Insuffisance veineuse superficielle
Olivier Pichot, Grenoble, France
Maladie veineuse superficielle
Classification Clinique CEAP
C0 Aucun signe visible ou palpable de maladie veineuse C1 Télangectasies ou v. réticulaires C2 V. variqueuse C3 Oedème C4 Troubles trophiques
C4 a Pigmentation ou eczema C4 b Lipodermatosclérose ou atrophie blanche
C5 Ulcère cicatrisé C6 Ulcère ouvert s Symptomatique (douleur, oppression, lourdeur, …) a Asymptomatique
Venous Clinical Severity Score
Anatomie veineuse
Terminologie
Terminologie
Varicose Veins Characterization Guidelines 2.3.0 of the American Venous Forum on duplex ultrasound
scanning of chronic venous obstruction and valvular incompetence In P Gloviczki,ed.Handbook of venous disorders Third Edition Hodder Arnold 2009: 142-55
Grade of
recommendation:
Grade of
evidence:
2.3.1 Duplex scanning is recommended as the first
diagnostic test for all patients with suspected chronic
venous obliteration or valvular incompetence. The test
is safe non invasive, cost effective, and reliable
1 A
2.3.2 The four components that should be included in
duplex scanning examinations for chronic venous
disease are visualization, compressibility, venous
flow, and augmentation.
1 A
2.3.3 Duplex scanning is suggested to distinguish acute
from chronic venous occlusion
2 B
2.3.4 Reflux can be elicited in two ways: increased intra
abdominal pressure using Valsalva manoeuver or
manual or cuff compression and release of the limb
distal to the point of examination.
2 B
2.3.4 We recommend that the cut-off value for abnormally
reversed venous flow (reflux) is 500 ms.
1 B
Varicose Veins Characterization Duplex Ultrasound Investigation of the Veins in Chronic Venous Disease of the
Lower Limbs – UIP Consensus Document. Part I . Basic Principles P. Coleridge-Smith, N. Labropoulos, H.Partsch, K. Myers, A Nicolaides, A. Cavezzi. Eur J Vasc Endovasc Surg 31, 83-92 (2006)
Aim of the DU examination:
1) Which saphenous junctions are incompetent, their location and diameters. 1) The extent of reflux in saphenous veins of the tighs and legs and their
diameters. The number, location, diameter and function of incompetent perforating veins.
1) Other relevant veins that show reflux. 1) The source of filling of all superficial varices if not from the veins already
described. 1) Veins that are hypoplastic, atretic, absent or have to be removed.
2) The state of deep venous system including competence of valves and
evidence of previous venous thrombosis.
Indications for Duplex Scanning Primary venous
insufficiency of the GSV & SSV
Venous insufficiency of non saphenous veins
Secondary venous insufficiency
Post treatment evaluation
Prevait
Venous malformations
Diagnostic du reflux
Mode B Mode Couleur
Mode Energie 3D
Traitements des varices en 2015
Sclérothérapie
liquide
Chirurgie
Conventionnelle
ASVAL / CHIVA
Echosclérose à la mousse
Ttt endoveineux:
- Thermiques - RF
- LEV
- Vapeur
- Physico-chimiques - Clarivein
- Sclerolux
- Colle biologique - Sapheon
Traitement médical:
- Hygiène de vie
- Compression
- Phléboactifs
Stripping sans crossectomie
Traitement “A la carte”
Pichot O, De Maeseneer M. Treatment of Varicose Veins: Does Each Technique Have a
Formal Indication? Perspect Vasc Surg Endovasc Ther. 2012 Jan 11
Patient expectations and preferences
The treatment of varicose veins: an investigation of patient preferences and
expectations Shepherd AC. Phlebology 2010;25:54-65
Aims of DU Investigation Aims:
Complement clinical examination
Anatomical and hemodynamic analyze of the lesions
Define the treatment strategy
Contribute to treatment realization
Approach of duplex ultrasound for LL SVI management:
i. Analyze, clearly understand, and precisely describe the SVI
ii. Contribute to define the best way to manage the SVI, using medical or operative treatment
iii. Determine the most suitable operative treatment and define his technical modalities
Level 3 DU Methodology Exhaustive examination:
SFJ & SPJ (if present) • Precise hemodynamic analysis of terminal & preterminal valve • Groin varicose network
Trunks: GSV, SSV, AASV, Giacomini vein, … Tributaries varicose veins and non saphenous varicose veins Perforating veins:
• Anatomical description • Hemodynamic analysis (re-entry, refluxing, bi directional)
Pelvic veins: • Escape points • Gluteal, pudendal, sciatic veins
Measurement: Diameter : SV, perforating veins, … Depth: SV Height: SPJ
Superficial Veins Mapping
Treatments options
Saphenous veins
Conventional surgery
Saphenous vein trunk ablation:
• RF, EVL, Steam
• UGFS
• Other: physico-chemical, glue, isolated stripping
With or without treatment of tributaries • Phlebectomies
• Foam sclerotherapy
ASVAL / CHIVA
Other veins
Tributaries Phlebectomies
(UG) Foam sclerotherapy
EVF, Steam, RF
Perforating veins Surgical ligation
SEPS
EVL, RF, steam
UGFS
Conventional Surgery Pros: - Large and/or superficial veins - Effective even in case of thrombophlebitis Cons: - Tortuous, thin veins - (General anesthesia) - Patient discomfort - Complications - Varicose veins recurrence
Thermal Ablation Pro: - Ambulatory procedure - Few patient discomfort - Precision of treatment - Efficiency
Cons: - Tortuous, thin, superficial veins
Specificities: - RF: ClosureFast /RFITT / FCare - EVL: Wave length / Type of fiber - Steam
ASVAL Pro: - Conservation of the SV - Ambulatory procedure - Few patient discomfort - Efficiency (C2)
Cons: - Limited efficiency
- Reflux down to the ankle - Nb of treated areas > 7
Midterm results of the surgical treatment ofvarices by phlebectomy with conservation of a
refluxing saphenous vein Pittaluga P, Chastanet S, Rea B, Barbe R. J Vasc Surg 2009
UG Foam Sclerotherapy Pros: - Tortuous, thin veins - In office procedure - Few patient discomfort - Cheap Cons: - Contra-indications & side effect - Thrombophlebitis & pigmentation - Diffusion of the foam
Reflux Extension
Type 1: 36.7%
Re-entry perforator
Saphenous vein
Deep vein
Type 2: 7.2% 0.7% 0.04% 2.3% 4.2%
Type 5: 5.9%
Re
Type 3: 13.3%
13.1% 0.2%
Type 4: 36.9%
29.9% 7.0%
Pittaluga P et al. Classification of saphenous reflux: implication for treatment. Phlebology 2008
Catheterization
SFJ Reflux
Terminal Valve Insufficiency Preterminal Valve Insufficiency
GVS Trunk Valve Insufficiency
Saphenous Compartment
Mesure des diamètres
Nerves
UGFS 1944: ORBACH EJ. Sclerotherapy of varicose veins : utilization of an
intravenous air block. Am.J.Surg. 1944 ; 66 : 362-66. 1997: SCHADECK M. Résultats à long terme de la sclérothérapie des
saphènes internes. Phlébologie 1997 ; 50 : 257-262. 1997: MONFREUX A. Traitement sclérosant des troncs saphéniens et leurs
collatérales de gros calibre par la méthode MUS.Phlébologie 1997 ; 50 : 351-53.
1997: CABRERA J. Elargissement des limites de la sclérothérapie : nouveaux produits sclérosants. Phlébologie 1997, 50 : 181-8.
2000: TESSARI L. Nouvelle technique d’obtention de la scléro-mousse. Phlébologie 2000 ; 53, 1 : 129.
2003: HAMEL DESNOS C. Sclérosant Laromacrogol 400 liquide versus mousse : étude prospective randomisée double aveugle Dermatol Surg 2003 ;30:718-22
2006: BREU X. 2eme european consensus meeting on foam sclerotherapy, Tegernsee Germany Vasa vol37 S71
2008: GACHET G, SPINI L. Référentiel sur le traitement endovasculaire des varices par injections échoguidées de mousses fibrosantes :le consensus d’experts de Grenoble. Phlébologie 2008;61(2):196-20
2013: RABE et al. European guidelines for sclerotherapy in chronic venous disorders Phlebology 2013
Interest of using foam
Non miscibility: Blood is embossed Better contact between sclerosing agent and vein wall
Adherence: Sticking of the bubbles on the vein wall
Cohesion: Avoid any risk of air embolization
Interest of echoguidance
Faisability:
Access to all the veins visible with ultrasound
Safety:
Accuracy of the puncture
Avoid arterial injection risk
Efficiency evaluation
Vein feeding
Spasm
Sclerotherapy is suitable for all the varicose veins
Incompetent saphenous vein 1A Tributary vv 1A Incompetent perforators 1B Reticular vv 1A Telangiectasia 1A Residual et recurrent vv (PREVAIT) 1B VV of pelvic origin 1B VV in proximity of a leg ulcer 1B Venous malformation 1B
Rabe et al. European guidelines for sclerotherapy in chronic venous disorders Phlebology 2013
SV trunks
Tributaries
Reticular varicose veins
Telangiectasia
Lymph node veins
UGFS is not suitable for all the patients
Absolute contraindications:
Allergy to the sclerosant Acute DVP and/or PE Long- lasting immobility Cutaneous infection Known symptomatic patent foramen ovale
Relative contraindication:
Pregnancy or breast feeding Severe peripheral arterial disease Poor general health Strong predisposition to allergies High TE risk (history of TED, Thrombophylia) Acute superficial venous thrombosis Prior UGFS induced neurological disturbance
Rabe et al. European guidelines for sclerotherapy in chronic venous disorders Phlebology 2013
UGFS efficiency
Systematic review of foam sclerotherapy for varicose veins. Jia X. et al British Journal of
Surgery 2007; 94: 925–936
Rabe et al. European guidelines for sclerotherapy in chronic venous disorders Phlebology 2013
Complications and side effects
Before UGFS
Patient information Alternative methods Details of the procedure Complications and side effects Efficiency
Clinical examination History taking Motive of consultation
DU examination IVS diagnosis Treatment planning
Rabe et al. European guidelines for sclerotherapy in chronic venous disorders Phlebology 2013
Cosmetic results
UGFS procedure
① Preoperative duplex examination Analysis of the vv to be treated Choice of the puncture site
• Incompetent saphenous junction and trunks • Other cases
② Visualisation of the vein to be accessed Longitudinal Transverse
③ Tip of the needle positioned in the center of the lumen ④ Venous blood backflow ⑤ Careful injection with continuous ultrasound guidance ⑥ Distribution of foam and venous spasm occurrence
assessment
Rabe et al. European guidelines for sclerotherapy in chronic venous disorders Phlebology 2013
Choice of the puncture site
Puncture feasibility
Intra-fascial varicose vein
Ideally: large, rectilinear, not too deep
Can be challenging (technical skill)
Choice of the puncture site
Safety
Away from arteries
Small saphenous vein Small saphenous vein
Choice of the puncture site
Safety
Away from arteries
Perforating vein
Choice of the puncture site
Safety
Away from the deep venous system
Efficiency
Manage diffusion of the foam into all the venous network to be treated
With preservation of the veins not to be treated (in a first step)
Determination of the optimal patient positioning
Confort of the patient (and practitioner)
Optimal vein distention
Volume of foam
Maximal (efficient) volume :
V (ml) = S (cm2) x L (cm)
Spasm
European recommendations
2nd European Consensus Meeting on Foam Sclerotherapy 2006, Tegernsee, Germany. Breu
F.X. Guggenbilchler S., Wollman J.C. Vasa vol 37 S/71 February 2008
Concentration of sclerosant
According to the type of vein to be treated (with polidocanol)
2nd European Consensus Meeting on Foam Sclerotherapy 2006, Tegernsee, Germany. Breu
F.X. Guggenbilchler S., Wollman J.C. Vasa vol 37 S/71 February 2008
Concentration of sclerosant
According to the diameter of vein to be treated (with polidocanol)
2nd European Consensus Meeting on Foam Sclerotherapy 2006, Tegernsee, Germany. Breu
F.X. Guggenbilchler S., Wollman J.C. Vasa vol 37 S/71 February 2008
Concentration of sclerosant
According to the type of vein to be treated
Rabe et al. European guidelines for sclerotherapy in chronic venous disorders Phlebology 2013
Foam
3 or 2 ways connector
1 + 4 volumes
Air
Injection less than 1 mn after creation
Volume < 10 ml
Matériel
Elaboration de la mousse
Ultrasound guided puncture
SSV UGFS
SSV: Spasm
SSV: Before, during and after
Specific indications for UGFS: (1) recurrence
Recurrent varicose veins and catheterization possibilities
Theivacumar N et al. Endovenous Laser Ablation (EVLA) to Treat Recurrent Varicose Veins. EJVES 2011
Specific indications for UGFS: (2) recanalization
After thermal ablation
After UGFS
c) Superficial veins insufficiency
C4
C5
C6
UGFS treatment of venous ulcers 130 patients (132 limbs) CEAP C5: 49 – C6: 83
Pang K et al. Healing and Recurrence Rates Following Ultrasound-guided Foam Sclerotherapy of Superficial Venous Reflux in Patients with Chronic Venous Ulceration EJVES 2010
We note (anecdotally) at this stage) that perforators in the vicinity of the ulcer are often occluded following UGFS.
Combined minimally invasive treatment of venous ulcers
86 patients with 95 ulcers – Retrospective study comparing: compression versus compression + ablation (RF / UGFS)
Alden P Chronic Venous Ulcer: Minimally Invasive Treatment of Superficial Axial and Perforator Vein Reflux Speeds Healing and Reduces Recurrence. Ann Vasc Surg 2013
Alden P Chronic Venous Ulcer: Minimally Invasive Treatment of Superficial Axial and Perforator Vein Reflux Speeds Healing and Reduces Recurrence. Ann Vasc Surg 2013
Vein diameter
Myers Ka et al. Outcome of Ultrasound-guided Sclerotherapy for Varicose Veins: Medium-term Results Assessed by Ultrasound Surveillance. EJVES 2007
UGFS versus Surgery
Shadid N et al. Randomized clinical trial of ultrasound-guided foam sclerotherapy versus surgery for the incompetent great saphenous vein. Br J Surg. 2012
UGFS versus Surgery
Shadid N et al. Randomized clinical trial of ultrasound-guided foam sclerotherapy versus surgery for the incompetent great saphenous vein. Br J Surg. 2012
UGFS versus others varicose veins treatment modalities
Rasmussen LH et al. Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Br J Surg. 2011
Recommandations
NICE guidelines [CG168] Published date: July 2013
Management of Chronic Venous Disease Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS) 2015
Recommandations
Management of Chronic Venous Disease Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS) 2015
81
VNUS® ClosurePlus™ System - 1998
Thermal ablation
82
• Intima destruction
• Shrinkage and and thickening of collagen fibers of media and adventitia tunica
• Necrosis of smooth muscle
Treatment objective
83
SFJ SEP
84
ClosureFAST - 2006
85
Segmental Ablation
7 cm length treated all at once
Energy delivery does not vary by pullback speed
86
Treatment Parameters
Device (set) temperature: 120° C
Vein wall contact temperature: 105 - 115° C
Energy delivery during 20 sec
40 Watts max power
Temperature controlled energy delivery
Average energy delivery is approximately 68 J/cm per treatment
87
Treatement procedure
Patient selection
Phlebectomies?
89
Procedure ultrasound guidance
① Percutaneous vein access
② Catheterization
③ Catheter positionning
④ Tumescent anesthesia
⑤ Termal ablation
⑥ Immediate post operative efficiency assessment
90
91
Percutaneous vein access
92
Catheterization
93
Catheter positionning
2 cm
94
Catheter positionning
95
Tumescent anesthesia
96
RF thermal ablation
97
Immediate post operative efficiency
assessment (RF)
GSV termination GSV trunk
98
Ex vivo GSV RF ablation
294 (99.7%) of 295 treated GSVs were occluded at 3 days
The single “immediate failure” GSV was found occluded at 3 months follow-up and therefore regarded as a delayed occlusion
Immediate Success Rate
100
Pain
70.1% of limbs had no pain any time after
treatment along the course of the treated
GSV
Patient return to normal activities average:
1.6 ± 3.7 days
70.1%
101
Obliteration “Not any flow in treated segments below 3 cm from SFJ”
Standard Error below 5% at all times
91.9% @ 5Y
Reflux Free “No reflux over 0.5 sec in any treated segment”
Standard Error below 1% at all times
94.9% @ 5Y
VCSS
Means and Std Deviations
Time Course of CEAP C
Means and Std Deviations
EVL vs RF: RECOVERY Trial Maximum pain score (0-10) since previous FU
106
Jose I. Almeida et al. Radiofrequency Endovenous ClosureFAST versus Laser Ablation for the Treatment of Great Saphenous Reflux:
A Multicenter, Single-blinded, Randomized Study (RECOVERY Study) J Vasc Interv Radiol 2009
EVL vs RF: RECOVERY Trial Presence of any ecchymosis (bruising)
107
RF versus others varicose veins treatment modalities
108
Rasmussen LH et al. Randomized clinical trial comparing endovenous laser ablation,
radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous
varicose veins. Br J Surg. 2011
Less Invasive Treatments
Clarivein
Less Invasive Treatments
Laser Assisted Foam Sclerotherapy (LAFOS)
Less Invasive Treatments
Cyanoacrylate glue
The New Approach THERMAL ablation NON THERMAL ablation
RF EVL Steam UGFS Surgery Glue Moca Lafos
No sclerosing agent ✔ ✔ ✔ ✗ ✔ ✔ ✗ ✗
No tum. anesthesia ✗ ✗ ✗ ✔ ✗ ✔ ✔ ✔
Large v. applicability ✔ ✔ (✔) (✔) ✔ ? ? ?
Tortuous veins ✗ ✗ ✗ ✔ ✗ ✗ ✗ ✗
Nerve injury risk ✗ ✗ ✗ ✔ ✗ ✔ ✔ ✔
TED risk ✔ ✔ ✔ ✗ ✗ (✔) (✔) ?
Return norm. activity ✔ ✔ ✔ ✔ ✗ ✔ ✔ ✔
Efficiency ✔ ✔ (✔) (✔) ✔ ✔ ✔ ?
Long term FU available ✔ ✔ (✔) ✔ ✔ ✗ ✗ ✗
In the everyday practice…
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