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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3771_Библиотеки_им_академика_М_И_Перельмана.pdf
40 Juan Carlos Jimenez
CEAP Class
30
25
20
15
Patient (n)
10
5
0
Class1 Class2 Class3 Class4 Class5 Class6
Figure 5.2 Our use of microfoam in below knee truncal veins resulted in excellent outcomes despite a study
cohort comprised of mostly patients with advanced CEAP class and chronic, refractory venous insufficiency.
catheter advancement is required for MFA, it can be readily injected with maximal luminal
contact in patients with tortuous and redundant venous anatomy.
Non-thermal superficial vein closure with MFA does not require injection of tumescent
anesthesia because there is no risk of heat-induced nerve injury or thermal propagation,
which can be a source of persistent, postoperative neuropathic pain following thermal
ablation. Superficial veins can also be treated without the risk of thermal skin burns. There
is usually less pain in sensitive and anxious patients because the multiple subcutaneous
perivenous injections required for tumescent administration are not required. Thus, the
risk of lidocaine toxicity is also lower because significantly less volumes are used with
Varithena.
Microfoam treatment is an ideal choice for superficial vein closure below the knee and
in patients with prior above knee truncal vein ablation and stripping.6 In our recent published experience, MFA of below knee truncal veins has been a safe and effective modality
in these patients. We reviewed 68 limbs treated with MFA for superficial truncal vein reflux
following prior saphenous ablation or stripping at our institution. The study population
was comprised mostly of patients with advanced chronic venous insufficiency (CEAP 4–6,
63%) (Figure5.2). Overall symptomatic relief was 78% following MFA, and the median
preoperative Venous Clinical Severity Score (VCSS) decreased from 12.5 to 10 post-procedure. Good clinical results were demonstrated despite a patient cohort comprised largely of
patients with advanced, refractory venous insufficiency (Figure5.3A and Figure5.3B). One
ablation related thrombus extension (ARTE) occurred and was resolved with anticoagulation and patient with an asymptomatic tibial vein deep vein thrombosis did not require
anticoagulation.
Polidocanol Microfoam Ablation of Refluxing Superficial Veins 41
Figure 5.3A A patient with severe, symptomatic
chronic venous ulceration prior to Varithena microfoam ablation.
Figure 5.3B The same patient 3years following micro-
foam ablation of her left great saphenous vein (GSV).
Her GSV remains occluded, and her ulcer healed
without recurrence.
TECHNIQUES
All MFA procedures are performed in our ambulatory venous center using local anesthesia and occasionally oral sedation (diazepam 5–10 mg). Patients are positioned supine for
GSV and AASV treatment and prone when the SSV is treated. In addition to the initial preprocedure ultrasound performed in the vascular lab, it is important for the venous specialist
to carefully map the target vein to confirm location, depth, diameter, anatomic variability,
and the presence of associated perforator veins (Figure5.4). Percutaneous ultrasound-guided
access for truncal veins is obtained with a micropuncture needle allowing for guidewire entry
into the venous lumen. We prefer to place a 4F sheath over the wire using Seldinger technique
whenever possible. A21G butterfly needle is most often used for direct injection of tributary
veins. Once venous access is obtained, the limb is elevated to greater than 45 degrees. We utilize a tilt table that is placed in steep Trendelenburg position for this portion of the procedure.
Two individuals are required to be in the room at the time of microfoam administration.
The clinician injects 10 mL of sterile saline solution to flush blood from the venous lumen. At
this time, the assistant withdraws MF from the Varithena canister based on the instructions
for use. If perforator veins are present in the target vein, the assistant may digitally compress
previously marked perforator veins prior to MF injection.
Microfoam is then directly injected in retrograde fashion into the target vein. This should
be performed as soon as possible following withdrawal from the proprietary canister to
reduce microfoam degradation. For truncal veins, we visualize the target vein 3–5cm caudal to the saphenofemoral or saphenopopliteal junctions. Varithena is highly echogenic, and
when it reaches this level, the vein is then firmly compressed with the ultrasound probe for
42 Juan Carlos Jimenez
vein prior to microfoam ablation and may minimize Varithena extension into the deep venous system.
5 minutes. Because increased foam volume has been associated with potentially increased
passage into the deep venous system, we attempt to limit foam volume to as close to 5 mL
as possible.
7,8
We also adhere to the Varithena Instructions for Use (IFU) of 15 mL maximal
microfoam volume per session. During this time, we ask the patient to dorsiflex and plantar
flex his/her ankle 20 times to increase flow through the deep venous system. Following 5
minutes of compression, ultrasound is used to ensure that vasospasm is present in the target
vein and that no acute thrombus is noted in the femoral or popliteal veins (Figure5.5). The
treated limb is then compressed with abdominal (ABD) pads overlying the treated veins
and long-stretch compression bandages. The patient is instructed to keep the compression
bandage in place until the first post-procedure visit 48–72hours later. They are then recommended to wear 20–30 mmHg compression stockings for 14 days. This is also recommended
based on the Varithena IFU.
EVIDENCE SUPPORTING THE EFFICACY OF POLIDOCANOL
MICROFOAM
Several level 1, randomized, blinded, controlled studies have demonstrated good clinical outcomes supporting the safety and efficacy of MFA.
9–11
King, etal. conducted the VANISH-1
study, a multicenter trial that randomized 279 patients to treatment with different concentrations of polidocanol MF (0.125%, 0.5%, 1%, 2%) or placebo.9 Veins treated included
the GSV, AASV, and associated superficial tributaries. Symptomatic improvement was the
primary endpoint measured. Secondary endpoints included improved appearance of visible
varicose veins from baseline to week 8. Objective quality-of-life evaluation demonstrated
significant clinical relief in the MFA groups compared with the control group (p < .0001).
The MFA cohort also demonstrated significantly improved appearance at all therapeutic
dose concentrations. The most common adverse thrombotic event (ATE) was superficial
thrombophlebitis which occurred in 10.5% of study patients. Twenty-seven patients experienced deep venous ATEs including 15 ablation related thrombus extensions (ARTE) and 12
peripheral deep venous thromboses (DVT). All resolved with oral anticoagulation, and no
Polidocanol Microfoam Ablation of Refluxing Superficial Veins 43
spasm following microfoam ablation of the GSV.
pulmonary emboli were noted. No neurologic complications or symptomatic embolic events
were reported.
The VANISH-2 was a 5-year, randomized, multicenter, parallel group study. Patients
(n= 232) were randomized to treatment with MF concentrations of 0.5%, 1%, and pla-
9,10
cebo.
Similar to VANISH-1, target veins included the GSV, AASV, and associated superficial tributaries. The mean vein diameter treated was 8.7mm (range 3.1mm–19.4mm). The
primary efficacy endpoint was patient-reported improvement in symptoms, as measured by
the change from baseline to week 8 in the 7-day average electronic daily diary VVSymQ
TM
score. The co-secondary endpoints were the improvement in appearance of visible varicosities
from baseline to week 8, as measured by patients and by an independent physician review
panel.
There were significant improvements for both the 0.5% and 1.0% treatment groups
compared with placebo. Overall, there was a 64% improvement in symptoms in the treatment groups compared with 22% in the placebo group (p < 0.0001). Statistically significant
improvement in appearance was also noted in both treatment groups. Elimination of reflux
and/or complete occlusion of the GSV was achieved in 83% and 86% of patients who received
0.5% and 1.0% polidocanol respectively. Adverse thrombotic events occurred in 10.4% of
patients. Thrombus extension into the common femoral vein (CFV) occurred in nine patients
(3.9%). None were occlusive. There were six proximal (2.6%) and seven distal (3%) DVTs.
Two patients developed gastrocnemius thrombi. Half of the patients received anticoagulation, and the remainder were managed with non-steroidal anti-inflammatory medications
and/or compression and observation.
Another study by Gibson and colleagues randomized 77 patients to treatment with 1%
polidocanol MF (n = 39) or placebo (n = 38) during the blinded portion of the study.
8
Subsequently, 34 placebo-group patients were crossed over into treatment with 1% polidocanol microfoam. Like the VANISH trials, symptoms and appearance both improved
44 Juan Carlos Jimenez
significantly in the Varithena group. This study protocol initially allowed <30 mL of MF per
treatment. However, because there was a trend suggesting higher occurrence of ATEs with
higher volumes, the protocol was amended mid-study to a maximum of 15 mL per procedure
(the current IFU recommended volume). Overall, the incidence of CFV ARTE was 4.1%, and
the incidence of new DVT was 9.6%. All but one venous thrombus resolved without clinical
significance. Asummary of Level 1 evidence validating Varithena 1% polidocanol MF compared with placebo can be found in Table5.1.
The literature supporting Varithena continues to reveal more specific indications, anatomic features, and techniques for microfoam use to optimize outcomes. We recently analyzed
results following both MFA and radiofrequency ablation (RFA) in large-diameter truncal
veins (> 8mm). Results following treatment of 66 limbs with MFA and 66 with RFA during
the same study period were analyzed.12 Immediate closure rates were excellent in both groups
(RFA–100%, MFA–95%) Overall, VCSS improved after treatment in both groups (RFA,
from 9.5 to 7.8; P < .001) (MFA, from 11.3 to 9.0; P < .001). In the RFA and MFA groups,
83% and 79% of venous ulcers healed during the study period, respectively. Symptomatic
superficial phlebitis occurred after RFA in 11% and 17% in MFA. The incidence of postablation ARTE was 3.0% in the RFA group and 6.1% in the MFA group, which was not
statistically significant. All resolved with short-term oral anticoagulant therapy. No remote
deep venous thromboses or pulmonary emboli occurred in either group.
Our group subsequently analyzed outcomes following primary closure of the GSV and
AASV in the thigh.
13
Atotal of 200 consecutive thigh GSVs and ASVs were treated within the
study period using either MFA (n=100) or RFA (n=100). Operative times were significantly
shorter in the MFA group (42.4 ± 15.4 minutes in the RFA group and 33.8 ±16.9 minutes in
the MFA group {P < .001}). The mean postoperative VCSS declined to 7.3 ± 2.1 in the RFA
group and 7.8 ± 2.9 in the MFA group. Complete closure occurred in 100% of the limbs
after RFA and 90% after MFA (P=.005). Overall, symptomatic relief was 90% following
RFA and 89.5% following MFA. The complete ulcer healing rate for the entire cohort was
77.8%. Ablation related thrombus extension (RFA, 1%; vs MFA, 4%; P=.37) and remote
DVT (RFA, 0%; vs MFA, 2%; P=.5) showed a trend toward being higher following MFA,
but the difference did not reach statistical significance. All were asymptomatic and resolved
with short-term anticoagulation therapy.
Deak demonstrated similar excellent outcomes following MFA compared with laser ablation (EVLA) of the saphenous veins.14 In his large cohort, MFA was used for 550 procedures,
and patients were followed for 43 ± 13 months; EVLA was used for 520 procedures and
Table 5.1 Summary of Randomized Trials Evaluating Polidocanol Microfoam
Study Patients (1% MF) or Closure (1% MF) in VCSS Thrombosis
King, et al. 279 63% 80.4% −3.70 2.5%
(VANISH-1)
Todd, et al. 232 77.8% 86% −5.15 6.1%
(VANISH-2)
Gibson, et al. 77
(Varithena change from baseline
013 Group)
*
HASTI: heaviness, achiness, swelling, throbbing, itching.
No. of Symptom Improvement Elimination of Reflux and/ Mean Change Deep Venous
9
10
*
HASTI Score Mean 90% −3.4 9.6%
8
30.7
(Not reported as
percentage)
Polidocanol Microfoam Ablation of Refluxing Superficial Veins 45
patients were followed for 57 ± 18 months. After complete treatment, the elimination of
reflux was documented in 93.5% (514/550) and 92.8% (482/520) of the MFA and EVLA
procedures, respectively. Ulcer healing rates were significantly improved following treatment
with Varithena (MFA–69%; EVLA–5%).
Studies with increased duration of follow-up are currently required to determine whether
the long-term closure rates and symptom relief following MFA compare favorably with thermal ablation and high ligation and stripping. Unlike those two modalities, there is no current
randomized data comparing long-term results with Varithena to other closure methods.
15
This information is particularly important because strong evidence supports that long-term
efficacy following PCF for truncal veins is inferior to thermal and surgical techniques.
16
COMPLICATIONS FOLLOWING MICROFOAM ABLATION
The incidence of serious complications is rare (ie. pulmonary embolus, neurologic complications). Localized pain at the injection site is the most common patient complaint during early follow-up but resolves in a few weeks. Adverse thrombotic events (ie. superficial
thrombophlebitis, ARTE, and DVT) continue to be reported and are potentially serious if left
untreated.
the incidence of ARTE to be 5.2% compared with 0.7% following RFA.
17
Arecent analysis of above knee GSVs treated with MFA at our institution found
18
This difference
was statistically significant. Based on our anecdotal experience and ATE rates in the recent
literature, we continue to advocate the use of early (48–72-hour) post-procedure ultrasound
to rule out ARTE and DVT following Varithena ablation of superficial truncal veins.
The most recent Clinical Practice Guidelines from the Society for Vascular Surgery (SVS),
American Venous Forum (AVF), and American Vein and Lymphatic Society (AVLS) do not
make specific recommendations for surveillance and treatment of superficial thrombophlebitis and ARTE following MFA (or other non-thermal treatments for truncal vein reflux)
due to insufficient published evidence.
19
Superficial thrombophlebitis with subsequent hyperpigmentation can be a frustrating post-procedure event for patients. Incision and drainage
with evacuation of thrombosed superficial veins can result in more rapid pain relief and can
lead to quicker resolution of hyperpigmentation. We do not routinely anticoagulate patients
for focal superficial thrombophlebitis. Patients with extensive and symptomatic superficial
thrombophlebitis and ARTE (SVS EHIT II or greater) are treated with directly acting oral
anticoagulants (DOACS) with reevaluation at 1-week intervals until the deep vein extension
retracts or resolves. We have demonstrated excellent clinical outcomes utilizing this surveillance and selective anticoagulation protocol.
4
CONCLUSIONS
Treatment of symptomatic, superficial, and incompetent truncal and tributary veins using
commercially manufactured polidocanol microfoam results in successful early closure rates,
excellent relief of symptoms, and effective ulcer healing rates. These early results compare
favorably to thermal ablation in non-randomized, short-term comparisons. Further investigation is required to determine and characterize the optimal clinical indications and patient
selection for MFA. Because the natural history of ARTE following MFA has not been fully
elucidated, there are no formal clinical practice guidelines for surveillance and management
of these post-procedure ATEs. Our clinical experience strongly suggests that early post-
46 Juan Carlos Jimenez
procedure ultrasound surveillance with selective anticoagulation following truncal vein MFA
constitutes best practice and optimizes patient safety when this technique is utilized.
REFERENCES
1. Puggioni A, Kalra M, Carmo M, Mozes G, Gloviczki P. Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: Analysis of early efficacy and complications. J Vasc
Surg. 2005;42:488–93.
2. Food and Drug Administration. Highlights of Prescribing Information, n.d. www.accessdata.
fda.gov/drugsatfda_docs/label/2013/205098s000lbl.pdf
3. Redondo P, Cabrera J. Microfoam sclerotherapy. Semin Cutan Med Surg. 2005;24:175–83.
4. Jimenez JC, Lawrence PF, Woo K, Chun TT, Farley SM, Rigberg DA, etal. Adjunctive techniques
to minimize thrombotic complications following microfoam sclerotherapy of saphenous trunks
and tributaries. J Vasc Surg Venous Lymphat Disord. 2021;9:904–9.
5. Regan JD, Gibson KD, Rush JE, Shortell CK, Hirsch SA, Wright DI. Clinical significance of cerebrovascular gas emboli during polidocanol endovenous ultra-low nitrogen microfoam ablation
and correlation with magnetic resonance imaging in patients with right-to-left shunt. J Vasc Surg
2011;53:131–37.
6. Jimenez JC, Lawrence PF, Pavlyha M, Farley SM, Rigberg DA, DeRubertis BG, etal. Endovenous microfoam ablation of below knee superficial truncal veins is safe and effective in patients
with prior saphenous treatment across a wide range of CEAP classes. J Vasc Surg Venous Lymphat Disord. 2022;10:390–94.
7. Yamaki T, Nozaki M, Sakurai H, Takeuchi M, Soejima K, Kono T. Multiple small-dose injections can reduce the passage of sclerosant foam into deep veins during foam sclerotherapy for
varicose veins. Eur J Vasc Endovasc Surg. 2009;37:343–48.
8. Gibson K, Kabnick L; Varithena
controlled study to evaluate the efficacy and safety of Varithena
microfoam 1%) for symptomatic, visible varicose veins with saphenofemoral junction incompetence. Phlebology. 2017;32:185–93.
9. King JT, O’Byrne M, Vasquez M, Wright D; VANISH-1 Investigator Group. Treatment of truncal incompetence and varicose veins with a single administration of a new polidocanol endovenous microfoam preparation improves symptoms and appearance. Eur J Vasc Endovasc Surg.
2015;50:784–93.
10. Todd KL, Wright DI; VANISH-2 Investigator Group. The VANISH-2 study: A randomized,
blinded, multicenter study to evaluate the efficacy and safety of polidocanol endovenous microfoam 0.5% and 1.0% compared with placebo for the treatment of saphenofemoral junction
incompetence. Phlebology. 2014;29:608–18.
11. Todd KL 3rd, Wright DI; VANISH-2 Investigator group. Durability of treatment effect with
polidocanol endovenous microfoam on varicose vein symptoms and appearance (VANISH-2). J
Vasc Surg Venous Lymphat Disord. 2015;3:258–64.e1.
12. Chin AL, Talutis SD, Lawrence PF, Jimenez JC. Early results following comparison of radiofrequency and microfoam ablation of large diameter truncal veins demonstrate high closure rates
and symptomatic relief. J Vasc Surg Venous Lymphat Disord. 2023;11:716–22.
13. Talutis SD, Chin AL, Lawrence PF, Woo K, Jimenez JC. Comparison of outcomes following
polidocanol microfoam and radiofrequency ablation of incompetent thigh great and accessory
saphenous veins. J Vasc Surg Venous Lymphat Disord. 2023;11(5):916–20.
14. Deak ST. Treatment of superficial venous insufficiency in a large patient cohort with retrograde
administration of ultrasound-guided polidocanol endovenous microfoam versus endovenous
laser ablation. J Vasc Surg Venous Lymphat Disord. 2022;10:999–1006.e2.
15. Eggen CAM, Alozai T, Pronk P, Mooij MC, Gaastra MTW, Unlu C, etal. Ten-year follow up
of a randomized controlled trial comparing saphenofemoral ligation and stripping of the great
®
013 Investigator group. Amulticenter, randomized, placebo-
®
(polidocanol endovenous
Polidocanol Microfoam Ablation of Refluxing Superficial Veins 47
saphenous vein with endovenous laser ablation (980 nm) using local tumescent anesthesia. J
Vasc Surg Venous Lymphat Disord. 2022;10:646–53.
16. Brittenden J, Cooper D, Dimitrova M, Scotland G, Cotton SC, Elders A, etal. Five-year outcomes of a randomized trial of treatments for varicose veins. N Engl J Med. 2019;381:912–22.
17. Yang J, Chung S, Srivatsa S. Prospective randomized trial of antithrombotic strategies following
great saphenous vein ablation using injectable polidocanol endovenous microfoam (Varithena).
J Vasc Surg Venous Lymphat Disord. 2023;11:488–97.e4.
18. Chin AL, Talutis SD, Lawrence PF, Woo K, Rollo J, Jimenez JC. Factors associated with ablation related thrombus extension (ARTE) following GSV closure with endovenous microfoam
ablation. [abstract]. In: Western Vascular Society 38th Annual Meeting; September9–12, 2023
(Accepted for presentation).
19. Gloviczki P, Lawrence PF, Wasan SM, Meissner MH, Almeida J, Brown KR, etal. The 2023
Society for Vascular, American Venous Forum and American Vein and Lymphatic Society clinical
practice guidelines for the management of varicose veins of the lower extremities. Part II. J Vasc
Surg Venous Lymphat Disord. 2024;12:101670.
Chapter 6
Cyanoacrylate Treatment of
Superficial Venous Insufficiency
Technique and Results
Amanda L. Chin and Johnathon C. Rollo
BACKGROUND
Cyanoacrylate is a liquid adhesive that was first approved by the US Food and Drug
Administration (FDA) for endovascular application in 2000, when Trufill n-BCA Liquid
Embolic System (Cordis, Miami Lakes, FL) obtained clearance for presurgical devascularizaton of cerebral arteriovenous malformations.
sists of an ethylene molecule with a cyano group and an ester attached to one of the carbons.
The specific hydrocarbon attached to the ester (the R position) contributes to the name of the
cyanoacrylate. When exposed to an anion, such as those in blood, polymerization into a solid
material is initiated with bonding of the ethylene units.
a vessel causes an inflammatory reaction in the wall followed by closure with coaptation.
Cyanoacrylate closure (CAC) of incompetent veins is a non-thermal, non-tumescent, and
non-sclerosant endovenous ablation technique for the treatment of venous insufficiency.
The concept was first developed by Dr. Rod Raabe, an interventional radiologist, at Inland
Imaging in Spokane, WA. In 2011, the results from a pilot study on use of CAC of truncal
veins in swine models were reported. Following adhesive delivery to swine superficial epigastric veins, chosen due to their similarities to human great saphenous veins, venous closure, segmental wall thickening, and fibrosis were observed on histologic examination at 60
(1)
days.
2013, demonstrating safety and efficacy.
sive, a proprietary n-butyl-2-cyanoacrylate (n-BCA) based formulation that received FDA
approval in 2015 for the treatment of symptomatic lower extremity varicose veins through
endovascular embolization with coaptation. CAC offers advantages over other endovenous
ablation techniques as it omits the need for tumescent anesthesia as well as post-procedure
compression stockings.
The first-in-human use of endovenous CAC in great saphenous veins was reported in
(3–6)
(1)
The monomeric form of cyanoacrylate con-
(2)
Instillation of cyanoacrylate within
(3, 4)
It was subsequently marketed as VenaSeal adhe-
DEVICE
The VenaSeal closure system is a sterile, single patient kit that includes the delivery system
and proprietary liquid adhesive. The adhesive, a proprietary n-butyl-2-cyanoacrylate (n-BCA)
based formulation, is a clear liquid that is contained within a screw-capped vial, sterilized by
exposure to dry heat. 5 mL total is provided within each kit. The delivery system is composed
of the following components: dispenser gun, dispenser tips, catheter, introducer, dilator, 3
mL syringes, and 0.035” 180cm straight floppy-tip guidewire. The dispenser gun consists
of an integrated barrel and trigger, which delivers 0.10 mL of adhesive with each 3-second
depression. The introducer is 7 Fr with an effective length of 80cm. Along its length, there are
circumferential markings spaced 10mm apart to aid in calculated retraction of the delivery
catheter during the procedure. The delivery catheter itself is 5 Fr with an effective length of
DOI: 10.1201/9781003316626-8 48
Cyanoacrylate Treatment of Superficial Venous Insufficiency 49
91cm. Its high echogenicity enables the catheter tip to be easily visualized for precise adhesive
administration. Alaser marking at 3cm from the tip indicates the optimal priming location
for the adhesive at the start of the procedure, and another marking at 85cm from the tip
assists with catheter and introducer alignment.
INDICATIONS
Like other endovenous ablation techniques, the VenaSeal closure system is indicated for
permanent closure of lower extremity superficial truncal veins, such as the great and small
saphenous veins (GSV and SSV), in adults with symptomatic venous reflux as demonstrated
by duplex ultrasound. While most studies discuss treatment of saphenous veins less than
2cm in diameter, there have been reports of successful closure of incompetent veins up to
2.8cm.
(7)
CONTRAINDICATIONS
CAC with the VenaSeal adhesive is contraindicated in patients with previous hypersensitivity reactions to the VenaSeal adhesive or cyanoacrylates, acute superficial thrombophlebitis,
thrombophlebitis migrans, and acute sepsis.
TECHNIQUE
The extremity is prepped and draped in standard sterile fashion. Ultrasound is first used to
map out the course of the target truncal vein and locate its most distal point for intended
access. Below the knee and/or above knee GSV is an acceptable target. The entire GSV can
be treated in one application. Accurate and effective treatment of the small saphenous or
anterior accessory GSV is also possible due to the lack of thermal action and viscosity of
the glue embolic material. Local anesthetic is administered at the access site. Using standard
micropuncture technique with a 5 Fr micropuncture access kit, the vein is accessed with a
21G needle under ultrasound guidance. An 0.018” microaccess wire is advanced into the
vein followed by the microsheath/dilator. After removal of the microaccess wire and dilator,
the 0.035” J-wire guidewire from the VenaSeal kit is advanced into the truncal vein via the
microsheath. The microsheath is then exchanged with the 7 Fr blue introducer/dilator over
the guidewire into the saphenofemoral junction (SFJ). Once fully advanced, the guidewire and
dilator are removed, and the introducer is flushed with saline. Under ultrasound guidance, the
introducer tip is then positioned 5cm caudal to the SFJ.
The delivery catheter is then prepped per manufacturer instructions. Using the provided
dispenser tip and 3 mL syringe, the VenaSeal adhesive is extracted from the vial and air bubbles removed. The dispenser tip is detached, and syringe is connected to the delivery catheter
with a standard Luer lock. To insert the syringe into the dispenser gun, the release button is
pushed and the plunger pulled back; the syringe can then be inserted and rotated firmly to
secure. The delivery can now be primed by pulling the trigger of the dispenser gun until adhesive is advanced to the 3cm laser marker from the tip; it is imperative that the adhesive is not
advanced beyond this point to prevent premature exposure and polymerization of the glue
upon insertion into the vein, as this will cause a glue plug in the delivery catheter. The catheter
is then advanced into the introducer until the 85cm laser marker on the catheter is aligned
with the hub of the introducer. Once at this position, the introducer is pulled back 5cm and