How advances in technology and science changed the treatments of venous disease
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1 How advances in technology and science changed the treatments of venous disease Mark Whiteley The Whiteley Clinic, Guildford, Bristol and London
2 Mark Whiteley Consultant Venous Surgeon Visiting Professor at University of Surrey Owner The Whiteley Clinic Ltd Founder of The College of Phlebology Founder of The Leg Ulcer Charity 120+ Peer reviewed papers Several international and national prizes 1 book written, 1 book edited, 1 book in press Research and Teaching Dept. Own research / Contract research Teach doctors, nurses and vascular scientists for TWC, CoP and on contract
3 Varicose Veins Venous Leg Ulcers Pelvic Congestion Syndrome
4 Varicose Veins NOT Just cosmetic CAN Lead to clots, bleeds and leg ulcers SHOULD NOT always come back after treatment
5 Venous Leg Ulcers CURE: Are totally curable in 85% of cases NEED: Duplex ultrasound SHOULD NOT BE: Dressed and compressed unless incurable
6 Pelvic Congestion Syndrome 30% females with pelvic pain Not diagnosed or treated in UK Reason leg varicose veins come back Haemorrhoids
7 The visible varicose veins are NOT the Problem Fig 24
8 All are part of SAME condition To treat: Thread veins Varicose veins Leg ulcers You MUST understand Venous Reflux All treatment starts with: Knowing which veins are refluxing Accurate assessment of hidden veins
9 Used to be: Varicose veins: Medical Superficial so: Cosmetic only Due to reflux in GSV +/- SSV Treatment = stripping
10 Used to be: Leg Ulcers: Medical Due to reflux in deep veins Treatment no surgery possible Elevation + Compression
11 So what has changed?
12 So what has changed? Virtually Everything!!
13 Why?
14 Why? Because it didn t work!!!!
15 Why? Because it didn t work!!!! Majority of thread veins came back
16 Why? Because it didn t work!!!! Majority of thread veins came back Majority of varicose veins recurred
17 Why? Because it didn t work!!!! Majority of thread veins came back Majority of varicose veins recurred Leg ulcers healed then recurred (95% in 1 year)
18 Varicose veins / Venous Eczema / Leg Ulcers: 1985: Approx 60% of leg ulcers due to SUPERFICIAL VEINS 1 Most leg ulcers CURABLE 2 Varicose veins are NOT cosmetic
19 Varicose veins: 1986: When making diagnosis and suggesting treatment without duplex ultrasound Only 33% are right Or 67% get the WRONG TREATMENT Never trust advice from a doctor or nurse UNLESS you have had a duplex ultrasound scan
20 Thread veins: 2001: 89% of leg thread veins have underlying reflux 40% Major underlying reflux Hidden Varicose Veins Never have leg thread veins treated without a scan
21 Varicose veins legs and vulva: 2007: 1 in 5 women with varicose veins Leg veins come from the pelvis NOT legs If you have veins high up you MUST have a pelvic duplex ultrasound scan
22 Better understanding of veins: All due to venous reflux 40% of population!!!!!
23 Venous return from feet to heart in a SUPINE person 15 mmhg 0 mmhg Direction of blood flow in veins following pressure gradient NO EFFECT OF GRAVITY Whiteley Publishing Understanding Venous Reflux The cause of varicose veins and venous leg ulcers
24 Venous return from feet to heart in an ERECT person Fig 8 Gravitational effect on a column of fluid = hρg (see text) 0 mmhg Resultant flow of blood in veins blood pools in lower leg Venous pressure in post-capillary venules = 15 mmhg hρg + 15 mmhg hρg mmhg Whiteley Publishing Understanding Venous Reflux The cause of varicose veins and venous leg ulcers
25 Normal valves in leg veins Fig 9 Normal vein wall A pair of bicuspid or pocket valves. Lumen containing flowing blood Whiteley Publishing Understanding Venous Reflux The cause of varicose veins and venous leg ulcers
26 Normal valves in leg veins During active muscle contraction Fig 10 Pumped blood flows up the vein, opening the valves and flattening them to the vein wall. Whiteley Publishing Understanding Venous Reflux The cause of varicose veins and venous leg ulcers
27 Normal valves in leg veins During passive phase blood Fig 11 Blood falling by effects of gravity close the valves causing the wall to bulge at this point Whiteley Publishing Understanding Venous Reflux The cause of varicose veins and venous leg ulcers
28 Normal functional anatomy of veins of the leg Fig 12 Heart Inferior vena cava and iliac veins (no valves) Great Saphenous Vein (GSV) Deep veins of the leg Small Saphenous Vein (SSV) Perforating veins Whiteley Publishing Understanding Venous Reflux The cause of varicose veins and venous leg ulcers
29 Normal flow of blood in veins of the leg during active pumping Fig 13 Heart Inferior vena cava and iliac veins Deep veins of the leg Great Saphenous Vein (GSV) Small Saphenous Vein (SSV) Perforating veins Whiteley Publishing Understanding Venous Reflux The cause of varicose veins and venous leg ulcers
30 Incompetent valves in leg veins Allowing venous blood to reflux (passive) Fig 20 Blood refluxing down vein by gravity, due to valve failure valve incompetence Whiteley Publishing Understanding Venous Reflux The cause of varicose veins and venous leg ulcers
31 2001 We published Ascending reflux Fig 22 Valves at top of GSV working (competent) despite GSV incompetence below and varicose veins Great Saphenous Vein (incompetent) distally feeding varicose veins Whiteley Publishing Understanding Venous Reflux The cause of varicose veins and venous leg ulcers
32 Phase 2 passive reflux SFJ become incompetent LAST Fig 24 Reflux has now ascended to affect all valves - total incompetence of the GSV Both impact pressure and volume of refluxing venous blood flow in the GSV and varicose veins increased, leading to larger, tenser varicose veins or more inflammation Whiteley Publishing Understanding Venous Reflux The cause of varicose veins and venous leg ulcers
33 Passive reflux Pelvic veins GSV Whiteley Publishing Understanding Venous Reflux The cause of varicose veins and venous leg ulcers
34 VV v Hidden VV Heart Soft impact at ankle - No inflammation Great Saphenous Vein (incompetent) Varicose vein acting as a silencer or Shock absorber Energy of blood impacting at ankle on standing - Low Whiteley Publishing Understanding Venous Reflux The cause of varicose veins and venous leg ulcers
35 VV v Hidden VV Heart Great Saphenous Vein (incompetent) With no visible varicosities Hard impact at ankle causing inflammation Energy of blood impacting at ankle on standing Swelling Eczema LDS Leg Ulcers Whiteley Publishing Understanding Venous Reflux The cause of varicose veins and venous leg ulcers
36 So how does SSV reflux? Many suggest not to treat SSV - Causes vv / ulcers Whiteley Publishing Understanding Venous Reflux The cause of varicose veins and venous leg ulcers
37 Active Phase Heart Inferior vena cava and iliac veins Valves open due to upward flow of blood pumped by active muscle contraction Muscle contraction Deep veins Great Saphenous Vein Whiteley Publishing Understanding Venous Reflux The cause of varicose veins and venous leg ulcers
38 Active Phase Reflux Heart Inferior vena cava and iliac veins Whiteley Publishing Understanding Venous Reflux The cause of varicose veins and venous leg ulcers
39 Weight, straining, pregnancy do not cause varicose veins Increased pressure in abdomen or pelvis pushes on top valve in GSV and causes it to fail Once top valve has failed weight of blood transfers onto next valve which fails, and so on like dominos falling
40 Valves at top of GSV working (competent) despite GSV incompetence below and varicose veins Great Saphenous Vein (incompetent) distally feeding varicose veins
41 Traditional View: Great Saphenous Vein Small Saphenous Vein
42 Hand Held Doppler is not acceptable now Duplex is required
43
44 AASV
45 Bifid GSV
46 Bifid SSV
47 Giacomini
48 Below Knee IPV (Perforators)
49 Above Knee IPV (Perforators)
50 Pelvic Vein Reflux
51 + - Distal reflux patterns - Phlebitis - Atrophic segments - Neovascularisation - Strip tract revasc - Aneurysmal segments - Venous Syndromes - Anomalies (ie: GSV x 3)
52
53 Since 2000: Increased awareness of varicose veins associated with pelvic venous reflux* * Marsh P, et al. Phlebology. 2009;24: Pelvic vein reflux in female patients with varicose veins: comparison of incidence between a specialist private vein clinic and the vascular department of a National Health Service District General Hospital.
54 Body Leg
55 GSV + AASV SSV Perforators
56 OV (Testicular in Male) IIV GSV + AASV SSV Perforators
57
58
59
60 PVR in 20% of women with varicose veins Most surgeons DON T LOOK for pelvic reflux PVR is treatable when found TVS = Gold Standard NOT MRI / CT / VENOGRAMS Aim is to investigate the proportion of recurrence due to pelvic incompetence * Marsh P, et al. Phlebology. 2009;24: Pelvic vein reflux in female patients with varicose veins: comparison of incidence between a specialist private vein clinic and the vascular department of a National Health Service District General Hospital.
61 Females with children no hysterectomy: Group 4 (n=111) % Neovascular tissue Pelvic Veins Incompetent Perforating Veins (IPV) % % % Missed or De Novo vein reflux % Inadequate operation % Previously untreated veins 7 6.3%
62 Diameter (mm) TVS Not MRI / CT / Venograms 14 Size vs. Reflux in Ovarian Veins Competent State of Refluxing
63 Some reduction of venous gradient: Only helps by reducing speed of deterioration Most use as post operative care NOT A TREATMENT!!!!
64
65 Traditional High Tie and Stripping: Now should NEVER be done
66 Damage to a Vein Vein cut by trauma (or surgery)
67 Damage to a Vein Bleeding
68 Damage to a Vein Clotting Haematoma and Thrombus
69 Damage to a Vein Endothelial budding solid cores of endothelial cells grow into haematoma
70 Damage to a Vein Solid endothelial buds connect with ones from the other part of the vein BUT with no valves!!!
71 Damage to a Vein Neovascular vessels join together until after a year or more, a new vessel is formed.
72 BJS 2007 Whiteley Clinic
73
74 Histology Normal except scar tissue and lumens Munasinghe A et al. Br J Surg. 2007;94: Strip-track revascularization after stripping of the great saphenous vein.
75 83% at 5-8 years
76 Do not MISS veins Perforators, Pelvic veins Local anaesthetic (Ambulatory) Keyhole (<2 mm incisions) Back to work next day Cause fibrosis NOT thrombosis In EXPERT hands reduction of recurrence
77 First in UK 12 th March 1999 Closure Catheters 8Fr 6Fr
78
79
80
81
82 Thermocouple on inner aspect = useless
83 Thermocouple on inner aspect = useless
84 EVG Stain Whiteley MS
85 Intimal / Sub-total Mural Damage Intraluminal Thrombosis Recanalisation Transmural Death Fibrosis Involution Whiteley 2004
86 93.5% closure at 11.1 years Venous Forum Poster Prize 2013 BUT Slow GA Binding
87
88 Poor technology some use but many disadvantages VNUS Closure FAST Venefit Bare tip EVLA 810 nm EVLA
89 RFiTT But ONLY if used with Whiteley Protocol 72J/cm 1470 nm Radial 1470 nm Jacket Tip NTD
90 Porcine Liver Model
91 Low LEED is Inadequate Normal LEED = 72 J/cm High power fast pull back = Carbonization = Inadequate thermal spread
92 LEED Thermal spread from device (mm) W, 1s/cm 20W, 1s/cm 20W, 3s/cm 18W, 4s/cm 12W, 6s/cm 6W, 12s/cm 6W, discont. Power (Watts), Pull-back speed (sec/cm) Badham GE et al. Phlebology 2014
93 Confirmed in Human GSV (ex vivo) LEED 72 J/cm 18 W 4 Sec/cm Control GSV LEED 72 J/cm 6 W 12 Sec/cm Whiteley MS etc al - Unpublished
94
95 Dominant Extra-Fascial Tributary of the GSV extra-fascial GSV Ashpitel HF, Dabbs EB, Nemchand JL, La Ragione RM, Salguero FJ, Whiteley MS. Histological and Immunofluorescent Analysis of a Large Tributary of the Great Saphenous Vein Treated with a 1920 nm Endovenous Laser: Preliminary Findings. EJVES Short Rep Apr 18;39:7-11.
96
97 810 nm v 1470 nm MSB Staining Control 810 nm 60 J/cm 1470 nm 60 J/cm H Ashpitel, Whiteley Clinic 2016
98 810 nm v 1470 nm SMA - Immunohistochemistry Control 810 nm 60 J/cm 1470 nm 60 J/cm H Ashpitel, Whiteley Clinic 2016
99 Bare tip / Jacket tip (Less so) Risk Perforation Ecchymosis
100
101 1470 nm Jacket v Radial Laser MSB Control x100 x J/cm x J/cm
102 Sounds cheap and easy: STD / Polidocanol Gas (CO2 and O2) NOT air!!!! MUST be put in under ultrasound control
103
104
105 BUT Results dependant on size of vein: < 3mm Good 100% occlusion at 3 y 4-5mm 80% occlusion at 3 y > 6mm 0% occlusion at 3 y
106 Gomori Staining Control 0.5% Pol 3% STS
107 CD31 = Endothelium α-actin = Smooth Muscle Cells Untreated
108 % reduction in stainining intenisty 120% Untreated 100% 80% 3% STS 10 minutes CD31 α-actin 60% 40% 20% 0% Damaged Undamaged Vein wall depth (µm) EVF Paris 2014
109 Intimal / Sub-total Mural Damage Intraluminal Thrombosis Recanalisation Large vein with thick wall Small vein with thin wall Transmural Death Fibrosis Involution Mark Whiteley. New Methods of Vein Ablation. In: Venous Disease Simplified Eds: Alun H Davies, Tim Lees & Ian F Lane. UK: Harley 2006
110
111 Ulcer: 2 IPV s only reflux No truncal reflux Normal deep veins Primary vv: 1 IPV only reflux No truncal reflux Recurrent vv: 1 IPV only reflux No truncal reflux
112 PPG: No Reflux Reflux
113 PPG: Any Active ( Systolic ) Reflux is Hidden No Passive ( Diastolic ) Reflux Any Active ( Systolic ) Reflux is Hidden Passive ( Diastolic ) Reflux
114 Needs Duplex ultrasound diagnosis: Looking for outwards flow ( reflux )
115 TRLOP RFiTT device Or radial laser
116
117 Clarivein Mechanical sclerotherapy Glue Superglue Steam Vein Sclerosis (SVS) Logical but? Control of steam Poor early results -? Technically difficult
118
119 MG Tal, SJ Dos Santos, KE Jansen, JP Marano, MS Whiteley Histological Findings After Mechanochemical Ablation (MOCA) in a Caprine Model: Justification for the Use of MOCA in Humans JVS: Venous and Lymphatic Disorders
120 MG Tal, SJ Dos Santos, KE Jansen, JP Marano, MS Whiteley Histological Findings After Mechanochemical Ablation (MOCA) in a Caprine Model: Justification for the Use of MOCA in Humans JVS: Venous and Lymphatic Disorders
121
122
![1] Intimal damage Allows STS](/docs-images/92/110593621/images/123-2.jpg "penetration 2] Deep media")
123 1] Intimal damage Allows STS penetration 2] Deep media damage Shear damage from mechanical rotation Allows STS penetration
124 CD31 (Endothelium) and α-actin (SMC) Untreated 3% STS 10 minutes MOCA + 3% STS 10 minutes
125 Staining intensity (% of untreated) Staining intensity (% of untreated) STS 10 mins only MOCA + 3% STS 10 mins Vein wall depth (μm) Vein wall depth (μm)
126 Our Own Research
127 Agreeing with everything The Whiteley Clinic has been saying 5 12 years ago Symptomatic vv / leg ulcers to be referred Vascular Unit MDT with Duplex Not a single handed doctor with a scanner!!! Endovenous treatment preferred Compression Stockings are NOT treatment
128 Remotely anywhere in the world At Guildford
129
130 In the last 12 months: Florence New York Phoenix Denver Paris Bangalore Barcelona Belgrade London
131 Bangalore Paris
132 Pre Med Course Summer Research Fellows PhD Students
133 Following our principles: Varicose veins recurrence rates 3.3% pa (Currently nationally about 30% pa) Venous leg ulcers cured in 85% (Saving > 3.2 billion pa) 30% of females with chromic pelvic pain could be cured UK Needs Phlebologists NOT: Vascular / General surgeons
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