VENOUS INSUFFICIENCY P. Altes Mas, MD, FEBVS Angiology and Vascular Surgery Hospital Universitari Germans Trias i Pujol

DEFINITION Chronic venous insufficiency encompasses diseases of the lower limb veins in which venous return is impaired, usually over a number of years, by reflux, obstruction or calf pump failure This leads to venous hypertension

INTRODUCTION Varicose veins and their complications affect up to half of the adult poplulation and lead to significance reduction in health-related quality of life (HRQL) Treatment of such diease is given a low priority, clinically and in terms of research VV surgery is a common cause of medico-legal claims and recurrence rates remain stubbornly high Successfully meeting the expectations requires excellent comunication skills, as well as understanding of the anatomy, pathophysiolgy and available treatments

Physical activity mandatory Human genome not adapted : The evolution… Hunter/gatherer Click n deliver Human genome: Few food Physical activity mandatory Human genome not adapted : Plenty of food Few physical activity  Energy accumulation 4

VEIN ANATOMY 5

VEIN PHYSIOLOGY IN THE VEIN PHYSIOLOGY WE SEE IT IS A SYSTEM THAT DEPENS ON MUSCLE CONTRACTION AND VALVES

PATHOPHYSIOLOGY Venous hipertension VARICOSE VEINS POST-TROMBOTIC SEQUELA

PATHOPHYSIOLOGY

PATHOPHYSIOLOGY Primary valve failure: degenerative changes in the valve annulus Secondary valve failure: weakness in the vein wall The objective severity of VV is determined by the severity of that reflux and the ability of the patients´s calf muscle pump to overcome the haemodynamic consequences

ETIOLOGY Multifactorial and complex, where the interaction between ambiental and genetical factors play an important role

DIAGNOSIS CLINICAL SIGNS AND SYMPTOMS PHISICAL EXPLORATION DUPLEX SCAN Con la anamnesis y la exploración física podemos confirmar la presencia y el sector implicado, pero no localizamos el punto exacto de fuga o la válvula/s responsables

DUPLEX ULTRASONOGRAPHY Routine preoperative duplex examination led to an improvement in results 2 years after surgery for patients with primary varicose veins* *Blomgren L, Johannsen G, Bergqvist D. Randomised clinical trial of routine preoperative duplex imaging befor varicose vein surgery. Br J Surg 2005;92:688-94

CLINICAL FEATURES Swelling: due to oedema fluid Skin changes: varicose eczema and pigmentation Ulceracion: in the lower leg, more commonly medial Varicose veins: the absence does not exclude reflux Pain: general ache and heaviness in the leg, after standing in the end of the day

SIGNS CEAP classification: 1. Telangiectasies or reticular veins

SIGNS CEAP classification 2. Varicose veins

SIGNS CEAP classification 3. Oedema

SIGNS CEAP classification 4. Pigmentation or eczema

SIGNS CEAP classification 5. Helaed venous ulcer

SIGNS CEAP classification 6. Active venous ulcer

TREATMENTS

TREATMENT OPTION Water steam Sclerotherapy COMPRESSION THERAPY Medication Sclerotherapy COMPRESSION THERAPY Criosclerotherapy Endoscopic ligature Laser Endolaser Lo primero que se nos ocurre al ver tantas posibilidades de tratamiento es que ninguna es buena; sino alguna se impondría y si lo hace es por modas o de forma temporal. Las nuevas técnicas se van incorporando pero no acaban de desplazar a las previas. Todas las técnicas quIrúrgicas si están bien realizadas mejoran la calidad de vida del paciente (síntomas); su utilización depende de la preferencia del cirujano, de intereses “mercantiles” . La idea en conseguir el menor dolor postoperatorio, el tratamiento ambulatorio y disminuir la posibilidad de recidivas. Radiofrequency CHIVA Stripping Criosurgery Water steam Flebectomy

PREVENTION TRY TO MAXIMIZE ALL ACTIVITIES INVOLVED IN MUSCLE COMPRESSION

PHARMACOLOGICAL TREATMENT Flebotonic Nutritional complements Symptoms relieve Not organical improvement

GRADUATED COMPRESSION Symptoms relieve Prevent skin deterioration Uncomfortable

SURGICAL TREATMENTS Surgical treatments provides symptomatic relief and significant improvements in the quality of life in patients refered to secondary care with uncomplicated varicose veins* * Michaels JA, Braizier JE, Campbell WB et al. Randomizes clinical trial comparing surgery with conservative treatment for uncomplicated varicose veins. Br J Surg 2006; 93:175-81

SURGICAL TREATMENTS For patients with uncomplicated varicose veins and evidence of sapheno-femoral or sapheno-popliteal reflux, surgical treatment offers a modest health benefit for relatively little addtional National Health System cost relative to conservative treatment* * Ratcliffe J, Brazier JE, Campbell WB et al. Cost-effectiveness analisys of surgery versus conservative treatment for uncomplicated varicose veins ina a randomized clinical trial. Br J Surg 2006; 93:182-6

SURGICAL TREATMENTS Patient should be warned about the common consequences of surgery: Bruisings Areas of paesthesias It´s impossible to remove all prominent veins with a stab avulsion technique

SURGICAL TREATMENTS GREAT SAFENOUS VEIN STRIPPING

SURGICAL TREATMENT STRIPPING ONLY TREATS GREAT SAPHENOUS VEIN!!!! CLOSURE OF PERFORANTS WITH COMPRESSION

SURGICAL TREATMENT One of the least invasive techniques: CHIVA CHIVA: cure conservatrice et hémodynamique de l'insuffisance veineuse en ambulatoire The ambulatory conservative hemodynamic correction of venous insufficiency method an approach based on venous hemodynamics with deliberate preservation of the superficial venous system There are many surgical options: one of that is CHIVA based on the venous hemodynamics. It is more an strategy that a tecniche an can be aplied to all type of veins

CHIVA Venous hemodynamics: ultrasound It´s an strategy based on surgical mapping Day-case surgery under local anaesthesia

CHIVA: INTERRUPTION OF POINTS OF REFLUX EXTIRPATION OF INCOMPETENT SEGMENTS CONVERT TO A CORRECT DRAIN SYSTEM

SURGICAL TREATMENTS Cochranes review evaluated the effectiveness and safety of the CHIVA method in CVI and included four randomized controlled trials with 796 participants* CHIVA method reduced recurrence of varicose veins and produce less bruising and nerve damage than vein stripping *Bellmunt-Montoya S, Escribano J, Dilme J, Martinez-Zapata M. CHIVA method for the treatment of chronic venous insufficiency. Cochrane Database of Systematic Reviews 2013, Issue 7. Art.

ENDOVENOUS LASER ABLATION (EVLA) Involves using a percutaneous placed catheter to deliver laser light energy to create thermal damage to the vein

ENDOVENOUS LASER ABLATION As effective as well-performed surgery but less morbidity and “down time”* Expensive, it only treats the great saphenous vein It´s LASER *Darwood RJ, Theivacumar N, Dellagrammaticas D et al. Randomised clinical trial comparing laser ablation with surgery for the treatment of primary great saphenous varicose veins. Br J Surg 2008; 93:294-301

RADIOFREQUENCY ABLATION (RFA) Involves using a percutaneous catheter to deliver radiofrequency energy to the vein

RADIOFREQUENCY ABLATION (RFA) The 2-year clinical results of RFA are at least equal stripping of GSV with improved quality of life* Expensive and only treats the GSV *Lurie F, Creton D, Eklof B et al. Prospective randomised study of endovenous radiofrequency obliteration (closure) versus ligation and vein stripping (EVOLVeS): two-year follow-up. Eur J Vasc Endovasc Surg 2005;29:67-73

SCLEROTHERAPY The aim is to pace sclerosant in the vein lumen empty of blood and appose the walls with compression Types sclerosants: - detergent: polidocanol/ sodium tetradecyl sulphate - osmotic: hypertonic saline - chemical irritant: chromated glycerine

SCLEROTHERAPY Tessari method: the conversion of detergent from liquid phase to foam: Increases power Pushes the blood out Becomes echogenic

SCLEROTHERAPY Ultrasound-guided foam sclerotherapy (UGFS) appears to be as effective as surgery, EVLA and RFA in the treatment of VV* *Myers KA, Jolley D, Clough A et al. Outcome fo ultraosun-guided sclerotherapy for varicose veins: medium-term results assessed by ultrasound surveillance. Eur J Vasc Endovasc Surg 2007;33:116-21

SCLEROTHERAPY Many sessions Pigmentation Treatment of any kind varicose veins Good for recurrence No special equipment Quick Not need to stop anticoagulation

VULVAL AND PERINEAL VARICES Women after pregnancy or following pelvic vein thrombosis Ovarian and internal iliac venous valve incompetence Related to pelvic congestion sindrome DX: US/MR/CT

VULVAL AND PERINEAL VARICES Treatment: radiological ovarian vein scleroterapy and embolisation with coils* *Creton D, Hennequin L, Kohler F et al. Embolisation of symptomatic pelvic veins in women presenting non-saphenous varicose veins of pelvic origin- three year follow-up. Eur J Vasc Endovasc Surg 2007; 34:112-17

Take home message! Intervention for symptomatic VV improve quality of life VV surgery is a common cause of medico-legal claims Meeting the expectations requires excellent comunication skills Ultrasound strongly recomended before any kind of surgery

Thanks for the attention!