How to choose which treatment method(s) to use for a particular varicose veins patient ESTABLISHING A TREATMENT PLAN Surgeon Dr G Mark Malouf Sydney Australia
Following History and Physical examination of the legs Comprehensive Venous Duplex Mapping to explain the clinical picture GSV territory SSV territory The saphenous trunks may NOT need treatment Non-spahenous varices? Connections Perfs lateral thigh perfs pelvic escape veins Deep veins especially femoral and popliteal Does your map explain the clinical picture?
Two broad patterns of VVs Patients Those whose MAIN pathology is saphenous trunks severe truncal disease into tribs Those whose MAIN pathology involves tributaries and clusters of varicosities, where saphenous trunks may not be badly diseased at all short length of reflux segmental reflux trickle TRUNCAL DISEASE vs TRIBUTARY DISEASE Of course the patient can have both but usually one is dominant
Treatment Options for VV s Conservative Life style improvements Venotonics oral veno-active drugs Graduated compression stockings Interventional Sclerotherapy Open surgery: ligt strip phlebectomies? Alone Thermal ablation: laser radiofrequency tume Non-T non-t : VenaSeal glue ClariVein Powered phlebectomy Trivex Many combinations may be used on any one pt
What influences your choice of Rx Abnormalities found CLINICALLY combined with relevant reflux found on duplex mapping BOTH considered Don t just treat a duplex scan report What bothers the patient and defined end-point of treatment What do YOU have available to offer the patient What are YOU trained experienced & comfortable with Affordable cost govt insurance hospital admission disposables regulations re reimbursement Logistics Local patient or far from home multiple visits or? all Rx on the day Published clinical trials reporting efficacy and safety results Published GUIDELINES for Rx NICE SVS/AVF ACP UIP Europe Pain morbidity anxiety down-time scars pigmentation List which pathologies you will treat, using what method
Treating refluxing Saphenous Trunks - 1 High ligation and strip giving way to endovenous chemical or thermal ablation done out of hospital Chemical sclerotherapy foam duplex cheap limits Thermal Laser duplex cheaper fibres? $ box tumescent Variables with laser w/l power speed energy(j) RF duplex catheter $ cheap box tumescent How far distally is reflux? Nerves? cycles Conformation and depth of the saph V Foam sclerotherapy to distal trunks
Treating refluxing Saphenous Trunks - 2 Cyanoacrylate glue via endovenous catheter VenaSeal small volumes strong closure Chemical embolisation or sclerotherapy $$ Non-thermal non-tumescent Mechanical abrasion of endothelium and sclerotherapy concurrently ClariVein Also Nt-Nt $ The high-cost treatments are almost ALL for treatment of refluxing saphenous trunks Open Sx RF laser glue clarivein
Refluxing Saphenous tributaries & clusters of varicosities May be the dominant pathology These veins are not in the saphenous compartment ie not located down on the deep fascia but at various depths They are more superficial in the fatty layer and possibly immediately beneath the skin Sensory nerves and lymphatics adjacent
Rx of refluxing saphenous tributaries and varicosities UGFS duplex needed foam phlebitis pigmentation Surgical phlebectomies easy for surgeons accurate marking stab incisions? vein hooks interrupt reflux debulk Can this be done under LA tumescent or GA? Thermal Abltn straight and able to be tumesced eg ant accessory v of thigh thigh extension SSV Powered phlebectomy with transillumination Trivex tumescent Combined foam sclerotherapy and phlebectomy in office works well, especially for recurrences
When and How do we have to treat incompetent perforating veins? When you consider them pathologically refluxing perforators not innocent re-entry perforators ie When they are a primary source of pathology Options Disconnect using phlebectomies Ligate perforator at deep fascia level Sclerotherapy foam to adjacent varicosities Thermal ablation with short stylette to perf
How does deep vein disease modify your treatment decisions in VV s Recognise on your initial duplex mapping what is pathological deep vein reflux as opposed to segmental reflux into the adjacent superficial vein Is deep vein disease dominant and? No point in treating superficial disease Extensive deep vein reflux? Evidence old DVT Deep vein thrombosis/obstruction With these deep vein pathologies you are less likely to relieve symptoms more wary of post-rx DVT and of early recurrence
Recurrent reflux on scan or recurrent clinical varicosities Does the patient have symptoms UGFS easy and effective Phlebectomies an easy addition If progressive disease all treatment options again come into play so start again in your treatment planning
Cosmetic tidy-up Sclerotherapy What was the patient s major complaint Final cosmetic outcome may be a big issue Symptoms and ulcers or eczema better, do we worry about the spiders? Very important to establish early in the process an agreed end-point of treatment accepted by the patient
SUMMARY Establish the patient s desired end point After careful consideration, list all the venous abnormalities you wish to treat Make sure you have at least one treatment option to cover each form of pathology Modify those treatment choices according to specific circumstances Establish plan for follow-up and recurrence
Thank you...from Sydney