Perforator veins why and how to treat them

Cees H.A.WittensCees H.A.Wittens

European Venous Centre European Venous Centre Aachen-MaastrichtAachen-Maastricht

Perforator veins: why Perforator veins: why and how to treat themand how to treat them

E CVEuropean Venous Centre: Maastricht-AachenEuropean Venous Centre: Maastricht-AachenTurkish Society of Vascular Surgery Antalya 2011Turkish Society of Vascular Surgery Antalya 2011

Why treat Incompetent Perforator Why treat Incompetent Perforator in:in:

Venous ulcers CVenous ulcers C6 6 and healed ulcers Cand healed ulcers C55 ? ? Lipodermatosclerotic legs CLipodermatosclerotic legs C44??

Recurrent varicosities CRecurrent varicosities C2,32,3??


Perforator treatment:Perforator treatment:pathophysiologypathophysiology

High ‘systolic’ intravenous pressures High ‘systolic’ intravenous pressures in calf veins are transmitted through in calf veins are transmitted through incompetent perf. veins to the skin incompetent perf. veins to the skin circulation circulation (200 mmHg) causing;(200 mmHg) causing;

White cell trapping and capillaryWhite cell trapping and capillary

cuffingcuffing Impairing nutritional skinflowImpairing nutritional skinflow


Perforator treatment CPerforator treatment C5,65,6::clinical outcomeclinical outcome

.. Depending oncompliance

Subgroup analysesQuality of SEPS

Turkish Society of Vascular Surgery Antalya 2011Turkish Society of Vascular Surgery Antalya 2011

Perforator treatment CPerforator treatment C66::clinical outcomeclinical outcome


SEPS-trial: SEPS-trial: residual and/or medial ulcersresidual and/or medial ulcers

223150576873 314258677885N =

non-primary and/or medial ulcer

period (6 months)

654321

ulc

us

pre

sen

t (%

da

ys)

100

90

80

70

60

50

40

30

20

10

0

TREAT

CH

CO

P= 0.045 (ANOVA)



Influence of the quality of the SEPS procedureInfluence of the quality of the SEPS procedure


Influence on Healing of the quality of the SEPS Influence on Healing of the quality of the SEPS procedureprocedure

months

60483624120

he

alin

g (

%)

100

90

80

70

60

50

40

30

20

10

0

SEPS

non succesfull

succesfull

NSNS

Compliance highCompliance high



Influence on Recurrence of the quality of the SEPS Influence on Recurrence of the quality of the SEPS procedureprocedure

months

60483624120

recu

rre

nce

(%

)

100

90

80

70

60

50

40

30

20

10

0

seps

not succesfull

succesfull

P<0.007P<0.007

Influence of perforator Influence of perforator incompetence !!incompetence !!

Compliance lowCompliance low



C C 5,65,6

medial ulcersmedial ulcers recurrent ulcersrecurrent ulcers large ulcerslarge ulcers

(around 90 % of patients with venous ulcers)(around 90 % of patients with venous ulcers)

E CVEuropean Venous Centre: Maastricht-AachenEuropean Venous Centre: Maastricht-Aachen

Why treat Incompetent PerforatorWhy treat Incompetent PerforatorBecause of improved clinical outcome in:Because of improved clinical outcome in:


YESYESCC5,65,6 (medial, recurrent and large) (medial, recurrent and large)

????Lipodermatosclerosis CLipodermatosclerosis C4 4

Recurrent varicosities in CRecurrent varicosities in C2,3 2,3

NoNoPrimary varicosities CPrimary varicosities C2,32,3

E CV

European Venous Centre: Maastricht-AachenEuropean Venous Centre: Maastricht-Aachen

Why treat Incompetent PerforatorWhy treat Incompetent PerforatorBecause of improved clinical outcome in:Because of improved clinical outcome in:


Open methods Open methods (Linton)(Linton)

Pierik 1996 (due to woundproblems >50%/0% trial stopped ) = Pierik 1996 (due to woundproblems >50%/0% trial stopped ) = ObsoleetObsoleet

Half blind methods Half blind methods (Edwards phlebotoom) = (Edwards phlebotoom) =

ObsoleetObsoleet

How to treat IPVHow to treat IPV


SEPS one port systemSEPS one port system

Olympus scoopOlympus scoop

CO2 insufflationCO2 insufflation

Bloodless fieldBloodless field

Mechanical space (force)Mechanical space (force)




SEPS two/three port systemSEPS two/three port system lap. equipm.lap. equipm.

CO2 insufflationCO2 insufflation

spacemakerspacemaker

no mech. space no mech. space




Sclerotherapy of IPV:Sclerotherapy of IPV:

intraluminalintraluminal 98 % succesfull occlusion immediately after 98 % succesfull occlusion immediately after

the procedure (cave: spasm)the procedure (cave: spasm) 33.3 % recurrence after 1 month33.3 % recurrence after 1 month

FutureFutureFoam ??Foam ??

Masuda et al; J Vasc Surg 2006Masuda et al; J Vasc Surg 2006E CV

European Venous Centre: Maastricht-AachenEuropean Venous Centre: Maastricht-AachenTurkish Society of Vascular Surgery Antalya 2011Turkish Society of Vascular Surgery Antalya 2011

Cryo Perforator Surgery (CPS):Cryo Perforator Surgery (CPS):

ExtraluminalExtraluminal Initial succes 100 %Initial succes 100 % Recanalisation after Recanalisation after

20 weeks 57 %20 weeks 57 %

ObsoleetObsoleet

Klem and Wittens; Vasc Endovascular Surg 2008/2010Klem and Wittens; Vasc Endovascular Surg 2008/2010E CV


Radiofrequency ablation of IPV: Radiofrequency ablation of IPV: IntraluminalIntraluminal Initial succes 96%Initial succes 96% 1 year1 year

VNUS: 60-80%VNUS: 60-80%RFITT: 75-90%RFITT: 75-90%

Future: Future: One hand procedure ?One hand procedure ?

Peden and Lumbsden ; Perspect Vasc Surg Endovasc Ther 2007Peden and Lumbsden ; Perspect Vasc Surg Endovasc Ther 2007E CV


Laser ablation of IPV:Laser ablation of IPV: IntraluminalIntraluminal Initial succes 96 %Initial succes 96 % 1year1year

60-80%60-80%

Future:Future:Length and energy level changeLength and energy level change

Proebstle et al.; Dermatol Surg 2007Proebstle et al.; Dermatol Surg 2007


Coil embolisation of IPV:Coil embolisation of IPV:

IntraluminalIntraluminal Initial succes 67 %Initial succes 67 % Recanalisation 75 % Recanalisation 75 %

after 1 yearafter 1 year

Future:Future:Obsoleet!Obsoleet!

Van Dijk and Wittens; J Vasc Interv Radiol 1999Van Dijk and Wittens; J Vasc Interv Radiol 1999 E CVEuropean Venous Centre: Maastricht-AachenEuropean Venous Centre: Maastricht-AachenTurkish Society of Vascular Surgery Antalya 2011Turkish Society of Vascular Surgery Antalya 2011

Duplex directed interruption of Duplex directed interruption of IPV:IPV:

ExtraluminalExtraluminal Initial succes 100 %Initial succes 100 % Recanalisation ??Recanalisation ??

Future Future ??

Siewert et al; poster AVF 2006Siewert et al; poster AVF 2006


All techniques:All techniques:

SEPSSEPS (cannot reach them all; short stay)(cannot reach them all; short stay) 60-9060-90 SclerotherapySclerotherapy (high recurrence; cheap)(high recurrence; cheap) 40-7040-70 CryoPSCryoPS (obsoleet)(obsoleet) <60<60 RFARFA (feasable; expensive)(feasable; expensive)

VNUSVNUS 60-8060-80RFITTRFITT 75-9075-90

Laser Laser (feasable; expensive)(feasable; expensive) 60-8060-80 Coil embolisationCoil embolisation (obsoleet)(obsoleet) <60<60 Duplex interrupt.Duplex interrupt. (extraluminal;distance, cheap)(extraluminal;distance, cheap) ????


Succes %Succes %


Why:Why:• Because it improve clinical outcome in CBecause it improve clinical outcome in C5,65,6

How:How:• SEPSSEPS• Quality control !!Quality control !!• New minimally invasive techniques:New minimally invasive techniques:

• which: trials!which: trials!Turkish Society of Vascular Surgery Antalya 2011Turkish Society of Vascular Surgery Antalya 2011


Perforator veins: why and how to Perforator veins: why and how to treat them:treat them:

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Perforator veins why and how to treat them