Management of great saphenous varicosities: Endovenous therapy or conventional surgery?
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Management of great saphenous varicosities:
Endovenous therapy or conventional surgery?
Joint Hospital Surgical Grand Round19th October 2013Wong Ka Ming CandyTseung Kwan O Hospital
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
Management Options
Surgery
• Gold standard over the past century• SFJ ligation +/- stripping • Disadvantages:
1. General anaesthesia / regional anaesthesia2. Painful groin wound 3. Risks of surgery4. Bruise is common
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.
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.
Radiofrequency Ablation ( RFA)
• First reported in 1998 in Switzerland• Approved by US FDA in 1999• Bipolar catheter used to generate energy
1st generation 2nd generation 3rd generation
Catheter name Closure Closure Plus Closure Fast
Year 1999 2003 2006
Temperature (℃) 85 85 120
Speed 2-3 cm / min 2-3 cm / min 7cm segment in 20sec cycle
Lohr J, Kulwicki A. Radiofrequency ablation: evolution of a treatment. Semin Vasc Surg. 2010;23:90-100. 20
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
EVLA / RFA Procedure
1. Duplex ultrasound localization2. GSV identified and cannulated 3. Introducer sheath and catheter inserted4. Catheter positioned 2cm from SFJ5. Injection of tumescent solution6. Catheter slowly withdrawn and fired until the
tip is 1cm from the skin surface
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
Foam sclerotherapy
• Chemical ablation• Sodium tetradecyl sulphate ( STS) /
Polidocanol• Tessari technique– Mix with air / CO2– 1: 4 ratio
Foam Sclerotherapy
Current evidence comparing endovenous procedure and surgery?
Published Aug 2012
EVLA versus Surgery
EVLA 1.5times higher risk of primary failure
EVLA 40% less chance of clinical recurrence
EVLA less post op complications
Outcomes No. of studies No. of patientsPooled RR (95%
CI)<EVLA vs Surgery>
Wound infection 8 1347 0.3 (0.1, 0.8)
Parasthesia 9 1387 0.8 ( 0.6, 1.1)
Superfical thromboplebitis 6 1121 1.0 (0.5 , 1.8)
Haematoma 4 708 0.5 ( 0.3, 0.8)
ecchymosis 6 876 0.7 ( 0.3, 1.6)
Other results ( EVLA vs Surgery)
• Less post-op pain *• Earlier return to normal activities / work• Better QOL ( by AVVSS)
* Statistical significantAVVSS = Aberdeen varicose vein severity score
RFA versus Surgery
RFA 1.3 times higher risk of primary failure
RFA 10% less chance of clinical recurrence
Post op complications
Outcomes No. of studies No. of patients Pooled RR (95% CI)<RFA vs Surgery>
Wound infection 5 671 0.3 ( 0.1, 0.4)
Parasthesia 7 759 1.0 ( 0.5, 0.7)
Superfical thromboplebitis 6 699 2.3 (1.1, 5.0)
Haematoma 5 437 0.4 ( 0.1, 0.8)
Other results ( RFA vs Surgery)
• Less post op pain *• Earlier return to normal activities / work*
* statistically significant
UGFS vs Surgery
Kendler M, Wetzig T, Simon JC. Foam sclerotherapy: a possible option in therapy of varicose veins
UGFS 2.4 times higher risk of primary failure
EVLA Surgery RFA Surgery UGFS Surgery
Primary failure Clinical
recurrence
Wound infection
Parasthesia
Superficial thromboplebitis
Haematoma
Post op pain
Return to normal activities
QOL
NICE guideline 2013
• Refer to vascular service if…– Symptomatic – Lower limb skin changes• Pigmentation / eczema
– Superficial vein thrombosis– Venous leg ulcer
NICE guideline 2013
• Assessment - Duplex ultrasound– Confirm diagnosis – Extent of truncal reflux
• Interventional Treatment
Thank You
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
CEAP classification – Etiological
• Ec: congenital• Ep: primary• Es: secondary (post-thrombotic)• En: no venous cause identified
CEAP classification – Anatomical
• As: superficial veins• Ap: perforator veins• Ad: deep veins• An: no venous location identified
CEAP classification – Pathophysiological
• Pr: reflux• Po: obstruction• Pr,o: reflux and obstruction• Pn: no venous pathophysiology identifiable
Duplex ultrasound
• Assess the size of the GSV• Relation to overlying varices• Evaluate the reflux time in conjunction with
venous diameter
EVLA Complications
• Saphenous nerve paraesthesia• DVT• Skin burns• Phlebitis • Bruises
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
Conservative
• Weight loss• Exercise• Elevation of lower limbs • Compression therapy– Different graded pressures for patient with
different severities
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
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
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