Varicose veins are caused by venous reflux affecting over 25 million Americans. Minimally invasive treatments like radiofrequency ablation using the VNUS Closure system are effective alternatives to traditional surgery for varicose veins and venous reflux. The VNUS Closure procedure uses a catheter to deliver radiofrequency energy to shrink and close diseased veins, providing improved treatment outcomes over surgery with faster recovery times.

1. Varicose Veins John F Eidt MD Vascular Surgery

2. Varicose Veins Venous anatomy Venous physiology Varicose veins Symptoms Treatment

3. Anatomy Superficial veins Deep veins Perforating veins Communicating veins

4. 25 Million people suffer from venous reflux disease, the underlying cause for most varicose veins VNUS Closure is the minimally invasive treatment for the medically indicated treatment of varicose veins Images courtesy of Paul McNeill, MD and Rajabrata Sarkar, MD

5. Annual U.S. Incidence U.S. Prevalence Prevalence and Etiology of Venous Insufficiency Venous reflux disease is 2x more prevalent than coronary heart disease (CHD) and 5x more prevalent than peripheral arterial disease (PAD)1 Millions

7. Over 23 million go untreatedPrevalence by Age and Gender3,4

8. Superficial Veins Great saphenous Small saphenous Vein of Giacomini

9. Venous System Deep femoral v. Perforating v. Femoral v. Popliteal v. Small saphenous v. Great saphenous v. Perforating v. Venous blood flows from the capillaries to the heart Flow occurs against gravity Muscular compression of the veins Negative intrathoracic pressure Calf muscle pump Low flow, low pressure system Image source: Fundamentals of Phlebology: Venous Disease for Clinicians. Illustration by Linda S. Nye. American College of Phlebology 2004.

16. Pathophysiology of Venous Insufficiency

17. Risk Factors and Symptoms of Venous Insufficiency

18. Manifestations of Venous Insufficiency Superficial venous reflux is progressive and if left untreated, may worsen over time. Below are manifestations of the disease.5 Skin Ulcers Swollen Legs Skin Changes Varicose Veins 20+ million 2 to 6 million 500,000 Photos courtesy of Rajabrata Sarkar, MD, PhD.

19. CEAP Classifications Clinical Classifications of Venous Insufficiency (CEAP) Class 0 - No visible or palpable signs of venous disease Class 1 - Telangiectasias or reticular veins Class 2 - Varicose veins Class 3 - Edema Class 4 - Skin changes (4a) Skin changes including pigmentation or venous eczema (4b) Skin changes with lipodermatosclerosis Class 5 - Healed venous ulceration Class 6 - Active venous ulceration

20. Types of Varicosities Varicose veins Saphenous Non-saphenous Reticular veins Venulectasia Telangiestasia

27. Lateral Reticular Complex

31. Treatment Compression Surgery Stripping Ambulatory phlebectomy Radiofrequency ablation Sclerotherapy Injection Laser

59. Sclerotherapy Hypertonic saline Ethoxyscerol – polidocanol Sodium tetradecyl sulfate

67. The VNUS Closure® System The VNUS Closure System is a minimally invasive treatment alternative for patients with symptomatic superficial venous reflux and varicose veins Using a catheter-based approach, the VNUS ClosureFAST™ catheter delivers radiofrequency (RF) energy to the vein wall RF energy creates conductive heatingthat contracts the vein wall collagen, thereby occluding the vein

68. VNUS Closure® Procedure using the ClosureFAST™ Catheter

69. Radiofrequency AblationProcedure Video

70. Efficacy of the ClosureFAST™ Catheter The ClosureFAST™ catheter ablates the vein in 7cm segments with 20-second treatment cycles, resulting in vein shrinkage and occlusion. Interim data from a multicenter prospective study have shown 97.4% vein occlusion 1 year post-treatment.6

72. Avoid heavy/strenuous exercise for a few days

73. Avoid prolonged sitting or standing

74. Wear compression stockings for up to 2 weeks

75. Patient should return for duplex scan within 72 hoursVNUS Closure® Visual Results One week post-treatment* Pre-treatment *Individual results may vary

76. Perforating Veins and Reflux Perforator valves maintain one-way flow from superficial to deep veins Perforator valve failure causes: Higher venous pressure and GSV/branch dilation Increasing pressure results in GSV valve failure Additional vein branches become varicose Further GSV incompetence and dilation

77. Systemic Reflux in Venous Ulceration Incompetent perforators found in 63% of venous ulcer patients Comprehensive care treats all sources of reflux Photos courtesy of Steven A. Kaufman, MD.

78. VNUS ClosureRFS™ VNUS ClosureRFS Benefits: Minimally invasive Outpatient procedure Quick patient recovery Only device cleared by the FDA for the endovenous ablation of incompetent perforator veins Click graphic to play video

79. Summary Varicose veins are common Due to gravity-dependent reflux Treatment options Compression Excision Ablation Sclerotherapy