complicated superficial venous disease

Complicated Superficial Venous Disease

Ron Bush, MD, FACSMidwest Vein & Laser Center

Dayton, OH

Disclosures

Dornier, VeinGogh, VeinExperts.org, BushVenousLectures.com

My Experience• In my 17 years of a purely venous practice, the

most complicated aspect of superficial disease are the aneurysms of the GSV, AAGSV, & SSV

• Most are benign in presentation• Potentially lethal• Inappropriate treatment may make a benign

condition be malignant

Definition of Aneurysm Conflicting• Pascarella, 2005, define an aneurysm as 1.5x

contiguous vein diameter• (Gabrielli, 2012) – 2.0x contiguous diameter or

3x normal vein size• Only histologic evaluation can differentiate

aneurysm from dilatation• But dilatation may mimic same presentation

and clinical outcome as an aneurysm

Histoslide of Aneurysm

High Ligation Aneurysm Photo

GSV Aneurysm

GSV Aneurysm with Small Neck

Type II aneurysm

• Treated with thermal ablation, stripping, or phelbectomy

SSV Aneurysm• At SPJ junction, excision is the only option• Mimics popliteal aneurysm• Distal aneurysm can be excised, ablated, or

foam and depends on the size

SSV Aneurysm

Treatment of GSV Aneurysm• Conventional treatment – high ligation• But treatment can be individualized

depending on anatomic location• Post-terminal vs. post-subterminal valve• Contradicts Pacarella and Bergan’s report

AAGSV Aneurysm

AAGSV Aneurysm

• This should be classified as a Type V aneurysm, since it is a distinct aneurysm

• True incidence not known• May be associated with GSV aneurysm• Treatment depends on diameter of

connection to GSV connection- ligation• Small connection – thermal ablation of distal

trunk or foam

Etiology

• Long standing venous hypertension• Turbulent flow at valve• Increased BMI

Final Considerations

• Consider unloading GSV circuit before definitive treatment (Personal communication – Allesandro Frullini, MD)

• 4-6 months later, there may be substantial reduction in aneurysm size

• Treatment can be individualized, but any persistent aneurysmal dilatation post terminal valve including junctional branches should be resected

Final Considerations

• All SSV aneurysms involving SPJ are excised• Inappropriate treatment may lead to clot

propagation and possible pulmonary embolus

References

• Pascarella L, Al-Tuwaijri, Bergan J, & Mekenas L. Lower extremity superficial venous aneurysms. Ann Vasc Surg 2005;19:69-73.