endovenous treatment of venous diseases: preprocedural assessment, indications and contraindications...

Endovenous Treatment of Venous Diseases: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and Preprocedural assessment, indications and contraindicationscontraindications

Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS

Professor of Vascular Surgery Faculty of Medicine, University of Thessalia, GreeceChairman, Dept. of Vascular Surgery, University Hospital of LarissaLarissa, Greece

GSV Before Treatment

Image courtesy of Olivier Pichot, MD, CHU de Grenoble, France.

Image courtesy of Olivier Pichot, MD, CHU de Grenoble, France.

GSV After Treatment

CEAP Clinical ClassificationCEAP Clinical Classification

Class0: Asymptomatic; no visible or palpablesigns1: Spider veins, reticular veins, telangiectasias2: Varicose veins3: Edema4a: Skin changes with hyperpigmentation and eczema4b: Skin changes with lipodermatosclerosis and atrophie blanche5: Healed ulcer6: Active ulcer

CEAP Clinical ClassificationsCEAP Clinical ClassificationsCClinical linical EEtiologytiology A Anatomynatomy P Pathophysiologyathophysiology

Varicose VeinsCEAP 2

SwellingCEAP 3

Skin ChangesCEAP 4

Skin UlcerCEAP 6

Is pre-op duplex assessment important for varicose vein surgery?

Ultrasonic assessmentUltrasonic assessment

ExplanationExplanation

Information provided by DS will have

significant impact on the selection of appropriate treatment

Failure to identify all sources of venous filling is likely to result in early recurrence

Indications for Duplex ScanIndications for Duplex Scan

Recommendation: both limbs should be studiedPrimary uncomplicated GSV VVs

Debated whether all pts – if not 30% of important connections between deep and superficial veins will be missed

Primary uncomplicated LSV VVs Essential

Non-saphenous & Recurrent VVs Essential

CVD with complications Essential

Surveillance after treatment the only way to obtain level I evidence as to outcome in the future

Venous malformations

anatomical information about the extent of the malformation and its relationship to other vessels

may be used to guide treatment by sclerotherapy

Position of the patientPosition of the patientGreater saphenous

Position of the patientPosition of the patientLesser saphenous

Anatomy of superficial veins of the Anatomy of superficial veins of the lower limblower limb

Important anatomical detailsImportant anatomical details

Anatomical structures on B-modeAnatomical structures on B-mode

Images courtesy of Olivier Pichot, MD

Fascial layers creating “saphenous eye”

GSVGSV

Bound anteriorly by superficial fascia & posteriorly by deep fascia

Often called “saphenous eye”

Tortuosity Side branches

GSV VariablesGSV Variables

Images courtesy of Olivier Pichot, MD

Aneurysmal segments

GSV Variables

SFJ Tributary VeinsSFJ Tributary Veins

SCI: Superficial Circumflex Iliac

SE: Superficial Epigastric

SEP: Superficial External Pudendal

AASV: Anterior Accessory

Saphenous

PASV: Posterior Accessory

Saphenous

Image adapted from: Chandler JG et al. Defining the role of extended saphenofemoral junction ligation: A prospective comparative study. JVS 2000;32:941-53

Initial Catheter Tip PositioningInitial Catheter Tip Positioning

Position catheter tip approximately 2.0 cm distal to SFJ◦ Confirm with measurement

calipers◦ Distance does not need to be

precise at this time because catheter position may shift during tumescent fluid infiltration

Final Tip Position VerificationFinal Tip Position Verification

◦ In both transverse and longitudinal imaging planes

◦ Use measurement calipers to confirm distance to SFJ

Important step to avoid misaligning catheter relative to deep venous system

Recommendation is 2.0 cm distal to SFJ Confirm tip position with ultrasound:

Image courtesy of Pranay Ramdev, MD

Anatomical structures on colour facilityAnatomical structures on colour facility

Small Saphenous Vein (SSV)Small Saphenous Vein (SSV)

Courses from lateral ankle up posterior calf

Terminates in popliteal fossa at Saphenopopliteal Junction (SPJ)◦ Variable confluence with Popliteal Vein

(PV)◦ Proximal portion lies between

superficial & deep fascial layers

SSV

SPJ

Pop V

Figure adapted from: Weiss RA, et al eds. Vein diagnosis and treatment: A comprehensive approach. McGraw-Hill Companies, Inc.; 2001.

Anatomical structures on colour facilityAnatomical structures on colour facility

Detection of reflux on colour facilityDetection of reflux on colour facility

Detection of reflux on colour facilityDetection of reflux on colour facility

Detection of reflux on colour facilityDetection of reflux on colour facility

Detection of reflux on colour facilityDetection of reflux on colour facilityPerforating vein

If reflux is present measure the diametre but this cannot distinguish competent from incompetentDuration of reflux

Detection of reflux on DopplerDetection of reflux on Doppler

Reflux is present when retrograde flow lasts for at least 1 sec

Patient selection for Endovenous AlationPatient selection for Endovenous Alation

Identification of all refluxing venous segments and their ablation is the key to minimise recurrence

Diametre of central GSV > 15 mm may be associated with thrombus extension to CFV

Uncorrectable coagulopathy

Liver dysfunction limiting local anaesthetic use

Immobility

Pregnancy

Breastfeeding

ContraindicationContraindication

Thrombus in the vein segment to be treated

Preoperative ultrasound evaluation◦Reflux > 0.5 seconds in superficial venous

system◦Assess GSV, noting:

Vein depth and maximum diameter Presence of tortuous or aneurysmal segments Other significant anatomy Duplicate systems Large side branches Incompetent perforators or tributaries

Choosing the Closure CandidateChoosing the Closure Candidate

The aim of ablation procedures is to damage the inner vein wall without causing a full-thickness burn, which

could lead to perforation of the vein resulting in bruising or haematoma formation

If vein lies superficially, close to skin the ablation may cause burn

Vein depth from the skin: Why is so important?

Pre-op Ultrasound Assessment Pre-op Ultrasound Assessment

Map and mark◦ Maximum diameter◦ Tortuous segments◦ Aneurysmal segments◦ Areas where vein is very

close to skin◦ Large branches or perforators◦ Potential access sites

Infiltration TechniqueInfiltration Technique

Do not leave any vein segments unprotected◦Re-scan to ensure:

• >10 mm distance between skin surface and vein wall

• Circumferential black “halo” appearance in fascial compartment

Perivenous vs. subcutaneous infiltration

Image courtesy of Carolyn Menendez, MD

Vein MappingVein MappingMake indentions in skin using a strawRemove US gel from legConnect marks on leg with marker to identify

pathway of vein and important anatomy

Image courtesy of Nick Morrison, MD

Pre-op Descending VenographyPre-op Descending Venography

Selective descending ovarian and hypogastric venogram

Significant ovarian vein reflux but No hypogastric vein reflux was detected

Hypogastric vein reflux Ovarian vein reflux

Descending Ovarian Venogram 4 weeks after embolisation

Hypogastric vein embolisation

CT venography

Chronic Venous Obstruction

DP=22 mmHgDP=8 mmHg

DP=2 mmHg

IVC filter placement IVC filter placement

Indications

DVT and covtraindication for anticoagulation

Reccurent PE being on adequate anticoagulation

Pre-procedural evaluation MR or CT venography is

required for IVC and iliac vein patency and IVC diametre measurement

Thank you for your attention