Management of great saphenous varicosities: Endovenous therapy or conventional surgery?

1. Management of great saphenous varicosities: Endovenous therapy or conventional surgery? Joint Hospital Surgical Grand Round 19th October 2013 Wong Ka Ming Candy Tseung Kwan O Hospital

2. Introduction • Dilated, tortuous superficial veins • Affect 20-30% of adults • More common in female • Symptoms varies • May develop complications with time • Venous ulcer in 3-6% of patients with varicose vein

3. Management Options

4. Surgery • Gold standard over the past century • SFJ ligation +/- stripping • Disadvantages: • General anaesthesia / regional anaesthesia • Painful groin wound • Risks of surgery • Bruise is common

5. Endovenous Laser Ablation ( EVLA) • First report by Bone in 1999 • Approved by US FDA in Jan 2002 • Available laser generators: Ash JL et al. Laser Treatment of Varicose veins: order out of the chaos. Semin Vasc Surg. 2010 Jun;23(2):101-6.

6. EVLA Mechanism Ash JL et al. Laser Treatment of Varicose veins: order out of the chaos. Semin Vasc Surg. 2010 Jun;23(2):101-6.

7. Radiofrequency Ablation ( RFA) • First reported in 1998 in Switzerland • Approved by US FDA in 1999 • Bipolar catheter used to generate energy Lohr J, Kulwicki A. Radiofrequency ablation: evolution of a treatment. Semin Vasc Surg. 2010;23:90-100. 20

8. RFA Mechanism • Denaturation of collagen matrix • Vein wall collagen contraction • Fibrotic sealing of vessel lumen due to injury and inflammation to vein wall Lohr J, Kulwicki A. Radiofrequency ablation: evolution of a treatment. Semin Vasc Surg. 2010;23:90-100. 20

9. EVLA / RFA Procedure • Duplex ultrasound localization • GSV identified and cannulated • Introducer sheath and catheter inserted • Catheter positioned 2cm from SFJ • Injection of tumescent solution • Catheter slowly withdrawn and fired until the tip is 1cm from the skin surface

10. Tumescent solution • Normal saline + lignocaine with adrenaline +/- 8.4% sodium bicarbonate • Instilled into the saphenous sheath under ultrasound guidance • Functions: • Heat sink • Separate of GSV from saphenous nerve • Contraction of the vein

11. Foam sclerotherapy • Chemical ablation • Sodium tetradecyl sulphate ( STS) / Polidocanol • Tessari technique • Mix with air / CO2 • 1: 4 ratio

12. Foam Sclerotherapy

13. Current evidence comparing endovenous procedure and surgery?

14. Published Aug 2012

16. EVLA versus Surgery

17. EVLA 1.5times higher risk of primary failure

18. EVLA 40% less chance of clinical recurrence

19. EVLA less post op complications

20. Other results ( EVLA vs Surgery) • Less post-op pain * • Earlier return to normal activities / work • Better QOL ( by AVVSS) * Statistical significant AVVSS = Aberdeen varicose vein severity score

21. RFA versus Surgery

22. RFA 1.3 times higher risk of primary failure

23. RFA 10% less chance of clinical recurrence

24. Post op complications

25. Other results ( RFA vs Surgery) • Less post op pain * • Earlier return to normal activities / work* * statistically significant

26. UGFS vs Surgery Kendler M, Wetzig T, Simon JC. Foam sclerotherapy: a possible option in therapy of varicose veins

27. UGFS 2.4 times higher risk of primary failure

30. NICE guideline 2013 • Refer to vascular service if… • Symptomatic • Lower limb skin changes • Pigmentation / eczema • Superficial vein thrombosis • Venous leg ulcer

31. NICE guideline 2013 • Assessment - Duplex ultrasound • Confirm diagnosis • Extent of truncal reflux • Interventional Treatment

32. Thank You

37. CEAP classification - Clinical • C0: no visible or palpable signs of venous disease • C1: telangiectasies 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

38. CEAP classification – Etiological • Ec: congenital • Ep: primary • Es: secondary (post-thrombotic) • En: no venous cause identified

39. CEAP classification – Anatomical • As: superficial veins • Ap: perforator veins • Ad: deep veins • An: no venous location identified

40. CEAP classification – Pathophysiological • Pr: reflux • Po: obstruction • Pr,o: reflux and obstruction • Pn: no venous pathophysiology identifiable

41. Duplex ultrasound • Assess the size of the GSV • Relation to overlying varices • Evaluate the reflux time in conjunction with venous diameter

42. EVLA Complications • Saphenous nerve paraesthesia • DVT • Skin burns • Phlebitis • Bruises

43. Contraindications for endovenous ablation • DVT • Non palpable pedal pulse • Inability to ambulate • General poor health • Pregnant • Relative contraindications: • Non traversable vein segment – thrombosis / extreme tortuosity

44. Conservative • Weight loss • Exercise • Elevation of lower limbs • Compression therapy • Different graded pressures for patient with different severities

45. Surgery Complications • Wound haematoma / infection • Lymphatic leaks • Common femoral vein and artery injuries • Neurological complications • Bruises are common, can last up to 6 weeks • Usually advised to return to work after 10-14 days

46. Proposed Benefits • Avoidance of general anaesthesia • Can be done in outpatient setting • Minimal pain • Earlier return to normal activity • Decrease risk of nerve injury • Lower risk of recurrence