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Management of great saphenous varicosities: Endovenous therapy or conventional surgery? Joint Hospital Surgical Grand Round 19 th October 2013 Wong Ka.

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Presentation on theme: "Management of great saphenous varicosities: Endovenous therapy or conventional surgery? Joint Hospital Surgical Grand Round 19 th October 2013 Wong Ka."— Presentation transcript:

1 Management of great saphenous varicosities: Endovenous therapy or conventional surgery? Joint Hospital Surgical Grand Round 19 th October 2013 Wong Ka Ming Candy Tseung Kwan O Hospital

2 Introduction Dilated, tortuous superficial veins Affect 20-30% of adults More common in female Symptoms varies May develop complications with time Venous ulcer in 3-6% of patients with varicose vein

3 Management Options Advice and Reassurance Compression Therapy Interventional Therapy Surgery Endovenous Ablation Thermal Laser Ablation Radiofrequency Ablation ChemicalSclerotherapy

4 Surgery Gold standard over the past century SFJ ligation +/- stripping Disadvantages: 1.General anaesthesia / regional anaesthesia 2.Painful groin wound 3.Risks of surgery 4.Bruise is common

5 Endovenous Laser Ablation ( EVLA) First report by Bone in 1999 Approved by US FDA in Jan 2002 Available laser generators: Ash JL et al. Laser Treatment of Varicose veins: order out of the chaos. Semin Vasc Surg. 2010 Jun;23(2):101-6.

6 EVLA Mechanism Ash JL et al. Laser Treatment of Varicose veins: order out of the chaos. Semin Vasc Surg. 2010 Jun;23(2):101-6. Direct thermal injury Carbonization of vein wall Indirect thermal injury Formation of steam bubbles Transmit heat energy to endothelium Thermal injury Thrombosis and occlusion of vein

7 Radiofrequency Ablation ( RFA) First reported in 1998 in Switzerland Approved by US FDA in 1999 Bipolar catheter used to generate energy 1 st generation2 nd generation3 rd generation Catheter nameClosureClosure PlusClosure Fast Year199920032006 Temperature ( ℃ )85 120 Speed2-3 cm / min 7cm segment in 20sec cycle Lohr J, Kulwicki A. Radiofrequency ablation: evolution of a treatment. Semin Vasc Surg. 2010;23:90-100. 20

8 RFA Mechanism Denaturation of collagen matrix Vein wall collagen contraction Fibrotic sealing of vessel lumen due to injury and inflammation to vein wall Lohr J, Kulwicki A. Radiofrequency ablation: evolution of a treatment. Semin Vasc Surg. 2010;23:90-100. 20

9 EVLA / RFA Procedure 1.Duplex ultrasound localization 2.GSV identified and cannulated 3.Introducer sheath and catheter inserted 4.Catheter positioned 2cm from SFJ 5.Injection of tumescent solution 6.Catheter slowly withdrawn and fired until the tip is 1cm from the skin surface

10 Tumescent solution Normal saline + lignocaine with adrenaline +/- 8.4% sodium bicarbonate Instilled into the saphenous sheath under ultrasound guidance Functions: – Heat sink – Separate of GSV from saphenous nerve – Contraction of the vein

11 Foam sclerotherapy Chemical ablation Sodium tetradecyl sulphate ( STS) / Polidocanol Tessari technique – Mix with air / CO2 – 1: 4 ratio

12 Foam Sclerotherapy Obliteration of the lumen Induces fibrosis, causing inflammation Foam displaces blood in vein Injection of foam sclerosant GSV cannulated under ultrasound guidance

13 Current evidence comparing endovenous procedure and surgery?

14 Published Aug 2012

15 Failure to completely abolish reflux Primary outcomes: Clinical recurrence Post op complications Post op pain Time return to normal activities / work QOL Secondary outcomes:

16 EVLA versus Surgery

17 EVLA 1.5times higher risk of primary failure

18 EVLA 40% less chance of clinical recurrence

19 EVLA less post op complications OutcomesNo. of studiesNo. of patients Pooled RR (95% CI) Wound infection813470.3 (0.1, 0.8) Parasthesia913870.8 ( 0.6, 1.1) Superfical thromboplebitis 611211.0 (0.5, 1.8) Haematoma47080.5 ( 0.3, 0.8) ecchymosis68760.7 ( 0.3, 1.6)

20 Other results ( EVLA vs Surgery) Less post-op pain * Earlier return to normal activities / work Better QOL ( by AVVSS) * Statistical significant AVVSS = Aberdeen varicose vein severity score

21 RFA versus Surgery

22 RFA 1.3 times higher risk of primary failure

23 RFA 10% less chance of clinical recurrence

24 Post op complications OutcomesNo. of studiesNo. of patients Pooled RR (95% CI) Wound infection56710.3 ( 0.1, 0.4) Parasthesia77591.0 ( 0.5, 0.7) Superfical thromboplebitis 66992.3 (1.1, 5.0) Haematoma54370.4 ( 0.1, 0.8)

25 Other results ( RFA vs Surgery) Less post op pain * Earlier return to normal activities / work* * statistically significant

26 UGFS vs Surgery Kendler M, Wetzig T, Simon JC. Foam sclerotherapy: a possible option in therapy of varicose veins

27 UGFS 2.4 times higher risk of primary failure

28 EVLASurgeryRFASurgeryUGFSSurgery Primary failure  Clinical recurrence  Wound infection  Parasthesia  Superficial thromboplebitis  Haematoma  Post op pain  Return to normal activities  QOL 

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30 NICE guideline 2013 Refer to vascular service if… – Symptomatic – Lower limb skin changes Pigmentation / eczema – Superficial vein thrombosis – Venous leg ulcer

31 NICE guideline 2013 Assessment - Duplex ultrasound – Confirm diagnosis – Extent of truncal reflux Interventional Treatment Endothermal ablation Ultrasound guided foam sclerotherapy Surgery

32 Thank You

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37 CEAP classification - Clinical C0: no visible or palpable signs of venous disease C1: telangiectasies or reticular veins C2: varicose veins C3: edema C4a: pigmentation or eczema C4b: lipodermatosclerosis or atrophie blanche C5: healed venous ulcer C6: active venous ulcer

38 CEAP classification – Etiological Ec: congenital Ep: primary Es: secondary (post-thrombotic) En: no venous cause identified

39 CEAP classification – Anatomical As: superficial veins Ap: perforator veins Ad: deep veins An: no venous location identified

40 CEAP classification – Pathophysiological Pr: reflux Po: obstruction Pr,o: reflux and obstruction Pn: no venous pathophysiology identifiable

41 Duplex ultrasound Assess the size of the GSV Relation to overlying varices Evaluate the reflux time in conjunction with venous diameter

42 EVLA Complications Saphenous nerve paraesthesia DVT Skin burns Phlebitis Bruises

43 Contraindications for endovenous ablation DVT Non palpable pedal pulse Inability to ambulate General poor health Pregnant Relative contraindications: – Non traversable vein segment – thrombosis / extreme tortuosity

44 Conservative Weight loss Exercise Elevation of lower limbs Compression therapy – Different graded pressures for patient with different severities

45 Surgery Complications Wound haematoma / infection Lymphatic leaks Common femoral vein and artery injuries Neurological complications Bruises are common, can last up to 6 weeks Usually advised to return to work after 10-14 days

46 Proposed Benefits Avoidance of general anaesthesia Can be done in outpatient setting Minimal pain Earlier return to normal activity Decrease risk of nerve injury Lower risk of recurrence


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