Introduction

Last updated: apr 5, 2023

  • Prevalence > 20% in Western population
  • 5% suffer from venous edema, skin changes or ulcerations
  • 0.5% active ulcers : 1.4% healed ulcers

The published success of the VenaSeal closure procedure is up to 98.9% (VeClose study), with far fewer complications than EVLA or surgery.

 

Presentation

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Venous anatomy
 

Anatomy

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Indications

  • Clinical symptoms
    • Aching
    • Throbbing
    • Heaviness
    • Fatigue
    • Pruritus
    • Night cramps
    • Restlessness
    • Generalized pain
    • Swelling
  • Objective reflux
    • 1 s reversed flow femoral or popliteal vein
    • Deep femoral and perforating veins
    • Perforators with a diameter > 3.5 mm
    • Perforators located underneath an ulcer
    • Refluxtijd ≥ 500ms (perforatoren ≥ 350ms)

 

Contra indications

Absolute

  • Deep vein thrombosis (DVT) in the past six months (caution for deep venous obstruction with secondary varices essential for venous drainage)
  • Acute superficial thrombophlebitis and migratory phlebitis
  • Allergy to acrylate (type 4 hypersensitivity)
  • Arterial insufficiency in Fontaine stages III and IV (Stage III marked by rest and nighttime pain; Stage IV with continuous pain and acral ulcerations). For arterial issues, adequate compression—crucial in sclerotherapy—cannot be used.
  • Severe systemic illnesses, especially those involving bed confinement (acute infections, liver or kidney dysfunctions, neoplasms, severe chronic cardiac or respiratory diseases)
  • Immobility due to musculoskeletal issues (typically accompanied by edema, intolerance to adequate compression, increased risk of thrombosis)
  • Pregnancy and breastfeeding: Varices are typically not sclerosed during pregnancy as aethoxysclerol lacks a "safe during pregnancy" label. Veins often revert to normal size 8–10 weeks postpartum. If symptomatic, treatment is better scheduled prior to a subsequent pregnancy to prevent progression.

Relative

  • History of recurrent DVT
  • Clotting disorders with hypercoagulability
  • Anticoagulant use
  • Severe edema
  • Complicating arteriosclerosis with risk of pressure necrosis
  • Angiodysplasia, such as varices associated with Klippel-Trénaunay syndrome, where Duplex ultrasound should exclude deep vein anomalies
  • Patient unable or unwilling to wear compression stockings

 

Workup

  • CEAP classification
  • Duplex/doppler

 

Pre procedural

  • No compression stockings necessary

 

Materials

Essentials

  • Sterile drape and square adhesive dressing
  • Ultrasound device with gel and sterile cover
  • Puncture needle and 5Fr sheath
  • VenaSeal™ Closure System treatment kit from Medtronic
  • Glue catheter is 5F, blue catheter is 7F, guidewire is 0.035"
  • EVLT/VNUS treatment pack

Non-Essentials

  • Evt tumescent bij forse vele diameter

 

Positioning the patient

  • Supine for Great Saphenous Vein
  • Prone for Small Saphenous Vein
  • Table tilted anti-trendelenburg

Venaseal
 

The procedure in steps

  • TOP
  • Clean the area with chlorhexidine and drape it sterilely.
  • Open the Venaseal kit.
  • Place the blue outer catheter (marked with centimeters) with the gray dilator on the "wet" table. Place the clear adhesive catheter (with a white stripe along its length) and the adhesive container on the "dry" table.
  • Flush the blue catheter and gray dilator with saline solution.
  • Keep the adhesive catheter dry; avoid contact with blood or saline. If accidental contact occurs, rinse with 5% glucose solution or flush vigorously with air.
  • Use the 3 ml Luer-lock syringe from the set to aspirate adhesive and remove air bubbles (do not let it contact moisture!). The adhesive is very viscous; position the syringe upright and expel air slowly.
  • Prime the adhesive catheter with adhesive. The dead space in the catheter is approximately 1 ml, so fill the first portion manually and the last centimeters with the adhesive gun. Secure the 3 ml Luer-lock syringe in the adhesive gun; each trigger click dispenses 0.10 ml of adhesive. Maintain an airlock of about 2-3 cm (preferably stopping near the white stripe at the catheter tip) to prevent premature adhesive contact with blood or saline.
  • Prepare the adhesive gun, connecting it firmly until resistance is felt.
  • Fill with adhesive up to the distal marker, leaving a small air pocket.
  • Refill adhesive if necessary.
  • Cover the ultrasound probe with a sterile sheath.
  • Apply local anesthesia with 2% lidocaine.
  • Under ultrasound guidance, puncture the vein.
  • Advance the guidewire to the saphenofemoral junction.
  • Remove the needle, leaving the guidewire in place, and insert the sheath with the dilator.
  • Confirm the sheath position using ultrasound, with the tip at the saphenofemoral junction.
  • Withdraw the sheath 5 cm to skin level.
  • Remove the guidewire and dilator.
  • Insert the treatment catheter up to the proximal marker on the adhesive catheter.
  • Retract the sheath and tighten.
  • Use ultrasound to compress the saphenofemoral junction.
  • Administer one injection (holding the adhesive gun trigger for 3 seconds), retract the catheter by 1 cm, administer another injection (holding for 3 seconds), then retract by 3 cm and apply manual compression for 3 minutes.
  • Continue with 3 cm intervals per injection, in sets of three injections with 30-second manual compression.
  • Final injection should be around 5 cm from skin level.
  • Withdraw the adhesive catheter into the sheath.
  • Remove all components from the skin.
  • Immediately after catheter removal, dry the catheter. Remove the syringe from the adhesive gun, manually retract the adhesive by 5-10 cm. Add adhesive if necessary, replace it in the adhesive gun, and re-prime the catheter to the last white mark (airlock) on the adhesive catheter.
  • Apply pressure after catheter removal.
  • SOP

 

Tips and tricks

  • Max diameter van vene mag 2 cm zijn, er kan eventueel tumescent gebruikt worden om diameter vene rond de katheter te verkleinen vóór aanbrengen van lijm.
  • Link
  • Link

 

Complications

  • Allergische reacties
  • Arteriovenous fistula
  • Bloeding van de acces site
  • DVT
  • Oedeem
  • Embolisme, incl pulmonair (PE),
  • Hematoom
  • Hyperpigmentatie
  • Infectie
  • Non-specifiike milde inflammatie
  • Pijn, paresthesie
  • Flebitis, superficial thrombophlebitis
  • Vasculair ruptuur and perforatie
  • Littekenvorming

 

Post-op

  • Vaak enige jeuk in de eerste week, evt antiflogistica.
  • De eerste Venaseals krijgen een poliklinische follow-up na 6 w met vaatlab.

 

Follow-up

  • Follow-up typically unnecessary unless symptoms indicate otherwise

HIX
 

Report

Time out. Positioneren patient. Been wordt gedesinfecteerd, liesstreek goed mee desinfecteren. Na desinfecteren steriel afdekken. Lijmkatheter met lijm vullen (primen). Gun aansluiten. Lokale anesthesie met lidocaïne 2%. Onder echo geleide inbrengen sheath, opvoeren over de voerdraad tot aan de crosse, 5 cm op huid niveau terugtrekken.Voerdraad en dilatator verwijderen en inbrengen van de behandelkatheter tot aan de proximale marker op de lijmkatheter. Sheath terugtrekken en koppelen. Met de echo wordt de crosse dicht gedrukt, en de lijm protocollair ingebracht. Eerste stap van 1 cm, waarna 3 min manuele compressie, vervolgens in stappen van 3 x 3 cm met 30 s manuele compressie. Laatste injectie op ca 5 cm op huidniveau, waarna de lijmkatheter in de sheath getrokken wordt en verwijderd.

 

Patient folder

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Literature

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The information contained herein has been obtained from sources believed to be reliable. However, no warranty as to the accuracy, completeness or adequacy of such information is implied. No liability is accepted for errors, omissions or inadequacies in the information contained herein or for interpretations thereof. The reader assumes sole responsibility for the selection of these materials to achieve its intended results. The opinions expressed herein are subject to change without notice.

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