insuffisance veineuse superficielle

Insuffisance veineuse superficielle

Olivier Pichot, Grenoble, France

Maladie veineuse superficielle

Classification Clinique CEAP

C0 Aucun signe visible ou palpable de maladie veineuse C1 Télangectasies ou v. réticulaires C2 V. variqueuse C3 Oedème C4 Troubles trophiques

C4 a Pigmentation ou eczema C4 b Lipodermatosclérose ou atrophie blanche

C5 Ulcère cicatrisé C6 Ulcère ouvert s Symptomatique (douleur, oppression, lourdeur, …) a Asymptomatique

Venous Clinical Severity Score

Anatomie veineuse

Terminologie

Varicose Veins Characterization Guidelines 2.3.0 of the American Venous Forum on duplex ultrasound

scanning of chronic venous obstruction and valvular incompetence In P Gloviczki,ed.Handbook of venous disorders Third Edition Hodder Arnold 2009: 142-55

Grade of

recommendation:

Grade of

evidence:

2.3.1 Duplex scanning is recommended as the first

diagnostic test for all patients with suspected chronic

venous obliteration or valvular incompetence. The test

is safe non invasive, cost effective, and reliable

1 A

2.3.2 The four components that should be included in

duplex scanning examinations for chronic venous

disease are visualization, compressibility, venous

flow, and augmentation.

1 A

2.3.3 Duplex scanning is suggested to distinguish acute

from chronic venous occlusion

2 B

2.3.4 Reflux can be elicited in two ways: increased intra

abdominal pressure using Valsalva manoeuver or

manual or cuff compression and release of the limb

distal to the point of examination.

2 B

2.3.4 We recommend that the cut-off value for abnormally

reversed venous flow (reflux) is 500 ms.

1 B

Varicose Veins Characterization Duplex Ultrasound Investigation of the Veins in Chronic Venous Disease of the

Lower Limbs – UIP Consensus Document. Part I . Basic Principles P. Coleridge-Smith, N. Labropoulos, H.Partsch, K. Myers, A Nicolaides, A. Cavezzi. Eur J Vasc Endovasc Surg 31, 83-92 (2006)

Aim of the DU examination:

1) Which saphenous junctions are incompetent, their location and diameters. 1) The extent of reflux in saphenous veins of the tighs and legs and their

diameters. The number, location, diameter and function of incompetent perforating veins.

1) Other relevant veins that show reflux. 1) The source of filling of all superficial varices if not from the veins already

described. 1) Veins that are hypoplastic, atretic, absent or have to be removed.

2) The state of deep venous system including competence of valves and

evidence of previous venous thrombosis.

Indications for Duplex Scanning Primary venous

insufficiency of the GSV & SSV

Venous insufficiency of non saphenous veins

Secondary venous insufficiency

Post treatment evaluation

Prevait

Venous malformations

Diagnostic du reflux

Mode B Mode Couleur

Mode Energie 3D

Traitements des varices en 2015

Sclérothérapie

liquide

Chirurgie

Conventionnelle

ASVAL / CHIVA

Echosclérose à la mousse

Ttt endoveineux:

- Thermiques - RF

- LEV

- Vapeur

- Physico-chimiques - Clarivein

- Sclerolux

- Colle biologique - Sapheon

Traitement médical:

- Hygiène de vie

- Compression

- Phléboactifs

Stripping sans crossectomie

Traitement “A la carte”

Pichot O, De Maeseneer M. Treatment of Varicose Veins: Does Each Technique Have a

Formal Indication? Perspect Vasc Surg Endovasc Ther. 2012 Jan 11

Patient expectations and preferences

The treatment of varicose veins: an investigation of patient preferences and

expectations Shepherd AC. Phlebology 2010;25:54-65

Aims of DU Investigation Aims:

Complement clinical examination

Anatomical and hemodynamic analyze of the lesions

Define the treatment strategy

Contribute to treatment realization

Approach of duplex ultrasound for LL SVI management:

i. Analyze, clearly understand, and precisely describe the SVI

ii. Contribute to define the best way to manage the SVI, using medical or operative treatment

iii. Determine the most suitable operative treatment and define his technical modalities

Level 3 DU Methodology Exhaustive examination:

SFJ & SPJ (if present) • Precise hemodynamic analysis of terminal & preterminal valve • Groin varicose network

Trunks: GSV, SSV, AASV, Giacomini vein, … Tributaries varicose veins and non saphenous varicose veins Perforating veins:

• Anatomical description • Hemodynamic analysis (re-entry, refluxing, bi directional)

Pelvic veins: • Escape points • Gluteal, pudendal, sciatic veins

Measurement: Diameter : SV, perforating veins, … Depth: SV Height: SPJ

Superficial Veins Mapping

Treatments options

Saphenous veins

Conventional surgery

Saphenous vein trunk ablation:

• RF, EVL, Steam

• UGFS

• Other: physico-chemical, glue, isolated stripping

With or without treatment of tributaries • Phlebectomies

• Foam sclerotherapy

ASVAL / CHIVA

Other veins

Tributaries Phlebectomies

(UG) Foam sclerotherapy

EVF, Steam, RF

Perforating veins Surgical ligation

SEPS

EVL, RF, steam

UGFS

Conventional Surgery Pros: - Large and/or superficial veins - Effective even in case of thrombophlebitis Cons: - Tortuous, thin veins - (General anesthesia) - Patient discomfort - Complications - Varicose veins recurrence

Thermal Ablation Pro: - Ambulatory procedure - Few patient discomfort - Precision of treatment - Efficiency

Cons: - Tortuous, thin, superficial veins

Specificities: - RF: ClosureFast /RFITT / FCare - EVL: Wave length / Type of fiber - Steam

ASVAL Pro: - Conservation of the SV - Ambulatory procedure - Few patient discomfort - Efficiency (C2)

Cons: - Limited efficiency

- Reflux down to the ankle - Nb of treated areas > 7

Midterm results of the surgical treatment ofvarices by phlebectomy with conservation of a

refluxing saphenous vein Pittaluga P, Chastanet S, Rea B, Barbe R. J Vasc Surg 2009

UG Foam Sclerotherapy Pros: - Tortuous, thin veins - In office procedure - Few patient discomfort - Cheap Cons: - Contra-indications & side effect - Thrombophlebitis & pigmentation - Diffusion of the foam

Reflux Extension

Type 1: 36.7%

Re-entry perforator

Saphenous vein

Deep vein

Type 2: 7.2% 0.7% 0.04% 2.3% 4.2%

Type 5: 5.9%

Re

Type 3: 13.3%

13.1% 0.2%

Type 4: 36.9%

29.9% 7.0%

Pittaluga P et al. Classification of saphenous reflux: implication for treatment. Phlebology 2008

Catheterization

SFJ Reflux

Terminal Valve Insufficiency Preterminal Valve Insufficiency

GVS Trunk Valve Insufficiency

Saphenous Compartment

Mesure des diamètres

Nerves

UGFS 1944: ORBACH EJ. Sclerotherapy of varicose veins : utilization of an

intravenous air block. Am.J.Surg. 1944 ; 66 : 362-66. 1997: SCHADECK M. Résultats à long terme de la sclérothérapie des

saphènes internes. Phlébologie 1997 ; 50 : 257-262. 1997: MONFREUX A. Traitement sclérosant des troncs saphéniens et leurs

collatérales de gros calibre par la méthode MUS.Phlébologie 1997 ; 50 : 351-53.

1997: CABRERA J. Elargissement des limites de la sclérothérapie : nouveaux produits sclérosants. Phlébologie 1997, 50 : 181-8.

2000: TESSARI L. Nouvelle technique d’obtention de la scléro-mousse. Phlébologie 2000 ; 53, 1 : 129.

2003: HAMEL DESNOS C. Sclérosant Laromacrogol 400 liquide versus mousse : étude prospective randomisée double aveugle Dermatol Surg 2003 ;30:718-22

2006: BREU X. 2eme european consensus meeting on foam sclerotherapy, Tegernsee Germany Vasa vol37 S71

2008: GACHET G, SPINI L. Référentiel sur le traitement endovasculaire des varices par injections échoguidées de mousses fibrosantes :le consensus d’experts de Grenoble. Phlébologie 2008;61(2):196-20

2013: RABE et al. European guidelines for sclerotherapy in chronic venous disorders Phlebology 2013

Interest of using foam

Non miscibility: Blood is embossed Better contact between sclerosing agent and vein wall

Adherence: Sticking of the bubbles on the vein wall

Cohesion: Avoid any risk of air embolization

Interest of echoguidance

Faisability:

Access to all the veins visible with ultrasound

Safety:

Accuracy of the puncture

Avoid arterial injection risk

Efficiency evaluation

Vein feeding

Spasm

Sclerotherapy is suitable for all the varicose veins

Incompetent saphenous vein 1A Tributary vv 1A Incompetent perforators 1B Reticular vv 1A Telangiectasia 1A Residual et recurrent vv (PREVAIT) 1B VV of pelvic origin 1B VV in proximity of a leg ulcer 1B Venous malformation 1B

Rabe et al. European guidelines for sclerotherapy in chronic venous disorders Phlebology 2013

SV trunks

Tributaries

Reticular varicose veins

Telangiectasia

Lymph node veins

UGFS is not suitable for all the patients

Absolute contraindications:

Allergy to the sclerosant Acute DVP and/or PE Long- lasting immobility Cutaneous infection Known symptomatic patent foramen ovale

Relative contraindication:

Pregnancy or breast feeding Severe peripheral arterial disease Poor general health Strong predisposition to allergies High TE risk (history of TED, Thrombophylia) Acute superficial venous thrombosis Prior UGFS induced neurological disturbance


UGFS efficiency

Systematic review of foam sclerotherapy for varicose veins. Jia X. et al British Journal of

Surgery 2007; 94: 925–936


Complications and side effects

Before UGFS

Patient information Alternative methods Details of the procedure Complications and side effects Efficiency

Clinical examination History taking Motive of consultation

DU examination IVS diagnosis Treatment planning


Cosmetic results

UGFS procedure

① Preoperative duplex examination Analysis of the vv to be treated Choice of the puncture site

• Incompetent saphenous junction and trunks • Other cases

② Visualisation of the vein to be accessed Longitudinal Transverse

③ Tip of the needle positioned in the center of the lumen ④ Venous blood backflow ⑤ Careful injection with continuous ultrasound guidance ⑥ Distribution of foam and venous spasm occurrence

assessment


Choice of the puncture site

Puncture feasibility

Intra-fascial varicose vein

Ideally: large, rectilinear, not too deep

Can be challenging (technical skill)


Safety

Away from arteries

Small saphenous vein Small saphenous vein


Safety

Away from arteries

Perforating vein


Safety

Away from the deep venous system

Efficiency

Manage diffusion of the foam into all the venous network to be treated

With preservation of the veins not to be treated (in a first step)

Determination of the optimal patient positioning

Confort of the patient (and practitioner)

Optimal vein distention

Volume of foam

Maximal (efficient) volume :

V (ml) = S (cm2) x L (cm)

Spasm

European recommendations

2nd European Consensus Meeting on Foam Sclerotherapy 2006, Tegernsee, Germany. Breu

F.X. Guggenbilchler S., Wollman J.C. Vasa vol 37 S/71 February 2008

Concentration of sclerosant

According to the type of vein to be treated (with polidocanol)




According to the diameter of vein to be treated (with polidocanol)




According to the type of vein to be treated


Foam

3 or 2 ways connector

1 + 4 volumes

Air

Injection less than 1 mn after creation

Volume < 10 ml

Matériel

Elaboration de la mousse

Ultrasound guided puncture

SSV UGFS

SSV: Spasm

SSV: Before, during and after

Specific indications for UGFS: (1) recurrence

Recurrent varicose veins and catheterization possibilities

Theivacumar N et al. Endovenous Laser Ablation (EVLA) to Treat Recurrent Varicose Veins. EJVES 2011

Specific indications for UGFS: (2) recanalization

After thermal ablation

After UGFS

c) Superficial veins insufficiency

C4

C5

C6

UGFS treatment of venous ulcers 130 patients (132 limbs) CEAP C5: 49 – C6: 83

Pang K et al. Healing and Recurrence Rates Following Ultrasound-guided Foam Sclerotherapy of Superficial Venous Reflux in Patients with Chronic Venous Ulceration EJVES 2010

We note (anecdotally) at this stage) that perforators in the vicinity of the ulcer are often occluded following UGFS.

Combined minimally invasive treatment of venous ulcers

86 patients with 95 ulcers – Retrospective study comparing: compression versus compression + ablation (RF / UGFS)

Alden P Chronic Venous Ulcer: Minimally Invasive Treatment of Superficial Axial and Perforator Vein Reflux Speeds Healing and Reduces Recurrence. Ann Vasc Surg 2013

Alden P Chronic Venous Ulcer: Minimally Invasive Treatment of Superficial Axial and Perforator Vein Reflux Speeds Healing and Reduces Recurrence. Ann Vasc Surg 2013

Vein diameter

Myers Ka et al. Outcome of Ultrasound-guided Sclerotherapy for Varicose Veins: Medium-term Results Assessed by Ultrasound Surveillance. EJVES 2007

UGFS versus Surgery

Shadid N et al. Randomized clinical trial of ultrasound-guided foam sclerotherapy versus surgery for the incompetent great saphenous vein. Br J Surg. 2012

UGFS versus others varicose veins treatment modalities

Rasmussen LH et al. Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Br J Surg. 2011

Recommandations

NICE guidelines [CG168] Published date: July 2013

Management of Chronic Venous Disease Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS) 2015

Recommandations

Management of Chronic Venous Disease Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS) 2015

81

VNUS® ClosurePlus™ System - 1998

Thermal ablation

82

• Intima destruction

• Shrinkage and and thickening of collagen fibers of media and adventitia tunica

• Necrosis of smooth muscle

Treatment objective

83

SFJ SEP

84

ClosureFAST - 2006

85

Segmental Ablation

7 cm length treated all at once

Energy delivery does not vary by pullback speed

86

Treatment Parameters

Device (set) temperature: 120° C

Vein wall contact temperature: 105 - 115° C

Energy delivery during 20 sec

40 Watts max power

Temperature controlled energy delivery

Average energy delivery is approximately 68 J/cm per treatment

87

Treatement procedure

Patient selection

Phlebectomies?

89

Procedure ultrasound guidance

① Percutaneous vein access

② Catheterization

③ Catheter positionning

④ Tumescent anesthesia

⑤ Termal ablation

⑥ Immediate post operative efficiency assessment

90

91

Percutaneous vein access

92

Catheterization

93

Catheter positionning

2 cm

94

Catheter positionning

95

Tumescent anesthesia

96

RF thermal ablation

97

Immediate post operative efficiency

assessment (RF)

GSV termination GSV trunk

98

Ex vivo GSV RF ablation

294 (99.7%) of 295 treated GSVs were occluded at 3 days

The single “immediate failure” GSV was found occluded at 3 months follow-up and therefore regarded as a delayed occlusion

Immediate Success Rate

100

Pain

70.1% of limbs had no pain any time after

treatment along the course of the treated

GSV

Patient return to normal activities average:

1.6 ± 3.7 days

70.1%

Obliteration “Not any flow in treated segments below 3 cm from SFJ”

Standard Error below 5% at all times

91.9% @ 5Y

Reflux Free “No reflux over 0.5 sec in any treated segment”

Standard Error below 1% at all times

94.9% @ 5Y

VCSS

Means and Std Deviations

Time Course of CEAP C

Means and Std Deviations

EVL vs RF: RECOVERY Trial Maximum pain score (0-10) since previous FU

106

Jose I. Almeida et al. Radiofrequency Endovenous ClosureFAST versus Laser Ablation for the Treatment of Great Saphenous Reflux:

A Multicenter, Single-blinded, Randomized Study (RECOVERY Study) J Vasc Interv Radiol 2009

EVL vs RF: RECOVERY Trial Presence of any ecchymosis (bruising)

107

RF versus others varicose veins treatment modalities

108

Rasmussen LH et al. Randomized clinical trial comparing endovenous laser ablation,

radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous

varicose veins. Br J Surg. 2011

Less Invasive Treatments

Clarivein


Laser Assisted Foam Sclerotherapy (LAFOS)


Cyanoacrylate glue

The New Approach THERMAL ablation NON THERMAL ablation

RF EVL Steam UGFS Surgery Glue Moca Lafos

No sclerosing agent ✔ ✔ ✔ ✗ ✔ ✔ ✗ ✗

No tum. anesthesia ✗ ✗ ✗ ✔ ✗ ✔ ✔ ✔

Large v. applicability ✔ ✔ (✔) (✔) ✔ ? ? ?

Tortuous veins ✗ ✗ ✗ ✔ ✗ ✗ ✗ ✗

Nerve injury risk ✗ ✗ ✗ ✔ ✗ ✔ ✔ ✔

TED risk ✔ ✔ ✔ ✗ ✗ (✔) (✔) ?

Return norm. activity ✔ ✔ ✔ ✔ ✗ ✔ ✔ ✔

Efficiency ✔ ✔ (✔) (✔) ✔ ✔ ✔ ?

Long term FU available ✔ ✔ (✔) ✔ ✔ ✗ ✗ ✗

In the everyday practice…

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insuffisance veineuse superficielle

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