We All See Them November 4, 2017 Austin, TX Arlington Heights, IL
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Terminology REVAS REcurrent Varices After Surgery PREVAIT PREsence of Varices After Interventional Treatment Recurrent varices Reappearance of varicose veins in an area previously treated successfully Residual varices Varicose veins remaining after treatment
Clinical definition includes True recurrences Residual refluxing veins Varicose veins caused by progression of the disease Frequency Estimated 20-80% depending on duration of follow up No data on the socioeconomic consequences (2001)
Clinical and Instrumental diagnosis Hx, PE, CW doppler essential but do not give precise diagnosis Duplex ultrasound primary choice Venography valuable tool Iliac CT, MRV Pelvic Evaluation
Historical development of systematic pretreatment evaluation and long term follow up 1998 Consensus group under the guidance of M. Perrin developed new classification system (REVAS) A revision of inconsistent International venous nomenclature begun-deep and superficial venous systems, lower extremities CEAP Classification
Classification Six items (2001) T Topographic sites e.g. T9 for groin S Sources of reflux 0-7, e.g. S1 pelvic/abdomen R Degree of reflux- +/-
Classification N Nature of Source P Contribution from a persistent trunk F Possible contributing factors
REVAS Recurrent veins after surgery are a common, complex and costly problem for the patients and physicians who treat venous disease. M. Perrin 2001
Post Procedure Uniform identification of the causes and patterns of recurrence has not been reported. Mainly because of the inconsistency in defining recurrence, the initial therapy performed and length of follow up. Nicos Labropoulos, Rutherford s Vascular Surgery, 8th edition
General facts from Rutherfords s Vascular Surgery, 8th Edition, Chapter 18 About 75% REVAS symptomatic Sources are multiple SFJ area 50% No source 10% Pelvic origin 17% About 17% have IP s
General facts Rutherford s Higher percentage of patients have skin changes Older mean age Below the knee saphenous trunk remnant segments have higher prevalence of reflux (GSV stripped to knee; SSV ligated)
2013 Journal of Vascular Surgery, Vol.57, No.3, 860-868, Maresa Brake, et al. Pathogenesis and Etiology of Recurrent Varicose Veins (RVV). 13-65% of patients Inadequate treatment, disease progression, neovascularization
References Phlebolymphology, 2014; 21(3):158-168 Phlebolymphology, 2015; 22(1):5-11 The Scientific World Journal, Volume 2014 (2014), Article ID 505843, 7 pages, http://dx.doi.org/10/1155/2014/505843
Recurrent veins after thermal ablation (REVATA) 2012 Ron Bush, Journal of Vascular and Endovascular Surgery
Conclusions Debilitating and costly problem common Document patient selection, DUS, accurate treatment and follow up procedures Use accepted international venous anatomic nomenclature, CEAP, disease scores e.g. VCSS
Conclusions Despite frequent occurrences, etiology and pathogenesis poorly understood Factors leading to recurrence after sclerotherapy and endothermal treatment may be different than surgery
Sclerotherapy-Endovenous Chemical Ablation Visual macro and micro DUS aided guided Truncal, tributary, IP Liquid traditional, MOCA-mechanical chemical ablation Foam office generated-air, CO2, CO2O2 Proprietary Varithena Combination with other modalities laser, glue
Sclerotherapy Historical perspective Before DUS French Tournay Top down SFJ Swiss Sigg Open needle Irish Fegan Bottom up IP s
Sclerotherapy Mechanism of action produces endothelial damage Introduction of a foreign substance into the vein lumen Direct endothelial cell damage complex interaction Endosclerosis Endofibrosis includes entire length of abnormal vein
Sclerotherapy DUS Evaluation and Guided Treatment Knight RM, Vin F, Zygmunt JA. Ultrasonic guidance of injections in to the superficial venous system. In: Davy A, Stemmer R, eds. Phlebologie 89. UIP Presentation Strasbourg, FR
Sclerotherapy Outcome papers Various rates of recurrence generally higher than surgery DUS Set the stage for reliable, reproducible method to evaluate, treat and follow multiple presentations of superficial venous insufficiency
- Past Long history of post-procedural (surgery, sclerotherapy) recurrent veins clinical exam Post-surgery SFJ neovascularization Re-do surgery difficult Some hope for DUS guided sclerotherapy
Sclerotherapy (1985-1990) Fegan sclerotherapy Bottom Up Standing evaluation, placement of needle into veins, inject in recumbent/supine position Compression wrap Ambulation Reduction of large varicose veins. Clinical follow up.
Sclerotherapy (1990-2000) DUS Diagnostic evaluation established 1990-1991 upright eval of SFJ, SPJ, total superficial system, deep system. All size GSV/SSV. DUS guided sclerotherapy Liquid sclerosant (Sotradecol) Compression Ambulation Up to 90% GSV fibrosis SFJ to knee (2 years)
Sclerotherapy (2000-present) Truncal vein therapy endovenous laser ablation of GSV Sclerotherapy for tributaries and and IP s mainly liquid >95% fibrosis of GSV from SFJ to knee
Sclerotherapy 2014-2015 - Varithena Polidocanol injectable foam-fda approved GSV insufficiency. Large scale multicenter use will determine if long term patient outcomes compare to published studies.
Sclerotherapy Follow up 30 years Clinical visible veins, symptoms CW doppler standing DUS Patients have tolerated all outpatient ambulatory non-anesthesia treatments well and with appropriate counseling return.
Sclerotherapy Post-sclerotherapy recurrences GSV AK + BK SFJ area neovascularization not demonstrated. Have imaged groin lymph node varices. Superior vessels (superficial epigastric, superficial circumflex, pudendal) independent evaluation Thigh distal thigh IP
Sclerotherapy Post-sclerotherapy recurrences GSV AK + BK Proximal medial calf anterior and posterior arch varices. IP s with tributary veins. Distal medial calf posterior arch veins. Intersaphenous varices. Tributaries from IP s
Sclerotherapy Post-sclerotherapy recurrences GSV AK + BK BK Independent varices from postero-medial IP sgastrocnemius muscle
Sclerotherapy Post-sclerotherapy recurrences SSV SSV is direct continuation of PAGSV SSV has origin other than SPJ in popliteal fossa Medial and lateral branch communications Various IP s includes mid- and distal calf
Sclerotherapy For all therapeutic modalities recurrent varicose veins increase with accurate diagnosis and long term follow up Standardized nomenclature anatomy, diagnostic evaluation, treatment modality
Sclerotherapy Primary and secondary therapy in wide range of superficial venous insufficiency patterns Must understand venous anatomy normal and abnormal including DUS Know sclerosants mechanism of action, safety profile and concentrations
Sclerotherapy Develop long term strategy. Includes discussion with patient about life long venous insufficiency In office protocols to standardize evaluation and treatment for long term follow up
Sclerotherapy Participate in patient reporting of all treatment modalities Will add insights into treatment outcomes relating to the causes of recurrent varicose veins and the natural history of venous insufficiency
Conclusion Estimated 13-65% recurrent varices posttreatment Socioeconomic consequences Cost, complications Possible mechanisms Tactical errors Technical problems
Conclusion Disease evolution Previously unaffected superficial veins or perforator veins become incompetent Genetic and other constitutional risk factors Family history not fully understand Genome wide studies with large sample size
Conclusion Recurrent Varicose Vein - Treatment Specific to recurrent pattern Ultrasound guided foam (UGFS) sclerotherapy IB recommendation European guidelines More needs to be done