Surgical Options for Venous Disease. Sandra C Carr MD Vascular Surgery Meriter Wisconsin Heart
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1 Surgical Options for Venous Disease Sandra C Carr MD Vascular Surgery Meriter Wisconsin Heart
2 Chronic Venous Disease Approximately 23% of adults in the US have varicose veins Estimated 22 million women and 11 million men ages years have varicose veins Up to 0.5% of the population has had problems with venous ulcers over the lower extremities
3 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
4 Clinical Classification C1 spider veins or telangectasias C2 varicose veins C3 edema C4 skin changes (eczema, pigmentation) C5 healed ulcer C6 active ulcer
5 Telangectasias C1
6 Varicose Veins C2
7 Edema with Dermatitis
8 Venous Stasis Dermatitis
9 Hyperpigmentation
10 Lipodermatosclerosis
11 Atrophie Blanche
12 Healed Venous Ulcer
13 Venous Stasis Ulcer
14 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
15 Treat the Underlying Cause Increased ambulatory venous pressures Severity is related to magnitude of venous hypertension Reflux is the most important hemodynamic feature
16 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
17 Normal Venous Valves
18 Venous Reflux
19 Postphlebitic Syndrome Chronic leg symptoms following old DVT May be due to old occlusive disease Valve damage and scarring leads to reflux
20 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
21 Venous Anatomy
22 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.
23
24 Diagnostic Studies Physical Exam Duplex Ultrasound CT Venography MR Venography Venogram with IVUS
25 Duplex Ultrasound Unilateral / limited Evaluate deep system for reflux or obstruction Locate sites of valvular incompetence GSV, SSV, perforators Develop a logical treatment plan
26 Venous Duplex Ultrasound img 5 Image courtesy of Olivier Pichot, MD
27 Duplex for Venous Reflux Normal GSV Reflux in the GSV
28 MR Venogram
29 CT Venogram Large left iliofemoral thrombus Compression of left iliac vein by right iliac aretery RCIA LCIV With extension into IVC May Thurner Syndrome
30 Venography with IVUS
31 Compression Therapy for Venous Ulcers
32 Compression Stockings Control edema Decrease aching and leg pain Prevent recurrent ulceration
33 Compression Stockings
34 Surgical Treatment It is not necessary to wait until the ulcer is healed to intervene Truncal superficial veins: GSV, SSV Tributary veins Perforating veins Deep veins Deep vein occlusive disease Deep vein reflux
35 Treatment of GSV/SSV Reflux Saphenous stripping Radiofrequency ablation Endovenous laser ablation Foam sclerotherapy
36 Open Surgical Techniques Ligation of the Saphenofemoral Junction Stripping of the GSV
37 Radiofrequency Ablation
38 Radiofrequency Ablation Venefit RFA Generator ClosureFast Catheter
39 Endovenous Laser Ablation (EVLT)
40 Endovenous Laser Ablation (EVLT) Diomed 810 nm Dornier 940 nm CoolTouch 1320 nm Angiodynamics 1470 nm
41 VenaCure
42 Endovenous Ablation
43 Endovenous Ablation
44 Treatment of Tributary Varicosities Sclerotherapy Phlebectomy
45 Sclerotherapy Injection into the vein Damages the endothelium Most effective for spider veins, reticular veins, and small varicosities Larger veins more prone to phlebitis
46 Sclerotherapy Agents Hypertonic saline Sodium tetradecyl sulfate Sodium morrhuate Polidocanol
47 Foam Sclerotherapy Uses detergent sclerosing agent Completely displaces blood from the vein Allows better contact with the vein wall Easily seen with ultrasound
48 Ultrasound Guided Sclerotherapy Method to increase the efficacy of sclerotherapy Provides precise visualization of the needle tip Used to treat saphenous veins or perforators
49 Duplex Guided Sclerotherapy
50 Ambulatory Phlebectomy
51 Perforating Veins
52 Venous Hypertension due to Incompetent Perforating Vein
53 Incompetent Perforating Veins
54 GSV plus Perforator Reflux
55 Subfascial Endoscopic Perforator Surgery Perforating veins are clipped or divided with the harmonic scalpel
56 Foam Sclerotherapy of Perforating Veins
57 Endovascular Closure of Perforating Vein
58 Treatment of Deep Vein Disease Occlusive disease postphlebitic syndrome Deep vein reflux valve failure
59 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
60 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
61 Mechanical Thrombolysis
62 Thrombolysis for Acute Iliofemoral DVT Wire crossing CIV occlusion After tpa, compression seen
63 CIV after PTA / Stenting
64 Chronic iliac vein occlusion Venous claudication bursting thigh and leg pain worse with exercise Swelling of the thigh and lower leg Suprapubic collaterals
65 Endovascular Treatment for Chronic Occlusive Disease
66 Venous Bypass Palma Procedure
67 Valvuloplasty
68 Valve Transplantation
69 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
70
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