Vein Grand R Ounds5 19 2011

Varicose Veins and Superficial Venous Insufficiency

Mark A. Smith, MD

Department of Surgery Division of Vascular Surgery

University of California, Irvine Medical CenterOrange, California

Varicose Veins in Vascular Surgery

Definitions

• Varicose Vein- dilated tortuous vein

• Venous Insufficiency- condition, typically chronic, of abnormal blood flow in vein leading to local damage and potentially regional/global effects.

Spider Veins

Large Varicosities GSV

Venous Stasis Ulceration

Long History of Varicose Veins

• 1550 B.C.- Elbers Papyrus from Egypt- described the condition, recommended not treating

• Hippocrates- noted venous hypertension in ulcers- recommended compression

• Da Vinci- described venous anatomy

• 1603- Fabricius- described venous valves

Incidence and Prevalence

• Incidence- Recent large U.S. cohort• 3% Women• 2% Men

• Prevalence- Review of Studies since 1942• CVI-

• Females- 1-40%, Males 1-17%

• Varicose Veins-• Females 1-73%, Males 2-53%

Ann Epidemiol. 2005 Mar;15(3):175-84.

Pathogenesis

• Primary- Valvular insufficiency, Vein Wall Weakening

• Secondary- DVT, Trauma, Expanded Blood Volume

• Congenital- Klippel- Trenaunay, Avalvulia

• Common Denominator- Venous Hypertension

Risk Factors

• Familial tendency

• Female Sex associated with pregnancies

• Obesity

• Age – greatest number >age50

• Prolonged standing or sitting

• Prior DVT• Tight fitting clothes- tourniquet effect

Classification- CEAP

• C- Clinical• C0 - No visible or palpable signs of venous

disease

• C1 - Telangiectases or reticular veins

• C2 - Varicose veins

• C3 – Edema

• C4a - Pigmentation or eczema

• C4b - Lipodermatosclerosis or atrophie blanche

• C5 - Healed venous ulcer

• C6 - Active venous ulcer

• Add S- Symptomatic or A- Asymptomatic

Classification- CEAP

• E- Etiology• Ec – Congenital• Ep – Primary• Es - Secondary (post-thrombotic)• En - No venous cause identified

• A- Anatomic• As - Superficial veins• Ap - Perforator veins• Ad - Deep veins

• An - No venous location identified

Classification- CEAP

• P- Pathophysiologic• Pr – Reflux• Po – Obstruction• Pr,o – Reflux and obstruction• Pn - No venous pathophysiology

identifiable

Diagnosis- History

• Appearance of enlarged veins of any size

• Heaviness, Aching, Pruritus• Symptoms progress through the day

• Mild to moderate edema

• Severe Symptoms- Phlebitis, Hyperpigmentation, lipodermatosclerosis, Ulceration, Bleeding

Diagnosis- Physical Examination

• Identification of varicosities and extent- skin, deeper tissue or both

• Look for the pigment changes and ulcerations

• Tests for Venous Insufficiency• Brodie- Trendelenberg Tourniquet-

separate deep from superficial venous insufficiency

• Bedside doppler- with Valsalva

Diagnosis- Laboratory Studies

• Ambulatory Venous Pressure- Gold Standard Physiologic test

• Duplex Ultrasound Scanning- Gold Standard Anatomic

Treatment

• Conservative• Do nothing• Compression

• Large Varicose Veins (Insufficiency)• Open Surgery• Endoluminal Closure• US Guided Foam Sclerotherapy

• Smaller Varicose Veins (<8mm)• Sclerotherapy• External Laser, Pulsed Light

• Ulcers

Conservative

Compression Treatment

• Over the Counter products

• Prescription Stockings- (e.g. Jobst, Sigvaris)• Can vary pressure, area covered,

material

• Unna Boots- “Soft Cast”- Zinc Oxide

• Multilayered Wraps- Profore System

Open Surgery

• Great Saphenous Vein Ligation and Stripping

• High Ligation of Sapheno-Femoral Vein Junction and Ligation of Tributaries

• Phlebectomy- Ambulatory or Stab Phlebectomy

Surgical TreatmentStripping and Ligation

Groin incision, ligation and tying off of tributaries and GSV

Once the “stripper” is tied in place, the surgeon rips the stripper and the vein from the leg

Ambulatory Phlebectomy

Endoluminal Closue

• EVLA- EndoVenous Laser Ablation• Generates heat, destroys endothelium,

inflammation, thrombosis• Wavelength- 810, 920, 980- Hgb, H2O

1320, 1470- H2O

• RFA- Radio Frequency Ablation• Direct contact with wall, endothelium

destruction, thrombosis

Percutaneous Venous Access

Advance Guidewire

Advance Sheath

Laser Fiber Passed into Sheath

Tumescent Anesthesia

• Idea is to circumferentially compress the vein so that it surrounds the fiber uniformly.

• Described as a tubular anesthetic affect along the course of the vein.

• Injections with a long 22+/- gauge needle every 2+/- cm.

• Must be done with Ultrasound Guidance,

• Must be in Perivenous space

Tumescent Anesthesia Delivered

Completion of Ablation Procedure

• Pull back of laser at 1-2 mm/sec.

• Goal is to deliver 80-85 joules/cm. of treated vein

• Preserve the Superficial Epigastric Vein

• Ideally treat GSV to below knee position

• Can treat GSV, SSV and Perforators with the Ablation method

Pre - EVLT

2 Wks Post - EVLT

Undesirable Outcome

EVLA- The Results

• 495 GSV’s treated in 423 Patients• 98% initial technical Success, more than 93%

remain closed over 2 years• Well tolerated by all patients under strictly

local anesthesia

Endovenous Laser Treatment of Saphenous Vein Reflux: Long-Term ResultsRobert J. Min, MD, Neil Khilnani, MD, and Steven E. Zimmet, MDJ Vasc Interv Radiol 2003; 14:991–996

EVLA Results

Combined Results Min, et al.

• > 3000 GSVs treated with endovenous laser• Up to 28 month follow-up• > 97% of GSVs have remained closed• Bruising & mild/moderate tenderness (< 2 wks)• No other minor or

major complications

Sclerotherapy

• Liquid agents to chemically ablate veins

• Agents• Hypertonic Saline

• Detergent Agents• Sodium Tetradecyl sulfate (Sotradecol)• Aethoxysclerol ( Polidocainol)

Sclerotherapy Complications

• Hyperpigmentation- occurs 10-30% of patients (resolution 70-99% at 1 yr)

• Telangiectatic matting- 15-20%• Pain- variable

• Cutaneous necrosis

• Allergic reaction- low

• DVT – issue with foam

Liquid Sclerotherapy

• Goldman (2002)- 70% efficacy for Sotradecol in prospective trial

• Belcaro reported 90.2% efficacy

SclerotherapyBefore After

SclerotherapyBefore After

US Guided Foam Sclerotherapy

• Frullini and Cavezzi- 93.3% success rate

• Bergan et al.- Complete absence of reflux in 79.8%

• Almeida and Raines- GSV closure rate of 100%

Venous Ulcers

• Compression is primary treatment

• Wound care particulars becoming more important

• Treat underlying pathology such as feeding perforator to decrease recurrence rate

Conclusions

• Varicose Veins and Superficial Venous Insufficiency should be seen as conditions on a continuum.

• It is treatable, not curable. Need a long term follow-up mind set.

• Fit the treatment to the individual situation- there is no one size fits all.

Thank you