Minimally Invasive Varicose Vein Therapy Dr Mamoun Al-Basheer MBBS (Lond) FRCSI FRCSEd JBS JBVS FICA ASTS Vascular and Transplant Surgeon KHMC

Abnormal Veins Telangiectasias Reticular veins Varicose vein

Definition Telangiectasias - are a confluence of dilated intradermal venules less than one millimeter in diameter. Reticular veins - are dilated bluish subdermal veins, one to three millimeters in diameter. Usually tortuous. Varicose veins - are subcutaneous dilated veins three millimeters or greater in size. They may involve the saphenous veins, saphenous tributaries, or nonsaphenous superficial leg veins.

INCIDENCE MEN : 10-15% WOMEN : 20-25% WHEN NON SAPHENOUS VARICOSITIES ARE INCLUDED MEN : 45% WOMEN : 50%

RISK FACTORS FEMALE GENDER ADVANCED AGE CAUCASIAN RACE FAMILY HISTORY ACCELERATORS PREGNANCY OBESITY

VENOUS SYSTEM OF LOWER LIMBS SUPERFICIAL VEINS DEEP VEINS PERFORATORS

CLINICAL EVALUATION ASYMPTOMATIC SYMPTOMATIC PAIN & SWELLING COSMETIC SYMPTOMATIC PAIN & SWELLING COMPLICATION

SYMPTOMS PAIN ITCHING SKIN CHANGES COMPLICATIONS THROBBING ACHING STINGING BURNING EXERCISE – VARIABLE EFFECT ON PAIN NIGHT PAIN—CRAMPINESS ITCHING SKIN CHANGES COMPLICATIONS EFFECTS OF PREVIOUS TREATMENTS.

Complications EXTREMELY PAINFUL ULCERS - NEAR VARICOSE VEINS, PARTICULARLY NEAR THE ANKLES. BROWNISH PIGMENTATION USUALLY PRECEDES THE DEVELOPMENT OF AN ULCER. OCCASIONALLY, VEINS DEEP BECOME ENLARGED. BLEEDING SUPERFICIAL THROMBOPHLEBITIS

STRONG FAMILIAL COMPONENT Not well studied Twin studies 75% identical, 52% non identical If both parents VVS - 90% of children VVs If one parent was affected 25 percent for men and 62 percent for women Cornu-Thenard, A, Boivin, P, Baud, JM, et al. Importance of the familial factor in varicose disease. Clinical study of 134 families. J Dermatol Surg Oncol 1994; 20:318.

CEAP CLASSIFICATION CLINICAL ETIOLOGIC ANATOMIC PATHOPHYSIOLOGIC

CLINICAL CLASSIFICATION CO NO SIGN OF VENOUS DISEASE C1 TELENGIECTASIA AND SPIDER VEINS C2 VARICOSE VEINS C3 EDEMA DUE TO VENOUS DISEASE C4 SKIN CHANGES; LIPODERMATOSCLEROSIS C5 HEALED ULCERS C6 ACTIVE ULCERS

DUPLEX SCANNING 84% SENSITIVITY 88% SPECIVICITY DIRECT DETECTION OF VALVULAR REFLUX. VISUALIZATION OF VALVE LEAFLET MOTION QUANTIFY DEGREE OF INCOMPETENCE

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

TREATMENT OPTIONS COMPRESSION THERAPY PHARMACOTHERAPY SCLEROTHERAPY SURGICAL TREATMENT SEPS (Subfascial Endoscopic Perforator Surgery) MIT ( Minimally invasive therapy)

Change in practice

COMPRESSION THERAPY ELASTIC COMPRESSION - Bandage - Stockings – Class II PASTE GAUZE (UNNA) BOOT CIRC AID ORTHOSIS INTERMITTENT PNEUMATIC COMPRESSION

PHARMACOLOGIC THERAPY DIURETICS – limited use ZINC FIBRINOLYTIC AGENTS STANOZOLOL – Androgenic steroid OXYPENTIPHYLLINE – Cytokine Antagonist PHLEBOTROPHIC AGENTS HYDROXY-RUTOSIDES CALCIUM DOBESILATE TROXERUTIN

SCLEROTHERAPY THE LOWEST APPROPRIATE CONCENTRATION AND VOLUME OF SOLUTION AT THE SLOWEST RATE AND LOWEST PRESSURE CAN MINIMISE COMPLICATIONS

SCLEROSANTS DETERGENT SOLUTIONS OSMOTIC SOLUTIONS CHEMICAL IRRITANTS SODIUM TETRADECYL SULFATE POLIDACANOL SODIUM MORRHUATE ETHANOLAMINE OLEATE OSMOTIC SOLUTIONS HYPERTONIC SALINE HYPERTONIC SALINE AND DEXTROSE SODIUM SALICYLATE CHEMICAL IRRITANTS POLYIODINATED IODINE CHROMATED GYLCERINE

MIT RFA EVLA Steam Clarivein

Procedure

Procedure

Endovenous Laser Ablation

RFA

Steam Therapy

Clarivein

Practice in RMS 34 legs in 32 patients 19 RFA 6 EVLA 3 Steam Ablation 6 Clarivein

Results 33 complete occlusion, 1 partial occlusion All day case 33 under local anesthesia 1 spinal anesthesia No DVT’s 1 case of severe thrombophlibitis, resolved after 2 weeks

Take Home Message 1) Traditional surgery is over • Endovenous techniques: at least as much efficient than stripping • Endovenous techniques: less side effects and (interactive) 2) Surgery should change • New strategy of treatment: more targeted and more tailored • New mini-invasive technical approach: TLA, microphlebectomy, ambulation 3) “New surgery” takes advantages from this evolution Efficiency / durability / selectivity / safety Very limited side effects 4) “Newsurgery”willtakemarketshares From the endovenous techniques: saphenous sparing From the foam +++: better results, better control The MEET 2014 from 08/06/2014 to 10/06/2014 in Nice, France is COMPLIANT with the Eucomed Code of Ethical TAKE HOME MESSAGE

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