VENOUS VALVES

1
VENOUS VALVES

2
CEAP Classification

• Clinical
• Etiologic
• Anatomic
• Pathology

3
C.E.A.P. Clinical Classification
4
Spider Veins Class 1
Varicose Veins Class 2
Varicose Veins with Swelling/Skin changesClass 3
4
5
Class 5 6 Healed or Active Ulcers
6
LOCATION OF PERFORATING VEINS
7
Perforating Vein Demonstrated on Ascending
Phlebography
Source Padberg Cardiovasc Surg Vol 7 1
8
Standing Reflux Study
Incompetent Greater Saphenous Vein Incompetent
Vein of Giacomini

• Standing Reflux Exam
• standing
• non-weight bearing
• rapid cuff inflation
• rapid cuff deflation
• time reflux duration

9
APG
AIR PLETHYSMOGRAPHY
10
AIR PLETHYSMOGRAPHY
11
Relationship Between VFI and CSS
CSS
Pain V. Veins Edema Pigmentation Inflammation Indu
ration Active Ulcers Ulcer Diameter
Comparison of Clinical Severity Score (CSS) And
Venous Filling Index
Source Owens JVS Vol32 5
12
Spider Veins And Sclerotherapy
13
Sclerotherapy Used For Spider Veins
Results Are Excellent
Non-Invasive Testing Not Necessary
14
Sclerotherapy Is Successful If Valves Are Intact
15
Sclerotherapy Includes The Reticular Veins
Goldman Bergan
16
Simple Device Which Is Helpful During
Sclerotherapy And Stab Phlebectomy
17
Sotradecol Hypertonic Saline Polidocanol
18
Sotradecol Has Been Repackaged In More Convenient
Dosage Sizes
19
Polidocanol
20
(No Transcript)
21
Polidocanol Foam
22
(No Transcript)
23
(No Transcript)
24
(No Transcript)
25
(No Transcript)
26
Vein Closure
27
EVLT
SAPHENOUS VEIN ABLATION
Radio-Frequency
28
Sterile Leg Prep
Prep the patients leg from toes to groin with
Betadine or comparable sterile scrub solution
29
Ultrasound Guided Vein Access
Needle
Image courtesy of Darcy Kessler, RVT
30
Closure Technique

• Needle entry into GSV under U/S control
• Guide wire passed through needle and up GSV
• Introducer sheath passed over guide wire

31
Tip Positioning
Catheter tip should be about 1.0 cm inferior to
the SFJ
Catheter tip
SFJ
32
Administer Local Anesthesia Consider Power
Injector

• Tumescent anesthesia is infiltrated along vein
  tract with ultrasound guidance
• Do not infiltrate the SFJ area yet as this may
  degrade the imaging quality

33
Administer Local Anesthesia
Tumescent infiltration can move superficial veins
to gt 10mm below skin surface to protect against
thermal injury
34
Confirm Procedure Success
35
Laser Fiber At Conclusion Of The Procedure
More Flexible Laser Fiber Is Needed
36
EVLT Follow-up Data
Min et. al., Aug 2003
37
Pain, Bruising and Short-term Efficacy After
Endovenous Treatment of the Greater
Saphenous Vein The Effect of Operative
Technique And Postoperative Care American
College of Phlebology, 16th Annual
Congress Steven Zimmet MD
38
Change in VFI After Saphenous Vein Ablation
RFA Radiofrequency N 58 EVLT Endovenous
Laser N 31 CEAP Class 3-6
Venous Filling Index
Marston UNC Data
Pre-OP
Post-OP
39
Thrombosis

• One PE discovered 7 days after treatment --
  patient presented with dyspnea
• Patient ankle sprain ? no post-operative
  ambulation
• Very fast pullback (11 cm/min)
• Other clinically-silent thromboses
  resolved with LMWH treatment

40
Removal Of Varicosities
Stab Phlebectomy Trivex Phlebectomy
41
Stab Phlebectomy
42
STAB PHLEBECTOMY
43
STAB PHLEBECTOMY
TIME CONSUMING AND UNSIGHTLY
44
Trivex Ablation
45
The Trivex System
New Percutaneous Method Is Needed
Requires General Anesthesia
46
Light Source Is Deep To Resector
High Pressure Infusion Protects Skin
47
TRIVEX ABLATION
BEFORE
AFTER
48
Trivex Ablation
49
Results Are Excellent
50
Perforating Veins
51
LOCATION OF PERFORATING VEINS
52
Perforating Vein Demonstrated on Ascending
Phlebography
Source Padberg Cardiovasc Surg Vol 7 1
53
SEPS Procedure
Source Padberg Annals Vasc Surg Vol13 3
54
Is Routine Perforator Ligation Necessary ?

• 24 Limbs
• Superficial Incompetence
• Perforator Incompetence
• Normal Deep Venous System

CEAP Classification
Operation Stripping From Groin to Knee Trivex
Ablation of Varicosities
55
PERFORATING VEIN CLASSIFICATION
56
Vein Of Giacomini
57
Vein of Giacomini

• Originally described by the Italian anatomist in
  1873
• Basically an anatomic variant of the lesser
  saphenous that ascends the posterior thigh to
  drain into the greater saphenous
• Remains deep to fascia except where drains into
  GSV
• Flow cephalad except if incompetent
• Drains also into popliteal vein

Carlo Giacomini
58
(No Transcript)
59

• The anastomotic branch between the LSV and GSV,
  which since then has been widely known as the
  vein of Giacomini, was found in 72 of the limbs
  (37/51). .

60
What Percentage of Patients With Venous Ulcers
Have a Normal Deep Venous System?

• 10
• 30
• 50
• 70

61
Venous Filling Index Values Before and After
Superficial Venous Ablation
Change in VFI
Source Mendes JVS Nov 2003
62
Comparison of Mean Clinical Symptom Score
(CSS) Before and After Superficial Ablative
Surgery
Source Mendes JVS Nov 2003
71 of Previously Incompetent Perforators were
Competent or Absent Post-Operatively
Pre-Op Post-Op
63
P lt 0.025
Source McDaniel April 2002
64
P lt 0.025
Source McDaniel April 2002
65
CONCLUSIONS

• Superficial Venous insufficiency May Result in
  Lower Extremity Ulceration
• Ablation of Superficial Veins May Result in
  Healing of Ulcerations
• Routine Perforator Ligation is not Mandatory
• Superficial Ablative Surgery Results in
  Correction of Prolonged Venous Filling Index
• Superficial Ablative Venous Surgery May be of
  Benefit in Patients with Deep Venous
  Insufficiency (Without Obstruction)

66
Combined Disease
67
(No Transcript)
68
(No Transcript)
69
(No Transcript)
70
(No Transcript)
71
Vein Stripping
72
Branches Ligated At The Sapheno-femoral Junction
73
VEIN STRIPPER PASSED FROM GROIN TO KNEE
Side Branches Ligated
74
GROIN TO KNEE REMOVAL
Stripper Retrieved Below The Knee
75
Vein Clinic Support
76
Financial Advantagesof Ancillary Services
77
(No Transcript)
78
HIPPOCRATES
Standing should be discouraged with lower
extremity ulcers. Recommended the use of
compression If varicose veins or hemorrhoids
occur during mania, the mania is cured. The
bald are not subject to varicose veins but
should they occur, the hairs are reproduced.
79
(No Transcript)