results of the 3-RF Trial. Eur J Vasc Endovasc Surg 2019; 58:401-408. [DOI: 10.1016/j.ejvs.2019.01.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 01/28/2019] [Indexed: 12/18/2022]
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13
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Ewertowska E, Andaluz A, Moll X, Aguilar A, Garcia F, Fondevila D, Quesada R, Trujillo M, Burdío F, Berjano E. Development of a catheter-based technique for endoluminal radiofrequency sealing of pancreatic duct. Int J Hyperthermia 2019; 36:677-686. [PMID: 31317817 DOI: 10.1080/02656736.2019.1627585] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Introduction: Endoluminal sealing of the pancreatic duct by glue or sutures facilitates the management of the pancreatic stump. Our objective was to develop a catheter-based alternative for endoluminal radiofrequency (RF) sealing of the pancreatic duct. Materials and methods: We devised a novel RF ablation technique based on impedance-guided catheter pullback. First, bench tests were performed on ex vivo models to tune up the technique before the in vivo study, after which endoluminal RF sealing of a ∼10 cm non-transected pancreatic duct was conducted on porcine models using a 3 Fr catheter. After 30 days, sealing effectiveness was assessed by a permeability test and a histological analysis. Results: The RF technique was feasible in all cases and delivered ∼5 W of power on an initial impedance of 308 ± 60 Ω. Electrical impedance evolution was similar in all cases and provided guidance for modulating the pullback speed to avoid tissue sticking and achieve a continuous lesion. During the follow-up the animals rate of weight gain was significantly reduced (p < 0.05). Apart from signs of exocrine atrophy, no other postoperative complications were found. At necropsy, the permeability test failed and the catheter could not be reintroduced endoluminally, confirming that sealing had been successful. The histological analysis revealed a homogeneous exocrine atrophy along the ablated segment in all the animals. Conclusions: Catheter-based RF ablation could be used effectively and safely for endoluminal sealing of the pancreatic duct. The findings suggest that a fully continuous lesion may not be required to obtain complete exocrine atrophy.
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Affiliation(s)
- Elżbieta Ewertowska
- a BioMIT, Department of Electronic Engineering , Universitat Politècnica de València , Valencia , Spain
| | - Anna Andaluz
- b Departament de Medicina i Cirurgia Animals, Facultat de Veterinària , Universitat Autònoma de Barcelona , Barcelona , Spain
| | - Xavier Moll
- b Departament de Medicina i Cirurgia Animals, Facultat de Veterinària , Universitat Autònoma de Barcelona , Barcelona , Spain
| | - Adrià Aguilar
- b Departament de Medicina i Cirurgia Animals, Facultat de Veterinària , Universitat Autònoma de Barcelona , Barcelona , Spain
| | - Felix Garcia
- b Departament de Medicina i Cirurgia Animals, Facultat de Veterinària , Universitat Autònoma de Barcelona , Barcelona , Spain
| | - Dolors Fondevila
- b Departament de Medicina i Cirurgia Animals, Facultat de Veterinària , Universitat Autònoma de Barcelona , Barcelona , Spain
| | - Rita Quesada
- c Department of Experimental and Health Sciences , Universitat Pompeu Fabra , Barcelona , Spain
| | - Macarena Trujillo
- d BioMIT, Department of Applied Mathematics , Universitat Politècnica de València , València , Spain
| | - Fernando Burdío
- e Department of Surgery , Hospital del Mar , Barcelona , Spain
| | - Enrique Berjano
- a BioMIT, Department of Electronic Engineering , Universitat Politècnica de València , Valencia , Spain
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14
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Andaluz A, Ewertowska E, Moll X, Aguilar A, García F, Fondevila D, Quesada R, Berjano E, Grande L, Burdío F. Endoluminal radiofrequency ablation of the main pancreatic duct is a secure and effective method to produce pancreatic atrophy and to achieve stump closure. Sci Rep 2019; 9:5928. [PMID: 30976043 PMCID: PMC6459817 DOI: 10.1038/s41598-019-42411-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 04/01/2019] [Indexed: 02/06/2023] Open
Abstract
Radiofrequency energy has been used both experimentally and clinically to manage the pancreatic remnant after distal pancreatectomies. Our goal was to determine whether endoluminal radiofrequency (RF) ablation of the main pancreatic duct in large animals would be more efficient than glue occlusion as an exocrine pancreatic atrophy-inducing procedure. Thirty-four Landrace pigs were assigned to either the transpapilar (n = 16) or transection (n = 18) groups. The transection implied the pancreas neck was severed. In each of these groups the remaining distal pancreatic duct was occluded either by RF or by glue. In the transpapilar group complete atrophy was observed in all the RF cases, while atrophy was incomplete in all the members of the glue subgroup. The failure rate of the main pancreatic duct (usually expressed by a pseudocyst) in the transection groups was dramatically higher in the glue subgroup than the RF subgroups (9 out of 9 and 1 out of 9, respectively) and postoperative mortality occurred only in the glue subgroup (3 out of 9). These results show the superiority of endoluminal RF ablation over glue for main pancreatic duct occlusion, as seen by the degree of atrophy and fewer postoperative pancreatic fistulas.
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Affiliation(s)
- Anna Andaluz
- Departament de Medicina i Cirurgia Animals, Facultat de Veterinària, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Elzbieta Ewertowska
- BioMIT, Department of Electronic Engineering, Universitat Politècnica de València, Valencia, Spain
| | - Xavier Moll
- Departament de Medicina i Cirurgia Animals, Facultat de Veterinària, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Adrià Aguilar
- Departament de Medicina i Cirurgia Animals, Facultat de Veterinària, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Félix García
- Departament de Medicina i Cirurgia Animals, Facultat de Veterinària, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Dolors Fondevila
- Departament de Medicina i Cirurgia Animals, Facultat de Veterinària, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Rita Quesada
- Department of Surgery, Hospital del Mar, Barcelona, Spain
| | - Enrique Berjano
- BioMIT, Department of Electronic Engineering, Universitat Politècnica de València, Valencia, Spain
| | - Luís Grande
- Department of Surgery, Hospital del Mar, Barcelona, Spain
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15
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Quehe P, Alavi Z, Kurylo-Touz T, Saliou AH, Badra A, Baudino L, Gladu G, Ledan F, Haudebourg R, Gestin S, Bressollette L. Endovenous Celon radiofrequency-induced thermal therapy of great saphenous vein: A retrospective study with a 3-year follow-up. SAGE Open Med 2018; 6:2050312118794591. [PMID: 30891243 PMCID: PMC6416801 DOI: 10.1177/2050312118794591] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 07/20/2018] [Indexed: 01/20/2023] Open
Abstract
Objective: Our main objective was to evaluate the short- and long-term efficacy of Celon radiofrequency-induced thermal therapy for endovenous treatment of incompetent great saphenous vein. The secondary objectives were to report on possible short-term side effects and complications. Methods: This was a retrospective study of 112 consecutive patients included between 2013 and June 2015. These patients were treated (146 great saphenous vein, C2–C6) either at the hemodynamic room using local anesthesia or at the operating theater under general anesthesia with or without phlebectomy. All patients received radiofrequency-induced thermal therapy at 18 W power, 1 s/cm pullback rate and 5–7 pullbacks per segment of 10 cm (i.e. maximum 10 pullbacks). A clinical follow-up via ultrasound monitoring was done at 1 week, 1 month, 6 months, 1 year, 2 years and 3 years. Results: The 3-year survival occlusion rate was 96.71% and 98% for overall and radiofrequency-induced thermal therapy patients, respectively. No major side effects were observed. A case of endovenous heat-induced thrombosis was reported. Slight neurological disorders were reported (0.88%). Conclusion: Our unit’s endovenous Celon radiofrequency-induced thermal therapy of incompetent great saphenous vein was efficient, well tolerated, without major side effects. Moreover, in order to reduce possible neurological disorders, we advise multiple pullbacks at 1 s/cm and using tumescence anesthesia.
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Affiliation(s)
- Philippe Quehe
- L'unité d'écho-doppler et de médecine vasculaire, CHRU La Cavale Blanche, Brest, France
| | - Zarrin Alavi
- Inserm CIC 1412, CHRU La Cavale Blanche, Brest, France
| | - Tatiana Kurylo-Touz
- L'unité d'écho-doppler et de médecine vasculaire, CHRU La Cavale Blanche, Brest, France
| | | | - Ali Badra
- Service de la chirurgie vasculaire, CHRU La Cavale Blanche, Brest, France
| | - Laurent Baudino
- L'unité d'écho-doppler et de médecine vasculaire, CHRU La Cavale Blanche, Brest, France
| | | | - Frederik Ledan
- L'unité d'écho-doppler et de médecine vasculaire, CHRU La Cavale Blanche, Brest, France
| | - Raphaël Haudebourg
- L'unité d'écho-doppler et de médecine vasculaire, CHRU La Cavale Blanche, Brest, France
| | - Simon Gestin
- L'unité d'écho-doppler et de médecine vasculaire, CHRU La Cavale Blanche, Brest, France
| | - Luc Bressollette
- L'unité d'écho-doppler et de médecine vasculaire, CHRU La Cavale Blanche, Brest, France
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Abstract
Varicose veins are a very common condition and have been the subject of a recent proliferation of treatment modalities. The advent of the endovenous treatment era has led to a confusing array of different techniques that can be daunting when making the transition from traditional surgery. All modalities offer excellent results in the right situation, and each has its own treatment profile. Thermal ablation techniques have matured and have a reassuring and reliable outcome, but the arrival of nonthermal techniques has delivered further options for both patient and surgeon. This article provides an overview of the different treatment devices and modalities available to the modern superficial vein surgeon and details the currently available evidence and summation analysis to help surgeons to make an appropriate treatment choice for their patients.
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Affiliation(s)
- Amjad Belramman
- 1 Section of Vascular Surgery, Imperial College London, London, United Kingdom
| | - Roshan Bootun
- 1 Section of Vascular Surgery, Imperial College London, London, United Kingdom
| | - Tristan R A Lane
- 1 Section of Vascular Surgery, Imperial College London, London, United Kingdom.,2 Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Alun H Davies
- 1 Section of Vascular Surgery, Imperial College London, London, United Kingdom.,2 Imperial College Healthcare NHS Trust, London, United Kingdom
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Badham GE, Dos Santos SJ, Lloyd LBA, Holdstock JM, Whiteley MS. One-year results of the use of endovenous radiofrequency ablation utilising an optimised radiofrequency-induced thermotherapy protocol for the treatment of truncal superficial venous reflux. Phlebology 2017; 33:298-302. [DOI: 10.1177/0268355517696611] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background In previous in vitro and ex vivo studies, we have shown increased thermal spread can be achieved with radiofrequency-induced thermotherapy when using a low power and slower, discontinuous pullback. We aimed to determine the clinical success rate of radiofrequency-induced thermotherapy using this optimised protocol for the treatment of superficial venous reflux in truncal veins. Methods Sixty-three patients were treated with radiofrequency-induced thermotherapy using the optimised protocol and were followed up after one year (mean 16.3 months). Thirty-five patients returned for audit, giving a response rate of 56%. Duplex ultrasonography was employed to check for truncal reflux and compared to initial scans. Results In the 35 patients studied, there were 48 legs, with 64 truncal veins treated by radiofrequency-induced thermotherapy (34 great saphenous, 15 small saphenous and 15 anterior accessory saphenous veins). One year post-treatment, complete closure of all previously refluxing truncal veins was demonstrated on ultrasound, giving a success rate of 100%. Conclusions Using a previously reported optimised, low power/slow pullback radiofrequency-induced thermotherapy protocol, we have shown it is possible to achieve a 100% ablation at one year. This compares favourably with results reported at one year post-procedure using the high power/fast pullback protocols that are currently recommended for this device.
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Affiliation(s)
| | - Scott J Dos Santos
- The Whiteley Clinic, Guildford, UK
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | | | | | - Mark S Whiteley
- The Whiteley Clinic, Guildford, UK
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
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18
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Badham GE, Dos Santos SJ, Whiteley MS. Radiofrequency-induced thermotherapy (RFiTT) in a porcine liver model andex vivogreat saphenous vein. MINIM INVASIV THER 2017; 26:200-206. [DOI: 10.1080/13645706.2017.1282520] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
| | - Scott J. Dos Santos
- The Whiteley Clinic, Guildford, Surrey, UK
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK
| | - Mark S. Whiteley
- The Whiteley Clinic, Guildford, Surrey, UK
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK
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19
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Abstract
SummaryBackground: In the search of alternative techniques to high ligation and stripping (HL/S) in the treatment of varicose veins, catheter-ablation methods have been implemented since 1998. Besides endovenous laser techniques (ELT) radiofrequency ablation (RFA) is a successful device in treating insufficiency of the Great (GSV) and Small saphenous vein (SSV). Methods: This review article sums up publications on Closure Plus™, ClosureFAST™, RFITT® (Celon Method), and EVRF®. It discusses the actually favorized treatment protocols and study results. Results of meta-analysis are presented, too.Results: The Closure Plus™ catheter was the first radiofrequency technique to be licensed in Europe in 1998. Trials and meta-analyzes show occlusion rates of 81–89 % after 5 years. The consecutive technique was the ClosureFAST™ (CLF) catheter that was introduced in 2007 and offered more standardization in treatment. Published data show occlusion rates of 98 % after 5 years and low profile on complications. Also in 2007 a bipolar radiofrequency technique called RFITT was presented. Due to lack of standards in treatment protocol it could not get accepted as well as CLF despite of good treatment results (92–98 % occlusion rates after 12 months) and low complications. A new RFA device called EVRF® shows weak evidence so far.Conclusion: Radiofrequency ablation of varicose veins has become a well-established treatment alternative to HL/S mostly represented by CLF.
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Goodyear SJ, Nyamekye IK. Radiofrequency ablation of varicose veins: Best practice techniques and evidence. Phlebology 2015; 30:9-17. [DOI: 10.1177/0268355515592771] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Scope of the review This article systematically reviews the practice of radiofrequency ablation of lower limb varicose veins. We present the clinical evidence and best practice techniques for currently available devices. Methods Manufacturer’s instructions-for-use were requested for all radiofrequency devices. The MEDLINE and EMBASE databases were searched using the following keywords: ‘varicose veins’ AND ‘radiofrequency’ OR ‘radio frequency’ OR ‘Venefit’ OR ‘ClosureFAST’ OR ‘RFiTT’ OR ‘EVRF’ OR ‘VeinCLEAR’, generating 240 articles. Titles and abstracts were screened, yielding 63 articles directly relevant to the scope of the review. Reference lists for publications were also searched to identify further manuscripts of relevance. The Cochrane Database and current National Institute for Clinical and Healthcare Excellence guidelines for varicose veins were also searched from relevant articles. Results Four radiofrequency ablation (RFA) systems are currently commercially available. Generic practice methods (common to all RF systems) and device-specific techniques are described. The weight of current evidence relates to the use of Covidien Venefit™ (formerly VNUS ClosureFAST™), which clearly demonstrates clinical advantages over open surgery at least to 2 years follow up. However, contemporary studies of the radiofrequency-induced thermal therapy device (RFiTT®), show that in experienced hands, clinical equivalence to the Venefit™ procedure can be achieved. The evidence base for EVRF® and VeinCLEAR™ devices is currently weak and absent, respectively. Conclusions Despite widespread uptake of RFA and acceptance of its clinical advantages over open surgery there is a paucity of Class 1 A evidence. This results from incongruent reporting of clinical outcome measures within existing literature. Similarly, lack of long-term follow-up studies precludes comparison of the durability of short- and medium-term advantages of RFA with the longer term results of open surgery. There remains scope for a large prospective high-quality trial to assess the clinical, anatomical and cost-effectiveness outcomes for the four commercially available RFA devices, with a particular focus on long-term follow up.
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Affiliation(s)
- Stephen J Goodyear
- Department of Vascular Surgery, Worcestershire Royal Hospital, Charles Hastings Way, Worcester, UK
| | - Isaac K Nyamekye
- Department of Vascular Surgery, Worcestershire Royal Hospital, Charles Hastings Way, Worcester, UK
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21
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Broe M, Shaikh FM, Leahy A. Endovenous radiofrequency ablation: no value in short-term duplex ultrasound follow-up. Ir J Med Sci 2014; 184:641-5. [PMID: 25218239 DOI: 10.1007/s11845-014-1194-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 09/02/2014] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Endogenous radiofrequency ablation (RFA) is a proven treatment for varicose veins that has equal efficacy to surgical stripping. It offers the benefit of reduced post operative pain and wound infection and quicker return to work. AIM To carry out a clinical audit of patients undergoing RFA to monitor outcomes, complication rates, follow-up sclerotherapy and to assess the need for post-operative duplex scan. METHODS A retrospective analysis was performed of 174 procedures carried out from January 2011 to March 2012. Patients were pre-assessed with history, physical exam and duplex ultrasound. They were followed up at 3 months with same. CEAP classification was applied to check for post-operative improvement. RESULTS 174 procedures, including 165 great saphenous vein and 9 short saphenous vein ablations were carried out on 154 patients. The duplex occlusion rate at 3 months was 99 %. 141 patients (81 %) showed a reduction in CEAP score with average CEAP decreasing from 2.37 to 0.96. Overall the complication rate was low at 7 %. Paraesthesia was the most common complication with 7 cases (4 %). There were no DVTs. 45.4 % of patients went on to have follow-up sclerotherapy for venous flares. CONCLUSION RFA is a safe and effective treatment for varicose veins. There is no benefit in performing routine short term follow-up duplex scan due to the high occlusion rates.
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Affiliation(s)
- M Broe
- Department of Surgery, Beaumont Hospital, Dublin, Ireland,
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22
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Badham GE, Strong SM, Whiteley MS. An in vitro study to optimise treatment of varicose veins with radiofrequency-induced thermo therapy. Phlebology 2014; 30:17-23. [DOI: 10.1177/0268355514552005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To develop a reproducible method of using radiofrequency-induced thermotherapy with adequate thermal spread to ablate the whole vein wall in a truncal vein but avoiding carbonisation, device sticking and high impedance “cut outs” reducing interruptions during endovenous treatments. Methods Porcine liver was treated with radiofrequency-induced thermotherapy under glass to allow measurements, observation and video recording. Powers of 6–20 W were used at varying pullback speeds to achieve linear endovenous energy densities of 18–100 J/cm. Thermal spread, carbonisation of treated tissue and high-impedance cut outs were recorded. Results The currently recommended power settings of 18 and 20 W produced sub-optimal results. If pulled back at 3 s/cm to achieve linear endovenous energy densities around 60 J/cm, tissue carbonisation and high impedance cut outs occurred. When high powers and fast pullbacks of 1 s/cm were used, no carbonisation or cut outs occurred but thermal ablation of the liver model was below target due to reduced time for thermal conduction. Low powers (6–12 W) with slow pullbacks (6–12 s/cm) achieved target thermal ablation with minimal carbonisation and high impedance cut outs. Conclusions Using low power (6 W) and a slow discontinuous pullback (6 s every 0.5 cm, in steps), we were able to achieve our target thermal ablation in the porcine liver model without carbonisation and high impedance cut outs. This suggests the currently recommended power levels could be reduced, reducing the need to remove the device to clean the electrodes during treatment while achieving target thermoablation of the treated tissue.
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Affiliation(s)
| | | | - Mark S Whiteley
- The Whiteley Clinic, Guildford, Surrey, UK
- Faculty of Health and Biomedical Sciences, University of Surrey, Guildford, Surrey, UK
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23
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Newman J, Meecham L, Walker R, Nyamekye I. Optimising Treatment Parameters for Radiofrequency Induced Thermal Therapy (RFiTT): A Comparison of the Manufacturer's Treatment Guidance with a Locally Developed Treatment Protocol. Eur J Vasc Endovasc Surg 2014; 47:664-9. [DOI: 10.1016/j.ejvs.2014.01.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Accepted: 01/20/2014] [Indexed: 11/16/2022]
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Taheri A, Mansoori P, Sandoval LF, Feldman SR, Pearce D, Williford PM. Electrosurgery: part II. Technology, applications, and safety of electrosurgical devices. J Am Acad Dermatol 2014; 70:607.e1-607.e12. [PMID: 24629362 DOI: 10.1016/j.jaad.2013.09.055] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Revised: 09/26/2013] [Accepted: 09/30/2013] [Indexed: 11/25/2022]
Abstract
Electrosurgical currents can be delivered to tissue in monopolar or bipolar and monoterminal or biterminal modes, with the primary difference between these modes being their safety profiles. A monopolar electrosurgical circuit includes an active electrode and a dispersive (return) electrode, while there are 2 active electrodes in bipolar mode. In monoterminal mode, there is an active electrode, but there is no dispersive electrode connected to the patient's body and instead the earth acts as the return electrode. Biterminal mode uses a dispersive electrode connected to the patient's body, has a higher maximum power, and can be safer than monoterminal mode in certain situations. Electrosurgical units have different technologies for controlling the output power and for providing safety. A thorough understanding of these technologies helps with a better selection of the appropriate surgical generator and modes.
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Affiliation(s)
- Arash Taheri
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina.
| | - Parisa Mansoori
- Center for Dermatology Research, Department of Pathology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Laura F Sandoval
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Steven R Feldman
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina; Center for Dermatology Research, Department of Pathology, Wake Forest School of Medicine, Winston-Salem, North Carolina; Center for Dermatology Research, Department of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Daniel Pearce
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Phillip M Williford
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Pavlović MD, Schuller-Petrović S, Pichot O, Rabe E, Maurins U, Morrison N, Pannier F. Guidelines of the First International Consensus Conference on Endovenous Thermal Ablation for Varicose Vein Disease--ETAV Consensus Meeting 2012. Phlebology 2014; 30:257-73. [PMID: 24534341 DOI: 10.1177/0268355514524568] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIM Endovenous thermal ablation (ETA) procedures are catheter-directed, ultrasound (US)-guided thermal methods for treatment in varicose veins disease. Radiofrequency, laser or steam energy thermally denatures vein wall collagen, leading first to vein wall inflammation, then fibrosis and finally to occlusion. The aim of this guideline is to give evidence-based recommendations for ETA procedures. METHODS These guidelines were drafted during a consensus meeting of a group of experts in the field of ETA in June 2012 (Hvar, Croatia) under the auspices of the International Union of Phlebology (IUP). These guidelines review the present state of knowledge as reflected in peer-reviewed published medical literature. The recommendations of these guidelines are graded according to the American College of Chest Physicians Task Force recommendations on Grading Strength of Recommendations and Quality of Evidence in Clinical Guidelines. RESULTS Recommendations on the use of ETA procedures were made based on the quality of evidence for efficacy, safety, tolerability, cosmetic outcome, patient satisfaction/preference and, where appropriate, on the experts' opinion. Health economics were not considered, since differences in national health systems and pricing make it difficult to form general conclusions that are relevant at an international level.
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Affiliation(s)
- Miloš D Pavlović
- Dermatology Centre Parmova & DCP-Venex Centre, Ljubljana, Slovenia
| | | | | | - Eberhard Rabe
- Department of Dermatology, University of Bonn, Bonn, Germany
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