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Venous Disease Beyond the Aesthetics

Faculty Disclosures. Cordis

Lucy
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Venous Disease Beyond the Aesthetics

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    1. Venous Disease Beyond the Aesthetics Sean D’Souza MD, MPH Cardiovascular Care Update 2011 Vascular Surgeon Cardiovascular Consultants

    2. Faculty Disclosures Cordis – Principal investigator Stroll SFA Study Sapphire Carotid Stenting

    4. Perforators Connect deep and superficial systems Flow normally from superficial to deep Common GSV perforators: - Hunterian (midthigh) - Dodd’s (above knee) - Boyd’s (below knee) - Cockett (distal leg)

    5. Subcutaneous Veins When abnormal: - Varicose (> 3mm) - Reticular (1- 3 mm) - Telangiectasia (spider)

    7. Muscle Pump Contractions propel blood toward heart Relaxation draws blood from - superficial veins - lower deep veins

    8. Thoracoabdominal Pump Inspiration decreases intrathoracic pressure promoting venous return Expiration reverses the process Findings easily seen in US

    9. Valves Maintain unidirectional flow - Extremity to heart - Superficial to deep GSV and SSV with terminal and preterminal valves Terminal (sentinel or first) valve with firm thickened white cusps different from the rest of the valves

    10. Pathophysiology > 90% LEVI

    11. Etiology Pregnancy Pelvic obstruction Chronic straining Prolonged standing Prolonged sitting

    12. Etiology Wearing constricting clothing Obesity Hormones Heredity risk? Both parents = 80% 50/50 chance if one parent 20% chance if neither parent

    13. Symptoms of Varicose Veins Pain: aching, throbbing, tingling, sharp Cramps, heaviness, tiredness of legs “Restless” legs at night Itching, dermatitis, hyperpigmentation, skin ulceration, bleeding, blood clots All increase with dependency, resolve with leg elevation or compression

    14. Superficial Venous Insufficiency Abnormal veins - telangiectasia (spider) - reticular - Non-saphenous VV - Saphenous VV Abnormal skin

    15. Superficial Venous Insufficiency Abnormal veins - telangiectasia (spider) - reticular - Non-saphenous VV - Saphenous VV Abnormal skin

    16. Superficial Venous Insufficiency Abnormal veins - telangiectasia (spider) - reticular - Non-saphenous VV - Saphenous VV Abnormal skin

    17. Superficial Venous Insufficiency Abnormal veins - telangiectasia (spider) - reticular - Non-saphenous VV - Saphenous VV Abnormal skin

    18. Superficial Venous Insufficiency Abnormal veins Abnormal skin - eczema - edema - corona phlebectatica - lipodermatosclerosis - ulceration

    19. Classification Of CVD CEAP C - clinical signs 0: No visible venous disease 1: Telangiectasias or reticular veins 2: Varicose veins 3: Edema 4: Skin changes 5: Healed ulceration 6: Active ulceration

    20. Evaluation of Vein Patients H & P Coagulopathy Thrombophlebitis or DVT PAD Results of previous treatment Blood flow tests Most tests non-invasive Hand-held Doppler Duplex ultrasound Patient selection

    21. Patterns of Reflux Truncal or saphenous related reflux - GSV: 4/6 of VV - SSV: 1/6 of VV Non-truncal reflux: 1/6 of VV - Pudendal, perforators - LSVS, Giacomini

    22. Duplex Ultrasonography Replaced plethysmography and venography 7-10MHz linear transducer Exam sitting and standing Superficial and deep systems evaluated Physiologic reflux: < 0.5 sec Pathologic reflux: > 0.5 sec

    23. Options Surgery Closure Ultrasound guided injections (Foam) Compression garments only No treatment

    24. Standard Surgical Treatment Saphenous vein ligation Saphenous vein stripping +/- ligation Flush SFJ ligation, stripping thigh portion of GSV with excision of tributaries and stab phlebectomies of VV SEPS (subfascial endoscopic perforator surgery)

    25. Ligation vs. Stripping

    27. Surgical Complications Wound Infection Hematoma/severe bruising Scarring DVT Recurrence

    28. Less Invasive Options

    29. ClosureTM Procedure

    30. ClosureTM Procedure

    31. Closure Procedure Method Local, regional, or general anesthesia Access vein Insert catheter into the vein and advance closure catheter tip to SFJ using US Compress saphenous vein and displace blood away from catheter electrodes

    32. Pre/Post

    33. Pre/Post

    34. Pre/Post

    35. Treatment of primary varicose veins by endovenous obliteration with the VNUS closure system: results of a prospective multicentre study RFA saphenous vein obliteration improves symptoms of varicose veins. Reflux-free rates in treated veins remain constant over 3 yr f/u. Eur J Vasc Endovasc Surg. 2005 Apr;29(4):433-9.

    36. Treatment of Small Vein disease Female Heredity Pregnancy Steroid or estrogens Red or blue in color Close to surface and not raised

    37. Common Symptoms Localized pain - similar to a bruise Burning sensation Aching Often no symptoms. Treatment cosmetic only Symptoms worsened by warm weather and/or by menstrual cycle

    38. Treatment Options Conservative – use of support hose to control symptoms Injection Sclerotherapy Laser or light source therapy

    39. Modern Sclerosants Detergents Hypertonic and ionic solutions Cellular toxins

    40. Detergents Most commonly used – protein denaturation Sodium morrhuate, sotradecol, polidocanol Liquid or Foam

    41. Polidocanol (0.5%) Advantages Injection is Painless Extravasation ? No Necrosis Disadvantages Pigmentation ? Intermediate

    42. Sclerotherapy - Results Excellent for small veins: reticular, telangiectasias High recanalization rates for larger veins GSV: > 50% recurrent reflux by US, which is likely the prelude for recurrence of VV

    43. Before and After

    44. Sclerotherapy-Complications Pigmentation Matting

    45. Sclerotherapy-Complications Ulceration

    46. Sclerotherapy vs. Surgery Prospective 10 year study (121 96) VV and superficial incompetence Group A: Sclerotherapy (39) Group B: Ligation + Sclerotherapy (40) Group C: Ligation only (42) No incompetence at SFJ in surgical groups Sclerotherapy with 20-44% reflux Sclerotherapy cheaper, surgery superior

    48. Sclerosing Foam Orbach(1944): the air block technique Displaces blood Induces more spasm Tiny bubbles covered by tensio-active liquid Treat larger veins

    50. Sclerosing Foam Less volume More potent Morbidity appears similar to liquid sclerosants

    51. Procedure Several injections per visit with small gauge needles Injected areas become reddened and “bee sting” wheals occur for several hours Moderately uncomfortable Several treatments Compressive bandaging after treatment Appearance often “worse before better”

    52. Patient Selection Better results with injection of spider veins and small varicose veins Some patients require combination of surgery for large veins followed by sclero for smaller veins Large varicose veins when injected may re-open soon after treatment Higher risk of complications with sclerotherapy of large varicose veins

    53. Contraindications Pregnancy Inability to walk Allergy to sclerosant

    54. Post Sclerotherapy Instructions Avoid vigorous impact activities for 3 days Compliance with use of compression garment Avoid prolonged sun exposure for several weeks Follow up visits essential for best results

    55. Long Term Results 80-90% clearing of treated area Improvement of symptoms Cosmetic improvement Variable rate of recurrence

    56. Sclerotherapy Before After

    57. Sclerotherapy Before After

    58. Sclerotherapy Before After

    59. 10 Week Interval

    60. Mechanism of Action Beam is directed to and heats a target vessel Blood in the vein coagulates, vessel is destroyed Minimal effect on surrounding skin and tissue

    61. Procedure Avoid sun exposure for 2 months prior to treatment Protective eye gear is worn by the patient and practitioner Cooling gel is applied to the skin before treatment

    62. Procedure Multiple pulsed light wavelengths directed at the vein with variable strength of laser energy Moderate discomfort during treatment similar to “snap of a rubber band” Multiple treatments usually necessary

    63. Risks Crusting or blistering of the skin Loss of pigmentation of skin “white dots” Increase in pigmentation “dark streaks” Transient redness / swelling of skin Most pigmentation changes resolve with time ? Photo of complications? Photo of complications

    64. Increase in Pigmentation “Dark Streaks”

    65. Laser Treatment Advantages Non- invasive ( no needles) “State of the art” - most current therapy Disadvantages Costly Uneven results Not amenable to all skin types Not applicable to all types of veins

    66. Post Treatment Instructions No vigorous exercise for 3 days Continuous support hose for 1 week Antibacterial ointment to treated areas for 7 days Avoid sun exposure until healed, 4-6 weeks Hose for 3 weeks while awakeHose for 3 weeks while awake

    67. Patient Selection Best results on small spider veins of the face or legs Better results with fair skin types No suntanned skin Poor results on varicose veins

    68. Novel Management of Deep Venous Thrombosis

    69. Clinical presentation 50 year-old female sent to ER from PCP C/O of pain in the left hip after playing tennis 4 days prior to ER visit. Seen by PMD, x-rays were negative, treated for sciatica with Vioxx. Then developed a swelling initially in the left leg rapidly extended to left thigh and groin area over 2-3 days.

    70. Clinical presentation Venous Doppler at PCP - DVT from popliteal fossa to CFV Denies SOB, CP, N/V PMH: MVP PSH: Abdominal liposuction 10 weeks ago, Breast Bx. (benign)

    71. DVT >600,000 cases of VTE annually in the US DVT of LE has traditionally been treated with anticoagulation. Anticoagulation is used to prevent the progression of DVT to PE and to limit clot propagation.

    72. Anticoagulation in DVT Anticoagulation alone results in complete clot lysis in less than 4% of cases. Anticoagulation is not effective for preventing the long-term sequelae of venous stasis disease. Catheter-directed thrombolysis help to relieve symptoms and prevent venous wall and valve injury.

    73. Indications for Thrombolysis Patients with phlegmasia cerulea dolens Patients with acute, extensive DVT Younger patients more aggressive because of potential for long-term complications from post-phlebitic syndrome

    74. Contraindications To Thrombolysis Obsolute Active bleeding IC lesions(Stroke, tumor, recent surgery) Pregnancy Nonviable limb Relative Bleeding diathesis Mal. HTN Recent Major Surgery Postpartum

    75. Complications of Thrombolysis Major hemorrhage (IC bleed, massive puncture site bleed) Distal embolization Pericatheter thrombosis

    76. Thrombolysis IVC filter prior to thrombolysis to prevent PE Usually temporary or retrievable filters Approach to clot Popliteal approach Direct administration into the clot Entire thrombosed segment should be crossed and treated in order to achieve thrombolysis.

    77. Thrombolysis Evaluated every 8-12 hours to assess the state of lysis. If no significant lysis has occurred in 24-36 hours, then successful thrombolysis is unlikely and the infusion should be ended. The procedures commonly take 2-3 days.

    78. Venogram show complete thrombosis of the LCIV

    79. Management Infusion catheter placed in LIV TPA infusion at 1mg/hr. Heparin infusion at 500 units/hr. ICU for close monitoring Bleeding – serial H/H Neuro-checks Serial labs to monitor for coagulopathy.

    80. 6 hours post TPA infusion show some improvement

    81. 16 hours post TPA infusion show further improvement with some residual clots

    82. 28 hours post TPA infusion, there is complete lysis, however extrinsic compression of LCIV

    83. May-Thurner syndrome Isolated LLE swelling secondary to LIV compression First described by McMurrich in 1908. Defined anatomically by May and Thurner in 1957. Defined clinically by Cockett and Thomas in 1965 The LIV usually posterior to RIA and can be compressed between artery and L5

    87. Post stenting and angioplasty

    88. Endovascular management of acute extensive iliofemoral deep venous thrombosis caused by May-Thurner syndrome. Over 1-year period, 10 symptomatic women treated with thrombolysis plus PTA/ stenting. Complete resolution of symptoms in all patients Mean follow-up of 15.2 months (range, 6-36 months) CONCLUSION: Catheter-directed thrombolysis for acute extensive iliofemoral DVT due to May-Thurner syndrome is effective method for restoring venous patency and relief of acute symptoms. The underlying LCIV invariably needs to undergo stent placement. J Vasc Interv Radiol. 2000 Nov-Dec;11(10):1297-302.

    89. Endovascular Management of Iliac Vein Compression (May-Thurner) Syndrome 39 patients 19 with acute DVT and 20 with chronic symptoms. Acute DVT treated with catheter thrombolysis plus PTA/stenting Chronic pts treated with PTA/stent J Vasc Interv Radiol 2000 11: 1297-1302

    90. Endovascular Management of Iliac Vein Compression (May-Thurner) Syndrome Initial technical success 87% 1-year patency rate for pts with acute DVT was 91.6% pts with chronic symptoms, 1-year patency rate was 93.9%. J Vasc Interv Radiol 2000 11: 1297-1302

    91. Endovascular Management of Iliac Vein Compression (May-Thurner) Syndrome Major complications included acute iliac vein rethrombosis (< 24 hours) requiring reintervention Minor complications included perisheath hematomas (n = 4) and minor bleeding (n = 1). no deaths, pulmonary embolus, cerebral hemorrhage, or major bleeding complications J Vasc Interv Radiol 2000 11: 1297-1302

    92. Endovascular Management of Iliac Vein Compression (May-Thurner) Syndrome CONCLUSION: Endovascular reconstruction of occluded iliac veins secondary to IVCS (May-Thurner) appears to be safe and effective. J Vasc Interv Radiol 2000 11: 1297-1302

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