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

2. Abnormal Veins
Telangiectasias
Reticular veins
Varicose vein

3. 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.

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

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

6. VENOUS SYSTEM OF LOWER LIMBS
SUPERFICIAL VEINS
DEEP VEINS
PERFORATORS

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

9. 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.

10. 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

11. 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.

12. CEAP CLASSIFICATION
CLINICAL
ETIOLOGIC
ANATOMIC
PATHOPHYSIOLOGIC

13. 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

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

15. 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

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

17. Change in practice

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

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

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

21. 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

22. MIT
RFA
EVLA
Steam
Clarivein

23. Procedure

24. Procedure

25. Endovenous Laser Ablation

26. RFA

27. Steam Therapy

28. Clarivein

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

30. 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

31. 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

32. Thank You