ra in varicose veins

7/29/2019 Ra in Varicose Veins

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RECENT ADVANCES

DR.MATHISEKARAN.T


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RECENT ADVANCES IN

MINIMALLY INVASIVE SURGERYFOR VARICOSE VEINS


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INTRODUCTION

VARICOSE VEIN AFFECTS A SIGNIFICANT

PERCENTAGE (40%) OF MIDDLE AGED

POPULATION.

ITS IMPORTANT TO LOCALIZE THE

PROBLEM BEFORE SURGICAL

MANAGEMENT.

CLINICAL EXAMINATION-

90% SENSITIVITY FOR SAPHENOFEMORAL JN

61.5% SENSITIVITY FOR PERFORATOR

INCOMPETENCE


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ENDO-VENOUS THERAPIES KEYHOLE

THERAPYSCLEROSE OR BURN THELEAKY VEIN CLOSE TO VALVE JUNCTIONS.

HEAT SOURCE

LASER RADIOFREQUENCY


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DIVISION OF INCOMPETENT PERFORATING

VEINS REGARDED AS APPROPRIATEAPPROACH FOR TREATMENT OF VENOUS

STASIS ULCERS.

NOW,SEPSSUB FASCIAL ENDOSCOPICSURGERYIMPORTANT PART OF

SURGICAL ARMAMENTARIUM FOR VENOUS

ULCERS.


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PATHOGENESIS


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Pathogenesis

MAIN CAUSE : Persistent chronic ambulatory

venous HTN.

Prevalence of venous ulceration:0.1 0.3%.

Cutaneous venous hypertension occurs as a

consequence of primary valvular incompetence in

60% of patients.


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Clinical features

C 0 NO VISIBLE SIGN OF VENOUS DISEASE

C1 TELANGIECTASES AND/OR RETICULAR

VEINS

C2 VARICOSE VEINS

C3 EDEMA

C4 CHANGES IN SKIN AND SUBCUTANEOUS TISSUE

A PIGMENTATION OR ECZEMA

B LIPODERMATOSCLEROSIS OR ATROPHICBLANCHE

C5 HEALED ULCER

C6 ACTIVE ULCER

Clinical classification is based on CEAP reporting system


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Clinical features

Sensation of heaviness and itching

Cramps and aching

Visible varicosed vein

Cutaneous skin breakdown over medial

malleolus

Complications :

Bleeding

Phlebitis

ulceration


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Indications for surgery

-cosmetic reasons

-chronic venous insufficiency-superficial thrombophlebitis

-bleeding

-anxiety


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Contra-indications

Previous deep vein thrombosis

Major lower limb fracture

Prolonged immobilization

white leg of pregnancy

Arterial insufficiency -relative


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Surgical aspects

Informed consent

Warned of possible complications

Minor hemorrhage

Track thrombophlebitis

Hematomas

Infections

Lymph leak.

Injury to sural or saphenous nv

Permanent lymphoedemaThromboembolism


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Common surgical procedures

Sapheno-femoral ligation

Stripping of long saphenous

vein

Multiple avulsionsSapheno-popliteal ligation

Perforator ligation


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Sapheno-femoral ligation Identification of long saphenous vein Superficial tributaries dissected

Followed back to secondary branches

Divided and ligated

Stripping of long saphenous vein

Reduces rate of recurrence Not universally performed


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Multiple avulsion-Small 3-5 incisions made-vein retrieved with phlebotomy hook

-avulsed.

-avulsions may be closed with steristrips

Sapheno-popliteal ligation

-location of sapheno-popliteal is veryvariable

-pre-operative Doppler or duplex scanning is

important.


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Perforator ligation:-significance of this surgery remains unclear

-surgery designed to divide perforating

veins COCKETT and

LINTONconsiderable morbidity.


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R t Ad


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Recent Advances

Endo-venous therapies(keyhole therapies)

R t Ad


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Recent Advances

Endo-venous therapies(keyhole

therapies) Sclerosing or burning the leaky vein close to valve

junctions.

The heat for burning the vein is provided by laser orradio frequency.

Less painful procedure.

The results are good and better than surgery.

The endovenous thermal ablation restores the normalblood flow towards the deep system.

The success rate is 93 -95%


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Subfascial endoscopic surgery(SEPS)

Procedure:

The patient in supine position

Esmarch bandage is tightly applied and a

sterile tourniquet is inflated high up on the

thigh.The esmarch is then removed.

A 10 mm endoscope is laid on the leg

A 13 mm skin incision is made 3cm from

the medial margin of tibia.

10mm opticview port with the scope is

inserted.


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It is rotated to reach the white fascia

Then the underlying muscles are exposed. At this point, the subfascial space has been

entered.

It is angled towards the patients foot and

advanced into this space. The scope and the inner cannula are removed

And CO2 insufflated to 30mm/hg pressure.

The scope is then reinserted into the port.

The second port is placed 5-10cm from the first

and approximately the same level.


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The endoscissors are inserted through 2nd port and

subfascial space opened. After creating the optical cavity, larger perforating

vein is clipped and divided.

Space is opened from medial tibial border to midline

posteriorly From the level of port to as far distally as dissection

can comfortably proceed

Paratibial fossa should be opened sharply so that

additional perforating veins can be divided in deepposterior compartment.

Cautionto avoid injury to postr tibial art,vn and tibial

nerve

DISCUSSION


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DISCUSSION

CLASSICALY VASCULAR SURGERY REMAINED

RELATIVELY AWAY FROM ENDOSCOPICTECHNIQUES

SEPS represents a safe,easily mastered technique for

vascular practitioner to enter ENDOSCOPIC world.

LINTON PROPOSED:

Patients with perforator incompetence treated directly by

dividing offending perforators.

Long incision had to be made85% patients enjoyed ulcerfree recurrence in long term.

Complicationsinfection, flap necrosis, delayed healing.

Minimally invasive surgeryre-evaluation of the procedure


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HAUER IN GERMANYmechanical system for

endoscopic subfascial surgeryto date has thegreatest experience.

ODONNELL OF USAemployed saline infusion

adequate optical space.

GLOVICZKI OF USAemployed CO2 insufflation


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APPROPRIATE PATIENTS FOR SEPS:

Active ulcersRecurrent ulcers

Healed ulcer present >4months.

It is advisable to synchonously treat superficial reflux by

stripping while also perrforming SEPS,if perforater

competence was documented.

Underlying pathophysiological process is

best documented by color flow duplex

scanning


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LASER/RADIOFREQUENCY

ABLATION SYSTEMS


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ELVeS Endo Laser Vein System is a

minimally-invasive laser treatment forIncompetent Saphenous and Accessory Veins a

problem which often leads to the formation of

varicose veins. ELVeS takes approximately 30

minutes and requires only local anesthesia allowing

patients to walk home after treatment. With virtuallyinstant relief from Venous Reflux and Venous

Hypertension, patients can return to their normal

lifestyle and activities immediately following

treatment.


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Benefits of ELVeS for varicose veins

& spiderveins:

Endovenous Laser Therapy ELVeS is a minimally

invasive laser vein treatment for damaged incompetent

veins. ELVeS requires no incisions, leaves no visible

scarring and with minimal postoperative pain recoveryperiods are quick and minimal.

Treatment in less than an hour in office with no general anesthesia or hospitalization.

Up to 98% success rate.

Immediate relief of symptoms.

Return to normal activity immediately with little or no

pain.

No scars.

CONCLUSION


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CONCLUSION

-minimal morbidity.

-out patient basis.

SEPS represents a promising new

approach to ulcer management in

patients with perforator

incompetence

NASEPS committee is warranting continued

evaluation, focusing in incidence of

recurrent ulceration and ultimately standard

evaluation of ulcer therapy


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THANKYOU

ra in varicose veins

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