Management of Incompetence in the Axial Veins

Vascular Health Clinics

Introduction

½ adult men, 2/3 adult women have varicose veins.

Severe chronic insufficiency seen in 20% of working men and women.

Varicosities can range in severity from venectasias to protuberant tortuous varicosities, with associated dermatitis, ulcers, severe pigmentation.

Introduction

• Venous disorders are divided into acute thromboembolic events or chronic stasis issues.

• Chronic issues includes varicose veins, venous incompetence (superficial and deep).

• Primary varicose veins can be treated for cure.• Deep venous reflux is treatable but not curable• Varicosities are a symptom of venous disease, not

just a cosmetic problem.• Regardless of treatment modality, recurrence rates

are high.

Varicose VeinsEpidemiology

• 50% of the population has some venous symptoms• 20-25% of women and 10-15% of men will have

visible varicose veins• 10% of venous ulcerations are secondary to purely

superficial disease• 3% of the population with some skin change• Superficial reflux contributes to ulceration in 70%

of cases

Venous Anatomy of the Leg

Anatomy of the Saphenofemoral Junction

• Five Named Branches– Long (greater) Saphenous– Anterior-lateral branch– Anteriormedial branch– Superficial Epigastric– External Pudendal

Varicose VeinsPathophysiology

• Valvular incompetence with axial reflux

• Venous pressure increases leading to dilation, lengthening and further valve damage

• Fluid and protein extravasation in soft tissue

Varicose VeinsMechanism of Development

• Perforator Incompetence– Ropey– Reticular– Spider

Anatomy of Telangiectasia

Function of The Skeletal Muscle Pump

• Superficial veins have mainly reservoir function

• Skeletal muscle pump responsible for majority of blood return in upright position (90%)

Risk Factors

• Female sex• Increased age• Obesity• Pregnancy• Geography• Race

Symptoms

• Achiness, heaviness• Stinging, burning• Edema• Warmth• Muscle spasms• Phlebitis• Bleeding• Skin changes

CEAP Classification

• Clinical

• Etiologic

• Anatomic

• Pathophysiologic

CEAP Classification

• Clinical Classes– 0 asymptomatic– 1 telangectasia– 2 varicose veins– 3 limb edema– 4 skin changes– 5 healed venous ulceration– 6 open venous ulceration

CEAP Classification

Incidence of Symptoms by CEAP Score

Source: Medicographia.com

Varicose Veins• Spider Veins• Reticular Veins• Ropey Varicosities

Phlebectatic Corona

Hemosiderin Deposition

Lipodermatosclerosis

Atrophie Blanche

Bleeding Intradermal Varices

Venous Ulceration

Cosmetic Benefit• Most common reason to

seek treatment• Baby Boomers reaching

retirement age• Cosmetic benefit will

occur in 2-3 weeks but not maximal until 6-12 months

Compression

Stockings Solaris Wrap

Pump Lymphatic Decongestive Therapy

Graded Compression Stockings• PROS

– Good effectiveness for relief of symptoms

– Effective at reducing risk of ulceration

– Effective at reducing risk of phlebitis

– Effective at slowing development or recurrence

• CONS– Difficult to don– Cosmetically unappealing– May create tourniquet effect

if not worn properly– Can be poorly tolerated in

neuropathy– Contraindicated with

arterial insufficiency

Algorithm for the TreatmentSymptomatic Venous Insufficiency

Principles

• Eliminate all sources of reflux

• Treat proximal to distal

• Largest to smallest• Important to create a

pre-op map of reflux

Surgical Therapy for Varicose Veins

• Flush Ligation of the Saphenofemoral Junction

• Stripping of the GSV• Individual

Ligation/Avulsion/ Interruption Secondary Branches

Complications of Surgical Therapy

• Hematomas• Paresthesias

– Up to 40%• Wound complications• Neovascularization of the SFJ

– 60% at 39 yrs– 30% requiring reintervention (Fischer,J Vasc

Surgery 2001;34:326-40.)

Trivex Powered Phlebectomy

• Minimally invasive• General or spinal

anesthetic• Learning curve• Good results

Subfascial Endoscopic Perforator Surgery (SEPS)

Subfascial Endoscopic Perforator Surgery

Microphlebectomy

Complications of Microphlebectomy

• Bruising• Phlebitis• Scarring• Retained Varicosities

Superficial Thrombophlebitis

Valve Replacement• Damaged valve • Surgical repair- poor long

term results• Percutanous techniques

being developed but so far outcomes poor

• Possible stem cell therapies on the horizon

Thermal Ablation of the Greater Saphenous Vein

• Done in the office• Mild sedation (oral benzodiazepine)• Local anesthetic• Tumescent anesthesia• 45-60 minute procedure• Minimal post-op pain• Return to work in 24 hours• More likely to be reimbursed by insurance

Before and After Closure• Secondary branches

will require secondary procedure

• Phlebectomy or sclerotherapy

• May be done concomitantly or staged (debated)

• Regression of perforator incompetence 60%

Tumescent Anesthesia

• High Volume of dilute lidocaine with epinephrine

• Provides anesthesia• Acts as a heat sink to

protect surrounding structures

• Relatively exsanguinates the vessel to improve heating (contact) and reduce bleeding

Pre-op Assessment

• Power-wave doppler of reflux

SFJ Ultrasound

Thermal Ablation

• Radiofrequency- heat delivered through direct contact with vessel wall

• Laser-980-1320nm heat delivered to the water component of blood and steam damage to the wall

EVOLVeS Trial

Journal of Vasc Endovasc Surg 29,67-73(2005)

EVOLVeS Trial

Journal of Vasc Endovasc Surg 29,67-73(2005)

VNUS (radiofrequency ablation)

Radiofrequency Ablation with ClosureFast Device

Post-closure Instructions

• Compressive wrap x 24 hours with leg elevation

• Class II graded compression stocking around the clock for 1 week

• Class II compression stocking x 3-4 weeks• Non-steroidal anti-inflammatory tx

Laser Ablation

Outcomes of Thermal Ablation

• Radiofrequency Ablation– 91.4% closure at 1 yr– 90.1% closure at 2 yr– 86.3% closure at 3 yr– 86.1% closure at 4 yr– (VNUS Clinical

Registry)

• Laser Ablation– 98.5 technical success– 1.5 couldn’t complete– 1 week 100% closure– 97.7 closure at 3

months– 96.2 at six months– 93.2 at 2 yrs– (Min et al

Endovascular today suppl. Nov/Dec 2004.)

Complications of Endoluminal Therapy

• Endoluminal Heat Induced Thrombus (EHIT)

• Grade 1-4

Comparison of Thermal Ablation and Surgical Removal

• EVOLVeS trial– Multicenter,

prospective, randomized control study

• Thermal ablation superior to stripping in all outcome variables– Faster recovery– Less pain– Fewer adverse events– Superior quality of life

score (p<.05)– Fewer recurrences at 2

yrs 91.2% vs 91.7%

Sclerotherapy• Hypertonic saline

– Painful, risk of ulceration• Polidocanol

– Least painful, less staining, most expensive

• Sotradecol– Less painful, FDA approved,

moderate staining• Glycerine

– Difficult to use, no staining, minimally painful

• Sodium Morrhuate– Rarely used

Sclerotherapy Results

Foam Sclerotherapy

• Works only with detergent sclerosants– Polidocanol– Sotradecol

• Sclerosant aerated 4:1 with air or CO2 to create “microbubbles”

• Pre-foamed options- Varithena

Foam Sclerotherapy• Can be deployed with only

a few injections• Painless

Foam Sclerotherapy• Potency and contact time increased• Foam can be directed with ultrasound

Complications of Foam Sclerotherapy

• Transient neurological symptoms (1:100 sessions)– Visual aura– Amaurosis fugax– Hemiballismus– Seizure– Stroke (1 case)

• Increased risk with history of migraine

• ? Patent foramen ovale

Liquid SclerotherapyBefore After

Complications of Sclerotherapy• Itching, Stinging, Burning• Muscle Cramps and Bruising• Extravasation• Hyperpigmentation• Talangectatic Matting• Phlebitis• Ulceration• Allergic Reaction; local or systemic• Neurologic• DVT (rare)

Trapped Hematoma

• Expected; if left undrained increased hyperpigmentation

• Drainage can be more painful than sclero

• Patients are warned ahead of time

Telangectatic Matting

• Usually represents deeper level of insufficiency

• May resolve over time• May respond to repeat

injection of cutaneous laser

Urticaria

• Usually transient• May ulcerate• Usually stings and

then may become pruritic

Ulceration

• Inadvertent extravasation

• Hemangioma vs spider vein

• Forceful injection

What’s New

• FDA News Release:• FDA approves closure system

to permanently treat varicose veins

Venaseal Sapheon SystemOnly one access site. One injection.No heat or pain.No phlebitis.Currently more expensive than EVLT or RFA.Unknown long term success rate.

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