Current Management of Varicose Veins
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1 Current Management of Varicose Veins Michael J. Heidenreich, MD St. Joseph Mercy Hospital Ann Arbor, MI March 23, 2013 Nothing to disclose
2 History Prevalence Anatomy Risk factors Clinical manifestations Classification Diagnostic evaluation Treatment options Outcomes Outline Historical perspective Galen Votive tablet Ebers Papyrus Hippocrates Celsus 1550 BC 400 BC 200 BC Anno Domini 200 AD
3 Historical perspective Galen Votive tablet Ebers Papyrus Hippocrates Celsus 1550 BC 400 BC 200 BC Anno Domini 200 AD
4
5 Mayo Unna Vein ablation developed Trendelenburg Venous reconstruction Pravaz Linton
6 Prevalence: Symptomatic Vascular Disease Venous Reflux Disease Coronary Heart Disease Peripheral Arterial Disease Congestive Heart Failure Stroke Cardiac Arrhythmias Heart Valve Disease Prevalence of varicosities Age Female Male % 1% % 24% % 43%
7 Anatomy
8 Perforator anatomy
9 Heredity Risk factors Variable genetic penetrance Gender Weight Height Occupation Hormones Pregnancy
10 Primary Etiology Decreased number of valves Vein wall weakness Aging Secondary Thrombosis (valve destruction) Increased intraluminal pressure Pelvic obstruction to venous return Neoplasm, gravid uterus, May- Thurner syndrome Venous physiology
11 Venous pathophysiology Deep venous obstruction Deep Reflux Superficial reflux Healthy Signs and symptoms None (cosmesis/appearance) Aches/pains/heaviness/pruritis Edema Cutaneous pigmentation Dermatitis Hemorrhage Superficial phlebitis Symptoms do not correlate with size of veins!
12 Clinical manifestations Diagnostic testing Plethysmography APG PPG Duplex imaging
13 Classification system - CEAP Class Telangiectasias, VV, pigmentation, ulceration Etiology Congenital, primary, post-thrombotic Anatomical distribution Superficial, perforator, deep Pathomechanism Reflux, obstruction, both Treatment considerations Severity Etiology Obstruction vs. reflux Location Deep, superficial, perforator
14 Compression therapy Always a consideration Various strengths 20-30, 30-40, mmhg Various lengths Knee high, thigh high, panty Limitations Patient discomfort Warmth Difficult to don in elderly, arthritic patients Deep venous obstruction New technology Endoluminal treatments Catheter lysis Surgical venous bypass sometimes beneficial
15 Deep venous reflux Usually following DVT Compression is mainstay of treatment Surgical options Valve repair Valve transposition Prosthetic valve Overall, surgical treatment is difficult, prone to failure, and rarely undertaken GSV reflux Normal Reflux s/p ablation
16 GSV reflux Treatment options Invasive treatment low risk, can make big clinical difference Treatment options Vein stripping EVLT Endovenous laser treatment RFA - Radiofrequency ablation Foam ablation Mechanochemical tumescentless endovenous ablation Ideal patient: symptomatic varicose veins, GSV reflux, no deep venous reflux Vein stripping Technically straightforward Effective Limitations Anesthesia Post-operative pain Need to heal incisions Poor public perception
17 Technique EVLT Laser fiber is inserted into vein Laser is activated and pulled back Intima is injured and the vein closes Disadvantages Post-procedure pain Thermal injury Radiofrequency Ablation Office procedure minutes Oral sedation Local anesthesia Same day ambulation No activity restrictions after 24 hours Can also be used for LSV ablation
18 RFA - Technique Ultrasound guided access Catheter positioned to proximal GSV Infiltrate tumescent solution around vein Local anesthetic Vasoconstriction Thermal protection Catheter heated to 120 degrees Celsius Catheter pulled back in segments to ablate vein Catheter position Catheter GSV SFJ CFV
19 Duplex Pre-procedure s/p RFA
20 S/P RFA - Microbiology Controlled heating of the vein wall causes: Shortening and thickening of the collagen fibrils Vein lumen diameter shrinkage Fibrotic sealing of the vessel
21 Clinical result Pre-procedure 2 weeks s/p RFA S/P RFA Symptomatic relief
22 Randomized trials Three randomized trials comparing RFA vs. vein stripping RFA was superior to vein stripping in every statistically significant outcome Less post-procedure pain Less bruising Quicker recovery Higher quality of life scores 81% of RFA patients returned to normal activity with 1 day vs. 47% of vein stripping patients Mechanochemical tumescentless endovenous ablation (Clarivein) Combines mechical injury to GSV with chemical injury (foam) Advantage of not requiring tumescent anesthesia Initial studies showed higher rate of PE
23 Treatment Varicose veins Large (>6 mm) Medium (1-5 mm) Microphlebectomy Trivex phlebectomy Foam sclerotherapy Small (< 1 mm) Sclerotherapy Transdermal ablation Microphlebectomy Revived by Robert Muller (1956) and Gabriel Goren (1991) Outpatient operation IV sedation Tumescent solution 2 mm incisions Avulsion of vein segments Return to full activity within 24 hours
24
25 Trivex phlebectomy OR procedure Several small (~ 5 mm) incisions Backlight vein Rotating blade resector Technique Office procedure Foam sclerotherapy No anesthesia needed Tessari Method Inexpensive Multiple agents Polidocanol, STS, sodium morrhuate Limitations Early appearance suboptimal Often requires compression stockings for ~ 1-2 weeks Rare systemic embolization Rare allergic reaction
26
27 Telangiectasias Small veins (< 1 mm) Sometimes symptomatic Generally not covered by insurance Sclerotherapy STS, polidocinol, hypertonic saline 32 gauge needle Thermal coagulator For veins < 0.4 mm Less discomfort VeinWave, Coolglide laser
28
29 Perforator reflux Surgical management Linton procedure, SEPS Catheter ablation Laser, RF Catheter expense Foam sclerotherapy Ultrasound guidance Less expensive Limitations May require more than one attempt Occasional tibial vein thrombus Laser ablation Indications Local pain, venous stasis Perforator > 3 mm Technique Ultrasound-guided Lower profile than RF Local anesthesia only Compression x 48 hours >90% sealed by Duplex
30 Laser Endless marketing Source of confusion GSV? Perforator? Transdermal laser? Limited clinical impact Better for low-pressure, facial telangiectasias Conclusions Varicose veins are frequent in the general population Valve reflux is the usual etiology Treatment options have improved
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