surgical options for venous disease...pathophysiology • primary varicose veins – result from...
TRANSCRIPT
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Surgical Options for Venous Disease
Sandra C Carr MD Vascular Surgery
Meriter Wisconsin Heart
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Chronic Venous Disease • Approximately 23% of adults in the US have varicose veins • Estimated 22 million women and 11 million men ages 40-80
years have varicose veins • Up to 0.5% of the population has had problems with venous
ulcers over the lower extremities
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Socioeconomic Impact • Medical costs in the US approx. $1 billion annually,
mostly due to advanced cases with ulceration • Venous ulcers cause loss of 2 million work days per year
in the US • Multiple studies have shown decreased scores on health
related as well as venous disease related quality of life surveys
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Clinical Classification
• C1 – spider veins or telangectasias • C2 – varicose veins • C3 – edema • C4 – skin changes (eczema, pigmentation) • C5 – healed ulcer • C6 – active ulcer
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Telangectasias C1
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Varicose Veins C2
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Edema with Dermatitis
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Venous Stasis Dermatitis
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Hyperpigmentation
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Lipodermatosclerosis
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Atrophie Blanche
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Healed Venous Ulcer
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Venous Stasis Ulcer
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Goals of Surgical Treatment • Attempt to address the underlying cause
of the ulcer • Speed ulcer healing rate • Prevent ulcer recurrence • Improve patient quality of life
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Treat the Underlying Cause • Increased ambulatory venous pressures • Severity is related to magnitude of venous
hypertension • Reflux is the most important hemodynamic
feature
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Pathophysiology
• Primary varicose veins – result from venous dilation and valve damage without previous DVT
• Secondary varicose veins – recanalization of thrombosed veins leads to reflux and residual obstruction
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Normal Venous Valves
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Venous Reflux
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Postphlebitic Syndrome
• Chronic leg symptoms following old DVT • May be due to old occlusive disease • Valve damage and scarring leads to reflux
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Venous Anatomy There are two venous systems in the lower
extremity • Deep venous system - veins that lie within the
muscular systems • Superficial veins – veins that lie outside the
muscular system.
These two systems are interconnected by many perforating veins
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Venous Anatomy
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Perforating Veins • Connectors between the
superficial and deep system.
• There are over 100 communicating veins in the leg.
• One way valves direct blood flow from the superficial system to the deep system.
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Diagnostic Studies
• Physical Exam • Duplex Ultrasound • CT Venography • MR Venography • Venogram with IVUS
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Duplex Ultrasound
• Unilateral / limited • Evaluate deep system
for reflux or obstruction • Locate sites of valvular
incompetence – GSV, SSV, perforators
• Develop a logical treatment plan
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Venous Duplex Ultrasound
img 5
Image courtesy of Olivier Pichot, MD
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Duplex for Venous Reflux
Normal GSV Reflux in the GSV
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With extension into IVC
Large left iliofemoral thrombus Compression of left iliac vein by right iliac aretery
RCIA
LCIV
May Thurner Syndrome
CT Venogram
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Venography with IVUS
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Compression Therapy for Venous Ulcers
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Compression Stockings
• Control edema • Decrease aching
and leg pain • Prevent recurrent
ulceration
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Compression Stockings
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Surgical Treatment
• Truncal superficial veins: GSV, SSV • Tributary veins • Perforating veins • Deep veins
–Deep vein occlusive disease –Deep vein reflux
It is not necessary to wait until the ulcer is healed to intervene
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Treatment of GSV/SSV Reflux
• Saphenous stripping • Radiofrequency ablation • Endovenous laser ablation • Foam sclerotherapy
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Open Surgical Techniques Ligation of the Saphenofemoral Junction
Stripping of the GSV
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Radiofrequency Ablation
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Radiofrequency Ablation – Venefit RFA Generator ClosureFast Catheter
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Endovenous Laser Ablation (EVLT)
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Endovenous Laser Ablation (EVLT)
• Diomed 810 nm • Dornier 940 nm • CoolTouch 1320 nm • Angiodynamics 1470 nm
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VenaCure
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Endovenous Ablation
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Endovenous Ablation
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Treatment of Tributary Varicosities
• Sclerotherapy • Phlebectomy
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Sclerotherapy • Injection into the vein • Damages the endothelium • Most effective for spider veins, reticular
veins, and small varicosities • Larger veins more prone to phlebitis
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Sclerotherapy Agents
• Hypertonic saline • Sodium tetradecyl sulfate • Sodium morrhuate • Polidocanol
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Foam Sclerotherapy • Uses detergent sclerosing agent • Completely displaces blood from the vein • Allows better contact with the vein wall • Easily seen with ultrasound
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Ultrasound Guided Sclerotherapy
• Method to increase the efficacy of sclerotherapy
• Provides precise visualization of the needle tip
• Used to treat saphenous veins or perforators
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Duplex Guided Sclerotherapy
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Ambulatory Phlebectomy
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Perforating Veins
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Venous Hypertension due to Incompetent Perforating Vein
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Incompetent Perforating Veins
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GSV plus Perforator Reflux
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Subfascial Endoscopic Perforator Surgery
Perforating veins are clipped or divided with the harmonic scalpel
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Foam Sclerotherapy of Perforating Veins
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Endovascular Closure of Perforating Vein
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Treatment of Deep Vein Disease
• Occlusive disease – postphlebitic syndrome
• Deep vein reflux – valve failure
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Iliac Vein Occlusion
• Can present acutely with DVT
• May have underlying compression of the left common iliac vein (May-Thurner Syndrome)
• Some present with chronic swelling of the left lower extremity
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Acute Iliac DVT
• Only 20% recannalize with anticoagulation alone
• 90% have chronic venous hypertension
• 40% develop venous claudication
• Up to 15% develop ulcers over 5 years
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Mechanical Thrombolysis
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Thrombolysis for Acute Iliofemoral DVT
Wire crossing CIV occlusion After tPA, compression seen
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CIV after PTA / Stenting
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Chronic iliac vein occlusion
• Venous claudication – bursting thigh and leg pain worse with exercise
• Swelling of the thigh and lower leg • Suprapubic collaterals
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Endovascular Treatment for Chronic Occlusive Disease
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Venous Bypass – Palma Procedure
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Valvuloplasty
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Valve Transplantation
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Conclusions
• Surgical treatment for venous disease helps to address the underlying mechanism of the venous stasis ulcer
• Intervention may help speed ulcer healing and decrease recurrence rates
• Large prospective randomized studies showing clear benefit are lacking
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