Perforator veins why and how to treat them

Cees H.A.WittensCees H.A.Wittens
European Venous CentreEuropean Venous Centre
Aachen-MaastrichtAachen-Maastricht
Perforator veins: whyPerforator veins: why
and how to treat themand how to treat them
E CV
European Venous Centre: Maastricht-AachenEuropean Venous Centre: Maastricht-AachenTurkish Society of Vascular Surgery Antalya 2011Turkish Society of Vascular Surgery Antalya 2011

Why treat Incompetent PerforatorWhy treat Incompetent Perforator
in:in:
 Venous ulcers CVenous ulcers C66 and healed ulcers Cand healed ulcers C55 ??
 Lipodermatosclerotic legs CLipodermatosclerotic legs C44??
 Recurrent varicosities CRecurrent varicosities C2,32,3??
E CV

Perforator treatment:Perforator treatment:
pathophysiologypathophysiology
 High ‘systolic’ intravenous pressuresHigh ‘systolic’ intravenous pressures
in calf veins are transmitted throughin calf veins are transmitted through
incompetent perf. veins to the skinincompetent perf. veins to the skin
circulationcirculation (200 mmHg) causing;(200 mmHg) causing;
 White cell trapping and capillaryWhite cell trapping and capillary
cuffingcuffing
 Impairing nutritional skinflowImpairing nutritional skinflow
E CV

Perforator treatment CPerforator treatment C5,65,6::
clinical outcomeclinical outcome
 ..
Depending on
compliance
Subgroup
analyses
Quality of SEPS
Turkish Society of Vascular Surgery Antalya 2011Turkish Society of Vascular Surgery Antalya 2011

Perforator treatment CPerforator treatment C66::
E CV

SEPS-trial:SEPS-trial:
residual and/or medial ulcersresidual and/or medial ulcers
223150576873 314258677885N =
non-primary and/or medial ulcer
period (6 months)
654321
ulcuspresent(%days)
100
90
80
70
60
50
40
30
20
10
0
TREAT
CH
CO
P= 0.045 (ANOVA)
E CV

Influence of the quality of the SEPS procedureInfluence of the quality of the SEPS procedure
E CV

Influence on Healing of the quality of the SEPSInfluence on Healing of the quality of the SEPS
procedureprocedure
months
60483624120
healing(%)
100
90
80
70
60
50
40
30
20
10
0
SEPS
non succesfull
succesfull
NSNS
Compliance highCompliance high
E CV

Influence on Recurrence of the quality of the SEPSInfluence on Recurrence of the quality of the SEPS
procedureprocedure
months
60483624120
recurrence(%)
100
90
80
70
60
50
40
30
20
10
0
seps
not succesfull
succesfull
P<0.007P<0.007
Influence of perforatorInfluence of perforator
incompetence !!incompetence !!
Compliance lowCompliance low
E CV

 CC 5,65,6
 medial ulcersmedial ulcers
 recurrent ulcersrecurrent ulcers
 large ulcerslarge ulcers
(around 90 % of patients with venous ulcers)(around 90 % of patients with venous ulcers)
E CV
European Venous Centre: Maastricht-AachenEuropean Venous Centre: Maastricht-Aachen
Because of improved clinical outcome in:Because of improved clinical outcome in:

 YESYES
CC5,65,6 (medial, recurrent and large)(medial, recurrent and large)
 ????
Lipodermatosclerosis CLipodermatosclerosis C44
Recurrent varicosities in CRecurrent varicosities in C2,32,3
 NoNo
Primary varicosities CPrimary varicosities C2,32,3
E CV
Because of improved clinical outcome in:Because of improved clinical outcome in:

Open methodsOpen methods (Linton)(Linton)
Pierik 1996 (due to woundproblems >50%/0% trial stopped ) =Pierik 1996 (due to woundproblems >50%/0% trial stopped ) =
ObsoleetObsoleet
Half blind methodsHalf blind methods
(Edwards phlebotoom) =(Edwards phlebotoom) =
ObsoleetObsoleet
How to treat IPVHow to treat IPV
E CV

SEPS one port systemSEPS one port system
Olympus scoopOlympus scoop
CO2 insufflationCO2 insufflation
Bloodless fieldBloodless field
Mechanical space (force)Mechanical space (force)
E CV

SEPS two/three port systemSEPS two/three port system
lap. equipm.lap. equipm.
CO2 insufflationCO2 insufflation
spacemakerspacemaker
no mech. spaceno mech. space
E CV

Sclerotherapy of IPV:Sclerotherapy of IPV:
 intraluminalintraluminal
 98 % succesfull occlusion immediately after98 % succesfull occlusion immediately after
the procedure (cave: spasm)the procedure (cave: spasm)
 33.3 % recurrence after 1 month33.3 % recurrence after 1 month
 FutureFuture
Foam ??Foam ??
Masuda et al; J Vasc Surg 2006Masuda et al; J Vasc Surg 2006
E CV

Cryo Perforator Surgery (CPS):Cryo Perforator Surgery (CPS):
 ExtraluminalExtraluminal
 Initial succes 100 %Initial succes 100 %
 Recanalisation afterRecanalisation after
20 weeks 57 %20 weeks 57 %
 ObsoleetObsoleet
Klem and Wittens; Vasc Endovascular Surg 2008/2010Klem and Wittens; Vasc Endovascular Surg 2008/2010
E CV

Radiofrequency ablation of IPV:Radiofrequency ablation of IPV:
 IntraluminalIntraluminal
 Initial succes 96%Initial succes 96%
 1 year1 year
VNUS: 60-80%VNUS: 60-80%
RFITT: 75-90%RFITT: 75-90%
 Future:Future:
One hand procedure ?One hand procedure ?
Peden and Lumbsden ; Perspect Vasc Surg Endovasc Ther 2007Peden and Lumbsden ; Perspect Vasc Surg Endovasc Ther 2007
E CV

Laser ablation of IPV:Laser ablation of IPV:
 1year1year
60-80%60-80%
 Future:Future:
Length and energy level changeLength and energy level change
Proebstle et al.; Dermatol Surg 2007Proebstle et al.; Dermatol Surg 2007
E CV

Coil embolisation of IPV:Coil embolisation of IPV:
 Recanalisation 75 %Recanalisation 75 %
after 1 yearafter 1 year
 Future:Future:
Obsoleet!Obsoleet!
Van Dijk and Wittens; J Vasc Interv Radiol 1999Van Dijk and Wittens; J Vasc Interv Radiol 1999 E CV

Duplex directed interruption ofDuplex directed interruption of
IPV:IPV:
 ExtraluminalExtraluminal
 Recanalisation ??Recanalisation ??
 FutureFuture
??
Siewert et al; poster AVF 2006Siewert et al; poster AVF 2006
E CV

All techniques:All techniques:
 SEPSSEPS (cannot reach them all; short stay)(cannot reach them all; short stay) 60-9060-90
 SclerotherapySclerotherapy (high recurrence; cheap)(high recurrence; cheap) 40-7040-70
 CryoPSCryoPS (obsoleet)(obsoleet) <60<60
 RFARFA (feasable; expensive)(feasable; expensive)
VNUSVNUS 60-8060-80
RFITTRFITT 75-9075-90
 LaserLaser (feasable; expensive)(feasable; expensive) 60-8060-80
 Coil embolisationCoil embolisation (obsoleet)(obsoleet) <60<60
 Duplex interrupt.Duplex interrupt. (extraluminal;distance, cheap)(extraluminal;distance, cheap) ????
E CV
Succes %Succes %

Why:Why:
• Because it improve clinical outcome in CBecause it improve clinical outcome in C5,65,6
How:How:
• SEPSSEPS
• Quality control !!Quality control !!
• New minimally invasive techniques:New minimally invasive techniques:
• which: trials!which: trials!
E CV
Perforator veins: why and how toPerforator veins: why and how to
treat them:treat them:

Perforator veins why and how to treat them

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