Retained Laser Fibre Following Endovenous Laser Ablation☆
Article Outline
Introduction
To report the breakage and retention of a laser fibre, following endovenous laser ablation (EVLA).
Case Report
The great saphenous vein (GSV) of a 57 year-old man was treated with EVLA. During withdrawal, a flash of light was seen from a hole that had burned through the introducer sheath. This device was removed and a second sheath and laser fibre inserted to complete the ablation procedure. A follow-up duplex scan identified a residual length of laser fibre within the GSV that was removed by an additional surgical procedure. A change in laser fibre length had not been identified during the initial procedure.
Discussion
This case highlights the importance of routinely inspecting the sheath and fibre following EVLA to ensure that they have been removed intact.
Keywords: Endovenous laser ablation, EVLA, Complication, Varicose veins
Introduction
Minimally invasive percutaneous techniques have become established as an alternative to surgery with stripping for the treatment of varicose veins.1 These include endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) techniques.
The complication rates for these new procedures are starting to be seen and understood.1, 2 Device related complications have been reported as burns and incorrect positioning in the femoral/popliteal veins.2 We report a device related complication that resulted in an additional surgical procedure being required to remove a retained segment of laser fibre following EVLA.
Case Report
A 57 year-old man with primary uncomplicat ed GSV incompetence attended for day case EVLA performed under local anaesthesia. In the standing position, the patient's GSV was scanned using duplex ultrasonography (SonoSite® 180 plus; SonoSite Inc., Bothell, WA, USA), confirming incompetence and suitability for EVLA.
The patient lay supine with the treatment leg externally rotated and the knee flexed. The GSV, in the distal thigh, was punctured with a 19-G needle under ultrasound control and a guidewire passed up the GSV. A 5-Fr introducer sheath was then passed over the guidewire until the tip reached approximately 2
cm below the saphenofemoral junction (SFJ). Tumescent local anaesthetic was infiltrated under ultrasound control into the perivenous space.
A 600-μm core laser fibre (Vari-Lase, Vascular Solutions Inc., Minneapolis, MN, USA) was passed through the sheath until the tip was positioned 2cm below the SFJ. Once in place, the sheath was withdrawn exposing 2cm of the laser fibre. The laser fibre was then locked into position on the sheath. Protective laser goggles were worn by the patient and all the theatre staff. Laser energy was delivered by an 810-nm endovascular laser console (Vari-Lase, Vascular Solutions Inc., Minneapolis, MN, USA) set at a power of 14W. The laser fibre withdrawal rate was 2mm/s.
During withdrawal of the laser fibre, a flash of light was seen from a hole that had burned through the introducer sheath, at the point where it was being held on its entry/exit into the thigh. The device was removed with the sheath intact. A second sheath and laser fibre were inserted to complete ablation of the vein. There were no further problems during the procedure. A full-length compression bandage was applied and the patient went home that day.
This incident was reported to the manufacturer, following completion of the procedure, who advised us to ensure that no components had been left within the GSV. A duplex scan, performed at 7 days, confirmed the presence of a foreign body (retained laser fibre) in the GSV (Fig. 1). An additional surgical procedure, under local anaesthesia, was therefore performed. Under ultrasound guidance a transverse skin incision exposed the ablated GSV. The GSV was opened and a residual length (28cm) of laser fibre was removed (Fig. 2).
Fig. 1
Duplex confirming foreign body in the great saphenous vein (GSV).
Fig. 2
Retained length of EVLA fibre (top), compared to a complete laser fibre (bottom).
The patient has returned to normal activities with no other complications, except bruising, following his EVLA treatment.
Discussion
This particular complication has not been reported in the published series in the literature. However, the Food and Drug Administration (FDA) Web site contains several reports of EVLA device related complications that have required additional surgical procedures to remove retained laser fibres and sheaths.3
The retention of surgical instruments and/or components (foreign bodies) following surgery can have clinical as well as medicolegal implications. Components of vein strippers that have been left in situ, following varicose vein surgery, have resulted in successful medicolegal claims in the United Kingdom.4, 5
Many clinicians are now performing EVLA in the “office” based setting and not within an operating theatre environment. An operating theatre scrub nurse who would normally help check that all instruments and devices are working correctly, and accounted for at the beginning and end of an operation, is not always present. This checking of instruments and devices remains just as essential with minimally invasive techniques where ever they are performed.
There are two possible causes of failure of the optical fibre, the first being of mechanical origin and the second, thermal destruction due to bending of the fibre. Because of its high maximum bending stress, which is unlikely to be exceeded during the procedure, mechanical failure is unlikely unless damage had occurred to the fibre during manufacture or prior to insertion. A more plausible explanation is that when an optical fibre is bent to a small bending radius, the high intensity laser light is able to escape from the core, be absorbed by the fibre coating and converted into heat. The smaller the radius of curvature, the more severe the thermal effects and this may result in damage to the fibre. Time to failure decreases with increasing bending stress and optical power.6, 7 We suspect that the operator in this case (a supervised surgical trainee) had applied a significant bend in the fibre at the point of breakage. The fact that a hole had burned through the introduce sheath implies that the laser fibre was broken at that point. This was not appreciated at the time and the loss in laser fibre length not noticed. As the fibre and sheath were locked together they should have been withdrawn as one with the stepped tip of the laser fibre core, protruding from the sheath, clearly visible (Fig. 3). Had a missing tip been noticed the GSV could have been checked, by duplex, at the end of the procedure to look for retained components.
Fig. 3
“Check Your Tip!” The stepped tip of the laser fibre protrudes from the distal end of the sheath on complete withdrawal.
This case highlights the importance of routinely inspecting the sheath and fibre following EVLA to ensure that they have been removed intact.
References
- . Treatment options for primary varicose veins- a review. Eur J Vasc Endovasc Surg. 2005;30:83–95
- . Systematic review of endovenous laser treatment for varicose veins. Br J Surg. 2005;92:1189–1194
- . VNUS and EVLT. Available at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/search.cfm
- . Medicolegal action following treatment for varicose veins. Br J Surg. 1996;83:291–292
- . Varicose veins: a review of 200 consecutive medicolegal claims. Clinical Risk. 2005;11(6):225–230
- Mechanical failure of bent optical fiber subjected to high power. J Am Ceram Soc. 2006;89(1):50–56
- . Catastrophic damage and accelerated ageing in bent fibres caused by high optical powers. Electron Lett. 2000;36(5):414–416
☆ The authors have no commercial, proprietary, or financial interest in any product or companies described in this article.
PII: S1533-3167(06)00088-4
doi:10.1016/j.ejvsextra.2006.11.001
© 2006 Elsevier Ltd. All rights reserved.
Refers to article:
- Retained Laser Fibre Following Endovenous Laser Ablation , 30 December 2006
