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

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

Management Options Advice and Reassurance Compression Therapy Interventional Therapy Surgery Endovenous Ablation Thermal Laser Ablation Radiofrequency Ablation Chemical Sclerotherapy

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

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.

Indirect thermal injury EVLA Mechanism 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 Ash JL et al. Laser Treatment of Varicose veins: order out of the chaos. Semin Vasc Surg. 2010 Jun;23(2):101-6.

Radiofrequency Ablation ( RFA) First reported in 1998 in Switzerland Approved by US FDA in 1999 Bipolar catheter used to generate energy 1st generation 2nd generation 3rd generation Catheter name Closure Closure Plus Closure Fast Year 1999 2003 2006 Temperature (℃) 85 120 Speed 2-3 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

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

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sheath and catheter inserted Catheter positioned 2cm from SFJ Injection of tumescent solution Catheter slowly withdrawn and fired until the tip is 1cm from the skin surface

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

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

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

Current evidence comparing endovenous procedure and surgery?

Published Aug 2012

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

EVLA versus Surgery

EVLA 1.5times higher risk of primary failure

EVLA 40% less chance of clinical recurrence

EVLA less post op complications Outcomes No. of studies No. of patients Pooled RR (95% CI) <EVLA vs Surgery> Wound infection 8 1347 0.3 (0.1, 0.8) Parasthesia 9 1387 0.8 ( 0.6, 1.1) Superfical thromboplebitis 6 1121 1.0 (0.5 , 1.8) Haematoma 4 708 0.5 ( 0.3, 0.8) ecchymosis 876 0.7 ( 0.3, 1.6)

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

RFA versus Surgery

RFA 1.3 times higher risk of primary failure

RFA 10% less chance of clinical recurrence

<RFA vs Surgery> Post op complications Outcomes No. of studies No. of patients Pooled RR (95% CI) <RFA vs Surgery> Wound infection 5 671 0.3 ( 0.1, 0.4) Parasthesia 7 759 1.0 ( 0.5, 0.7) Superfical thromboplebitis 6 699 2.3 (1.1, 5.0) Haematoma 437 0.4 ( 0.1, 0.8)

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

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

UGFS 2.4 times higher risk of primary failure

  EVLA Surgery RFA UGFS Primary failure Clinical recurrence Wound infection Parasthesia Superficial thromboplebitis Haematoma Post op pain Return to normal activities QOL

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

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

Thank You

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 Clinical severity Etiology or cause Anatomy Pathophysiology

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

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

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

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

EVLA Complications Saphenous nerve paraesthesia DVT Skin burns Phlebitis Bruises Generally very safe DVT ( 0- 7.7%) : though 15-20mm of GSV untreated, potential for thrombus extension into the common femoral vein. Improper placement of the catheter cause generate of steam bubbles within the CFV and a thrombotic response within the vein DUS on day 7: To assess CFV patency, To assess successful closure of GSV Saphenous nerve: becomes more superficial and travel with GSV at below knee level. Injury – medial calf numbness generally resolves in 6-8 weeks Phlebitis: 3 to 5 days post op , incidence 1.6-12%. Treated with NSAID + warm moist compression, resolves in a few days on onset Bruises: 23% - 100%, usu at sites where tumescent solution has been instilled

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

Conservative Weight loss Exercise Elevation of lower limbs Compression therapy Different graded pressures for patient with different severities For mild disease , we can advise weight loss, light to moderate exercise to improve muscle pump function, or intermittent elevation to improve symptoms, and avoid factors that are known to make their symptoms worse if possible. Compression therapy can also be recommended which provide effective relief for chronic venous insufficiency and to allow healing of many ulcers. Compression stockings with different graded pressures were available for patient with different severities Compression: graded compression stocking, 20-30mmHg for mod disease, 30-40mmHg for more severe disease.

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

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 There are a few proposed benefits of these endovenous ablation method. First, these procedure can be done with the tumusent anaesthesia with or without sedation, in an outpatient setting And to the patient, there is less pain post operatively, thus earlier return to work The risk of nerve injury may be decrease by avoiding stripping And the risk of recurrence may be decrease by avoidance of neovascularization