1. Complicated Superficial Venous Disease Ron Bush, MD, FACS Midwest Vein & Laser Center Dayton, OH

2. Disclosures Dornier, VeinGogh, VeinExperts.org, BushVenousLectures.com

3. My Experience In my 17 years of a purely venous practice, the most complicated aspect of superficial disease are the aneurysms of the GSV, AAGSV, & SSV Most are benign in presentation Potentially lethal Inappropriate treatment may make a benign condition be malignant

4. Definition of Aneurysm Conflicting Pascarella, 2005, define an aneurysm as 1.5x contiguous vein diameter (Gabrielli, 2012) – 2.0x contiguous diameter or 3x normal vein size Only histologic evaluation can differentiate aneurysm from dilatation But dilatation may mimic same presentation and clinical outcome as an aneurysm

5. Histoslide of Aneurysm

6. High Ligation Aneurysm Photo

7. GSV Aneurysm

8. GSV Aneurysm with Small Neck

9. Type II aneurysm Treated with thermal ablation, stripping, or phelbectomy

10. SSV Aneurysm At SPJ junction, excision is the only option Mimics popliteal aneurysm Distal aneurysm can be excised, ablated, or foam and depends on the size

11. SSV Aneurysm

12. Treatment of GSV Aneurysm Conventional treatment – high ligation But treatment can be individualized depending on anatomic location Post-terminal vs. post-subterminal valve Contradicts Pacarella and Bergan’s report

13. AAGSV Aneurysm

14. This should be classified as a Type V aneurysm, since it is a distinct aneurysm True incidence not known May be associated with GSV aneurysm Treatment depends on diameter of connection to GSV connection- ligation Small connection – thermal ablation of distal trunk or foam

15. Etiology Long standing venous hypertension Turbulent flow at valve Increased BMI

16. Final Considerations Consider unloading GSV circuit before definitive treatment (Personal communication – Allesandro Frullini, MD) 4-6 months later, there may be substantial reduction in aneurysm size Treatment can be individualized, but any persistent aneurysmal dilatation post terminal valve including junctional branches should be resected

17. Final Considerations All SSV aneurysms involving SPJ are excised Inappropriate treatment may lead to clot propagation and possible pulmonary embolus

18. References Pascarella L, Al-Tuwaijri, Bergan J, & Mekenas L. Lower extremity superficial venous aneurysms. Ann Vasc Surg 2005;19:69-73.