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Mechanochemical Ablation: MOCA 2 year follow up, lessons learned

Steve Elias MD FACS FACPh Director, Division of Vascular Surgery Vein Programs Columbia University and Medical Center, NY Assistant Professor of Surgery Columbia University. Mechanochemical Ablation: MOCA 2 year follow up, lessons learned. Disclosure: .

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Mechanochemical Ablation: MOCA 2 year follow up, lessons learned

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  1. Steve Elias MD FACS FACPh Director, Division of Vascular Surgery Vein Programs Columbia University and Medical Center, NY Assistant Professor of Surgery Columbia University Mechanochemical Ablation: MOCA2 year follow up, lessons learned

  2. Disclosure: • Vascular Insights LLC – Advisory Board • Covidien Inc. – Advisory Board

  3. What Is It? MOCA

  4. How Does It Work: • Combination – endovenous mechanical and chemical • Mechanical – wire > rotates > intimal damage • Chemical – liquid > penetrates > scar • End result – venous occlusion

  5. Mechanical Component

  6. Chemical Component

  7. Mechanochemical Together

  8. Access: MOCA • Percutaneous ultrasound guided • 4 fr. micropunture sheath • 18 gauge IV access • No further wires or larger sheath exchange

  9. Position: Wire exposed

  10. Position: Wire 2 cm SFJ

  11. Treat: MOCA • Pullback 1.o – 1.5 mm. per second • Inject during pullback • Sodium tetradecyl sulfate 1.5% liquid (or equivalent sclerosant) • Volume dependent on size/length

  12. Treat SFJ: Rotate and Inject

  13. Treat Mid GSV: Wire/Sclerosant Mix

  14. Treat: Injection & Pullback

  15. MOCA: Mechanism of action

  16. Elias FIM: Clinical Trial2/09* • 30 limbs • GSV only • C2 – 24 C3 – 2 C4 – 4 • Avg. 55 years • Treat GSV only (no treatment VV or IPV) • 1 yr. follow up to complete trial • No tumescence or sedation *Elias S, Raines JK. Mechanochemicaltumescentlessendovenous ablation: final results of the initial clinical trial. Phlebology;27:67-72.

  17. Procedure Statistics: MOCA • GSV size – 8.1 mm. • GSV length treated – 36 cm. • GSV treatment time – 5 min. • Overall treatment time - 14 min

  18. Completed Trial * • All closed except 1st patient – btw 3-6mos • 6 month – 29/30 (96%) • 12 month – 29/30 (96%) • 24 month – 27/28 (96%) ( 1 died, 1 no US yet) *Elias S, Raines JK. Mechanochemicaltumescentlessendovenous ablation: final results of the initial clinical trial. Phlebology;27:67-72.

  19. Complications • Subcutaneous ecchymoses – 3 pts. • Side branch tear? • No DVT • No nerve injury • No skin injury

  20. GSV Results: Dutch seriesMichel Reijnen/ Jean Paul DeVries • 224 GSV’s • C2 (13%) C3 (67%) C4 (20%) • GSV diameter 7 mm • GSV length41 cm • treatment time 16 min Ramon RJP, van Eekeren MD et al. Endovenousmechanochemical ablation of great saphenous vein incompetence using the ClariVein device: a safety study. J EndovascTher 2011; 18:328-334.

  21. Dutch MOCA: Results • 6 weeks – 182/185 closed 98% • 6 months – 40/42 closed 95% • No nerve/skin/DVT

  22. MOCA 2012: Results Summary • 6,000 cases worldwide (GSV/SSV) • > 90% occlusion rate – various intervals • Chaloner – 92% at 1 yr. • QoL – improves as any successful EVA • DVT - < 1% • No nerve/skin injury • No tumescence – longest part of short procedure

  23. What We Have Learned: Technique • Rotate 1st(spasm/vortex) then inject slow • Catheter ON = Catheter MOVING • Two handed technique – 1 pulls – 1 injects • Tendency: Pull too fast, inject too slow

  24. What We Have Learned: Volume • Volume originally 12 cc (1.5%STD) for all • Volume now based on diameter/length • Volume tends to be less • Table available • GSV – 6-10 cc SSV – 2-4 cc PPV – 1cc

  25. What We Have Learned: Concentration • Stronger is better • STD 1.5% - 2% 93-96% 1% < 90% (Chaloner UK) • PLD – 2 – 3 % (volume based on weight) • Lower volume, maximum concentration

  26. What We Have Learned: Duplex • Slower contraction and scarring • No flow but appears sponge like (color flow) • Can take up to 1 year for contraction • If some flow – reimage 3 months

  27. Post MOCA 1 month

  28. Advantages: MOCA • No thermal injury – nerves, skin • SSV, BK GSV, PPV • Ulcers – retrograde • Eliminates tumescence – patient and MD

  29. Conclusions MOCA: 2012 • It works, It is safe – 96% at 2 years • Learning curve -5 – 8cases • No tumescence – the future, only one now • Glue, PEM, TAHOE (RF) • Another good option for ablation (95% pts.)

  30. Words To Live By: • Respect the elders, • Embrace the new, • Encourage the improbable and impractical • Without bias

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