athanasios d. giannoukas md, msc(lond.), phd(lond.), febvs professor of vascular surgery

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Endovenous Treatment of Venous Endovenous Treatment of Venous Diseases: Preprocedural Diseases: Preprocedural assessment, indications and assessment, indications and contraindications contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery Faculty of Medicine, University of Thessalia, Greece Chairman, Dept. of Vascular Surgery, University Hospital of Larissa Larissa, Greece

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Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications. Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery Faculty of Medicine, University of Thessalia, Greece - PowerPoint PPT Presentation

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Page 1: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

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

Page 2: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

GSV Before Treatment

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

Page 3: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

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

GSV After Treatment

Page 4: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

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

Page 5: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

CEAP Clinical ClassificationsCEAP Clinical ClassificationsCClinical linical EEtiologytiology A Anatomynatomy P Pathophysiologyathophysiology

Varicose VeinsCEAP 2

SwellingCEAP 3

Skin ChangesCEAP 4

Skin UlcerCEAP 6

Page 6: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

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

Page 7: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

Ultrasonic assessmentUltrasonic assessment

Page 8: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

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

Page 9: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

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

Page 10: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

Position of the patientPosition of the patientGreater saphenous

Page 11: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

Position of the patientPosition of the patientLesser saphenous

Page 12: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

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

Page 13: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

Important anatomical detailsImportant anatomical details

Page 14: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

Anatomical structures on B-modeAnatomical structures on B-mode

Page 15: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

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”

Page 16: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

Tortuosity Side branches

GSV VariablesGSV Variables

Images courtesy of Olivier Pichot, MD

Page 17: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

Aneurysmal segments

GSV Variables

Page 18: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

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

Page 19: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery
Page 20: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery
Page 21: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

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

Page 22: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

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

Page 23: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

Anatomical structures on colour facilityAnatomical structures on colour facility

Page 24: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

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.

Page 25: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

Anatomical structures on colour facilityAnatomical structures on colour facility

Page 26: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

Detection of reflux on colour facilityDetection of reflux on colour facility

Page 27: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

Detection of reflux on colour facilityDetection of reflux on colour facility

Page 28: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

Detection of reflux on colour facilityDetection of reflux on colour facility

Page 29: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

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

Page 30: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

Detection of reflux on DopplerDetection of reflux on Doppler

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

Page 31: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

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

Page 32: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

ContraindicationContraindication

Thrombus in the vein segment to be treated

Page 33: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

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

Page 34: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

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?

Page 35: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

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

Page 36: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

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

Page 37: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

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

Page 38: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

Pre-op Descending VenographyPre-op Descending Venography

Page 39: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery
Page 40: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

Selective descending ovarian and hypogastric venogram

Significant ovarian vein reflux but No hypogastric vein reflux was detected

Page 41: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

Hypogastric vein reflux Ovarian vein reflux

Page 42: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

Descending Ovarian Venogram 4 weeks after embolisation

Page 43: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

Hypogastric vein embolisation

Page 44: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

CT venography

Page 45: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

Chronic Venous Obstruction

Page 46: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

DP=22 mmHgDP=8 mmHg

DP=2 mmHg

Page 47: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

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

Page 48: Athanasios D. Giannoukas  MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

Thank you for your attention