Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery Faculty of Medicine, University of Thessalia, Greece Chairman, Dept. of Vascular Surgery, University Hospital of Larissa Larissa, Greece

GSV Before Treatment Image courtesy of Olivier Pichot, MD, CHU de Grenoble, France.

GSV After Treatment Image courtesy of Olivier Pichot, MD, CHU de Grenoble, France.

CEAP Clinical Classification 0: Asymptomatic; no visible or palpablesigns 1: Spider veins, reticular veins, telangiectasias 2: Varicose veins 3: Edema 4a: Skin changes with hyperpigmentation and eczema 4b: Skin changes with lipodermatosclerosis and atrophie blanche 5: Healed ulcer 6: Active ulcer 4

CEAP Clinical Classifications Clinical Etiology Anatomy Pathophysiology Varicose Veins CEAP 2 Swelling CEAP 3 Skin Changes CEAP 4 Skin Ulcer CEAP 6

Is pre-op duplex assessment important for varicose vein surgery?

Ultrasonic assessment

Explanation Information provided by DS will have significant impact on the selection of appropriate treatment Failure to identify all sources of venous filling is likely to result in early recurrence

Indications for Duplex Scan Recommendation: both limbs should be studied Primary uncomplicated GSV VVs Debated whether all pts – if not 30% of important connections between deep and superficial veins will be missed Primary uncomplicated LSV VVs Essential Non-saphenous & Recurrent VVs Essential CVD with complications Essential Surveillance after treatment the only way to obtain level I evidence as to outcome in the future Venous malformations anatomical information about the extent of the malformation and its relationship to other vessels may be used to guide treatment by sclerotherapy

Position of the patient Greater saphenous

Position of the patient Lesser saphenous

Anatomy of superficial veins of the lower limb

Important anatomical details

Anatomical structures on B-mode

Fascial layers creating “saphenous eye” GSV Bound anteriorly by superficial fascia & posteriorly by deep fascia Often called “saphenous eye” Fascial layers creating “saphenous eye” Images courtesy of Olivier Pichot, MD

GSV Variables Tortuosity Side branches Images courtesy of Olivier Pichot, MD

GSV Variables Aneurysmal segments

SFJ Tributary Veins SCI: Superficial Circumflex Iliac SE: Superficial Epigastric SEP: Superficial External Pudendal AASV: Anterior Accessory Saphenous PASV: Posterior Accessory Saphenous Image adapted from: Chandler JG et al. Defining the role of extended saphenofemoral junction ligation: A prospective comparative study. JVS 2000;32:941-53

Initial Catheter Tip Positioning Position catheter tip approximately 2.0 cm distal to SFJ Confirm with measurement calipers Distance does not need to be precise at this time because catheter position may shift during tumescent fluid infiltration

Final Tip Position Verification Recommendation is 2.0 cm distal to SFJ Confirm tip position with ultrasound: In both transverse and longitudinal imaging planes Use measurement calipers to confirm distance to SFJ Important step to avoid misaligning catheter relative to deep venous system Image courtesy of Pranay Ramdev, MD The final tip position of the catheter should be confirmed with duplex ultrasound to ensure the device is not in the deep venous system: in transverse view from proximal thigh towards SFJ; Note transition where echogenic dot of catheter and corresponding vertical shadow disappear from image In longitudinal or oblique view, gently manipulate catheter to see tip move in and out of image The correct catheter tip position is just distal to the ostium of the superficial epigastric vein, or 1-2 centimeters from the saphenofemoral junction, if the SEV is not identified. A longitudinal or oblique view of the common femoral vein, saphenofemoral junction, and great saphenous vein provides the most accurate visualization of the tip placement. Because there are no expanding electrodes as a landmark it is important to perform a secondary verification of tip position by scanning from proximal thigh to SFJ in transverse to detect the true distal end of the catheter and see the transition where the catheter disappears from the image. Once proper catheter tip placement is confirmed, tumescent fluid is injected around the SFJ.

Anatomical structures on colour facility

Small Saphenous Vein (SSV) Courses from lateral ankle up posterior calf Terminates in popliteal fossa at Saphenopopliteal Junction (SPJ) Variable confluence with Popliteal Vein (PV) Proximal portion lies between superficial & deep fascial layers SPJ Pop V SSV Figure adapted from: Weiss RA, et al eds. Vein diagnosis and treatment: A comprehensive approach. McGraw-Hill Companies, Inc.; 2001.

Anatomical structures on colour facility

Detection of reflux on colour facility

Detection of reflux on colour facility

Detection of reflux on colour facility

Detection of reflux on colour facility Perforating vein If reflux is present measure the diametre but this cannot distinguish competent from incompetent Duration of reflux

Detection of reflux on Doppler Reflux is present when retrograde flow lasts for at least 1 sec

Patient selection for Endovenous Alation Identification of all refluxing venous segments and their ablation is the key to minimise recurrence Diametre of central GSV > 15 mm may be associated with thrombus extension to CFV Uncorrectable coagulopathy Liver dysfunction limiting local anaesthetic use Immobility Pregnancy Breastfeeding

Contraindication Thrombus in the vein segment to be treated

Choosing the Closure Candidate Preoperative ultrasound evaluation Reflux > 0.5 seconds in superficial venous system Assess GSV, noting: Vein depth and maximum diameter Presence of tortuous or aneurysmal segments Other significant anatomy Duplicate systems Large side branches Incompetent perforators or tributaries

If vein lies superficially, close to skin the ablation may cause burn Vein depth from the skin: Why is so important? The aim of ablation procedures is to damage the inner vein wall without causing a full-thickness burn, which could lead to perforation of the vein resulting in bruising or haematoma formation If vein lies superficially, close to skin the ablation may cause burn

Pre-op Ultrasound Assessment Map and mark Maximum diameter Tortuous segments Aneurysmal segments Areas where vein is very close to skin Large branches or perforators Potential access sites

Infiltration Technique Do not leave any vein segments unprotected Re-scan to ensure: >10 mm distance between skin surface and vein wall Circumferential black “halo” appearance in fascial compartment Perivenous vs. subcutaneous infiltration Image courtesy of Carolyn Menendez, MD During endovenous ablation procedure, if patient experiences discomfort, energy delivery can be stopped and additional tumescent fluid can be administered – as long as within patient’s dosage limits – and the procedure resumed If dosage limit has been met, plain injectable saline may be used in place of tumescent anesthesia

Vein Mapping Make indentions in skin using a straw Remove US gel from leg Connect marks on leg with marker to identify pathway of vein and important anatomy Image courtesy of Nick Morrison, MD

Pre-op Descending Venography

Selective descending ovarian and hypogastric venogram Significant ovarian vein reflux but No hypogastric vein reflux was detected

Hypogastric vein reflux Ovarian vein reflux

Descending Ovarian Venogram 4 weeks after embolisation

Hypogastric vein embolisation

CT venography

Chronic Venous Obstruction

DP=8 mmHg DP=22 mmHg DP=2 mmHg

IVC filter placement Indications DVT and covtraindication for anticoagulation Reccurent PE being on adequate anticoagulation Pre-procedural evaluation MR or CT venography is required for IVC and iliac vein patency and IVC diametre measurement

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