1. 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

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
Chemical
Sclerotherapy

4. Surgery Gold standard over the past century SFJ ligation +/- stripping
Disadvantages:
General anaesthesia / regional anaesthesia
Painful groin wound
Risks of surgery
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 Jun;23(2):101-6.

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 Jun;23(2):101-6.

7. 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:

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:

9. 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Catheter slowly withdrawn and fired until the tip is 1cm from the skin surface

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

13. Current evidence comparing endovenous procedure and surgery?

14. Published Aug 2012

15. 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

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
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)

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. <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)

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

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

31. 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

32. Thank You

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
Clinical severity
Etiology or cause
Anatomy
Pathophysiology

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
Generally very safe
DVT ( %) : 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 %. 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

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
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.

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 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
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