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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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Page 1: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

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: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

GSV Before Treatment

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

Page 3: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

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

GSV After Treatment

Page 4: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

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: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

CEAP Clinical ClassificationsCEAP Clinical ClassificationsCClinical linical EEtiologytiology A Anatomynatomy P Pathophysiologyathophysiology

Varicose VeinsCEAP 2

SwellingCEAP 3

Skin ChangesCEAP 4

Skin UlcerCEAP 6

Page 6: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

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

Page 7: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

Ultrasonic assessmentUltrasonic assessment

Page 8: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

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: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

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: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

Position of the patientPosition of the patientGreater saphenous

Page 11: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

Position of the patientPosition of the patientLesser saphenous

Page 12: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

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

Page 13: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

Important anatomical detailsImportant anatomical details

Page 14: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

Anatomical structures on B-modeAnatomical structures on B-mode

Page 15: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

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: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

Tortuosity Side branches

GSV VariablesGSV Variables

Images courtesy of Olivier Pichot, MD

Page 17: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

Aneurysmal segments

GSV Variables

Page 18: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

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: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),
Page 20: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),
Page 21: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

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: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

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: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

Anatomical structures on colour facilityAnatomical structures on colour facility

Page 24: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

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: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

Anatomical structures on colour facilityAnatomical structures on colour facility

Page 26: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

Detection of reflux on colour facilityDetection of reflux on colour facility

Page 27: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

Detection of reflux on colour facilityDetection of reflux on colour facility

Page 28: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

Detection of reflux on colour facilityDetection of reflux on colour facility

Page 29: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

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: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

Detection of reflux on DopplerDetection of reflux on Doppler

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

Page 31: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

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: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

ContraindicationContraindication

Thrombus in the vein segment to be treated

Page 33: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

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: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

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: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

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: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

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: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

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: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

Pre-op Descending VenographyPre-op Descending Venography

Page 39: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),
Page 40: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

Selective descending ovarian and hypogastric venogram

Significant ovarian vein reflux but No hypogastric vein reflux was detected

Page 41: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

Hypogastric vein reflux Ovarian vein reflux

Page 42: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

Descending Ovarian Venogram 4 weeks after embolisation

Page 43: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

Hypogastric vein embolisation

Page 44: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

CT venography

Page 45: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

Chronic Venous Obstruction

Page 46: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

DP=22 mmHgDP=8 mmHg

DP=2 mmHg

Page 47: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

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: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.),

Thank you for your attention