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Varicose vein

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Varicose vein

  1. 1. Varicose vein Dr.Atul Kumar Mishra M.S. (Gen. Surgery)
  2. 2. History Description of varicose vein as clinical entity can be traced back as early as 5th century BC. Forefathers of medicine including Hippocrates and Galen described the disease and treatment modalities, which are still used. Royle J et al Varicose vein ANZ J Surg. D2007;77(12):1120-7 Throughout centuries, surgical treatments have evolved from large, open surgeries to minimally invasive approaches.
  3. 3. Problem  vein is significant clinical problem and not just a “ cosmetic “issue because of their unsighty nature  Problem arises from fact that varicose vein actually represent underlying chronic venous insufficiency with ensuing venous hypertension  Venous hypertension leads spectrum of clinical menifestations, ranging from symptoms to cuteneous findings like varicose veins, reticular veins, telangiectasias, swelling, skin discolouration, and ulcerations
  4. 4. Varicose veins and even chronic venous insufficiency can be managed conservatively with stockings and compression  Aggressive management can be pursued for cosmesis, worsening cuteneous findings or symptoms despite conservative management, or if patients prefer surgical management  Most procedures are elective, emergent treatment and workup usually reserved for bleeding or if DVT is suspected Biemans AA et al J Vasc Surg. Sep 2013;58(3):727-34.e1
  5. 5. Pathway leading to varicose veins and other clinical manifestations of venous hypertension
  6. 6. Varicose vein Telangectesia Reticula vein
  7. 7. Lipodermatosclerosis Varicose vein Venous statis ulcer
  8. 8. Epidemiology  Incidence and prevalence in 1973, United States Tecumseh community health study estimated about 40 million persons (26 million females) in US were affected Coon WW et al Circulation. Oct 1973;48(4):839-46  In 1994, a review by Callam found half of adult poppulation have minor stigmata of venous disease (women 50-55%; men 40-50%) and fewer than half have visible varicose veins (women 20-25%; men 10-15%) Callam MJ. Br J Surg. Feb1994;81(2):167-73  In 2004, these finding also seen in a French cross- sectional study that found odds ratio per year for varicose veins 1.04 for women and 1.05 for men Carpentier PH et al J Vasc Surg. Oct 2004;40(4):650-9.
  9. 9. Etiology Primary varicose veins - incompitent venous valves result venous hypertension Secondary varicose vein - DVT and its sequelae or congenital anatomic abnormalities Etiology of varicose veins can be classified three group Primary Valvular insufficiency of superficial veins, most commonly at saphenofemoral junction Secondary Mainly by DVT that leads chronic deep venous obstruction or valvular insufficiency. Long term clinical sequelae from this is called post thrombotic syndrome
  10. 10.  Catheter- associated DVTs  Pregnancy- induced and progestrone – induced venous wall and valve weakness worsen by expanded circulating blood volume and enlarged uterus compresses IVC and venous return from the lower extremites  Trauma Congenital - Any venous malformation Klippel-trenaunay variants Avalvulia Biemans AA et al J Vasc Surg. Sep 2013;58(3):727-34.e1
  11. 11. Pathophysiology  Dilated, tortuous veins of subcuteneous/superficial venous system  Pathophysiology is complicated and involves concept of ambulatory venous hypertension  Two venous system in lower extrimity, deep and superficial  Deep system ultimately leads back to IVC, then to heart  Superficial system found above deep fascia of extrimity, within subcuteneous tissue lower Many superficial veins exist, but they all drain into two largest, the great saphenous and short saphenous vein
  12. 12. Schematic diagram of deep and superficial venous system of lower limb (1) Normal venous drainage; arrows dipict flow of venous blood, (2) Venous HTN bold arrows are pathway of venous reflux
  13. 13. Superficial venous system connected to deep system at following locations 1) Perforator veins- These veins transverse deep fascia of lower extrimity. Number of named perforators found at thigh, knee and leg Named perforators along Greater saphenous distribution
  14. 14. 2) Saphenofemoral junction(SFJ)- Located proximally at groin where GSV meets femoral vein Major tributeries of GSV Saphenofemoral junction
  15. 15. 3) Saphnopopliteal junction- Behind knee where SSV join Popliteal vein  Normaly, flow of venous blood is through superficial system to deep and up the leg and toward heart  One-way venous valve in both systems and perforating veins  Incompetence in any of these valves lead disruption in unidirectional flow result in ambulatory venous HTN  Incompetence in one system can lead incompetence in another  In a study by Shami et al, limbs of 59 patients with venous ulceration accessed by colour duplex ultrasound scanning. In 53% only superficial venous reflux found, in
  16. 16.  Incompetence in superficial venous system alone usually result from failure at valves located at SFJ and SPJ  Gravitational weight of blood column along the length of vein creates hydrostatic pressure, which is worse at distal aspect of the length of vein  Incompetence of pressure perforating veins leads to hydrodynamic  Calf pump mechanism helps to empty deep venous system, but if perforating vein valves fail, then pressure generated in deep venous system are transmitted into superficial system via incompetent perforating veins Recek C et al Angiology. Oct-Nov 2006;57(5):556-63
  17. 17. Complications  Thrombophlebitis  Pigmentation- black to brown due to hemosiderin from RBC breakdown  Eczema- Extravasated RBC –> itching –> scratch –> eczema  Lipodermatosclerosis -Induration and fibrosis of skin and sub cuteneous tissue  Haemorrhage  Equinus deformity
  18. 18. Presentation Subjective symptoms  Usually caused by venous HTN rather varicose vein  Often, symptoms are purely aesthetic, and patients desire treatment of unsighty nature of varicosities  Pain, soreness, burning, aching, throbbing, heavy legs, cramping, muscle fatigue, pruritus, night cramps, and “restless legs” are usuallly secondary to venous HTN  Pain and other symptoms may worsen with menstrual cycle, with pregnancy, and in response to exogenous hormonal therapy (oral contraceptives)
  19. 19. History  Age Usually in older people  Sex     Female > male Occupation Prolonged standing Symptoms Cosmetic, pain, ankle swelling, superficial thrombophlebitis, skin changes (thickening, pigmentation, ulceration and eczema) Past history Similar complaints, treatment and DVT especially during pregnancy Family history Similar complaints
  20. 20. Clinical features  Age : Any  Sex : F:M 10:1  Occupation : Jobs demanding prolong standing person doing muscular work  Leg heaviness, exercise intolerance, pain in lower limb. However, bursting pain means DVT  Ankle swelling usuallly at the end of day  Tortous dilated visible vein  Pruritus, restless legs, and paresthesias  Skin changes : pigmentation, ulcer  Dermal flare/thread veins  Reticular vein
  21. 21.  Pain of venous HTN is dull ache that worsen after prolonged standing, improves by walking or by elevating legs  Subjective symptoms more severe early in progression of disease, less severe in middle phases, and more severe again with advancing age  Patients who become acclimatized to chronic disease may not volunteer information about symptoms. After treatment, patients often surprised to realize how much chronic discomfort they had accepted as “normal”
  22. 22. Examination (Properly exposed, standing and supine position, both in front and behind)  Inspection  Visible veins (site, size and extent, effect of elevation and dependency)  Skin of the lower 3rd medial aspect of calf (swelling, redness, pigmentation, eczema and ulceration)  Palpation  Skin and subcutaneous tissue (texture, oedema, thickening and tenderness)  Course of the veins (defect)  SFJ and SPJ (cough impulse and thrill)  Special tests (to be demonstrated separately)  Percussion  For percussion impulse conducting up or down  Auscultation  Bruit
  23. 23. For all tests SaphenoFemoral incometence 1) Trendelenberg I 2) Modified Perthes test Perforator incompetence 1) Tourniquet test 2) Pratt’s test 3) Fegan’s test 4) Trendelenberg II Deep vein thrombosis 1) 2) 3) 4) Perthes’test Modified Perthes Homan’s sign Moses sign
  24. 24. Indications  Often for cosmetic reasons  Noncosmetic indications fatigability, heaviness, thrombophlebitis, bleeding) varicosities recurrent (e.g. pain, superficial For treatment of venous hypertension after skin or subcutaneous tissue changes, (lipodermatosclerosis, atrophie blanche, ulceration, or hyperpigmentation)  Nonetheless, a patient's desire for surgical management over conservative treatment or for cosmetic purposes alone are reasonable relative indications for surgery. Naoum JJ et al Vascular. Sep-Oct 2007;15(5):242-9.
  25. 25. Contraindications  Patients with venous outflow obstruction because they are important bypass pathways that allow blood to flow around the obstruction  Who cannot remain active enough to reduce risk of postoperative DVT  Surgery during pregnancy because many varicose veins of pregnancy spontaneously regress after delivery
  26. 26. Laboratory Studies  No lab test useful in diagnosis or therapy Patients with varicose veins may have spuriously positive Ddimer test because of chronic low-level thrombosis within varices  Diagnostic Procedures Duplex ultrasound  Most useful tool for workup, replaced many of physical examination maneuvers and physiological tests  Tests used to rule out deep vein thrombosis obstruction as a cause of varicose veins  Noninvasive imaging with good sensitivity and selectivity
  27. 27. Maximum venous outflow (MVO)  Functional test, detect obstruction to venous outflow  It can help detect more proximal occlusion of iliac veins and IVC, as well as extrinsic causes of obstruction in addition to DVTs  MVO uses plethysmography (technique to measure volume changes of leg) to measure speed at with which blood can flow out of a maximally congested lower leg when an occluding thigh tourniquet is suddenly removed Hafner J et al. New York, New York: Karger Publishers; 1999.
  28. 28. Magnetic resonance venography (MRV)  Most sensitive and most specific test to find causes of anatomic obstruction Particularly useful because unsuspected nonvascular causes for leg pain and edema may often seen when clinical presentation erroneously suggests venous insufficiency or venous obstruction  Expensive test used as adjuvant, when doubt exists. Hafner J et al. New York, New York: Karger Publishers; 1999.
  29. 29. Tests used to demonstrate reflux Duplex US with color-flow imaging (sometimes called triplex ultrasound) Special type of 2-dimensional ultrasound that uses Doppler-flow information to add color for blood flow in the image Vessels in blood are colored red for flow in one direction and blue for flow in other, with a graduated color scale to reflect the speed of flow Venous valvular reflux is defined as regurgitant flow with Valsalva that lasts great than 2 seconds
  30. 30. Doppler auscultation  Doppler transducer is positioned along the axis of vein with probe at angle of 45 to skin When distal vein is compressed, audible forward flow exists  If valves competent, no audible backward flow is heard with the release of compression  If valves incompetent, an audible backflow exists.  These compression-decompression maneuvers repeated while gradually ascending the limb to a level at which reflux can no longer be appreciated
  31. 31. Venous refilling time (VRT)  Physiologic test, using plethysmography VRT is time necessary for lower leg to become infused with blood after the calf-muscle pump has emptied the lower leg as thoroughly as possible  In healthy subjects, venous refilling >120 seconds  In mild and asymptomatic venous insufficiency between 40 -120 seconds  In significant venous insufficiency 20-40 seconds. Such patients have nocturnal leg cramps, restless legs, leg soreness, burning leg pain, and premature leg fatigue  If < 20 seconds markedly abnormal, and nearly always symptomatic  If < 10 seconds, venous ulcerations are likely Hafner J et al. New York, New York: Karger Publishers; 1999.
  32. 32. Muscle pump ejection fraction (MPEF)  Detect failure of calf muscle pump to expel blood from lower leg Results are highly repeatable but require skilled operator  Patient performs ankle dorsiflexion 10-20 times, and plethysmography is used to record change in calf blood volume  In healthy patients, venous systems will drain, but in patients with muscle pump failure, severe proximal obstruction, or severe deep vein insufficiency, amount of blood remaining within the calf has little or no change. Hafner J et al. New York, New York: Karger Publishers; 1999.
  33. 33. Tests used to define anatomy Duplex US  Two-dimensional ultrasound forms an anatomic picture  Normal vessel appears as a dark-filled, white-walled structure .  Doppler-shift measurement of flow direction and velocity.  Structural details that can be observed include –  most delicate venous valves  small perforating veins  reticular veins as small as 1 mm in diameter  and (using special 13-MHz probes) even tiny lymphatic channels
  34. 34. Direct contrast venogram  Intravenous catheter placed in dorsal vein of foot, and radiographic contrast material is infused into the vein  X-rays used to obtain image of superficial venous anatomy  If deep vein imaging is desired, superficial tourniquet is placed around leg to occlude superficial veins and contrast is forced into deep veins  Assessment of reflux can be difficult because it requires passing a catheter from ankle to groin, with selective introduction of contrast material into each vein segment  Labor-intensive and invasive venous imaging technique with a 15% chance of developing new venous thrombosis from the procedure itself. Rarely used, and has been replaced by duplex ultrasound.  Reserved for difficult or confusing cases.
  35. 35. Classification of chronic lower extremity venous disease C C Clinical signs (grade0-6), supplemented by (A) for asymptomatic and (S) for symptomatic presentation E Etiologic Classification (Congenital, Primary, Secondary) A Anatomic Distribution (Superficial, Deep, or Perforator, alone or in combination) P Pathophysiologic Dysfunction (Reflux or Obstruction, alone or in combination)
  36. 36. Staging  CEAP classification from American Venous Forum, last revised 2004  Used to standardize recording of venous disease Clinical C0 - No visible or palpable signs of venous disease C1 - Telangiectases 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 S – Symptomatic, includes: ache, pain, tightness, skin irritation, heaviness, and muscle cramps A – Asymptomatic Eklöf B et al. J Vasc Surg. Dec 2004;40(6):1248-52
  37. 37. Etiologic classification Ec - Congenital Ep - Primary Es - Secondary (post-thrombotic) En - No venous cause identified Anatomic classification As - Superficial veins Ap - Perforator veins Ad - Deep veins An - No venous location identified Pathophysiologic classification Pr - Reflux Po - Obstruction Pr,o – Reflux and obstruction Pn - No venous pathophysiology identifiable
  38. 38. Advanced CEAP Same as basic CEAP, with addition that any of 18 named venous segments can be used as locators for venous pathology Superficial veins (1) telangiectasias or reticular veins, GSV (2) above knee or (3) below knee, (4) small saphenous vein, or (5) nonsaphenous veins Deep veins (6) Inferior vena cava, (7) common iliac vein, (8) internal iliac vein, (9) external iliac vein, (10) pelvic veins gonadal, broad ligament veins, other, (11) common femoral vein, (12) deep femoral vein, (13) femoral vein, (14) popliteal vein, (15) crural veins (anterior tibial, posterior tibial, peroneal veins (all paired)), or (16)
  39. 39. Example: Patient has painful swelling of leg, and varicose veins, lipodermatosclerosis, and active ulceration. Duplex scanning on 17th May 2014 showed axial reflux of GSV above and below knee, incompetent calf perforator veins, and axial reflux in femoral and popliteal veins. No signs of post-thrombotic obstruction. Classification according to basic CEAP: C6,S, Ep,As,p,d, Pr . Classification according to advanced CEAP: C2,3,4b,6,S, Ep,As,p,d, Pr2,3,18,13,14 (2004-05-17, L II).
  40. 40. Treatment  Conservative – For elderly unfit patients or with mild symptoms – Elastic support, weight reduction, regular exercise, avoidance of constricting garments and prolonged standing  Sclerotherapy – For small varices below the knee or recurrent varices after surgery – Vein is injected with sclerosant (sodium tetradecyl sulphate) and compression bandage applied for 2 week  Surgery – Aims to remove varices and intercept incompetant perforators – SFJ or SPJ is ligated flush – Long saphenous vein stripped out from knee to groin – Short saphenous vein may be but normally not stripped out for fear of sural nerve injury – Remaining varices are avulsed via tiny stab incisions
  41. 41. Surgical Therapy Under development for more than 2000 years, but until present era, relatively little weight was given to cosmetic outcome  Current therapies becoming less invasive with improved recovery, but long-term outcomes are uncertain  Therapies aim to remove superficial venous system either through surgery, endovenous ablation, or sclerotherapy ablation Biemans AA et al J Vasc Surg. Sep 2013;58(3):727-34.e1
  42. 42.  In 90% cases where venous hypertension is from superficial and perforator vein reflux, removal or obliteration of GSV alone can resolve venous hypertension. In remaining 10%, additional treatment to incompetent perforator veins may be needed Kalra M et al Surg Clin North Am. Jun 2003;83(3):671-705.  Additionally, if severe deep venous incompetence exists, treatment of GSV alone usually does not resolve venous hypertension. Additional interventions with subfascial endoscopic perforating vein surgery (SEPS), perforator vein ablation, and/or venous reconstruction can be attempted
  43. 43. Prior intervention, Duplex US to map reflux pathways, and skin marker to mark surface vessels to be removed Open techniques  Rindfleisch-Friedel procedure of early 1900s involved one incision to level of deep fascia that wrapped around leg 6 times, creating a spiral gutter that brought into view a large number of superficial veins, each one of which was ligated. This wound was left open to heal by granulation.  Linton procedure, introduced in late 1930s, used a large linear medial leg incision that brought into view all the superficial and perforator veins of leg. Incompetent superficial veins were removed, and perforating veins were interrupted.
  44. 44. Friedrich Trendelenburg, in late 1800s, introduced a midthigh ligation of GSV. Outcomes were variable This procedure modified by Trendelenburg's student Perthes, who advocated a groin incision and a ligation of GSV at SFJ  Later, better outcomes were found if saphenectomy (removal of the GSV) with ligation at SFJ was performed over ligation alone  In a randomized trial, two thirds patients with ligation without saphenectomy expected to need reintervention within 5 years for recurrent reflux, either through recanalization or collateral formation around the ligated GSV Recek 2012;21(3):181-6 C et al.Int J Angiol. Sep
  45. 45. Trendelenberg’s Sapheno-Femoral Flush Ligation
  46. 46. GSV saphenectomy Evolved from large open incisions to less invasive stripping Original methods of stripping used different devices and variations of techniques.  Mayo stripper was an extraluminal ring that cut the tributaries as it was passed along the vein Babcock device was an intraluminal stripper with an acorn-shaped head that pleated up the vein as it pulled the vessel loose from its attachments Keller device an internal wire used to pull the vein through itself, as is done today with perforation-invagination (PIN) strippers
  47. 47. Stripping of Long Saphnous Vein
  48. 48.  PIN stripping begins with 2- 3 cm incision at groin crease. Femoral vein and SFJ exposed and all tributaries of SFJ identified and flush-ligated to minimize incidence of reflux recurrence Then, stripping instrument passed into GSV at groin and threaded through incompetent vein distally to level of upper calf  Stripper brought out through a small incision (5 mm or smaller) approximately 1 cm from the tibial tuberosity of knee.  An inverting head is attached to stripper at groin and secured to the proximal end of vein. Vessel is then inverted into itself, tearing away from each tributary and perforator as stripper is pulled downward through leg and out through the incision in upper calf.  If desired, epinephrine-soaked gauze or ligature may be secured to the stripper before invagination, allowing hemostatic packing to be pulled into place after stripping is complete.
  49. 49. SSV saphenectomy Removal of SSV is complicated by variable local anatomy and risk of injury to popliteal vein and peroneal nerve  SPJ must be located by duplex before dissection After ligation and division of junction, stripper passed into distal calf, where it is brought out through small incision (2-4 mm)  Stripper secured to proximal end of vein, which is invaginated into itself as it is pulled downward from knee to ankle and withdrawn from below
  50. 50. Stab phlebectomy (or ambulatory phlebectomy) Performed by Galen as early as second century, procedure came back into modern favor during 1960s Useful for treatment of residual vein after saphenectomy and for removal of nontruncal tributaries when the saphenous vein is competent Microincision made over vessel, phlebectomy hook introduced into microincision, and vein delivered through incision  With traction, as long a segment as possible is pulled out until vein breaks or cannot be pulled further Another microincision made and process begun again and repeated along the entire length of vein to be extracted Weiss RA segments of veinsApproach New York, NY: McGraw-Hill;2001. Short et al, A Comprehensive can be removed through tiny incisions
  51. 51. Endovascular techniques Endovenous (EV) laser Laser fiber produces endoluminal heat that destroys vascularendothelium  Seldinger technique used to advance long catheter along entire length of truncal varicosity (usually the GSV) to be ablate Position confirmed by ultrasound and by use of laser guide light  Under ultrasound guidance, tumescent solution with local anesthetic is injected around the entire length of vessel, separating it from its fascial sheath. This serves to insulate the heat from damaging adjacent structures, including nerves and skin, as well as pain control
  52. 52.  Firm pressure applied to collapse vein around the laser fiber, and laser fired generating heat, leading intraluminal steam bubbles and irreversible endothelial damage and thrombosis  Fiber and catheter withdrawn approximately 2 mm, and laser is fired again  Process repeated along entire course of vessel Biemans AA et al J Vasc Surg. Sep 2013;58(3):727-34.e1
  53. 53. Radiofrequency (RF) ablation RF thermal energy delivered directly to vessel wall, causing denaturation, collagenous contraction, and immediate closure of vessel protein  In contrast to laser therapy, RF catheter actually comes into contact with lumen walls Introducer sheath inserted into proposed vein of treatment (usually GSV)  RF ablation catheter passed through sheath and along the vein until active tip is at SFJ Like endovenous laser, tumescent local anesthetic is injected Metal fingers at tip of RF catheter are deployed until they make contact with vessel endothelium  RF energy is delivered, both in and around vessel to be treated. Thermal sensors record the temperature within vessel and deliver just enough energy to ensure endothelial ablation  RF catheter withdrawn a short distance, and process repeated along length of vein
  54. 54.  Subramonia and Lees found that, compared with conventional high ligation and stripping, radiofrequency ablation of great saphenous varicose veins took longer to perform, but patients returned to their normal activities significantly earlier and had significantly less postoperative pain. Johnson CM et al, Vascular. Sep-Oct 2007;15(5):250-4.
  55. 55. Minimally invasive techniques Cutaneous electrodesiccation Old technique involving electrical cautery for destruction of small vessels that is rarely used today because of disfiguring cutaneous injury Sclerotherapy Chemical sclerosis of varicose veins has waxed and waned in popularity since late 1800s  Modern sclerosants with acceptable risk profile became widely available in 1930s, and, since that time, there use expanded  Initially, sclerotherapy was used as surgical adjunct after saphenectomy to treat residual varicosities, reticular veins, or telangiectasias. Now being used to treat GSV and main tributaries
  56. 56. Under US guidance, sclerosing substance injected into abnormal vessels to produce endothelial destruction followed by formation of fibrotic cord and eventual reabsorption of all vascular tissue layers
  57. 57. Caution used when using sclerosing agents  inadvertent injection into arteriovenous malformation or directly into unrecognized artery can cause extensive tissue loss or loss of entire limb  Inadvertent injection of concentrated sclerosants into deep system can cause DVT, pulmonary embolism, and death. Most commonly used sclerosants are polidocanol (Asclera) and sodium tetradecyl sulfate  Both are known as detergent sclerosants because they are amphiphilic substances, inactive in dilute solution, but biologically active when they form micelles These agents preferred because they have low incidence of allergic reactions, staining and adverse cutaneous effects, and relatively forgiving if extravasated Polidocanol, most forgiving sclerosing agent, originally developed as local anesthetic agent
  58. 58. Other agents that have fallen out of favor include sodium morrhuate, high incidence of anaphylaxis  Ethanolamine oleate, weak detergent, excessively soluble, decreasing its ability to denature cell surface proteins  Hypertonic saline in 20% or 23.4% solution, because of dilutional effects with injection, difficult to achieve adequate sclerosis of large vessels without exceeding a tolerable salt load. If extravasated, it causes significant necrosis Addition of foam with sclerosing agents has allowed for decreased amounts of sclerosing agent injection and improved efficacy Rabe E et al, Eur J Vasc Endovasc Surg. Feb 2008;35(2):238-45.  Foam pushes blood out of vein, allowing for less dilution and more contact of sclerosant with endothelium
  59. 59. Varisolve (BTG, West Conshohocken, PA) is one such product using carbon dioxide foam and polidocanol sclerosant Biemans AA et al J Vasc Surg. Sep 2013;58(3):727-34.e1
  60. 60. Ultrasound image of GSV after foam sclerotherapy treatment, Hyperechogenicity within vein is from foam
  61. 61. In US, sodium tetradecyl sulfate, sodium morrhuate, and ethanolamine oleate were all developed prior to establishment of FDA  These agents never been submitted to FDA for approval, but available in United States as grandfathered agents  No FDA–approved foam/sclerosing agents available; however, Varisolve is currently under clinical trials in United States after being used extensively in Europe Wright D et al Europian randomized controlled trial.Phlebectomy. 2006;21:180-90.
  62. 62. Postoperative Details After treatment by any method, 30-40 mm Hg gradient compression stocking applied and patients instructed to maintain or increase their normal activity levels  Most practitioners also recommend use of gradient compression stockings even after treatment of spider veins and smaller tributary veins O'Hare et al found that compression bandaging for 24 hours, followed by use of thromboembolus deterrent stockings for remainder 14 days, gave results comparable to compression bandaging for 5 days  In a randomized trial in patients undergoing foam sclerotherapy for primary uncomplicated varicose veins, no significant difference noted in et al, Brocclusion, phlebitis, skin vein J Surg. May 2010;97(5):650-6. O’Hare JL discoloration, or pain at 2 and 6 weeks with the two
  63. 63.  Activity is important after treatment because all modalities of treatment have potential to increase risk of DVT  Activity is strong protective factor against venous stasis  Activity is so important that most venous specialists not treat a patient who is unable to remain active following treatment
  64. 64. Most annoying minor complications of any venous surgery Dysesthesias from injury to sural nerve or saphenous nerve Subcutaneous hematoma is common complication, regardless of treatment technique. Managed with warm compress, NSAIDS, or aspiration if necessary At SFJ, accidental treatment of femoral vein by inappropriate RF or laser catheter placement, or spread of sclerosant, or inappropriate surgical ligation can all lead to endothelium damage at deep vein, causing DVT with potential of pulmonary embolism and even death.[18]  Postoperative infection  Arterial injury (less common and may be kept to minimum through strict attention to good technique Endovenous techniques have potential of excessive tissue heating, lead skin burns. Avoided if sufficient volumes of tumescent anesthetic injected to elevate the skin away from vein.[18]
  65. 65. Outcome and Prognosis  With appropriate treatment, majority of patients have good outcome and progression is arrested  Surgical stripping of GSV, or saphenectomy, standard to which most therapies compared  In a randomized trial entitled endovenous radiofrequency obliteration versus ligation and stripping (EVOLVeS) study, 68 legs randomly assigned to undergo RFA or surgical stripping of GSV. Immediate success for RFA versus stripping on day of treatment was 95% versus 100%, respectively. At 3 weeks, duplex ultrasonography confirmed closure of GSV in 90.9% of RFA group. Lurie 2003;38(2):207-14. F et al J Vasc Surg. Aug
  66. 66. In extended 2-year follow-up, there was nonsignificant difference of cumulative rates of recurrent varicose veins: 14% for RFA and 21% for stripping. However global qualityof-life scores were still in favor of RFA. Rasmussen LH et al Br J Surg. Aug 2011;98(8):1079-87. In a randomized trial of 137 legs, endovenous laser ablation was compared with saphenectomy. Both methods were equally efficacious at obliterating GSV, but saphenectomy group had higher postoperative pain scores. Other similar results between saphenectomy and endovenous laser groups included time to resume normal physical activity (7.7 d vs 6.9 d), time to resume work (7.6 d vs 7 d), and total cost of procedures ($3948 vs $4347 USD). Rasmussen LH et al J Vasc Surg. Aug 2007;46(2):308-15.
  67. 67.  In a trial of 280 patients randomized to endovenous laser ablation compared with saphenectomy, follow up extended to over a year. The authors found at 1 year, lower rates of clinical recurrence with endovenous laser ablation versus surgery (4% vs 20.4%, P < .001). Twelve of 23 surgical recurrences related to incompetent belowknee GSV and 10 to neovascularization. In endovenous laser group, 5 recurrences reported. Two related to neoreflux in groin tributaries and 1 to recanalization. Carradice D et al Br J Surg. Aug 2011;98(8):1117-23.
  68. 68. In a more recent randomized trial of 500 patients and 580 legs, endovenous ablation, RFA, foam sclerotherapy, and surgical stripping were compared. At 1 year, Highest failure rates seen in foam ablation (16.3%) and endovenous ablation (5.8%) groups. Lowest seen in RFA (4.8%) and stripping groups (4.8%), although these 2 groups also had highest postintervention pain scores. Rasmussen LH et al Br J Surg. Aug 2011;98(8):1079-87.
  69. 69. Foam sclerotherapy used in Europe, and phase III randomized clinical trials compared it with saphenectomy and sclerotherapy without foam  At 12 months, GSV closure rates 68.2% in Varisolve. Sclerotherapy closure rates for Varisolve group efficacious, Varisolve caused less normal more quickly. 87.2% in saphenectomy versus without foam versus Varisolve, 93.8%. Although surgery more pain and patients returned to  In 710 patients enrolled, no pulmonary embolus found, and DVTs found in 2.5% of Varisolve, none in surgery, and 0.8% in sclerotherapy without foam Wright D et al European randomized controlled trial. Phlebectomy. 2006;21:180-90.
  70. 70. Future and Controversies Management of varicose veins has evolved over the centuries and will continue to do so  Less invasive techniques continue to be refined but long-term efficacy must always be questioned and compared with criterion standard of surgical saphenectomy

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