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INVITED COMMENTARY
Year : 2017  |  Volume : 4  |  Issue : 3  |  Page : 135

On PE Following RF Ablation for of Varicose Veins by Dr. P. C. Gupta: Adequate Caution Should be Exercised to Prevent VTE


Department of Vascular and Endovascular Surgery and Vascular Interventional Radiology, Care Hospital, Hyderabad, Telangana, India

Date of Web Publication31-Jul-2017

Correspondence Address:
Prem Chand Gupta
Department of Vascular and Endovascular Surgery and Vascular Interventional Radiology, Care Hospital, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_38_17

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How to cite this article:
Gupta PC. On PE Following RF Ablation for of Varicose Veins by Dr. P. C. Gupta: Adequate Caution Should be Exercised to Prevent VTE. Indian J Vasc Endovasc Surg 2017;4:135

How to cite this URL:
Gupta PC. On PE Following RF Ablation for of Varicose Veins by Dr. P. C. Gupta: Adequate Caution Should be Exercised to Prevent VTE. Indian J Vasc Endovasc Surg [serial online] 2017 [cited 2020 Jun 2];4:135. Available from: http://www.indjvascsurg.org/text.asp?2017/4/3/135/211912



Endovenous ablation of great saphenous vein (GSV) has become the accepted standard of care for primary varicose veins due to GSV reflux. It is often being performed as a day care procedure, and increasing number of vascular surgeons are now practicing this technique. Depending on the training, operators perform the procedure under tumescent anesthesia, regional anesthesia, nerve blocks, or general anesthesia.

The authors have highlighted an uncommon yet important complication following ablation of GSV using Radiofrequency ablation (RFA)[1]: symptomatic pulmonary embolism. They have successfully treated the complication with thrombolysis resulting in good recovery of the patient. Many reasons have been given for increased risk of thrombotic complications.[2] These could be related to the patient: hypercoagulable state, increasing age, increasing severity of venous disease as also noted by the authors and possibly use of oral contraceptive pills. Other factors may be related to the procedure itself: use of general or spinal anesthesia, failure to maintain patency of tributaries near sapheno femoral junction (SFJ), thermal injury to femoral vein, or mechanical intimal injury with wire or catheter.

Vascular Surgeons performing endovenous ablation should be aware of thrombotic complications and take steps to minimize them. Routinely performing an ultrasound at the end of the procedure and in the early follow-up will help recognize the problem early and treatment with low molecular weight heparin could be initiated. Deep vein thrombosis (DVT) prophylaxis could be used in high-risk individuals. Maintaining proper distance of the catheter tip from the SFJ is important to avoid heat injury and preserve the tributaries that can maintain forward flow and prevent propagation of thrombus from GSV into femoral vein. It is also important to reconfirm the position of the catheter tip after putting the patient in Trendelenburg position and injecting tumescence since the catheter tip can move in relation to the SFJ.[3]

The importance of proper tumescence cannot be overstated.[4] Good tumescence under ultrasound guidance with patient in Trendelenburg position will enable performance of the procedure under local anesthesia, empty out the vein, thereby minimizing phlebitis, and act as a heat sink to avoid damage to surrounding tissues. These would enable early and better mobilization of the patient, reducing the risk of thrombosis. Finally, while treating patients with RFA, it is important to follow the instructions for use that state that compression be applied with the ultrasound transducer positioned longitudinally over the heating element, as well as with two fingers distal to the transducer.[5] Failure to do so may result in inadequate ablation, excessive thrombus formation, phlebitis, and of course failure of the procedure.

While endovenous therapies are exciting and frequently performed, adequate caution should be exercised so that a major DVT or pulmonary embolism does not become a dampener.



 
  References Top

1.
Jayakumar P, Robinson CS, Maruthupandian D, Ganesh R. Pulmonary Embolism following Radiofrequency Ablation for Varicose Vein Treated with Thrombolytic Therapy: A Case Report and Review of Literature. Indian J Vasc Endovasc Surg 2017;4:132-4.   Back to cited text no. 1
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2.
Marsh P, Price BA, Holdstock J, Harrison C, Whiteley MS. Deep vein thrombosis (DVT) after venous thermoablation techniques: Rates of endovenous heat-induced thrombosis (EHIT) and classical DVT after radiofrequency and endovenous laser ablation in a single centre. Eur J Vasc Endovasc Surg 2010;40:521-7.  Back to cited text no. 2
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3.
Vohra R. Effect of Tumescence & Head Down Position on Junction Distance between Laser Tip and SFJ During EVLT. Paper Presented at the 21st Annual Conference of Vascular Society of India, 16-18 October, 2014 Bhubaneshwar; 2014.  Back to cited text no. 3
    
4.
Proebstle TM, Vago B, Alm J, Göckeritz O, Lebard C, Pichot O. Treatment of the incompetent great saphenous vein by endovenous radiofrequency powered segmental thermal ablation:First clinical experience. J Vasc Surg 2008;47:151-6.  Back to cited text no. 4
    
5.
VNUS Medical Technologies, Inc.: VNUS ClosureFAST Catheter Instructions for Use, San Jose, CA, VNUS Medical Technologies, Inc. [RM55-529-01 Rev B]. 2007.  Back to cited text no. 5
    




 

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