Disclosure Steve Elias M.D.
I disclose the following financial relationship(s):
•Consultant/Advisory Board: Covidien Inc,
Vascular Insights LLC
Steve Elias MD FACS FACPh Director, Vascular Surgery Vein Programs NY Presbyterian Hospital Columbia University Medical Center Assistant Professor of Surgery Columbia University NY
“The Treachery of Images”: Rene Magritte
Veins Sources of problems
Occlusion is goal
Thermal, mechanical, chemical
Anatomy
Pathophysiology
Treatment technique
Complications
Access points Positioning at SPJ Tumescence placement Distal points of treatment Avoid Injury - nerves, skin, DVT
1.Giacomini’s vein
2.Profunda
Femoris vein
3.Perforating veins
from lateral thigh
4.Anterior lateral
branch of the
GSV
1. GSV
2. Giacomini’s
vein
3. Calf plexus
4. SSV
5. communicating
Variable termination vs. GSV Popliteal fossa - 70% time Femoral vein - 25% Below popliteal fossa - 5% Intersaphenous vein - branch to GSV Thigh Extension (TE) of SSV – no
popliteal connection
Cavezzi A et al. Duplex ulrasound investigation of the veins
In chronic venous disease - UIP Consensus Document.
Part II. Anatomy. Phlebology 2006;21:168-179.
Gibson KD et al. Endovenous laser treatment of the short
saphenous vein: Efficacy and complications. JVS 2007;
45:795-803.
VV - Calf (SSV) and medial thigh
varicosities (GV) or TE of SSV
Diameter – Elias 5.8 mm
- Kontothanassis 6.4 mm*
VV - due to SSV 20% of the time**
**Gibson KD et al. Endovenous laser of the short saphenous
vein: Efficacy and complications. JVS 2007;45:795-803.
*Kontothanassis et al. Endovenous laser ablation of SSV. JVS. April 2009
Distal access - sural nerve
Proximal positioning - nerves and PV
Skin and nerve concerns
*King, T. Can saphenous and sural nerve
parathesia be prevented during ELT. Abstract
EVF 2010
Sciatic nerve divides into the tibial and common peroneal nerves, proximal to the knee
Peroneal crosses posterior to lateral head of gastrocnemius, and becomes subcutaneous behind head of fibula
Tibial Nerve Anatomy
Popliteus muscle
Gastroc heads
Soleus muscle
Plantaris muscle
Sural nerve - Kontothanassis – 2.2%
- Gibson - 1.6%
- Wang - 2%
- Huisman - 1.3%
- King – 0%
Inferior border gastroc and tumescence
Kontothanassis D. et al. Endovenous laser treatment of the
small saphenous vein. JVS April 2009
Huisman et al. Endovenous laser ablation of SSV:
Prospective analysis 150 patients. VascEndovasc Surg 2009
Tibial nerve injury - plantar “push”
Runners, jump etc. walking OK
Visualize tibial nerve
Higher nerve injury with open tx
SPJ - Fascial curve (2-3cms avg.2.8 cm)
Tumescence to push SPJ/Nerves deeper
Range - 0% - 5.7%
Ravi - 0% *
Elias - 0.8%
Kontothanassis – 0%
Gibson - 5.7% (close to junction?)
VV Surgery - 5.3% *
*Ravi R et al. Endovenous ablationof saphenous veins:a large
single center experience. J Endovasc Ther 2006;13:244-8
*Van Rij et al. Incidence of deep vein thrombosis after varicose
vein surgery. Br J Surg 2004;91:1582-85
Distal - inferior border of gastrocnemius muscle (sural nerve) ZOC
Proximal - “fascial curve”2-3 cms. SPJ (2.8 cm)* Perivenous tumesence - push sural nerve
and tibial nerve away
Skin protection - 1-2 cms. Energy - same as GSV
*Wang XJ, Elias SM. Small saphenous vein ablation:
Reasons, risks,results. Poster session, AVF Annual
Meeting 2/07; San Diego , CA.
15 - 20 % of all litigation cases involve nerve injury
Even MIVS can cause nerve injury
Temporary or permanent
Nerve injury - tumescence and anatomy
awareness Nerve injury – not treatable and can be
permanent DVT - lower occurrence with proper
technique DVT - Treatable and temporary All may change with non thermal techniques Chemical, MOCA, Cyanoacrylate glue
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