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.

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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

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