Clinical Case nlabrop@yahoo.com Nicos Labropoulos Professor of Surgery and Radiology Director, Vascular Laboratory Division of Vascular Surgery Stony Brook Medicine Stony Brook, New York, USA nlabrop@yahoo.com

Female patient, 57 years old presented with symptomatic varicose veins in the right lower limb. She noticed the varicosities over 30 years ago. Signs and symptoms -Swelling -Burning sensation -Itching -Heaviness The veins are larger and the symptoms are worst at the end of the day. She gets relief with limb elevation. The left lower limb is asymptomatic with spider and reticular veins that do not bother her.

She had 2 children with normal pregnancies and delivery. Her mother had varicose veins and skin discoloration. The right limb developed symptoms gradually after the second pregnancy. She had SFJ ligation and phlebectomies 12 years ago. The patient remained asymptomatic for a few years but over time her veins became larger. She started developing new symptoms 7 years ago that are far more intense now.

Because of the worsening of her symptoms she went to a vascular specialist. She was given compression stockings but she could not tolerated them well. She felt better with the stockings on however, there was no change in her limb after 3 months. No other pertinent history, surgeries or medications. The arterial exam was normal and she had no mobility problems. Venous ultrasound was ordered

Right groin varicose veins with reflux Cross-sectional view Longitudinal view Multiple varicose veins connect with the SFJ stump and CFV. Very tortuous course with many small channels of flow and larger veins anterior, superior and medial to CFV.

Right groin varicose veins with reflux Reflux after release of thigh compression Reflux during Valsalva When reflux is induced with distal limb compression followed by sudden release the Valsalva maneuver is not needed. However, when the former is negative then the latter is performed.

Lympho-venous networks with reflux Veins within the lymph nodes are tortuous and dilated. They are connected with incompetent tributaries of the GSV and AASV. Other connections may occur through the CFV, FV and tributaries extending from pelvic veins. Uhl JF, Lo Vuolo M, Labropoulos N. Anatomy of the lymph node venous networks of the groin and their investigation by ultrasonography. Phlebology. 2016 Jun;31(5):334-43.

Lympho-venous networks with reflux occur Sclerotherapy In the majority of the cases without previous interventions After groin surgery (SFJ ligation) After endovenous ablation

Lympho-venous networks with reflux occur Sclerotherapy In the majority of the cases without previous interventions After groin surgery (SFJ ligation) After endovenous ablation The refluxing lympho-venous networks are more often seen after SFJ ligation with or without GSV stripping but can also be found without any previous procedure. Uhl JF, Lo Vuolo M, Labropoulos N. Anatomy of the lymph node venous networks of the groin and their investigation by ultrasonography. Phlebology. 2016 Jun;31(5):334-43.

LNVN are characterized by transnodal networks connected to the GSV and/or AAGSV. They exist prior to any treatment and can be found, thin and competent, in any healthy patient. Uhl JF, Lo Vuolo M, Labropoulos N. Anatomy of the lymph node venous networks of the groin and their investigation by ultrasonography. Phlebology. 2016 Jun;31(5):334-43.

Lympho-venous networks with reflux 9.2mm 4.3mm 3.7mm 3.6mm 5.2mm 6.8mm Uhl JF, Lo Vuolo M, Labropoulos N. Anatomy of the lymph node venous networks of the groin and their investigation by ultrasonography. Phlebology. 2016 Jun;31(5):334-43.

What most likely has happened? 1. Development of new varicose veins 2. Residual varicose veins from incomplete treatment 3. Neovascularization due to SFJ ligation 4. Neovascularization, residual and recurrent disease

What most likely has happened? 1. Development of new varicose veins 2. Residual varicose veins from incomplete treatment 3. Neovascularization due to SFJ ligation 4. Neovascularization, residual and recurrent disease van Rij AM, Jones GT, Hill GB, Jiang P. Neovascularization and recurrent varicose veins: more histologic and ultrasound evidence. J Vasc Surg 2004;40:296–302 Perrin MR, Labropoulos N, Leon LR Jr. Presentation of the patient with recurrent varices after surgery (REVAS). J Vasc Surg 2006;43:327–34; De Maeseneer M, Pichot O, Cavezzi A, et al. Duplex ultrasound investigation of the veins of the lower limbs after treatment for varicose veins – UIP consensus document. Eur J Vasc Endovasc Surg 2011;42:89–102

LNVN seem to be venous ‘‘remodeling’’, with dilation and dystrophic changes of normal pre-existing networks, as an adaptive response to surgical approach due to angiogenic factors, and thus could be a consequence rather than a cause of recurrence. When they are found to be dilated and refluxing, surgery of the groin is contraindicated, and echoguided foam sclerotherapy is the method of choice. Perrin MR, Labropoulos N and Leon LR Jr. Presentation of the patient with recurrent varices after surgery (REVAS). J Vasc Surg 2006; 43: 327–334. Pittaluga P, Chastanet S, Locret T, et al. Retrospective evaluation of the need of a redo surgery at the groin for the surgical treatment of varicose vein. J Vasc Surg 2010;51: 1442–1450.

GSV reflux at mid-thigh and below Proximal GSV is normal GSV reflux at mid-thigh and below The GSV diameter at the proximal non-refluxing segment measures 3.6mm while the incompetent segment below has a larger diameter of 6.8mm. The larger the GSV diameter the higher the chance for reflux. However, many patients with normal size or even small diameter GSV may have reflux. Therefore, diameter should not be used to determine reflux. Labropoulos N, Kokkosis AA, Spentzouris G, et al. The distribution and significance of varicosities in the saphenous trunks. J Vasc Surg 2010;51:96-103.

Reflux in lower extremity veins develops 1. Ascending manner 2. Descending manner 3. Through perforator veins 4. Ascending and descending manner

Reflux in lower extremity veins develops 1. Ascending manner 2. Descending manner 3. Through perforator veins 4. Ascending and descending manner Labropoulos N, et al. Where does venous reflux start? J Vasc Surg. 1997 Nov;26(5):736-42. Labropoulos N, et al. Study on the venous rfeflux progression. J Vasc Surg. 2005 Feb;41(2):291-5.

GSV reflux at mid-thigh and below Proximal GSV is normal GSV reflux at mid-thigh and below 9.2mm 3.6mm 6.8mm

Focal GSV eccentric dilatation GSV is enlarged posterior to the valve. The valve is frozen and does not move. Focal dilations are common but varicosities of the saphenous trunk are rare (<5%) 8.9mm Labropoulos N, Kokkosis AA, Spentzouris G, et al. The distribution and significance of varicosities in the saphenous trunks. J Vasc Surg 2010;51:96-103.

aplasia, which is often seen in the thigh and calf segments. GSV is exiting the saphenous canal at the Knee and continues its course as a dilated accessory vein (7.5-8.3mm) that connects with many calf varicose veins. The GSV is not seen from the knee to the lower calf. This is segmental GSV aplasia, which is often seen in the thigh and calf segments. It is easy to confuse the accessory vein with the GSV. The accessory vein in this patient was outside the saphenous canal and run medial to GSV. Cavezzi A, Labropoulos N, Partsch H, et.al. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs--UIP consensus document. Part II. Anatomy. Eur J Vasc Endovasc Surg 2006;31:288-99.

8.3mm GSV Aplasia 7.6mm Cavezzi A, Labropoulos N, Partsch H, et.al. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs--UIP consensus document. Part II. Anatomy. Eur J Vasc Endovasc Surg 2006;31:288-99.

Accessory vein in the calf is 6mm below the skin High velocity reflux with long duration >5s Thermal ablation is performed for veins that are ≥4mm from the skin in order to avoid -skin burns -induration -feeling a palpable cord Labropoulos N, Tiongson J, Pryor L, et al. Definition of venous reflux in lower-extremity veins. J Vasc Surg 2003;38:793–8.

Multiple calf varicosities with prolonged reflux 8.3mm 7.6mm Labropoulos N, Tiongson J, Pryor L, et al. Definition of venous reflux in lower-extremity veins. J Vasc Surg 2003;38:793–8.

SSV has a small diameter. 2.2mm 1.4mm 3.9mm 1.9mm 3.7mm 1.8mm SPJ and thigh extension are dilated and have reflux. Labropoulos N, Giannoukas AD, Delis K, et al. The impact of isolated lesser saphenous vein system incompetence on clinical signs and symptoms of chronic venous disease. J Vasc Surg 2000;32:954-60. Cavezzi A, Labropoulos N, Partsch H, et.al. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs--UIP consensus document. Part II. Anatomy. Eur J Vasc Endovasc Surg 2006;31:288-99.

C1-3S EP AS+P+D PR The small “normal” GSV segment in the upper thigh is usually treated together with the refluxing segment below.

How this patient should be treated? 1. Conservative treatment 2. Groin exploration and stripping 3. EVA, phlebectomies and sclerotherapy 4. Modified stripping and phlebectomies

How this patient should be treated? 1. Conservative treatment 2. Groin exploration and stripping 3. EVA, phlebectomies and sclerotherapy 4. Modified stripping and phlebectomies Gloviczki P, Comerota AJ, Dalsing MC, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 2011;53(5 Suppl):2S-48S Marsden G, Perry M, Kelley K, Davies AH; Guideline Development Group. Diagnosis and management of varicose veins in the legs: summary of NICE guidance. BMJ. 2013;347:f4279.

Treatment plan Follow-up RFA of the GSV and accessory saphenous vein Multiple phlebectomies for the tributaries Ultrasound-guided foam sclerotherapy for the neovascularization Follow-up Phlebectomies of two residual tributaries at 1 month Ultrasound-guided foam sclerotherapy at 1, 8 and 23 months At 36 months she was asymptomatic with a few reticular and spider veins.

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