Surgical Options for Venous Disease Sandra C Carr MD Vascular Surgery Meriter Wisconsin Heart
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
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
Clinical Classification C1 spider veins or telangectasias C2 varicose veins C3 edema C4 skin changes (eczema, pigmentation) C5 healed ulcer C6 active ulcer
Telangectasias C1
Varicose Veins C2
Edema with Dermatitis
Venous Stasis Dermatitis
Hyperpigmentation
Lipodermatosclerosis
Atrophie Blanche
Healed Venous Ulcer
Venous Stasis Ulcer
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
Treat the Underlying Cause Increased ambulatory venous pressures Severity is related to magnitude of venous hypertension Reflux is the most important hemodynamic feature
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
Normal Venous Valves
Venous Reflux
Postphlebitic Syndrome Chronic leg symptoms following old DVT May be due to old occlusive disease Valve damage and scarring leads to reflux
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
Venous Anatomy
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.
Diagnostic Studies Physical Exam Duplex Ultrasound CT Venography MR Venography Venogram with IVUS
Duplex Ultrasound Unilateral / limited Evaluate deep system for reflux or obstruction Locate sites of valvular incompetence GSV, SSV, perforators Develop a logical treatment plan
Venous Duplex Ultrasound img 5 Image courtesy of Olivier Pichot, MD
Duplex for Venous Reflux Normal GSV Reflux in the GSV
MR Venogram
CT Venogram Large left iliofemoral thrombus Compression of left iliac vein by right iliac aretery RCIA LCIV With extension into IVC May Thurner Syndrome
Venography with IVUS
Compression Therapy for Venous Ulcers
Compression Stockings Control edema Decrease aching and leg pain Prevent recurrent ulceration
Compression Stockings
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
Treatment of GSV/SSV Reflux Saphenous stripping Radiofrequency ablation Endovenous laser ablation Foam sclerotherapy
Open Surgical Techniques Ligation of the Saphenofemoral Junction Stripping of the GSV
Radiofrequency Ablation
Radiofrequency Ablation Venefit RFA Generator ClosureFast Catheter
Endovenous Laser Ablation (EVLT)
Endovenous Laser Ablation (EVLT) Diomed 810 nm Dornier 940 nm CoolTouch 1320 nm Angiodynamics 1470 nm
VenaCure
Endovenous Ablation
Endovenous Ablation
Treatment of Tributary Varicosities Sclerotherapy Phlebectomy
Sclerotherapy Injection into the vein Damages the endothelium Most effective for spider veins, reticular veins, and small varicosities Larger veins more prone to phlebitis
Sclerotherapy Agents Hypertonic saline Sodium tetradecyl sulfate Sodium morrhuate Polidocanol
Foam Sclerotherapy Uses detergent sclerosing agent Completely displaces blood from the vein Allows better contact with the vein wall Easily seen with ultrasound
Ultrasound Guided Sclerotherapy Method to increase the efficacy of sclerotherapy Provides precise visualization of the needle tip Used to treat saphenous veins or perforators
Duplex Guided Sclerotherapy
Ambulatory Phlebectomy
Perforating Veins
Venous Hypertension due to Incompetent Perforating Vein
Incompetent Perforating Veins
GSV plus Perforator Reflux
Subfascial Endoscopic Perforator Surgery Perforating veins are clipped or divided with the harmonic scalpel
Foam Sclerotherapy of Perforating Veins
Endovascular Closure of Perforating Vein
Treatment of Deep Vein Disease Occlusive disease postphlebitic syndrome Deep vein reflux valve failure
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
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
Mechanical Thrombolysis
Thrombolysis for Acute Iliofemoral DVT Wire crossing CIV occlusion After tpa, compression seen
CIV after PTA / Stenting
Chronic iliac vein occlusion Venous claudication bursting thigh and leg pain worse with exercise Swelling of the thigh and lower leg Suprapubic collaterals
Endovascular Treatment for Chronic Occlusive Disease
Venous Bypass Palma Procedure
Valvuloplasty
Valve Transplantation
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