 I'm George Nahas, an interventional cardiologist. I have been practicing for over 20 years. I do cardiac care, I take care of people with vascular disease, and also take care of people with venous disease. Venous disease, as you may know by now, is very common. Patients with varicose veins or patients who have leg pain, ulcers in their legs, pigmentation, discoloration are often ignored in our medical society because we always worry about the arterial side of the circulation, the heart side, but people actually don't pay attention to the venous side that much. I've seen many patients with a lot of swelling in their legs, ulcers who were told to just wear compression stockings, use some antibiotic creams, and live with it. Fortunately, this strategy has changed in our medical community for the past 10 years. We have invented new ways to take care of varicose veins that are very simple, much simpler than what used to happen before with surgery when the veins used to be stripped and patients will be in the hospital for an extended period of time. They will have clots in their legs, they will need blood transfusion. Thank God for office-based procedures, now we can do everything in the office without even needing to go anywhere else. For example, if patients have varicose vein, we evaluate them, we give them stockings, if they don't respond to stockings after three months or so, then we do ultrasound on their legs. After that, we can plan series of minimally invasive procedures based on their anatomy and based on how extensive the disease is. Some patients may need one procedure, some may need more than one, it all depends on the case. So let me take you through a little journey about a patient who I'm going to do next. His name is John, I will not say his last name for confidential reasons. He is 62 years old, a retired policeman. He was referred to me by another cardiologist who asked me to take care of his legs. He has been having ulcers in both legs, he has been struggling to treat those or heal them. He has pigmentation, he has swelling, discomfort. When he stands, he has to sit down because of the achiness of his legs. So we did ultrasound on him, he has many veins that are leaking in his legs and let me just explain that one more time. The mechanism of varicose veins is really leakage in valves inside the veins and those are usually superficial veins and when the valve leaks the blood comes back down with gravity and the veins under high pressure start to balloon up, they start to leak blood and they stain the skin with brown color, the skin become inflamed, sometimes you see eczema, sometimes you see ulcers and they don't go away. We need to really be careful of telling patients to ignore them because 20% of those patients will have ulcers in their heels that will never heal without some invasive measures. So today we will treat his left leg, we will ablate the left great softness vein. This is a vein that is the longest vein on the body, starts at the foot and goes all the way to the groin. It's very commonly involved with this process. So we will do something called the radiofrequency ablation procedure. It's a catheter I will insert in his vein around the knee area with ultrasound guidance under local anesthesia and we are going to shut down that vein with radiofrequency energy. So we are in the procedure here with our patient. He is prepped in the office with the sterile techniques and basically we'll do this procedure under local anesthesia. He's fully awake and we didn't give him any sedation or any he doesn't have IV, he doesn't have to fast for this and we will do this with ultrasound guidance. As you can see this is the ultrasound probe. I have the monitor over there showing the vein. The black circle is actually the vein that we will enter under local anesthesia. So that's the softness vein. Now we're going to numb the skin. You're going to feel a little poke, a little burn John. Did you eat breakfast? I did not. Well you're going to have to go somewhere and eat after this huh? Drink a lot of fluids too. Okay if you feel any significant pain let me know. So now we're entering the vein with the ultrasound. You can see the vein is going to dip down like that and this is my needle coming in to bend it. You can see the blood coming back in the needle. We will put this wire. You don't feel any of this. Okay John okay and we will make a tiny, tiny, tiny nick. Take the needle out and then put the catheter in. So now we will insert the radio frequency catheter. So this is the catheter. It's very simple. This is the part that oblates the vein, this copper tip here. And the patient doesn't feel any of this when we insert in the catheter. Take this. So we'll push it until we see it on the monitor by the groin with ultrasound. And as you see this white line is the catheter and as you can tell from the procedure everything is done with ultrasound guidance. So we know exactly where everything is. We don't do it blindly. So we will position the tip of the catheter about three centimeter from the end of the vein where it comes to the deep vein which is seen on the bottom of the screen that white, black, you see the end there. That's the valve, point the valve Laura. So that's the valve that is broken that we talked about earlier. That's the main reason why people have varicose veins. That valve is broken, is not opening or closing. You can see it fixed in place and the blood leaks backward from the big deep vein, the big black circle to the superficial vein. And this is something called thymicent anesthesia. We inject it through a pump. It's basically saline with lidocaine and bicarbonate to take away the acidity of the lidocaine so it doesn't burn as much. And we'll start here by injecting the fluid around the vein. Pushing away the tissue to protect the tissue from the radiofrequency heat. You can see that black space forming around the white line. The white line is the catheter and the grayish line around it is the vein that spasm over the catheter. So now we have a protective layer of fluid and lidocaine around this vein. So the tip of the needle is in the black space around the vein. So I inject and you can see how the fluid push away the muscle and the tissue and the skin away from this vein. The goal of this process is to shut down the leaky vein that is causing the high pressure down at the ankle and the ulcers and the swelling and the skin pigmentation. By shutting it down we're taking the pressure away from the skin, from the vein, from the tissue and then normal healing process starts after that and usually those ulcers heal within weeks and most of all, best of all is that they usually don't come back. Sometimes they do after many years we have to visit them again and see what else is leaking and treated because you know very good veins is a genetic disorder meaning the patients who have them are always going to be predisposed to having them and they come back sometimes and we have to deal with the new branches that come back. Now we're done with the numbing process which we call the mucent anesthesia and the final step is to ablate the vein to close it. So my assistant is going to push where the tip is push it down to achieve better contact with the vein. I'm going to push this spot on here and the machine behind me is delivering the energy. We do two ablation treatment for the first part of the vein and the machine behind me heats the vein to 120 degrees so each segment will get 120 degrees heating up to 20 seconds. It's timed by the manufacturer 20 seconds for each segment. This cut is very simple it has markers to mark how long the segment is so you don't miss any part of the vein and I'm going to pull the sheet back one time and we'll do a final segment. You can see when you see those markers this is a sign that this is the last segment that we can ablate before we go inside the sheet. This is the sheet, this is the catheter. Okay and we're done. This is where we entered a very small tiny hole there's no need to stitch it just little compression with the finger was enough to stop any bleeding. Those are pokes with a needle to deliver the the mesent anesthesia or the lidocaine and that's all what you see and we're going to clean his leg going to put the stockings and he's going to be going home. So now we are done with the procedure we will put the stocking on him while he's still laying down. It will be thigh high for two weeks he'll wear it day and night except to shower. First time you can shower John is two days from now. You can take a bath without wetting the stockings of the left leg. Okay after two weeks you can use stockings up to the knees not necessarily up to the thigh. I will ask him to us will use more than 400 milligram every eight hours to thin the blood to achieve some pain control which is very minimal and to decrease inflammation. John I'm going to ask you to walk a lot. When you're awake every hour or so walk for five ten minutes avoid long sitting laying down and especially today and tomorrow. All right so activity is very important avoid lifting that makes you grunt or hold your breath. If you see any bleeding outside the stocking call us right away. I have not had any patient bleed on me but there's always a first. You will see some spots on the stockings where we poked to give you the numbing that's normal you see some staining of blood-tinged fluid because we injected lidocaine under the skin it will start to ooze out slowly in the next few hours. Your thigh area will be numb for a few hours just like lidocaine does usually when you go to a dentist it goes away in a couple hours.