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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

Published in: Health & Medicine
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Advances In Varicose Vein Treatment

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