Sean TierneyDean of Professional Development & Practice RCSI

Consultant Vascular Surgeon

Venous diseaseVenous disease

IssuesIssues

• Varicose veins

• Chronic venous hypertension– Leg ulcers

• (DVT & PE)

IssuesIssues

• Varicose veins

• Chronic venous hypertension– Leg ulcers

• Symptoms• Quality of life• Surgical outcomes• Cost effectiveness

• Complications/consent

• Surgical options

IssuesIssues

• Varicose veins

• Chronic venous hypertension– Leg ulcers

• Treatment options

• Indications for surgery

• Special surgery

Varicose veinsVaricose veins

Guidelines for referral

•Symptomatic primary or symptomatic recurrent varicose veins.

•Venous related skin changes (pigmentation or eczema•Superficial vein thrombosis•Venous leg ulcer (active or healed)

http://goo.gl/VRrQwP

http://goo.gl/crufTj

Edinburgh veins studyEdinburgh veins study

• Cross sectional population study

• N = 1566 people from 12 GPs in Edinburgh

• Self administered questionnaire (symptoms) and physical examination (presence and severity of varicose veins).

Bradbury et al, Edinburgh vein study (cross sectional population survey) . Br Med J 1999

Edinburgh veins studyEdinburgh veins study

Bradbury et al, Edinburgh vein study (cross sectional population survey) . Br Med J 1999

Edinburgh veins studyEdinburgh veins study

Bradbury et al, Edinburgh vein study (cross sectional population survey) . Br Med J 1999

Varicose veins & QOLVaricose veins & QOL

Patients with VV having surgery•SF-36•Aberdeen Varicose Veins Questionnaire

•n=137

•Preop and 6/52 post op

Smith et al. J Vasc Surg 1999

http://goo.gl/VRrQwP

Varicose veins & QOLVaricose veins & QOL

Smith et al. J Vasc Surg 1999

Men vs UK population (women similar)

PF physical functioningRP Role limitationBP Bodily pain

Varicose veins & QOLVaricose veins & QOL

Smith et al. J Vasc Surg 1999

All patients (n=137)

GH General healthMH mental health

Varicose veins & QOLVaricose veins & QOL

Smith et al. J Vasc Surg 1999

“Compared to before your operation …, How would you rate your health in general?

Varicose veins & QOLVaricose veins & QOL

1Smith et al. J Vasc Surg 19992Kelleher Phlebology 2012

• The presence of varicose veins “significantly” affects patients’ quality of life

• Surgery for varicose veins significantly improves patients’ HRQOL

• Equally applies to other treatment modalities

Cost effectiveness Cost effectiveness

• N=246

• Surgery (£733) vs conservative treatment (£345)

• £4682 per QALY gained

Ratcliffe et al. Br J Surg 2006

Cost effectiveness Cost effectiveness

Ratcliffe et al. Br J Surg 2006

Cost effectiveness - IICost effectiveness - II

• Surgery provides a gain of 0.453 QALY

• Incremental cost of £879.80

• ICER of £1941 per QALY

• Surgery for VVs is cost effective

But…But…

ConsentConsent

Dillon et al Irish Journal of Medical Science 2005

AssessmentAssessment

• Clinical

• Duplex

Surgical optionsSurgical options

• Open– Sapheno-femoral ligation

– Saphenopopliteal ligation

– Avulsion of varicosities

• Endovenous– Radiofrequency

– Laser

– Non-thermal

• Sclerosant

Choice of treatmentChoice of treatment

• Offer endothermal ablation or Endovenous laser treatment of the long saphenous vein

• If unsuitable offer ultrasound guided ‑foam sclerotherapy

• If unsuitable offer surgery.

Choice of treatmentChoice of treatment

• 13 RCTs

Implications for practice

• Foam sclerotherapy and endovenous ablation (laser and radiofrequency) and open surgery have similar outcomes.

? Cost

? Patient preference

? Scarring, nerve injury, recurrence

http://goo.gl/OHTYwn

Superficial thrombophlebitisSuperficial thrombophlebitis

• 50 yr old female

• Long standing varicose veins

• Early skin changes

• Tender, inflamed area of thrombophlebitis

OptionsOptions

NothingNothingNothingNothing

NSAIDSNSAIDSAntibioticsAntibioticsNSAIDSNSAIDS

AntibioticsAntibioticsStockingsStockingsStockingsStockings

AnticoagulationAnticoagulationAnticoagulationAnticoagulation

Superficial thrombophlebitisSuperficial thrombophlebitis

• Isolated superficial vein t-phlebitis– risk of PE/DVT 3.3% at 6 months

• CALISTO trial– 300 patients– 2.5mg fondparinux s.c. for 45 days– reduction in DVT from 1.3% to 0.2%

Decousous et al. NEJM 2010

Clexane 40mg sc od for 6 weeksClexane 40mg sc od for 6 weeks

Venous ulcerationVenous ulceration

Venous ulcerationVenous ulceration

0

25

50

75

100

0 3 6

Cont rol Compression

* Diamond P. Management of leg ulcers in a rural community. J Wound Care 1994

Venous ulcerationVenous ulceration

* Gohel et al. British Journal of Surgery 2005; 92: 291–297

• open or recently healed ankle ulceration (>4 weeks)

• ABI < 0·85

• Either• superficial venous reflux• mixed superficial and deep venous reflux

• Excluded

• No reflux, deep reflux only, deep occlusion

Venous ulcerationVenous ulceration

* Gohel et al. British Journal of Surgery 2005; 92: 291–297

Healing Recurrence

Indications for surgery (Eschar)Indications for surgery (Eschar)

• Either• superficial venous reflux• mixed superficial and deep venous reflux• role of perforators ?

• But not • deep occlusion ?• deep reflux only ?

Perforator surgeryPerforator surgery

SEPS

SEPS - evidenceSEPS - evidence

• knowledge about the efficacy and applicability of SEPS is incomplete

• No prospective, randomized studies are needed.

• role of surgery and SEPS is controversial as only 50% of patients can be predicted to have long-term freedom from ulcer recurrence.

Kalra et al Surg Clin North Am. 2003

Deep venous diseaseDeep venous disease

• Venoplasty (& stenting)

• Valve transplantation

• Venous bypass

• Small cases series only

• No RCT

• Selected centres & patients.

Bond et al Ann Vasc Surg. 2013

• Appropriate treatment• Correct operation• Right patient• Right time• Technical accuracy• Postoperative care

www.perfuse.netwww.perfuse.net

@theseant@theseant

http://www.slideshare.net/stierneyhttp://www.slideshare.net/stierney