Slide 1

Harry Ma MD, PhD Assistant Professor of Surgery University of Oklahoma Tulsa, Oklahoma Department of Surgery Slide 2 Disclosures None Slide 3 Outline and Objectives Defining chronic venous disease Clinical manifestations Diagnostic evaluation Treatment Non-operative Operative Slide 4 Spectrum of Disease Spider veins (telangiectases) Reticular veins Varicose veins Edema Chronic skin changes Ulcers Slide 5 Impact of CVD Most common form of vascular disorder Chronic Venous Disease: 25 million people in US Health care cost: $1 to 3 Billion dollars annually Indirect cost: ~2 million work days lost annually Slide 6 Definitions 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. Slide 7 Definitions of Skin Changes Lipodermatosclerosis: localized chronic inflammation and fibrosis of the skin and subcutaneous tissue Atrophie blanche: localized, often circular whitis and atrophic skin areas surrounded by dilated capillary spots and hyperpigmentation Venous Ulcer: full thickness skin defect Slide 8 CEAP classification Clinical Etiology Anatomy Pathophysiology Slide 9 Clinical Classification C0: no visible or palpable signs of venous disease. C1: telangiectasies or reticular veins. C2: varicose veins. C3: edema. C4a: pigmentation and eczema. C4b: lipodermatosclerosis and atrophie blanche. C5: healed venous ulcer. C6: active venous ulcer. Slide 10 Etiologic Classification Ec: congenital ( Compression Stockings CLASSPRESSURESTRENGTHINDICATIONCEAP OTC< 15mmHGMinimalMinimal symptoms0,1 I15-20mmHgMildMinor varicosities, minor edema1,2,3 II20-30mmHgModerate Moderate varicosities, phlebitis, moderate edema, post-op ablation 3,4 III30-40mmHgFirmSevere varicosities, active or history of ulcers, DVT4,5,6 IV>40mmHgExtra FirmLymphedemaN/A Slide 23 Compression Bandages Elastic In-elastic Types: ACE wrap Easier to use Higher pressures at rest Can cause pressure ulcers Minimal increase in pressure when ambulatory Types: Profore multi-layer wraps High stiffness Exert about 40mmHg Can lose pressure quickly due to limb volume reduction Difficult to apply Better for ambulatory patients Slide 24 Benefits of Compression Increased ulcer healing 30-40mmHg compression resulted in 93% ulcer healing rate by 6 months Prevention of recurrence with compliance: 29% recurrence at 5 years Disadvantages: Compliance Slide 25 Operative Management Ligation and Stripping Ablative therapy Radiofrequency Laser Sclerotherapy Slide 26 Ligation and Stripping Traditional surgical approach Reduced recurrence rates compared to high ligation alone Slide 27 Ablation Laser Use a bare tipped optical fiber which applies laser light energy to the vein. Therapy based on photothermolysis (light induced thermal damage). Laser light heats the target tissue inducing thermal injury Wavelength of light is chosen based on the target structure's chromophore Radiofrequency A high frequency alternating current resulting in energy that heats the adjacent vein walls to the probe which alters the protein structure of the vein effecting its closure Slide 28 Complications of ablation Nerve injury Which is Better? Equivalent therapy Similar outcomes Success rates >95% for both (N=159) Improvement in QoL surveys and VVQ surveys Cochrane review in 2014 13 randomized trials included 3081 patients total Complication rates equivalent Efficacy: equivalent for laser, RFA, foam sclerotherapy and ligation and stripping Slide 30 Sclerosing Agents Hypertonic Saline Chromated glycerin Nonchromated glycerin Monoethanolamine oleate Sotradecol (STS) Polidocanol Foam Slide 31 Mechanism of action and use Endothelial damage Thrombosis Resultant sclerosis and closure of the vein For telangiectasias Reticular veins Perforator veins More recently incompetent GSV Slide 32 Ultrasound Guided Foam Sclerotherapy First reported in 1995 Mixed with air or CO2 Bubble size of 100 m or less Ration of sclerosant to air or CO2 is usually 1:4 Slide 33 Limitations and complications Large veins Phlebitis 3-8% Embolus (CVA) Visual disturbance DVT Failure or recurrence Anaphylaxis Slide 34 Short term outcomes 1 year follow-up equivalent QoL improvement 72% success rate (vs 89% for EVLA) Two year follow-up in patients with ulcers 85% healing rate Slide 35 Long term outcomes 5-8 year follow-up of 285 patients 89% had improvement in QoL survey and AVSS 15% required repeat treatment Slide 36 References Andr P, Hartwell D, Hrachovinov I, Saffaripour S, Wagner DD. Pro-coagulant state resulting from high levels of soluble P-selectin in blood. Proc Natl Acad Sci U S A 2000;97:13835-40. PMID: 11095738Beebe-Dimmer JL, Pfeifer JR, Engle JS, Schottenfeld D. The Epidemiology of Chronic Venous Insufficiency and Varicose Veins. Ann Epidemiol 2005;15:175-84. PMID: 15723761 Bradbury A, Evans C, Allan P, Lee A, Ruckley V, Fowkes FG. What are the symptoms of varicose veins? Edinburgh vein study cross sectional population survey. BMJ 1999;318:353-6. PMID: 9933194. Bradbury A, Evans CJ, Allan P, Lee AJ, Ruckley CV, Fowkes FG. The relationship between lower limb symptoms and superficial and deep venous reflux on duplex ultrasonography: The Edinburgh Vein Study. J Vasc Surg 2000;32:921-31. PMID: 11054224 Browse NL. The diagnosis and management of primary lymphedema. J Vasc Surg 1986;3:181-4. PMID: 3510325 Burnand KG, Whimster I, Naidoo A, Browse NL. Pericapillary fibrin in the ulcer-bearing skin of the leg: the cause of lipodermatosclerosis and venous ulceration. BMJ (Clin Res Ed) 1982;16;285:1071-2. PMID: 6812751 Cardinal M, Eisenbud DE, Phillips T, Harding K. Early healing rates and wound area measurements are reliable predictors of later complete wound closure. Wound Repair Regen 2008;16:19-22. PMID: 18211575 Slide 37 References Carpentier PH, Maricq HR, Biro C, Ponot-Makinen CO, Franco A. Prevalence, risk factors, and clinical patterns of chronic venous disorders of lower limbs: a population-based study in France. J Vasc Surg 2004;40:650-9. PMID: 15472591 Carpentier PH, Poulain C, Fabry R, Chleir F, Guias B, Bettarel-Binon C; Venous Working Group of the Socit Franaise de Mdecine Vasculaire. Ascribing leg symptoms to chronic venous disorders: the construction of a diagnostic score. J Vasc Surg 2007;46:991-6. PMID: 17980285 Christopoulos D, Nicolaides AN, Szendro G. Venous reflux: Quantitation and correlation with the clinical severity of chronic venous disease. Br J Surg 1988;75:352-6. PMID: 3359149 Comerota AJ, The ATTRACT Trial: Rationale for early intervention for iliofemoral DVT. Perspect Vasc Surg Endovas Ther 2009; 21(4): 221-4. Epub 2010 Jan 3. PMID: 20047905 Comerota AJ, Throm RC, Mathias SD, Haughton S, Mewissen M. Catheter-directed thrombolysis for iliofemoral deep venous thrombosis improves health-related quality of life. J Vasc Surg 2000;32:130-7. PMID: 10876214 Cornu-Thenard A, Boivin P, Baud JM, De Vincenzi I, Carpentier PH. Importance of the familial factor in varicose disease. Clinical study of 134 families. J Dermatol Surg Oncol 1994;20:318-26. PMID: 8176043 Corriere MA, Suave KJ, Ayerdi J, Craven BL, Stafford JM, Geary RL, Edwards MS: Vena cava filters and inferior vena cava thrombosis. J Vasc Surg 2007;45:789-94. PMID: 17398389