Le varici recidive Recurrent varices: how to manage them?

Le varici recidive Recurrent varices: how to manage them? Marianne De Maeseneer MD PhD, Vascular Surgeon Department of Dermatology, Rotterdam, Netherlands & Faculty of Medicine and Health Sciences University of Antwerp, Belgium

varicose vein recurrence or PREVAIT: = presence of varicose veins (residual or recurrent) after a previous intervention Eklöf B et al. JVS 2009; 49: 498-501

major surgical re-intervention? bad reputation! laborious, time consuming high incidence of complications worse outcome vs. primary vv surgery* at 5 yrs: 42 % rec. vv after redo vs. 20 % after primary surgery *De Maeseneer et al. EJVES 2005; 29: 308-12

Anno 2014: no more extensive redo surgery!

Perspect Vasc Surg Endovasc Ther. 2011 Dec;23(4):244-9

1. multiple phlebectomies without re-opening the groin retrospective study in 2 consecutive groups of pts with GSV rec vv (n=137: classic redo n=151 focusing on varicose réservoir ) excellent mid-term results (3y) less complications much lower cost Pittaluga et al. JVS 2010; 51: 1442-50

1. multiple phlebectomies without re-opening the groin retrospective study in 2 consecutive groups of pts with GSV rec vv (n=137: classic redo n=151 focusing on varicose reservoir ) excellent mid-term results (3y) less complications much lower cost Pittaluga et al. JVS 2010; 51: 1442-50

2. endovenous thermal ablation of residual GSV / AASV / SSV trunk EVLA, RFA or STEAM (usually with phlebectomies)

2. endovenous thermal ablation of residual GSV / AASV / SSV trunk 1 RCT in 16 pts with bilateral GSV rec vv one leg treated with VNUS Closure Plus other leg classic redo + phlebectomies in both groups faster procedure significantly less pain and bruising in RFA treated legs Hinchliffe et al, EJVES 2006; 31: 212-8

EVTA for recurrent varicose veins Authors, year 2006 Hinchliffe 2009, van Groenendael 2010 Nwaejike 2010 Anchala 2011,Theivacumar Treatment N limbs Surgery 16 infection 1; numbness 3; phlebitis 3, oedema 1 Complications FU DUS reflux / clin rec 6 w;1 y 2/16; 2 AASV RFA 16 neuralgia 2 3/16; 3 AASV Surgery 149 infection 8 %; paraesth 27 %; recovery time EVLA 67 infection 0 %; paraesth 13 %; tightness 31 % EVLA 77 PE 1 18 m (1-38) 13.5 m 25.8 % 15 m 11.5 %* all occluded EVLA 56 bruising, some 4-6 w all occluded EVLA GSV* (+ FS 37 %) EVLA SSV (+ FS 33 %) 51 phlebitis 3 6 w; 12 w; 1 y 4 % part recan (12 w) 24 phlebitis 2 all occluded

Theivacumar et al. EJVES 2011; 2011; 41:691-6

Theivacumar et al. EJVES 2011; 2011; 41:691-6 10 cm

3. (ultrasound guided) foam sclerotherapy technique most widely used nowadays to treat recurrent varicose veins survey in UK 71 % of vascular surgeons would use foam sclerotherapy in case of recurrent vv [O Hare, EJVES, 2007] survey in USA (attendants of ACP 2009): 87 % of practicioners reported using foam sclerotherapy for CVD «The most common indication was sclerosis of recurrent truncal or tributary veins of the leg.» [Rathbun, Phlebology, 2012]

treatment of major vv recurrence (SFJ) at University Hospital of Antwerp 1991-2009 100 80 60 40 REDO USGFS EVA 20 0 1991-1995 1996-2000 2001-2005 2006-2009

3. (ultrasound guided) foam sclerotherapy limited reports in literature: excellent immediate results (3 wks) in 45 legs with recurrent vv [Kakkos, J Endovasc Ther, 2006] 72 % occlusion rate (6 mths) in 32 patients (very high satisfaction) [O Hare, EJVES 2008] low re-recurrence rate of GSV reflux after one year [Darvall, EJVES 2011]

recanalisation GSV (12 mths): above knee 9 % below knee 12 %

4. combined min. invasive procedures a. EVTA + peroperative foam sclerotherapy: indications: large (> 4 mm) groin / popl fossa varicose network (neovascular) in connection with residual trunk can be easily performed with VNUS Closure Fast technique: positioning of RF catheter tumescent anesthesia foam injection through catheter RF ablation phlebectomies

after 1 week

4. combined less invasive procedures b. phlebectomies + immediate foam sclerotherapy: indications: large (> 4 mm) groin / popl fossa varicose network (neovascular) in connection with recurrent varicose veins technique: phlebectomies of recurrent varicose veins cannula in cranial end of highest tributary (tumescence around varicose network) foam injection through cannula ligation of tributary after injection (to avoid foam leakage) AASV

2 yrs after EVLA

5. treatment of underlying pelvic vein incompetence in female patients, often multiparous Asciutto (EJVES, 2009): 75 % of patients with pelvic vein incompetence had recurrent varicose veins after GSV surgery best outcome in patients with isolated ovarian vein incompetence poor mid-term results (3 yrs) in patients with combined incompetence (ovarian + internal iliac vein)

6. treatment of underlying deep venous obstruction

GUIDELINES???

Guidelines SVS and AVF (2011) Guideline 10. Open venous surgery 10.9 For treatment of recurrent varicose veins, we suggest ligation of the saphenous stump, ambulatory phlebectomy, sclerotherapy, or endovenous thermal ablation, depending on the etiology, source, location, and extent of varicosity. grade 2 level C (= weak recommendation, low quality) Gloviczki P et al. J Vasc Surg 2011; 53: 2S-48S

NICE guidelines UK (2013) No specific recommendations

conclusion redo surgery at the SFJ / SPJ should belong to the past

conclusion redo surgery at the SFJ / SPJ should belong to the past minimally invasive alternative techniques are preferred: extensive phlebectomies EVTA and US guided foam sclerotherapy growing evidence - long-term results???

conclusion redo surgery at the SFJ / SPJ should belong to the past minimally invasive alternative techniques are preferred: extensive phlebectomies EVTA and US guided foam sclerotherapy growing evidence - long-term results??? 4 main principles of the modern approach for (recurrent) vv: choose a duplex-guided à la carte treatment don t touch the SFJ/SPJ prefer step-by-step approach try to communicate well with your patient

in the future more well designed prospective studies are needed to validate the alternative methods registry?

in the future more well designed prospective studies are needed to validate the alternative methods registry? setting up a RCT to compare one of these new techniques with classic redo surgery does not seem to be justified anymore