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Premier Laser Vein ClinicTHE BASICS OF

VENOUS DISEASE:What You Should Know.

Dr. Rajan ModiM.S. F.M.A.S.

An Introductory Lecture

P. Fujimura, MD

Surgical Intern

University of California School of Medicine

“It is ironic that medical education does not cover three of the most common medical problems: back pain,

hemorrhoids, and varicose veins.”

PHLEBOLOGY

The medical specialty devoted to the diagnosis and treatment of patients with venous disorders

Anatomy and physiology of the venous system

Deep venous system: the channel through which 90% of venous blood is pumped out of the legs

Superficial venous system: the collecting system of veins

Perforating veins: the conduits for blood to travel from the superficial to the deep veins

Musculovenous pump: Contraction of foot and leg muscles pumps the blood through one-way valves up and out of the legs

Venous Anatomy

Valve Failure

Prolonged dilation damages the valves, so the blood flows in the wrong direction

The resulting backpressure is termed “venous hypertension”, and this is what causes symptoms

IMPORTANCE OF CHRONIC VENOUS DISEASE

Incidence increases with age and is more common in women with over 40% of women in their 50’s suffering from some sort of venous disorder

Etiology of Venous Insufficiency Inherited genetic predisposition

Normal aging process

Hormonal changes

History of venous thrombosis

Excess pressure on leg veins Standing

Obesity

Pregnancy

Tumors

Constipation

Previous surgery

Venous Disease is a Hereditary Disorder

The risk of developing varicose veins was:

89% if both parents had varicose veins

47% if one parent had varicose veins

20% if neither parent had varicose veins

Other Factors Chronic Venous Insufficiency

Although some risk factors for venous disease such as age, family history of venous disease are immutable others can be modified, such as weight, physical activity, and cigarette smoking.

Presenting Symptoms of Chronic Venous Disease Aching 17percentCramping-14Tired legs-12 Swelling-12 Heaviness-12 Itching -6 Restless legs-6

THE SPECTRUM OF CHRONIC VENOUS DISEASE

telangiectasias

lipodermatosclerosis varicose veins

Superficial phlebitis

venous ulceration 5

Venous Disease Classification

CEAP

Clinical

Etiologic

Anatomic

Pathologic

What? How ? Where? Why?

Venous Disease Classification Clinical C0 - No visible or palpable venous disease

C1 - Telangectasias or reticular veins

C2 - Varicose veins

C3 - Edema

C4 - Skin changes (a - pigmentation b - dematosclerosis)

C5 - Healed ulcers

C6 - Active ulcers

Venous Disease Classification Etiological

C - congenital

P - primary (venous failure without other cause)

S - secondary (post-phlebitic syndrome)

Venous Disease Classification Anatomical

S - superficial

D - deep P - perforator

Venous Disease Classification Pathological

R - reflux

O - obstruction

Venous Disease Diagnosis

Physical Exam Visible veins

Swelling

Ulceration

Skin changes

Standing venous reflux exam Duplex ultrasound with compression and release

Standing venous reflux exam

Standing Venous Reflux Exam Establishes presence of reflux

Deep and/or superficial systems Results dictate treatment option

Superficial only Conservative or

interventional Deep only Conservative

Deep and superficial involvement Conservative Selective interventional

Venous Disease Treatment Options

Conservative Elevation

Compression

Interventional Stripping

Laser ablation Radio frequency ablation Micro or stab phlebectomy Sclerotherapy

Conservative Treatment Compression Therapy

Treatment of telangiectasias

Sclerotherapy most effective

Laser may be helpful Multiple treatments usually

required Reduces symptoms in 85%

of patients Improves quality of life

Surgical Treatment of Varicose Veins: Vein Stripping

Vein stripping used to

remove Great and Small saphenous veins

Crossectomie and Stripping ► Very invasive and traumatic procedure

► General anaesthesia is required

► Destroys the connective tissue

► Poor cosmetical result due to scarring

► Patients have to be hospitalised

► Recovery time 2-3 weeks

► High Recurrence Rates

Conventional Treatment

EVLT Less invasive technique: Endovenous Laser Treatment (EVLT). EVLT uses targeted laser energy to seal the vein shut

Why ELVeS™ - Advantages GSV treatment

• Gentle, moderate and yet effective method of treatment • Less traumatic • Minimal discomfort • Quick and easy to perform • No scarring • No general anaesthesia required • Excellent aesthetic results • Recurrence rates are extremely low • Outpatient Procedure • A rapid return to normal activities

ELVeS™ by biolitec

EVLT Procedure A catheter is placed in the vein through a needle utilizing ultrasound guidance

• The laser is passed through the catheter to the saphenofemoral junction which is confirmed by ultrasound

EVLT Procedure

ELVeS™ - The Procedure for the GSV

Map the Course of the Vein

ELVeS™ - The Procedure for the GSV Access to the Vein

• Anaesthesia by local intradermal injection• Entry of the needle into the vein under Ultrasound

Guidance

ELVeS™ - The Procedure for the GSV

• After the puncture the guide wire is inserted into the vein

• The entry needle is withdrawn and the introducer sheath and dilator are inserted over the guide wire and into the vein

• The guide wire is then removed and the laser fibre is inserted into the introducer sheath and advanced along its length

• The introduction of the laser fiber can be monitored by using the aiming beam

ELVeS™ by biolitec

ELVeS™ - The Procedure for the GSV

• The fibre is advanced to a position 2-3 centimeters below the sapheno-femoral junction to preserve the integrity of the femoral vein from the first pulse of laser energy

• The final position 2-3 cm below the sapheno femoral junction is controlled by ultrasound

ELVeS™ by biolitec

EVLT Advantages

Relief of chronic pain symptoms Faster return to normal activity Improves venous stasis wound healing potential Decreases wound recurrence Minimal-to-no scarring Typically is covered by insurance

EVLT Post-op Care

Dress leg with compression bandage Class II compression stocking on POD 2 Resume normal activities as tolerated Avoid hot baths Avoid vigorous gym workouts

EVLT Post-op

Mild Bruising can occur along the leg that has been treated A “tightening” sensation along the vein is reported by many patients Some mild tenderness along the vein

EVLT - Patient 1

Before EVLT

2 Months After EVLT

EVLT - Patient 2

Before EVLT

2 Months After EVLT

Before - After Pictures

ELVeS™ by biolitec

Surgical Treatment of Varicose Veins: Phlebectomy

Very esthetic method of removing varicose veins

Usually requires only local anesthetic

Especially useful for tributaries of GSV, SSV

Institute Experience n>370

0% mortality

0% major adverse events

0.9% DVT (n=3) 0% skin burns

0% major infection rate

Conclusions Venous disease is common

Venous disease is related to either reflux or obstruction

Symptoms include pain, swelling, and ulceration Duplex imaging aids diagnosis and treatment Treatment options are both conservative and

interventional

Endovenous laser treatment provides potential relief of symptoms in a minimally invasive manner

Why Refer Patients to PLVC for Venous Disease

Comprehensive care by surgeon. Member of american board of phlebology. Sterile surgical environment.Dedicated anesthesiology.

THANK YOU FOR YOUR ATTENTION