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Anatomy and Physiology of Veins; Principles of Sclerotherapy Gerant Rivera-Sanfeliz,MD

Anatomy and Physiology of Veins; Principles of Sclerotherapy Gerant Rivera-Sanfeliz,MD. Venous Pathology. > 100 million people with venous disorders in US and Europe > 40% women and 20% men living with superficial venous disease > One million vein stripping procedures/year in US and europe.

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Anatomy and Physiology of Veins; Principles of Sclerotherapy Gerant Rivera-Sanfeliz,MD

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  1. Anatomy and Physiology of Veins;Principles of SclerotherapyGerant Rivera-Sanfeliz,MD

  2. Venous Pathology • > 100 million people with venous disorders in US and Europe • > 40% women and 20% men living with superficial venous disease • > One million vein stripping procedures/year in US and europe

  3. Varicose Veins (Rutherford) • Venous Disorders - 211 of 2032 pages • Varicose Veins - 4 pages

  4. Lower Extremity Veins • Deep system • Superficial system • Perforator system • Lateral subdermic venous system (LSVS)

  5. Great Saphenous Vein (GSV)Previous Long Saphenous Vein (LSV) • Known as “el safin” by Arabic physicians, which means the concealed • Located along the medial aspect of the lower extremity • True duplication seen in 10-37%, often joining within 10 cm of the knee • Saphenous nerve • Saphenous compartment • Joins CFV at fossa ovalis (SFJ)

  6. Small Saphenous Vein (SSV)Previous Lesser Saphenous Vein • Travels, with the sural nerve, along the lateral aspect of the leg • Joins popliteal vein at SPJ between the two heads of the gastrocnemius • May extend into the thigh and communicate with the femoral vein or GSV (Vein of Giacomini) • True duplication rarely reported

  7. Perforating Veins • Communicate the deep and superficial systems • Horizontal or slightly upward orientation • Flow normally from superficial to deep • Common GSV perforators: - Hunterian (midthigh) - Dodd’s (above knee) - Boyd’s (below knee) - Cockett (distal leg)

  8. Subcutaneous Veins • When abnormal: - Varicose (> 3mm) - Reticular (1- 3 mm) - Telangiectasia (spider)

  9. Lateral Subdermic Venous System (LSVS) • Lateral aspect of leg above and below the knee • Embryonic superficial vessels fail to involute • Varicosities at young age, not increasing with age • Perforators

  10. Three Anatomical Areas: Epifascial Subcutaneous veins Intrafascial Superficial veins Subfascial Deep veins Three fully interacting systems: superficial, deep, perforators

  11. Vein Physiology • Pumps • Valves

  12. Muscle Pump (Peripheral Heart) • Contractions propel blood toward heart • Relaxation draws blood from - superficial veins - lower deep veins

  13. Thoracoabdominal Pump • Inspiration decreases intrathoracic pressure promoting venous return • Expiration reverses the process • Findings easily seen in US

  14. Valves • Maintain unidirectional flow - Extremity to heart - Superficial to deep • GSV and SSV with terminal and preterminal valves • Terminal (sentinel or first) valve with firm thickened white cusps different from the rest of the valves

  15. PathophysiologyVaricose Veins (VV) • Histologic studies show the collagen content of primary VV less than normal veins • Muscle content, although high, shows disorganization with areas broken up by similarly disorganized collagen • These findings may account for the decreased elasticity of VV

  16. A. Normal B. Leaky Valve Syndrome -Valves become stretched -Allow back flow of Blood C. Superficial Valvular Reflux -Vein becomes engorged -Increasing pressure -Thinning walls -Weaken muscle support -Can enlarge vessel diameters greater than 10mm Pathophysiology> 90% LEVI Incompetent Valve Progression

  17. Patterns of Reflux • Truncal or saphenous related reflux - GSV: 4/6 of VV - SSV: 1/6 of VV • Non-truncal reflux: 1/6 of VV - Pudendal, perforators - LSVS, Giacomini

  18. SVI – SymptomsBad looks, bad feelings • Aching • Vague Discomfort • Heat/Burning • Skin changes, bleeding • ? Swelling All tend to increase with dependency and resolve with leg elevation or compression

  19. SVI - Stigmata • Abnormal veins - telangiectasia (spider) - reticular - Non-saphenous VV (perforans varicosis) - Saphenous VV • Abnormal skin

  20. SVI - Stigmata • Abnormal veins - telangiectasia (spider) - reticular - Non-saphenous VV - Saphenous VV • Abnormal skin

  21. SVI - Stigmata • Abnormal veins - telangiectasia (spider) - reticular - Non-saphenous VV - Saphenous VV • Abnormal skin

  22. SVI - Stigmata • Abnormal veins - telangiectasia (spider) - reticular - Non-saphenous VV - Saphenous VV • Abnormal skin

  23. SVI - Stigmata • Abnormal veins - telangiectasia (spider) - reticular - Non-saphenous VV - Saphenous VV • Abnormal skin Courtesy of Dr. J. Golan

  24. SVI - Stigmata • Abnormal veins • Abnormal skin - eczema - edema - corona phlebectatica - lipodermatosclerosis - ulceration

  25. Classification Of CVDCEAP • C - clinical signs 0: No visible venous disease 1: Telangiectasias or reticular veins 2: Varicose veins 3: Edema 4: Skin changes 5: Healed ulceration 6: Active ulceration J Vasc Surg 1995; 21:635-645.

  26. Courtesy of Dr. J. Golan

  27. Courtesy of Dr. J. Golan

  28. Imaging In PVI • Duplex ultrasonography • Has replaced plethysmography and venography • 7-10MHz linear array transducer • Examination performed in sitting and standing positions • Superficial and deep systems evaluated • Physiologic reflux: < 0.5 sec • Pathologic reflux: > 0.5 sec

  29. Standard Surgical Treatment • Saphenous vein ligation • Saphenous vein stripping +/- ligation • Flush SFJ ligation, stripping the thigh portion of the GSV with excision of its tributaries and stab avulsion phlebectomies of the VV • SEPS (subfascial endoscopic perforator surgery)

  30. Ligation vs. Stripping Recurence of VV higher with ligation when compared to stripping of the thigh portion of the GSV (McMullin GM, et al. Br J Surg 1991; 78:1139-1142/ Stonebridge PA, et al. Br J Surg 1995; 82:60-62/ Rutgers PH, et al. Am J Surg 1994; 168:311-315)

  31. Fischer R, et al. The Unresolved Problem of Recurrent Saphenofemoral Reflux. J Am Coll Surg 2002; 195:80-94.

  32. Surgical Complications • Wound Infection • Hematoma/severe bruising • Scarring • DVT • Recurrence Courtesy of Dr. J. Golan

  33. One conclusion is apparent from the surgical literature: The crucial step in treating VV is removing the thigh portion of the refluxing saphenous vein from the circulation.

  34. Percutaneous Options • Sclerotherapy • Endovenous Ablation - Radiofrequency - Laser

  35. A small amount of damage will produce … … but a thrombosed vessel with intact endothelium will not sclerose

  36. Volume Dilution • Zone 1: vessel is irreversibly injured • Zone 2: vessel will be able to recanalize • Zone 3:no endothelial injury, dilute sclerosant

  37. Modern Sclerosants • Detergents • Hypertonic and ionic solutions • Cellular toxins

  38. Detergents Detergent sclerosants work by a mechanism known as protein theft denaturation, in which an aggregation of detergent molecules forms a lipid bilayer in the form of a sheet, a cylinder or a micelle, which then disrupts the cell surface membrane and may steal away essential proteins from the cell membrane surface. Cell Death • Most commonly used • Sodium morrhuate, sotradecol, polidocanol, among others • Liquid or Foam

  39. Advantages Injection is Painless Extravasation  No Necrosis Disadvantages Pigmentation  Intermediate Polidocanol (0.5%)

  40. Sclerotherapy - Results • Excellent for small veins: reticular, telangiectasias • High recanalization rates for larger veins • GSV: > 50% recurrent reflux by US, which is likely the prelude for recurrence of VV

  41. Sclerotherapy-Complications • Pigmentation • Matting • Ulceration Courtesy of Dr. J. Golan

  42. Sclerotherapy vs. Surgery • Prospective 10 year study (121 96) • VV and superficial incompetence • Group A: Sclerotherapy (39) • Group B: Ligation + Sclerotherapy (40) • Group C: Ligation only (42) • No incompetence at SFJ in surgical groups • Sclerotherapy with 20-44% reflux • Sclerotherapy cheaper, surgery superior Belcaro G, et al. Angiology 2000; 51:529-534.

  43. Sclerosing Foam • Orbach(1944): the air block technique • Displaces blood • Induces more spasm • Tiny bubbles covered by tensio-active liquid • Treat larger veins

  44. 1ml of 3% STS injected in a vein dilutes with 10ml of blood Final drug concentration: 0.3% 1ml of 1% Foam STS injected in the same vein displaces blood Final drug concentration: 1%

  45. Sclerosing Foam • Less volume • More potent • Morbidity appears similar to liquid sclerosants • Being used clinically since 1997, results in GSV better than liquid ~ 20-30% recanalization

  46. Percutaneous Options • Sclerotherapy • Endovenous Ablation - Radiofrequency - Laser

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