Treatment of accessory and non-saphenous

veins

Jose I. Almeida, MD, FACS, RPVI, RVTDirector, Miami Vein Center

Voluntary Associate Professor of Surgery

University of Miami - Jackson Memorial Hospital

Faculty DisclosureJose I. Almeida, MD, FACS, RPVI, RVT

1. Research grant supportAngioDynamics, Covidien, Sapheon, Vascular Insights

2. Managing PartnerVascular Device Partners, LLC

Great saphenous vein anatomy

The Venous Map

Pitfalls

Failure to recognize anatomic variability.

Failure to correlate duplex to the clinical exam.

Common patterns of VV

GSV DoddPudendal Giacomini

Surgical failures:

Imaging will identify

the refluxing vein

causing varicosis.

AASV

GSV

Great Saphenous Incompetence

The great saphenous vein (GSV) is the most

common source of superficial venous reflux

occurring in up to 70% of patients presenting

with symptomatic varicose veins and venous

insufficiency

Myers KA, Ziegenbein RW, Zeng GH, et al. Duplex ultrasonography scanning for

chronic venous disease: patterns of venous reflux. J Vasc Surg. 1995;21:605-

612.605-12.)

Labropoulos N, Giannoukas AD, Delis K, et al. Where does venous reflux start? J

Vasc Surg. 1997;26:736-742.

60% 30% 10%SSV Insertions

Up to 20% of patients with varicose veins have

incompetence of the SSV.

Englehorn CA, Englehorn AL, Cassou MF, Salles-Cunha SX. Patterns of saphenous

reflux in women with varicose veins. J Vasc Surg 2005;41: 645-51.

Anterior Accessory SV

Drawing courtesy of Olivier Pichot, MDDrawing courtesy of Olivier Pichot, MD

img 27

Image courtesy of Olivier Pichot, MD

img 27

Image courtesy of Olivier Pichot, MD

AASV PASV

Isolated AAGSV reflux occurs in

approximately 10% of patients with

symptomatic varicose veins

33 patients who underwent EVLT of the

AAGSV had no recanalization of the treated

vein at 1 year.

Patient-satisfaction scores 84%

Theivacumar NS, Darwood RJ, Gough MJ. Endovenous laser ablation (EVLA) of the

anterior accessory great saphenous vein (AAGSV): abolition of sapheno-femoral reflux

with preservation of the great saphenous vein. Eur J Vasc Endovasc Surg. 2009;37:477-

481.

Almeida, Ann Vasc Surg, 2006

img 22

Image courtesy of Olivier Pichot, MD

Image courtesy of Olivier Pichot, MD

Dual GSV and AASV reflux

Dual ablation

Superficial Accessory SV

Risk of thermal injury

img 51 img 51

Images courtesy of Olivier Pichot, MD

Post-op staining from epifascial GSV

img 50

Re-entry via inter-saphenous connections

Perforators

Drawing courtesy of Olivier Pichot, MDDrawing courtesy of Olivier Pichot, MD

case 1

LADS- laser assisted distal saphenectomy

GSV in canalDermal GSV

(sasv)

LADS- laser assisted distal saphenectomy

LADS- laser assisted distal saphenectomy

LADS

case 2

Foam

EVL straight remnant

EVL AASV

Recurrent VV s/p saphenectomy

EVL versatility: fits through micropuncture

RF 7cm long heating element limits short

length veins

case 3

Klippel-Trenauney Syndrome

Pain & non-healing ulcer

Normal deep venogram

ELT of KTS- 6 superficial axial veins closed over 1 year

period, followed by sclerofoam.

Lateral embryonic vein

R then LLSV

R then L

Anterolateral leg vein

R only

Lateral thigh vein

L only

Now 9 years, UGS once a quarter

MAP correctly,

& you won’t go astray

Thank you!

Conclusion: