3. VNVDAII - Venous diseases of lower extremities

1. Venous diseases of lower extremities
Dr. Sandeep Raj Pandey
MBBS,MS,FVES, EVES
Consultant Vascular & Endovascular Specialist
Annapurna & Norvic Hospital, Kathmandu,Nepal
Secretary (Vascular society of Nepal)
Secretary (SAARC SVS)
Vice Chairman(Youth Int’l union of Angiology)
Councillor (Asian society of Vascular Sx)

2. Common
1.Varicose veins
2.DVT
Rare
-- Venous malformation

3. Varicose veins
• Varicose veins are veins that have become Long, tortuous and dilated due to non-functional valves.

4. Signs and Symptoms
• Burning or itching
• Night Cramps
• Throbbing pain
• Stinging sensation
• Swelling in the legs
• Leg heaviness or fatigue
• Skin discoloration
• Non- healing Ulcer

6. Investigation
• Duplex Venous Scan – GOLD STANDARD
• Patency of deep veins
• Competency of valves
• Site of incompetence
• Assessment of arterial system

7. Rx options
• Compression stockings
• Sclerotherapy
• Phlebectomy
• Surgery
• Laser
• RFA
• MOCA

8. Would you like to enter these groins?

9. To ensure safe surgical practice,there are alternatives to open surgery of
VV(stripping , ligation or phlebectomy):
1.EVTA
a.RFA b.Laser
2.MOCA
3.Sclero

10. RFA Rx Parameters
• 7 cm treatment in 20 sec
• Device (set) temperature: 120° C
• Vein wall contact temperature: 105 - 115° C
• 40 Watts max power
• Average energy delivery is approxiately
67 J/cm per treatment

11. VNUS® Closure FAST™ Catheter
• 7cm heating element on distal end of catheter
• 7F heating element diameter
• Temperature controlled energy delivery
• Non-stick surface prevents coagulum build-up on heating
element
• Center lumen accommodates a .025” guidewire
• Available in 60cm and 100cm lengths
• 7F, 11cm sheath recommended
Closure FAST Catheter

12. Pre-op Mapping & Marking
• Evaluate for and note:
• Depth of vein from surface
• Minimum and maximum vein diameters
• Significant anatomy
• Tortuous and aneurysmal segments
• Duplicate saphaneous system
• Tributaries, branches and perforators
• Identify potential vein access sites
• Mark vein pathway and significant anatomical findings
Procedure steps

29. Pre & post RFA

30. • Thermal destruction of the venous tissues with diode laser
• The laser is repeatedly fired as the laser fiber is gradually
withdrawn along the course of the vein until the entire vessel is
treated.
Laser

31. •Endo-venous LASER surgery uses the advanced technology of duplex scanning to accurately place a laser fiber probe
into the main varicose venous channel (Saphenous V).
•The probe is passed into the varicose vein using only a needle puncture in the leg. The LASER causes the vein to scar
completely, eliminating the varicosities with no surgery required.

33. Advantages of EVTA:
Outpatient procedure
Quick & easy to perform
Minimally invasive
No scarring
Excellent clininical & aesthetic results

34. Post Op Doppler

35. Time Required to Ablate 45cm GSV Segment
Closure FAST (120°C) 3 - 5 min(1)
Closure Plus (85°C) 18 - 24 min(1)
Closure Plus (90°C) 10 - 12 min
810nm Laser (10 - 14W) 10 – 15 min(2)
1320nm Laser (6 - 10W) 7.5 min(3)
1470 nm diode laser
References:
1 – How it Works; VNUS® ClosureFAST™ website 4/09/07
2 - EVLT® – Compare Alternatives; Diomed website 4/09/07
3 - Proebstle; ACP2004 abstract

36. MOCA

37. MOCA
Advantages:
1.Only one time injection instead of multiple injections as in EVTA.
2.Comfortable.
3.Walk out & straight back to work in most cases.
4.No risk of thermal damage to nerves.
5.Almost no bruising.
Disadvantages:
1.No long term studies yet.
2.Subsequent sclerotherapy often needed.
3.Not yet covered by some insurance companies.

38. Sclerotherapy
Application of a sclerosing agent in the form of foam, guided by USG
or without it, in a given insufficient vein, in order to occlude vein.

39. • Sclerosing agents cause venous tunica intima chemical irritation & inflammation of the endothelial layer of the
vein which originates a local thrombus attached to the vein's walls and it turns into a fibrotic or sclerotic.
The most utilized sclerosing agents: polidocanol & STS, in
concentrations ranging from 1% to 3% and volumes ranging
between 2 to 15 ml.

40. Advantages of Sclerotherapy:
Quick relief from symptoms
No downtime with minimal risk of side effects
Minimally invasive with no scarring
Cost-effective

41. EVTA+sclero+phlebectomy+excision

42. DVT: Symptoms and Signs
Leg pain
Swelling of the limb
Sensation of muscle cramping
Tenderness of the calf (or arm)
Symptoms are neither sensitive nor
specific for DVT

43. Gold standard
Duplex Scan

44. Long Term Complications of VTE
• Recurrence
• PTS

45. Impact of PTS
• In developing world major morbidity
• Poorer QOL

46. Management of VTE
Aim of Management:
• Initially : to prevent propagation of thrombus
• Chronic anticoagulation to allow fibrinolysis and recanalization.

47. Indirect thrombin inhibition
Heparin/antithrombin/thrombin complex
Heparin
Antithrombin
Thrombin
 Heparin immediately and for at least 3 to 5 days
 VKA started on the 1st day
 Failure to achieve optimum treatment early on leads to recurrence
rates of 20 %

48. UFH vs. LMWH
• Similar efficacy &superior safety
• Monitoring
• Risk of bleeding (lower risk in LMWH 1.3% vs. 2.1%, odds ratio 0.60, meta-analysis
of 14 studies)
• Lower overall mortality ( cancer pts.)
• Outpatient management
• Overall cost
• Reversal in bleeding patients: only the AT activity, not the Xa is
neutralized
• Obese patients: adjusted vs. total body weight
• Renal failure

49. Prevention & management of PE
• UFH gradually replaced by LMWH
• Similar efficacy and safety in sub-
massive PE
• Thrombolytic therapy essential in
massive PE (better identification of
patients needed).

50. Absolute
Indications for Caval Filter
1.Recurrent PE despite adequate anticoagulation
2. PE in a patient who cannot be anticoagulated
3. Increasing PAH despite anticoagulation
4. Large, bilateral defects in a decompensated patient

51. Vitamin K Antagonists
• > reduction of risk of recurrence
• Bleeding risk is 1.4% per year of major bleeds
• 0.25% of fatal bleeds per year
• Inhibits Vitamin K dependent carboxylase activity
• Prevents reduction of Vitamin K
• Does not affect proteins already synthesized
• Monitoring
• Multiple interactions with other drugs

52. Novel oral anticoagulants
• Fondaparinux : Pentasaccharide
• Dabigartran : oral DTI
• Rivaroxaban: direct factor Xa inhibitor
Advantages
No coagulation lab monitoring
No dose adjustments
No drug-food interactions
No incidence of HIT
Rare drug-drug interactions
No bridging needed prior to invasive procedures

53. Open surgery:
Early Thrombus Removal for prox. DVT to prevent valvular damage and PTS.

54. Endovascular management of DVT
Proximal
lower-extremity
DVT
and
a reasonable life
expectancy.

55. Endovascular Treatment Options:
Catheter-directed thrombolysis (CDT)
- allows infusion of thrombolytics directly into the VT, limiting systemic drug exposure.
-Thrombolytic agents used with CDT include: urokinase , tPA, r-tPA or tenecteplase .

56. Ultrasound-accelerated thrombolysis — EKOS EndoWave.
-The EKOS EndoWave uses low-power, high-frequency ultrasound (2 MHz) in combination with CDT to achieve clot
disruption .
-Ultrasound waves generated by the unit do not directly macerate the clot, but rather create microstreams that increase
thrombus permeability via alteration of fibrin composition.

57. Percutaneous Mechanical Thrombectomy
-OFFERS the benefit of early thrombus removal, while limiting thrombolytic dosages and bleeding complications.
-PMT additionally offers aRx option for patients with absolute contraindications for lytic therapy as the AngioJet.
AngioJet Rheolytic Thrombectomy System —
Pulse Power Spray Technique.
The AngioJet catheter system is comprised of a single-use catheter, a single-use pump set and a drive unit.

58. Trellis-8 Infusion System —
Pharmacomechanical Thrombectomy.
The Trellis-8 infusion system incorporates the use of both chemical thrombolysis and mechanical thrombectomy .
-The Trellis device consists of a single-use catheter, a dispersion wire and an integral drive unit. The catheter contains
proximal and distal occlusion balloons that allow infusion of thrombolytics to an isolated segment of thrombosed vein.

59. Venoplasty and Stenting:
-Post-treatment evaluation of the venous segment may reveal areas of venous
compression, stenosis or recalcitrant thrombus in > 90% of patients.
-May-Thurner syndrome
most common anatomic variant found on COMPLETION imaging during the
treatment of proximal DVT .

60. -Endovascular Rx are more effective in reducing long-term morbidity after prox DVT when
compared to anticoagulation alone.
-These options should be considered for all patients with prox lower-extremity DVT and a
reasonable life expectancy.
-PMT is at least as effective as CDT, with reduced ICU and hospital stays and decreased overall
COSTS.
-Venous angioplasty and stenting may be required to treat recalcitrant thrombus or anatomic
causes of DVT.
Conclusions:

61. PREVENT VENOUS THROMBOEMBOLISM

62. Thnx
Vietnam Vascular disease
association.
See you
@ESCVS Pari
June 14-16

63. See you all at ASVS 2023 Antalya

64. See you all at ASVS 2024 Bangkok

65. See you all at ASVS S’pore 2025

66. 31s IUA ,Porto,June 2024 Columbia ,2026

67. Thanxs