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Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications. Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery Faculty of Medicine, University of Thessalia, Greece

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Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery

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  1. Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery Faculty of Medicine, University of Thessalia, Greece Chairman, Dept. of Vascular Surgery, University Hospital of Larissa Larissa, Greece

  2. GSV Before Treatment Image courtesy of Olivier Pichot, MD, CHU de Grenoble, France.

  3. GSV After Treatment Image courtesy of Olivier Pichot, MD, CHU de Grenoble, France.

  4. CEAP Clinical Classification Class 0: Asymptomatic; no visible or palpablesigns 1: Spider veins, reticular veins, telangiectasias 2: Varicose veins 3: Edema 4a: Skin changes with hyperpigmentation and eczema 4b: Skin changes with lipodermatosclerosis and atrophie blanche 5: Healed ulcer 6: Active ulcer

  5. CEAP Clinical ClassificationsClinical Etiology AnatomyPathophysiology Varicose Veins CEAP 2 Swelling CEAP 3 Skin Changes CEAP 4 Skin Ulcer CEAP 6

  6. Is pre-op duplex assessment important for varicose vein surgery?

  7. Ultrasonic assessment

  8. Explanation • Information provided by DS will have significant impact on the selection of appropriate treatment • Failure to identify all sources of venous filling is likely to result in early recurrence

  9. Indications for Duplex Scan Recommendation: both limbs should be studied • Primary uncomplicated GSV VVs Debated whether all pts – if not 30% of important connections between deep and superficial veins will be missed • Primary uncomplicated LSV VVs Essential • Non-saphenous & Recurrent VVs Essential • CVD with complications Essential • Surveillance after treatment the only way to obtain level I evidence as to outcome in the future • Venous malformations anatomical information about the extent of the malformation and its relationship to other vessels may be used to guide treatment by sclerotherapy

  10. Position of the patient Greater saphenous

  11. Position of the patient Lesser saphenous

  12. Anatomy of superficial veins of the lower limb

  13. Important anatomical details

  14. Anatomical structures on B-mode

  15. Images courtesy of Olivier Pichot, MD GSV • Bound anteriorly by superficial fascia & posteriorly by deep fascia • Often called “saphenous eye” Fascial layers creating “saphenous eye”

  16. Images courtesy of Olivier Pichot, MD GSV Variables Tortuosity Side branches

  17. GSV Variables Aneurysmal segments

  18. SFJ Tributary Veins • SCI: Superficial Circumflex Iliac • SE: Superficial Epigastric • SEP: Superficial External Pudendal • AASV: Anterior Accessory Saphenous • PASV: Posterior Accessory Saphenous Image adapted from: Chandler JG et al. Defining the role of extended saphenofemoral junction ligation: A prospective comparative study. JVS 2000;32:941-53

  19. Initial Catheter Tip Positioning • Position catheter tip approximately 2.0 cm distal to SFJ • Confirm with measurement calipers • Distance does not need to be precise at this time because catheter position may shift during tumescent fluid infiltration

  20. Image courtesy of Pranay Ramdev, MD Final Tip Position Verification • Recommendation is 2.0 cm distal to SFJ • In both transverse and longitudinal imaging planes • Use measurement calipers to confirm distance to SFJ • Important step to avoid misaligning catheter relative to deep venous system • Confirm tip position with ultrasound:

  21. Anatomical structures on colour facility

  22. Small Saphenous Vein (SSV) • Courses from lateral ankle up posterior calf • Terminates in popliteal fossa at Saphenopopliteal Junction (SPJ) • Variable confluence with Popliteal Vein (PV) • Proximal portion lies between superficial & deep fascial layers SPJ Pop V SSV Figure adapted from: Weiss RA, et al eds. Vein diagnosis and treatment: A comprehensive approach. McGraw-Hill Companies, Inc.; 2001.

  23. Anatomical structures on colour facility

  24. Detection of reflux on colour facility

  25. Detection of reflux on colour facility

  26. Detection of reflux on colour facility

  27. Detection of reflux on colour facility Perforating vein If reflux is present measure the diametre but this cannot distinguish competent from incompetent Duration of reflux

  28. Detection of reflux on Doppler Reflux is present when retrograde flow lasts for at least 1 sec

  29. Patient selection for EndovenousAlation • Identification of all refluxing venous segments and their ablation is the key to minimise recurrence • Diametre of central GSV > 15 mm may be associated with thrombus extension to CFV • Uncorrectable coagulopathy • Liver dysfunction limiting local anaesthetic use • Immobility • Pregnancy • Breastfeeding

  30. Contraindication • Thrombus in the vein segment to be treated

  31. Choosing the Closure Candidate • Preoperative ultrasound evaluation • Reflux > 0.5 seconds in superficial venous system • Assess GSV, noting: • Vein depth and maximum diameter • Presence of tortuous or aneurysmal segments • Other significant anatomy • Duplicate systems • Large side branches • Incompetent perforators or tributaries

  32. Vein depth from the skin: Why is so important? The aim of ablation procedures is to damage the inner vein wall without causing a full-thickness burn, which could lead to perforation of the vein resulting in bruising or haematoma formation If vein lies superficially, close to skin the ablation may cause burn

  33. Pre-op Ultrasound Assessment • Map and mark • Maximum diameter • Tortuous segments • Aneurysmal segments • Areas where vein is very close to skin • Large branches or perforators • Potential access sites

  34. Image courtesy of Carolyn Menendez, MD Infiltration Technique • Do not leave any vein segments unprotected • Re-scan to ensure: • >10 mm distance between skin surface and vein wall • Circumferential black “halo” appearance in fascial compartment • Perivenous vs. subcutaneous infiltration

  35. Image courtesy of Nick Morrison, MD Vein Mapping • Make indentions in skin using a straw • Remove US gel from leg • Connect marks on leg with marker to identify pathway of vein and important anatomy

  36. Pre-op Descending Venography

  37. Selective descending ovarian and hypogastric venogram Significant ovarian vein reflux but No hypogastric vein reflux was detected

  38. Ovarian vein reflux Hypogastric vein reflux

  39. Descending Ovarian Venogram 4 weeks after embolisation

  40. Hypogastric vein embolisation

  41. CT venography

  42. Chronic Venous Obstruction

  43. DP=8 mmHg DP=22 mmHg DP=2 mmHg

  44. IVC filter placement Indications • DVT and covtraindication for anticoagulation • Reccurent PE being on adequate anticoagulation Pre-procedural evaluation • MR or CT venography is required for IVC and iliac vein patency and IVC diametre measurement

  45. Thank you for your attention

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