Introduction to Saphenous Vein Ablations: When/Why/How?
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1 John Ligush, MD SMJH Vascular and Vein Center Introduction to Saphenous Vein Ablations: When/Why/How?
2 Saphenous Vein Ablations: When/Why/How? Venous disease is easy Treatment is straightforward The patients are always healthy I always treat them the same way It s just a useless vein anyway
3 Not so fast Saphenous Vein Ablations: When/Why/How? When/why/how not to treat Allow me to introduce Mr. C.68 yo presented on 10/28/15 with a several year history of leg fatigue with ambulation. However, for the preceding several months he was experiencing short distance bilateral claudication; fatigue-free walking distance approximately 100 yards. As an aside at the time, Mr. C also gave a history of undergoing bilateral great saphenous RF ablation for "leg swelling". He was told that he should undergo the procedure because his Presenter venous condition name was "dangerous". Arterial noninvasive imaging revealed normal femoral waveforms with bilateral SFA and distal small vessel disease. The ABIs were 0.74 on the right and 0.85 on the left. Normal EF - 60%. Non-smoker. I started Mr. C on cilostazol. He was scheduled for a 3 month follow-up, but missed his appointment.
4 Short Answer The story continues As it turns out Mr. C missed his follow-up appointment for lower extremity occlusive disease because of major medical reasons. He required urgent coronary artery bypass. Unfortunately he lacked the venous conduit necessary to perform the optimal procedure. He underwent Presenter internal name mammary and left radial artery bypass with additional highrisk PTCI x 2.
5 The story continues Short Answer Mr. C returned on 4/16/18, now 70, describing worsening symptoms of claudication. However, he also described severe fatigue, extremity poikilothermia, paresthesias, shortness of breath, and difficulty arising from a chair. In fact, he had to use a wheelchair to get to the office. He told me that he could leave the office, but that he had to "lie Presenter down first". name His repeat ABIs were 0.56 on the right and 0.71 the left (previously 0.74 and 0.85 respectively). I sent him directly to the emergency room.
6 Short Answer The story continues Workup revealed new, fixed ischemic changes on EKG. Severe heart failure with ejection fraction 25%. Occluded stents on coronary angiography. Stents could not be recanalized/no additional Presenter PTCI name options.
7 Superficial Venous Disease Never life threatening Never limb threatening Never dangerous Never cures leg swelling with treatment
8 Saphenous Vein Ablations: When/Why/How? Complex Pathophysiology Anatomical considerations Symptoms Individualized treatment Comorbidities
9 Saphenous Vein Ablations: When/Why/How? The basic abnormality underlying the constellation of signs and symptoms known as Chronic Venous Insufficiency is an Elevation of Venous Pressure Venous Hypertension Estimated that 30 million people in the U.S. are affected with varicose veins & symptomatic chronic venous insufficiency 30% of adult U.S. population afflicted Presenter but only 10% name correctly diagnosed or seek care Approximately 2 million new cases per year
10 Venous Anatomy
11 Venous Anatomy
12 Pathophysiology of Venous Insufficiency/Hypertension Valves fail. Reflux. Increase AVP. Normal Vein Dilated Vein Valve Open Valve Closed Leaky Valve
13 Pathophysiology of Venous Insufficiency/Hypertension
14 Saphenous Vein Ablations: When? Symptomatic and attributable to GSV/SSV Painful axial varicose veins Recurrent phlebitis/thrombophlebitis Venous hemorrhage Venous ulcer (isolated to superficial Presenter source name - rare) Failure of conservative therapy no one ever died from a varicose vein
15 Saphenous Vein Ablations: Why? To relieve venous hypertension in the saphenous system by eliminating reflux
16 Saphenous Vein Ablations: How? Multiple procedures available Classic vein stripping Endovenous ablation Laser Radiofrequency Foam Glue
17 Saphenous Vein Ablations: Vein stripping How?
18 Saphenous Vein Ablations: How? Endovenous laser ablation
19 Saphenous Vein Ablations: How? Would patient recommend catheter based treatment to a friend with similar leg vein problems? Yes: 94.2% No: 2.5%
20 Saphenous Vein Ablations: When/Why/How? Do the right thing for your patient Treat failures of conservative therapy Focus on venous pathophysiology Treat venous hypertension Treat to your comfort level Know what you are treating and why you are treating it.
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