Venous Disease and Leg Ulcers. Edward G Mackay MD St. Petersburg, FL NCVH 2015 Orlando, FL

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1 Venous Disease and Leg Ulcers Edward G Mackay MD St. Petersburg, FL NCVH 2015 Orlando, FL

2 Disclosures Stocks Endoshape Sapheon Medical Advisory Board BTG, Boston Scientific

3 Venous Leg Ulcer Most common leg ulcer Mostly due to superficial disease or combination of superficial and deep Rarely a cause of leg loss but a cause of significant disability Many options for treatment that lessen recurrence and possibly speed healing almost all office base and the remaining mostly outpatient

4 Venous Ulcer Pathophysiology Venous stasis Fig 3 Capillary distension Fig 1 Fibrin deposition in dermis; fibrinous pericapillary cuff forms Skin deprived of oxygen and nutrients Fig 2 Skin destruction Fig 1: Phua J. Fig 2: Image courtesy of David MacMillan, MD Fig 3: Adapted from Paletta C, Massey B. Vascular Ulcers

5 Causes of Stasis or Venous Hypertension Reflux or valve failure: -superficial axial Great, Small, Accessory Saphenous veins -perforator -pelvic -deep Obstruction Iliac, femoral and popliteal Pump failure

6 Diagnosis of Reflux History and Physical Duplex mapping

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8 Treatment Options for Superficial Axial Reflux Compression Traditional surgery: ligation, stripping Endovenous Thermal Ablation Mechanical Chemical Ablation Chemical Ablation

9 Action of GC Hose

10 Endovenous Thermal Ablation RF Closure now Venefit Endovenous Laser of which multiple suppliers Requires Tumescent anesthesia Requires fairly straight vein Cannot treat right under the skin

11 ULTRSOUND GUIDED VENOPUNCTURE

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14 Pretty Boxes

15 RF Catheter

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18 Endovenous Laser Treatment

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21 Mechanical Chemical Tumescentless Clarivein Uses combination of mechanical and chemical injury Still requires a fairly straight vein No risk of burn so superficial veins are okay

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23 Postoperative pain and early quality of life after radiofrequency ablation and mechanochemical endovenous ablation of incompetent great saphenous veins van Eekeren RR1, Boersma D, Konijn V, de Vries JP, Reijnen MM. J Vasc Surg Feb;57(2): Patients treated with MOCA reported significantly less postoperative pain than patients treated with RFA during the first 14 days after treatment (4.8 ± 9.7 mm vs 18.6 ± 17.0 mm; P <.001) significantly earlier return to normal activities (1.2 ± 1.8 vs 2.4 ± 2.8 days; P =.02) work resumption (3.3 ± 4.7 vs 5.6 ± 5.8 days, respectively; P =.02).

24 Chemical Ablation Sclerotherapy Physician compounded foam Polidocanol Microfoam (Varithena ) Cyanoacrylate (VenaSeal ) Tumescentless

25 Physician Compounded Foam

26 US Guided Sclerotherapy

27 Liquid I inject; high concentration low volume

28 Cerebral Vascular Incidents J Vasc Surg Jan;43(1):162-4 Forlee MV, Grouden M, Moore DJ, Shanik G : Stroke after varicose vein foam injection sclerotherapy Phlebology. 2008;23(4): Bush RG, Derrick M, Manjoney D.: Report describes two complications of severe neurologic alterations (TIA, CVA) after foamed sclerotherapy injection Eur J Vasc Endovasc Surg Nov;38(5): Epub 2009 Aug 14 Hartmann K, Harms L, Simon M : Reversible neurological deficit after foam sclerotherapy Ceulen RPM. Sommer A, Vernooy K. Microembolism during foam sclerotherapy of varicose veins. N Engl J Med 2008;358: % incidence of serious neurologic complications

29 Polidocanol Microfoam Varithena FDA approval 2014 Superficial veins Tortuous veins Approved for GSV, Accessory veins Superficial varicosities Not the SSV

30 Cyanoacrylate Just got FDA approval Superglue Venaseal Delivered through a catheter so fairly straight veins Questionable for superficial veins

31 Perforator veins Usually not acting alone Deep and/or superficial disease usually present Treat with ligation, sclerotherapy, or thermal

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33 RF Ablation of Incompetent Perforators Low morbidity Can perform through ulcer Results: IP s in 506 limbs 79% closed at 1year 76% remained closed at 2 years Image courtesy of Paul McNeill, MD 1. E. Peden, A. Lumsden, Radiofrequency Ablation of Incompetent Perforator Veins. Perspect Vasc Surg Endovas Ther. 2007; 19;

34 Pelvic Veins If for leg symptoms just treat the leg portion Treat from above for pelvic symptoms

35 Deep vein reflux Think obstruction Valve reconstruction has high morbidity Percutaneous valve replacement in the works

36 Marston W, Fish D, et al Incidence of and risk factor for iliocaval venous obstruction in patients with active or healed venous leg ulcers J Vasc Surg May 2011;53:

37 78 patients with ceap 5/6 37% had ICVO >50% 23% had ICVO >80% Risk factors for ICVO >80% were female, h/o DVT and DVR Duplex with absent respiratory phasicity 100% specificity and PPV (only 77% sensitive) No patients with superficial reflux alone was found to have ICVO>80%

38 Iliac Vein Duplex Ultrasound

39 MR Venography NIVL lesions present in silent form in 30-50% of the general population Courtesy Barry Stein, MD

40 IVUS, IVUS, IVUS

41 IVUS Phased array transducer Mechanical transducer

42 Contrast venography: oblique views Require more ionizing radiation Require more nephrotoxic contrast

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46 Conclusion Lots of treatment options and more coming Most done in office and some in the vascular lab Minimal morbidity and minimal downtime