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
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