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Advances In Varicose Vein Treatment


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Advances in treatment of varicose veins Lecture given to the students of Medical Career Institute in Ocean Township on Feb 3, 2010

Advances in treatment of varicose veins Lecture given to the students of Medical Career Institute in Ocean Township on Feb 3, 2010

Published in: Health & Medicine
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  • 1. Advances In Varicose Vein Treatment
    Louis Grella, MD, F.A.C.S.
    Medical Director
    Advanced Vein Care
    Louis Grella, MD F.A.C.S.
  • 2. Vascular Training Experience
    Stony Brook Medical Center
    SUNY Syracuse: MD Degree
    Flushing Hospital Medical Center : General Surgery
    SUNY Stony Brook: Vascular Surgery Fellow
    North Port VA: Vascular Laboratory training
    Jersey Coast Vascular Institute: Vascular Surgery practice
    Advanced Vein Care: Medical Director
    Louis Grella, MD F.A.C.S.
  • 3. Venous Disease
    Divided into Superficial and Deep System
    Deep System
    • Named for by associated arteries
    • 4. Found running along the arteries
    • 5. Predictable anatomy
    • 6. Causes most of the Morbidity
    DVT 200,000 cases/year in USA
    PE 50,000 caser/year
    Severe Leg Swelling
    • Little Surgical interventions (IVC Filter)
    • 7. Medical Management
    • 8. Anticoagulation
    • 9. Thrombolytic therapy
    • 10. Systemic vs. Catheter directed
    • 11. Elevation and Compression
    Louis Grella, MD F.A.C.S.
  • 12. Superficial Venous System
    These are the veins we see
    • Two main named branches
    • 13. Greater saphenous
    • 14. Small saphenous
    • 15. Perforators connect superficial and deep systems
    • 16. Highly variable anatomy
    • 17. Many unnamed branches and Tributaries
    Louis Grella, MD F.A.C.S.
  • 18. Venous Disease
    Superficial System
    Varicose Veins
    Spider Veins
    Venous Malformation (birth marks and others)
    Venous Reflux
    Leg Swelling
    Venous Ulceration
  • 19. Superficial Anatomy
    Deep System = Light blue
    Superficial System = Dark blue
    • Complex and variable anatomy
  • Physiology
    Arteries deliver blood to tissue
    Veins return blood to the hart
    Hart is the arterial pump
    What pumps the venous blood back to the heart?
    Venous pressure is about 25mmHg at the foot
    Pressure needed 80mmHg to return blood
    Two unique features of veins accomplish this
    Most important one-way Venous Valves
    Easily compressible by surrounding muscle (calf pump)
    Louis Grella, MD F.A.C.S.
  • 20. Calf Muscle Pump
    Just like the in heart we have diastole and systole
    This is why stretching your legs or walking improves circulation
  • 21. Normal venous flow in the Leg
    Normal Flow
    • Superficial veins drain into the deep veins
    • 22. From the foot up to the heart
    Superficial vein disease always starts with abnormal valves and interruption to normal flow called venous reflux
  • 23. Abnormal flow = Venous Reflux
    Damaged Valves
    Blood flows to the skin
    Blood is pushed distally and proximally
    Close loop recirculation
    Blood is retained in the leg
    Increased volume of blood (heaviness Fatigue)
    Increased venous pressure
    Veins Dilate (varicose veins)
  • 24. Causes of Venous Reflux
  • 25. Symptoms of venous reflux
    Leg Fatigue
    Leg Heaviness
    Itching and pain along veins
    Varicose Veins
    Spider veins (not always 2nd to reflux)
    Leg swelling( think DVT 1st)
    Skin Discoloration (lipo dermatosclerosis)
    Venous ulceration
  • 26. Varicose Veins
    Definition: Visible tortious bulging blue veins found in the lower extremities
    • Located in the Subcutis(between skin and fascia)
    • 27. Remember this is only a manifestation of the underlying disease
    • 28. Mild Disease is cosmetic issue
    • 29. Advanced Disease significant medical problem
    • 30. Pain
    • 31. Swelling
    • 32. Ulcerations
  • Varicose Veins
    • Incidence Increases with age
    • 33. Females to male 3 to 1
    • 34. 50% of the population will affected in their life time
  • Spider Veins
    The proper term is Telangiectasia
    • These are non raised dilated veins located in the Dermis (deep layer of the skin)
    • 35. Single layer endothelium, minimal muscle
    • 36. Can be Red or Blue in color depending on the origin
    • 37. Do not cause major medical complications
    • 38. Appears earlier than varicose veins (4% of teenagers , and 13 % in 18 to 20 year olds
    • 39. More common in females
    • 40. Reticular Veins are lager feeding veins
  • Spider Veins
    Etiology: Multifactorial
    Venous Hypertension associated with varicose veins
    Congenital: vascular nevi, neonatal hemangiomatosis, others..
    Collage Vascular Disease: lupus,
    Hormonal factors: pregnancy, estrogen therapy, topical steroids
    Trauma: contusion, incisions
  • 41. Venous Stasis Ulcers
    Differential Diagnosis
    Venous ulcerations 50% on non healing ulcers
    Arterial ulcers in about 10%
    Malignancy : basal and squamous cell, lymphoma
    Infections: HIV, fungal
    Collagen vascular disorders: Lupus ec.
    Lymphatic obstruction
    Affects over 1 million people in the US
    100,000 are disabled from this
    More common in elderly population
  • 42. Venous Stasis Ulcers
    Venous Hypertension
    Venous reflux
    Varicose veins
    Biological factors
    Leakage of proteins impedes diffusion O2
    Aggregation of white cells
    Block capillary flow
    Release on inflammatory proteins
  • 43. Diagnosis of venous disease
    Physical exam
    Trendelenburg test
    Hand Doppler
    Duplex Examination
    R/O DVT
    Size of veins
    Map out superficial veins
    Locate the site of reflux
    Reflux 0.5 sec in GSV and 1 sec in deep system
    Find refluxing perforators
  • 44. Venous Duplex
    R/O DVT
    Scan deep system in cross section, look for total compression of the vein in B mode
    Examine from the femoral vein to the below the pop
    Check flow characteristics with Doppler
    Sharp up stroke with calf compression
    Small or No flow with relaxation
    R/O DVI
    This must be done with patient upright
    Reversal of flow of > 1 sec with Valsalva or after calf compression
  • 45. Duplex Anatomy
    Locate GSV Junction(FSJ)
    Look for Mickey's hat
    Normal venous flow Look at valve
    Venous flow is opposite the artery
  • 46. Scan of Common Femoral Vein
  • Venous Duplex
    Examine superficial system with patient upright
    Start with the GSV at the groin and follow to below knee
    Take cross section diameter measurements
    Doppler in longitudinal for reflux > 0.5 sec significant
    Look for mid Thigh perforators and look for reflux
    Draw map of GSV and other superficial tributaries
    Examine the Small Saphenous
    Look for size and reflux
    Find connection to deep system
    Look for the vein of Giacomini ( superior extension of SSV to the GSV)
  • 52. Anatomy of Great Saphenous
    Femoral junction has multiple branches
    Runs on medial side of leg down to ankle
    Found in a facial sheet
    Perforators connect it to deep system
  • 53. Anatomy of Great Saphenous
    From Jose Almeida, MD, IVC talk
  • 54. Anatomy of Great Saphenous
    From Jose Almeida, MD, IVC talk
  • 55. Duplex Of Saphenous Proximal
    Epigastric vein
    Epigastric Vein
    • Locate Terminal valves
    Femoral Vein
    Fem Vein
    Reflux at the Saphenous Femoral Junction
    Look at reversal of flow
  • 56. Duplex Mid Thigh
  • 57. Treatment of Varicose Veins
    Conservative management
    Leg elevation
    Compression stocking
    Surgical treatment
    Standard Ligation and stripping
    Minimally invasive procedures (Currently accepted standard)
    Laser Ablation
    Radio Frequency ablation
  • 58. Surgical ligation and Stripping
    Standard treatment for a century
    General anesthesia
    Long recovery
    Some complications
    Good cosmetic results
  • 59. Vein Ablation
    Laser Ablation (EVLA or EVLT)
    Uses light to heat the vein
    Radio Frequency (VNUS Procedure)
    Uses radio frequency to heat the vein
    • Office based procedure
    • 60. Done under local anesthesia
    • 61. One needle puncture at the level of the knee
    • 62. Takes about 1 hour
    • 63. Patient resumes normal activity same day
  • Vein Ablation Steps
  • 64. EVLA Results
    Images from
  • 65. EVLA Results
    Images from
  • 66. EVLA Results
    Images from
  • 67. Sclerotherapy
    Cumulate vein with needle
    Inject Sclerosing Solution
    Sotradecol (Sodium tetradecyl sulfate)
    Hyper tonic Saline
    Foam (Mix STS with air and make bubbles)
    Intravenous injection causes intima inflammation and thrombus formation
  • 68. Sclerotherapy Use
    Clean up after Phlebectomies
    Spider veins
    Reticular veins
    GSV: can closure the, but has high recurrence rate
  • 69. Sclerotherapy results
  • 70. Thank you for your attention