Advances In Varicose Vein Treatment 2

Advances In Varicose Vein Treatment

Louis Grella, MD, F.A.C.S.Medical DirectorAdvanced Vein Care

Louis Grella, MD F.A.C.S. www.Advancedveincare.org


Vascular Training Experience

SUNY Syracuse: MD Degree

Flushing Hospital Medical Center : General

Surgery

SUNY Stony Brook: Vascular Surgery

Fellow

North Port VA: Vascular Laboratory

training

Jersey Coast Vascular Institute: Vascular

Surgery practice

Advanced Vein Care: Medical Director


Stony Brook Medical Center


Venous Disease


Divided into Superficial and Deep SystemDeep System• Named for by associated arteries• Found running along the arteries• Predictable anatomy• Causes most of the Morbidity

1. DVT 200,000 cases/year in USA2. PE 50,000 caser/year3. Severe Leg Swelling4. Ulcerations

• Little Surgical interventions (IVC Filter)• Medical Management• Anticoagulation• Thrombolytic therapy

• Systemic vs. Catheter directed• Elevation and Compression


Superficial Venous SystemThese are the veins we see• Two main named branches

• Greater saphenous• Small saphenous

• Perforators connect superficial and deep systems

• Highly variable anatomy• Many unnamed branches

and Tributaries



Venous DiseaseSuperficial SystemVaricose VeinsSpider VeinsVenous Malformation (birth marks and

others)Venous RefluxLeg SwellingVenous Ulceration


PhysiologyArteries deliver blood to tissueVeins return blood to the hartHart is the arterial pumpWhat pumps the venous blood back to the

heart? Venous pressure is about 25mmHg at the foot Pressure needed 80mmHg to return blood

Two unique features of veins accomplish this Most important one-way Venous Valves Easily compressible by surrounding muscle (calf pump)



Calf Muscle Pump

Just like the in heart we have diastole and systole

This is why stretching your legs or walking improves circulation


Normal venous flow in the Leg

Normal Flow • Superficial veins drain into the deep

veins• From the foot up to the heart

Superficial vein disease always starts with abnormal valves and interruption to normal flow called venous reflux


Abnormal flow = Venous RefluxDamaged Valves

1. Blood flows to the skin2. Blood is pushed distally and

proximally3. Close loop recirculation4. Blood is retained in the leg

Increased volume of blood (heaviness Fatigue)

Increased venous pressure Veins Dilate (varicose veins)


Symptoms of venous refluxLeg FatigueLeg HeavinessItching and pain along veinsVaricose VeinsSpider veins (not always 2nd to reflux)Leg swelling( think DVT 1st)

Skin Discoloration (lipo dermatosclerosis)

Venous ulceration


Varicose Veins

Definition: Visible tortious bulging blue veins found in the lower extremities

•Located in the Subcutis(between skin and fascia)• Remember this is only a manifestation of the underlying disease •Mild Disease is cosmetic issue•Advanced Disease significant medical problem • Pain• Swelling• Ulcerations


Varicose Veins

20 to 30

30 to 60

Above 60

0

40

80

Incidence of Varicose Veins

FemalesMales

•Incidence Increases with age

•Females to male 3 to 1

•50% of the population will affected in their life time


Spider Veins

The proper term is Telangiectasia

•These are non raised dilated veins located in the Dermis (deep layer of the skin)

•Single layer endothelium, minimal muscle

•Can be Red or Blue in color depending on the origin

•Do not cause major medical complications

•Appears earlier than varicose veins (4% of teenagers , and 13 % in 18 to 20 year olds

•More common in females

•Reticular Veins are lager feeding veins


Spider VeinsEtiology: Multifactorial

Venous Hypertension associated with varicose veins

Congenital: vascular nevi, neonatal hemangiomatosis, others..

Collage Vascular Disease: lupus,

Hormonal factors: pregnancy, estrogen therapy, topical steroids

Trauma: contusion, incisions

Infections


Venous Stasis UlcersDifferential Diagnosis

1. Venous ulcerations 50% on non healing ulcers2. Arterial ulcers in about 10%3. Malignancy : basal and squamous cell,

lymphoma4. Infections: HIV, fungal 5. Collagen vascular disorders: Lupus ec.6. Lymphatic obstruction

Affects over 1 million people in the US100,000 are disabled from thisMore common in elderly population


Venous Stasis UlcersEtiology

1. Venous Hypertension Venous reflux DVT Varicose veins

2. Edema3. Biological factors

Leakage of proteins impedes diffusion O2

Aggregation of white cells Block capillary flow Release on inflammatory proteins


Diagnosis of venous diseasePhysical exam

Appearance Trendelenburg test Palpation Hand Doppler

Duplex Examination R/O DVT Size of veins Map out superficial veins Locate the site of reflux Reflux 0.5 sec in GSV and 1 sec in deep

system Find refluxing perforators


Venous DuplexR/O DVT

Scan deep system in cross section, look for total compression of the vein in B mode

Examine from the femoral vein to the below the pop Check flow characteristics with Doppler

Sharp up stroke with calf compression Small or No flow with relaxation

R/O DVI This must be done with patient upright Reversal of flow of > 1 sec with Valsalva or after

calf compression


Duplex Anatomy Locate GSV Junction(FSJ)Look for Mickey's hat

Normal venous flow Look at valveVenous flow is opposite the artery


Scan of Common Femoral Vein

•Look for filling defect

•Look for compressibility

•Filling defects

•Echogenicity of defect

• Fresh

• Old

Femoral vein scan.avi


Venous DuplexExamine superficial system with patient

upright Start with the GSV at the groin and follow to below

knee Take cross section diameter measurements Doppler in longitudinal for reflux > 0.5 sec

significant Look for mid Thigh perforators and look for reflux Draw map of GSV and other superficial tributaries

Examine the Small Saphenous Look for size and reflux Find connection to deep system Look for the vein of Giacomini ( superior extension of

SSV to the GSV)


Anatomy of Great Saphenous

Femoral junction has multiple branches

Runs on medial side of leg down to ankle

Found in a facial sheetPerforators connect it to deep

system


Anatomy of Great Saphenous

From Jose Almeida, MD, IVC talk


Duplex Of Saphenous Proximal

Reflux at the Saphenous Femoral JunctionLook at reversal of flow

Locate Terminal valves

Epigastric vein

Femoral Vein

Epigastric Vein

Fem Vein

Saphenous


Duplex Mid Thigh


Treatment of Varicose VeinsConservative management

Exercise Leg elevation Compression stocking

Surgical treatment Standard Ligation and stripping Phlebectomies

Minimally invasive procedures (Currently accepted standard)

Laser Ablation Radio Frequency ablation Sclerotherapy


Surgical ligation and Stripping

Standard treatment for a century

General anesthesiaPainLong recoverySome complicationsGood cosmetic

results


Vein AblationLaser Ablation (EVLA or EVLT)

Uses light to heat the vein

Radio Frequency (VNUS Procedure) Uses radio frequency to heat the vein

• Office based procedure• Done under local anesthesia• One needle puncture at the level of the

knee• Takes about 1 hour• Patient resumes normal activity same day


Vein Ablation Steps

Vein is cumulated with Ultrasound

Guide wire is inserted under ultrasound guidance

Laser or RF fiber inserted over wire

Energy applied as the fiber is removed

The vein is sealed closed


EVLA Results

Images from http://venacure-evlt.com/


Sclerotherapy Cumulate vein with needleInject Sclerosing Solution

Sotradecol (Sodium tetradecyl sulfate)PilodocanolHyper tonic SalineFoam (Mix STS with air and make bubbles)

Intravenous injection causes intima inflammation and thrombus formation


Sclerotherapy Use

NeovascularizationPerforatorsClean up after PhlebectomiesSpider veinsReticular veinsGSV: can closure the, but has high

recurrence rate


Sclerotherapy results


Thank you for your attention

Advances In Varicose Vein Treatment 2

Health & Medicine

Transcript of Advances In Varicose Vein Treatment 2