• How does it work ?

• How to treat patients ?

• What are the results ?

• R.Milleret – Montpellier - France

Steam : Return to the future ?

Generation of Endo Venous Steam

• Water is pumped under high pressure through a microtube of 100 µ internal diameter.

• Electrical current heats the microtube.• Steam is emitted at a temperature of 150° At the tip of the catheter it decreases to

120°C120

Catheter and vein entrance device .

Microscopic study / Animal

Jonction Sapheno-Femorale

Sapheno femoral junction – control at 1 month .

Large trunks

• Steam allows treatment of very large trunks

• At one year they have shrinked even if they were more than 2 cm diameter

Trunk at one year

Dilatation anevrysmale

Small Saphenous Trunk

Obliterating Perforators

• Easy : just puncture on 1 or 2 cm under echo-guidance ,

• Inject a small quantity of tumescent solution

• Send repeated pulses into the perforator .

• In the deep veins , only droplets of hot water , no harm done .

Steam Phlebectomy

• Large Tributaries and Perforators can be treated .

• Several punctures are made along the vein.

• The catheter is not retracted , repeated pulses are sent : steam can thus travel up to

8/10 cm

* No tumescence needed if under general anesthesia . Skin cooling by gel .

1 month result , 6 punctures

Results

• Multi center French study GSV ,

1 year follow up .

• Randomized study for superficial veins

Multi-Center Trial

• CHU Besançon : Pr G.Camelot , Dr Mazen , Dr A. Lopinnet

• Clinique du Grand Large Lyon : Dr P.Nicolini

• Vein Center Montpellier : Dr R.Milleret

• Clinique Ambroise Paré Nancy : Dr D.Creton

Material

• 80 patients included

1 year results for 73 patients are available .

• Criteria :GSV only , 4/12 mm at mid-tigh .

• Each center was free to use General or Local , tumescent anesthesia .

• Median diameter mid tigh : 8 mm

• Length treated : 42 cm

Post-operative course

• Pain at 8 days : 0,75 median value

• Pain at 1 month : 0,60 median value

• No DVT , No PE No infection.

• 1 paresthesia at 8 days , 1 at 1 month .

• 0 pigmentation.

Abnormal Duplex findings

• At 8 days :

1 protrusion of thrombus in the femoral vein (less than 1 cm).

1 patient with non occluded vein segments (10 and 13 cm) at lower part of tight without reflux = technical fault (introducer not removed !) Treated with Foam injection .

Vein Resorption

• Evolution of the diameter :

8 days 1 month 12 months

Junction 9,84 7.15 4.65

Tigh 7,27 5.14 1,90

Obliteration at 1 year

• 73 patients followed up ,

• 72 with obliteration at thigh level.

NB . 6 had a more than 3 cm long stump under the junction ,they’ll be followed to check evolution .

QOL results

• SF 12

inclusion 6 months P

Physical 51,27 49,99 0,049

Mental 52,05 46,01 0,001

Randomized study of Steam Phlebectomy versus Foam

obliteration of superficial tributaries

Aim of the study

• To compare efficiency , complications and patient’s satisfaction between two obliterative techniques :

*** Foam – Chemical obliteration

*** Steam – Thermal obliteration

Material

• 2 groups of 20 patients each,randomized .

• Location of varices : Anterior Accessory ,

Internal Calf

Posterior Calf

* Diameter of varices : 3 to 10 , mean 6 mm .

Methods

• Foam : 1% Polidocanol ,

Tessari tourbillon technique,

6 to 10 cc in one session (Tegernsee)

• Steam : 3 to 6 pulses/location

3 to 6 18G / 20 G infusion catheters

* Eccentric compression .

Eccentric compression

Results at 8 days

Foam Steam

Inflammation 6/20 0/20

Pain 2,4 0,5

Results at 1 month

Foam Steam

Blood extraction 12/20 6/20

Pigmentation 12/20 4/20

Results at 6 months

Foam Steam

Pigmentation 4/18 2/19

Cosmetic result 10/18 15/19

(patient’s evaluation

Good/very good)

Venous Malformations

Steam : a less invasive heating technique

• Heat transfer is very quick : less than 1/2 s as compared with 20 s sequential heating with Closure Fast®

• Wall thickening is maximal , thus clot in the lumen minimal , reducing inflammatory reactions and post-op pain . .

• No perforation of the vein wall .

• Less heating of peri-venous structures.

THANK YOU FORYOUR ATTENTION

Nicolas de Staël – Les Mouettes

VISIT US IN MONTPELLIER !

So , I use steam ... But not exclusively .

• The power of heating techniques ,• The versatility of foam ,• Safety on top .

• Steam will not replace foam , especially for small vessels , but will complement it for larger veins which may lead to inflammatory reactions and pigmentation after foam injection .leaand pigmentation

Alpha Technique

• A mbulatory

• B loodless

• C atheter

• D elivered

• E ndovenous

• F oam

Foam technique

• Tessari Tourbillon technique

• 2% Polidocanol

• Desilet F5 introducer

• Cook Royal Flush F5 catheter

• Tumescence to compress the junction and the localized dilatations

• Banding of the limb before injection

Long term results

• 5 years

• RF Laser Alpha

• N 42 58 65

• OBL 37 41 59

• % 88 70 88

Is there a future for steam ?

• It’s a new method , so equipment will improve and hopefully be cheaper.

• Reimbursement still an issue in many countries ...

• Large bulging varicose veins, recurrences and malformations are applications where no other technique can compete .