Skip to main content
UploadLanguage (EN)Support
BusinessMobileSocial MediaMarketingTechnologyArt & PhotosCareerDesignEducationPresentations & Public SpeakingGovernment & NonprofitHealthcareInternetLawLeadership & ManagementAutomotiveEngineeringSoftwareRecruiting & HRRetailSalesServicesScienceSmall Business & EntrepreneurshipFoodEnvironmentEconomy & FinanceData & AnalyticsInvestor RelationsSportsSpiritualNews & PoliticsTravelSelf ImprovementReal EstateEntertainment & HumorHealth & MedicineDevices & HardwareLifestyle
PW
Uploaded byPAIRS WEB
PPTX, PDF1,806 views

THE MIGHTY GSV2

The document discusses the anatomy of the great saphenous vein (GSV) and treatments for varicose veins. It describes the GSV as the main superficial vein in the leg that connects to the femoral vein. It summarizes current treatments as including sclerotherapy, surgery such as vein stripping, and newer endovascular techniques like radiofrequency ablation and endovenous laser therapy to close the GSV non-invasively. These minimally invasive methods are presented as promising new alternatives to surgery with benefits of shorter recovery times and fewer complications.

Health & Medicine◦
Downloaded 37 times
The MIGHTY Greater Saphenous Vein Abbas A. Chamsuddn, M.D. 1-Clinical Associate Professor, Department of Radiology AlBalamand University-School of Medicine Beirut, Lebanon 2-Chief, IR Service, Quantum Medical Radiology Atlanta, GA 3-Director, The Center for Laser and Interventional Surgery, Beirut, Lebanon
Disclosure:  Bard: – Honoraria – Research Grant  Angiodynamics: – Honoraria  Abbott: – Research Grant
Background
VENOUS ANATOMY: SUPERFICIAL VEINS • The veins of the lower extremity that are superficial to the muscular compartment • Include innumerable draining veins as well as the GSV and LSV
Lower Extremity Venous Anatomy  Superficial Veins  Deep veins  Great Saphenous Vein: Replaces “Greater” or “Long”  Small Saphenous Vein: Replaces “Lesser” or “Short”  Anterior and Posterior Accessory GSVs  Giacomini Veins  Truncal veins
Varicose Veins: Venous Anatomy  SFJ: Saphenofemoral junction  SPJ: Saphenopopliteal junction
The Great Saphenous Vein  Begins on the dorsum of the foot  Ascends along the medial aspect of the leg  Drains in the femoral vein  Resides in a space deep to the superficial fascia and superficial to the deep fascia
The Small Saphenous Vein  Begins along the lateral aspect of the foot  Ascends up the midline of the calf  In 2/3rd of cases drains in the popliteal vein  In 1/3rd of cases it drains more cephalad in the posterior thigh  Also resides in the saphenous space
Anterior and Posterior Accessory GSVs  Located in the saphenous space and travel parallel anterior/porterior to the GSV  Anterior AGSV is more common
Giacomini Vein  The intersaphenous vein  A communication between GSV and SSV
Perforators
Venous Anatomy  Deep Veins: – Femoral and Popliteal Tibial Veins  Superficial Veins – Small Saphenous Vein – Great Saphenous Vein  Perforators: Connectors of the deep veins to the superficial veins  Reticular Veins: Tributaries to the saphenous vein-connecting branch veins to deep, superficial or perforators  Telangiectasia: Spider Veins
Venous Anatomy
How Do Leg Veins Work?  Blood Travels Easily downhill! – pumped by the powerful action of the heart from above – aided by the elastic recoil of the artery walls – and of course, by the effect of gravity
How do Veins Work?  In the standing position: – blood has to be actively pumped up the column of veins – this is achieved with our calf muscles which squeeze the venous sinuses – when the muscles relax, the blood tends to rush back into the leg
Venous Insufficiency  Occur because: 1-Problem with the veins themselves 2-Weakness of the pumping mechanism of the calf:  Reflux of the column of blood through the leaky valve  Strain on the vein wall  Stretching and weakness at various points  End result: Varicose veins!
Venous Insufficiency  Varicose Veins: – Dilated, protruding, tortuous saccular superficial veins. – Develop in the superficial veins of the leg and mainly affect the long saphenous vein – Are higgledy-piggledy, dilated veins whose valves have failed allowing increasing amounts of blood to reflux the wrong way down the limb  Reticular Veins: Dilated, tortuous, non-protruding superficial veins  Telangiectasia: Spider appearing, tortuous, non-protruding or dilated
Varicose Veins  Symptoms: – Often unrecognized by patients and physicians – Aching pain – Night cramps – Fatigue – Heaviness – Restlesness
Varicose Veins  A health issue: Left untreated: – 50% will develop symptoms of severe venous insufficiency:  lower-extremity swelling  eczema  pigmentation  hemorrhage  ulceration
Venous Insufficiency  As the vein dilates the wall stretches in both width and length so that the vein becomes tortuous  As the situation gets worse the veins become so dilated that large sacs form at the bends  Turbulent flow occurs with areas of stagnation like extreme bends…  …in an otherwise fast running river and the vein can sometimes thrombose leading to inflammation called superficial thrombophlebitis
Complications  Skin discoloration  Hemosiderin deposition  Edema  Lipodermatosclerosis  Skin ulceration  DVT  SVT  Thrombophlebitis  Hemorrhage
Complications: Skin discoloration
Complications: edema, “corona phlebectasia”
Venous Ulcers  constitute 90% of the ulcers seen in a busy specialist clinic  ulcer will never heal unless the chain of events which led to it are reversed
Complications of Venous Insufficiency
Indications for Treatment  Absolute Indications: – Complications from venous reflux  Relative Indications: – Desire to have legs without blemish – Personal body image – Sexual motives
Evaluation for Venous Reflux
Evaluation for Venous Reflux
Evaluation for Venous Reflux
Evaluation for Venous Reflux
Evaluation for Venous Reflux
Current Treatments  I-Ultrasound guided sclerotherapy: – Effective short term but no long term durability:  Neglen P, et al: J cardiovascular surgery 1993; 34(4): 295-301: – Compression Slerotherapy (CST): 5 year failure rate: 51% – Stripping: 5 years: 60% “cured”, 35% “improved” – High ligation and CST: 5 years failure rate: 84%
Current Treatments  II-Surgical Treatment: – High ligation – High ligation and stripping
Surgical Treatment
Surgical Treatment: Stripping/SEPS
Surgical Treatment  Dwerryhouse S et al, J Vasc Surg, April 1999; 29(4): 589-592: – 100 pts randomized to ligation or stripping – After 5 years, 78 pts available for duplex scan:  29% SFJ incompetence in the stripping group  71% SFJ incompetence in the high ligation group
Surgical Treatment  Fisher R, et al, J Vasc Surg 2001; 34 (2):236-40 – 602 pts underwent high ligation and stripping – 125 limbs in 77 pts available for duplex scan 34 years after ligation and stripping – 60% limbs showed SFJ reflux by US – Neovascularization accounted for identified failure
Varicose Veins: Venous Anatomy  AL: AAGSV  PM: PAGSV  SEP: Superficial External Pudendal  SE: Superficial Epigastric  SCI: Superficial circumflex iliac
“Mini” Surgical: Ambulatory Phlebectomy  Permits removal of nearly any incompetent vein below the saphenofemoral and saphenopopliteal junctions  Major tributaries; perforators; and reticular veins, including small reticular veins associated with telangiectasias  The procedure is well tolerated by patients and produces good cosmetic results
Ambulatory Phlebectomy
Ambulatory Phlebectomy
Cyanoacrylate glue for saphenous ablation Nick Morrison  Approved in Europe  Not FDA approved  92% GSV occlusion at 1 month  Clot extension to SFJ in 21%
Other Techniques:  Coil Embolization  Combined Coil/Foam embolization
Current Treatments  III-Endovascular ablation of saphenous vein: – New treatment out of necessity:  Trauma of surgical treatment  High morbidity of surgical treatment  Minimally invasive treatment  A new “gold standard”??.....YES!
Endovascular ablation of saphenous vein:
Radiofrequency Closure  Received FDA clearance in 3/99  Largest collection of published data  Longuest F/U regarding endovenous therapy
Radiofrequency Closure
Radiofrequency Closure
Covidien ClosureFast™
RF Closure of the GSV: Dr Rosenblatt  139 limbs treated in 124 patients  Mean F/U 17.5 months (34-854 days)  Symptomatic improvement in 97%  Persistent and complete occlusion of the vein in 132 limb (95%) by duplex U/S
RF Closure of the GSV: Dr Rosenblatt  Complications: – 12.4% – Transient paresthesia 11% (resolved in all by 4 months) – Focal skin burn 1.4%  No DVT
Endovenous Laser Therapy  FDA Clearance: – Diomed Jan 02 – Biolitech Jun 02 – Angiodynamics Nov 02 – Dornier Nov 02
Precision980 Diode Laser
980nm Diode Laser Wavelength How it works  Water makes up over 80% of blood & Endothelial Cells  The precision of the 980 Wavelength Targets the water to create a “Steam Bubble”  Resulting Heat Destroys endothelial wall to cause Thrombosis & Vessel Occlusion  Safer more precise treatment with less chance of collateral damage to surrounding tissue or nerves
1470nm Diode Laser Wavelength
Endovascular Laser Treatment
Endovenous Laser Therapy  Robert J. Min et al, J Vasc Interv Radiol 2003; 14:991–996 – Large published series to date – 499 limb in 423 patients – Successful occlusion of GSV in 490 patients (absence of flow by duplex U/S), 98.2%
Procedure Steps: 1-Vein Puncture
Procedure Steps: 2-Placement of Vascular Sheath
Procedure Steps: 3-Positioning of Vascular Sheath
Procedure Steps: 4-Placement of Laser Fiber
Procedure Steps: 5-Tumescent Anesthesia
Procedure Steps: 5-Laser on, Pull Back at 3- 4mm/sec
Procedure Steps: Final Touch
Before/After
Procedure Comparison  Vein Stripping – Overnight Hospital stay – Significant Patient discomfort – Risk of Infection and Complications of Surgical – Long Recovery time – Surgical Suite cost  Laser/RFA (Minimally Invasive) – 45min out patient procedure – Minimal Patient Discomfort – Minimal Complications – 95% Efficacy – Radiology/Office Suite Cost
Conclusion: Beware The Power of Her Majesty The Mighty GSV…
Thank you for attending PAIRS 2014 See you at PAIRS 2015, March 12-15, Dubai UAE