So far this this has all been the build up for the activation of the laser.
So we have had the cannulation of the vein, the precise placement of the laser fiber and
the application of tumescence: all leading to the point where we can activate the laser
and treat the vein by endo-thermal ablation - a procedure in which we heat the vein from
the inside to a temperature at which it is closed, sterilised, cauterised and de-vitalised.
Jane who is in charge of laser safety is asking us to wear safety glasses.
We are going to put laser safety glasses on.
Could you enable the laser please?
Right, so now we are going to deliver energy.
Could I have a swab please Pam?
So Jane has checked the power settings on the machine.
She has called them out to make sure that we are so we are all aware of the power settings.
She has made sure that the doors are closed, that the sign outside says “do not enter”
that there is laser in progress, that we are all wearing laser safety glasses and she has
pressed the “enable button”.
If there are any problems Jane is in charge of turning off the laser and she is in charge
of safety.
So at any time if you feel discomfort I want to know and the best way to let me know is
to say in a loud voice “ouch!”.
Now you might feel at the beginning of the procedure a little “crackle” in your thigh.
I describe it sometimes as sitting on a bag of crisps.
It’s that sort of feeling.
It shouldn’t be painful but if I don’t tell you about it, it might give you a startle.
So right at the beginning as I say you might feel a little “pop” and “crackle”.
You might feel nothing at all.
Now the laser is delivering a certain amount of energy per second measured in watts and
in the background you may be able to hear a little “musical note” which indicates
that the laser is in action.
It has also a metronome beat.
Every 5 seconds, there is a 0.2 second pause.
That tells us that there is a 5 second marker and by withdrawing the catheter at a certain
rate – the catheter is marked in centimetres – if I withdraw the catheter at a certain
rate in time with the metronome, I can be sure of delivering the correct amount of energy
(to the vein).
So I am concentrating on the speed at which I am withdrawing the catheter in relation
to the metronome auditory signal that I am hearing in the background.
At the end of the procedure, Jane will have a record of the length of the vein that we
have treated and there will also be a record of the total amount of energy delivered by
the laser equipment.
So by a simple calculation, dividing the total amount of energy delivered by the length of
vein treated, we can calculate the number of joules delivered to each centimetre of
vein.
Experts vary as to what is the correct amount of energy that should be delivered to the
vein.
But on my reading of the (medical) literature and my own personal experience, for a 1470
nanometre laser delivered through a radial fibre using the Biolitec system, I aim to
deliver between 50 and 70 joules per centimetre.
The evidence in the literature would suggest that this gives the best outcome in terms
of vein ablation rates (vein closure) together with a very kind and gentle post-procedure
recovery with very little discomfort afterwards.
Certainly my own personal experience of this procedure, is that the discomfort is minimal
both during and after.
It is certainly a great alternative now to surgical stripping.
Indeed, I haven’t done any surgical stripping now for nearly a decade.
This procedure is the treatment of choice: endothermal ablation- that is heating the
vein from the inside using laser energy or radiofrequency energy – is the number one
choice now for the treatment of superficial vein reflux caused by reflux in the great
saphenous vein, the vein we are treating this morning now or the small saphenous vein the
vein at the back of the calf.
Having reached a certain point, I need to withdraw the catheter-introducer and continue
the laser to the final portion of the vein.
(I am) gently withdrawing the laser fibre at a rate that is in keeping with the metronome
auditory signal in the background.
Very shortly we will reach the end of the procedure.
Jane will “disable” the laser equipment before I finally withdraw the laser fibre
from the leg to confirm that there is no possibility that the laser is active outside the patient’s
vein.
At that point, we will take off our laser goggles and the procedure will be complete.
So far this procedure has taken just over 30 minutes.
That somewhat slower than we would normally do because I have talking and demonstrating.
But as you can see, in real time it’s about 30 minutes.
The cannula (laser fibre) is now very close to the exit point.
I am taking great care to make sure that I do not inadvertently withdraw it completely.
I am going to stop there.
At this point Jane will disable the laser fibre (laser machine).
It’s 3766 joules delivered to 49 centimetres of vein.
Disable.
Standby.
You can turn it off now Jane.
There we are, this patient’s procedure is complete.
I am going apply a little local pressure to the puncture site.
The patient is smiling off camera.
I am going to apply a plaster to this area and apply a compression stocking.
The patient will probably wear the stocking for 48 hours and thereafter, he can wear it
as he sees fit.
Some people get on very well with the stocking and they wear it for longer, some people don’t
like wearing the stocking and they can take it off a that point.