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Management of great saphenous varicosities: Endovenous therapy or conventional surgery? Joint Hospital Surgical Grand Round 19 th October 2013 Wong Ka Ming Candy Tseung Kwan O Hospital Slide 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 Slide 3 Management Options Advice and Reassurance Compression Therapy Interventional Therapy Surgery Endovenous Ablation Thermal Laser Ablation Radiofrequency Ablation ChemicalSclerotherapy Slide 4 Surgery Gold standard over the past century SFJ ligation +/- stripping Disadvantages: 1.General anaesthesia / regional anaesthesia 2.Painful groin wound 3.Risks of surgery 4.Bruise is common Slide 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. Slide 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. Direct thermal injury Carbonization of vein wall Indirect thermal injury Formation of steam bubbles Transmit heat energy to endothelium Thermal injury Thrombosis and occlusion of vein Slide 7 Radiofrequency Ablation ( RFA) First reported in 1998 in Switzerland Approved by US FDA in 1999 Bipolar catheter used to generate energy 1 st generation2 nd generation3 rd generation Catheter nameClosureClosure PlusClosure Fast Year199920032006 Temperature ( )85 120 Speed2-3 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 Slide 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 Slide 9 EVLA / RFA Procedure 1.Duplex ultrasound localization 2.GSV identified and cannulated 3.Introducer sheath and catheter inserted 4.Catheter positioned 2cm from SFJ 5.Injection of tumescent solution 6.Catheter slowly withdrawn and fired until the tip is 1cm from the skin surface Slide 10 Tumescent solution Normal saline + lignocaine with adrenaline +/- 8.4% sodium bicarbonate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 Slide 11 Foam sclerotherapy Chemical ablation Sodium tetradecyl sulphate ( STS) / Polidocanol Tessari technique Mix with air / CO2 1: 4 ratio Slide 12 Foam Sclerotherapy Obliteration of the lumen Induces fibrosis, causing inflammation Foam displaces blood in vein Injection of foam sclerosant GSV cannulated under ultrasound guidance Slide 13 Current evidence comparing endovenous procedure and surgery? Slide 14 Published Aug 2012 Slide 15 Failure to completely abolish reflux Primary outcomes: Clinical recurrence Post op complications Post op pain Time return to normal activities / work QOL Secondary outcomes: Slide 16 EVLA versus Surgery Slide 17 EVLA 1.5times higher risk of primary failure Slide 18 EVLA 40% less chance of clinical recurrence Slide 19 EVLA less post op complications OutcomesNo. of studiesNo. of patients Pooled RR (95% CI) Wound infection813470.3 (0.1, 0.8) Parasthesia913870.8 ( 0.6, 1.1) Superfical thromboplebitis 611211.0 (0.5, 1.8) Haematoma47080.5 ( 0.3, 0.8) ecchymosis68760.7 ( 0.3, 1.6) Slide 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 Slide 21 RFA versus Surgery Slide 22 RFA 1.3 times higher risk of primary failure Slide 23 RFA 10% less chance of clinical recurrence Slide 24 Post op complications OutcomesNo. of studiesNo. of patients Pooled RR (95% CI) Wound infection56710.3 ( 0.1, 0.4) Parasthesia77591.0 ( 0.5, 0.7) Superfical thromboplebitis 66992.3 (1.1, 5.0) Haematoma54370.4 ( 0.1, 0.8) Slide 25 Other results ( RFA vs Surgery) Less post op pain * Earlier return to normal activities / work* * statistically significant Slide 26 UGFS vs Surgery Kendler M, Wetzig T, Simon JC. Foam sclerotherapy: a possible option in therapy of varicose veins Slide 27 UGFS 2.4 times higher risk of primary failure Slide 28 EVLASurgeryRFASurgeryUGFSSurgery Primary failure Clinical recurrence Wound infection Parasthesia Superficial thromboplebitis Haematoma Post op pain Return to normal activities QOL Slide 29 Slide 30 NICE guideline 2013 Refer to vascular service if Symptomatic Lower limb skin changes Pigmentation / eczema Superficial vein thrombosis Venous leg ulcer Slide 31 NICE guideline 2013 Assessment - Duplex ultrasound Confirm diagnosis Extent of truncal reflux Interventional Treatment Endothermal ablation Ultrasound guided foam sclerotherapy Surgery Slide 32 Thank You Slide 33 Slide 34 Slide 35 Slide 36 Slide 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 Slide 38 CEAP classification Etiological Ec: congenital Ep: primary Es: secondary (post-thrombotic) En: no venous cause identified Slide 39 CEAP classification Anatomical As: superficial veins Ap: perforator veins Ad: deep veins An: no venous location identified Slide 40 CEAP classification Pathophysiological Pr: reflux Po: obstruction Pr,o: reflux and obstruction Pn: no venous pathophysiology identifiable Slide 41 Duplex ultrasound Assess the size of the GSV Relation to overlying varices Evaluate the reflux time in conjunction with venous diameter Slide 42 EVLA Complications Saphenous nerve paraesthesia DVT Skin burns Phlebitis Bruises Slide 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 Slide 44 Conservative Weight loss Exercise Elevation of lower limbs Compression therapy Different graded pressures for patient with different severities Slide 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 Slide 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