Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery
description
Transcript of Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery
![Page 1: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/1.jpg)
Endovenous Treatment of Venous Diseases: Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and Preprocedural assessment, indications and contraindicationscontraindications
Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS
Professor of Vascular Surgery Faculty of Medicine, University of Thessalia, GreeceChairman, Dept. of Vascular Surgery, University Hospital of LarissaLarissa, Greece
![Page 2: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/2.jpg)
GSV Before Treatment
Image courtesy of Olivier Pichot, MD, CHU de Grenoble, France.
![Page 3: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/3.jpg)
Image courtesy of Olivier Pichot, MD, CHU de Grenoble, France.
GSV After Treatment
![Page 4: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/4.jpg)
CEAP Clinical ClassificationCEAP Clinical Classification
Class0: Asymptomatic; no visible or palpablesigns1: Spider veins, reticular veins, telangiectasias2: Varicose veins3: Edema4a: Skin changes with hyperpigmentation and eczema4b: Skin changes with lipodermatosclerosis and atrophie blanche5: Healed ulcer6: Active ulcer
![Page 5: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/5.jpg)
CEAP Clinical ClassificationsCEAP Clinical ClassificationsCClinical linical EEtiologytiology A Anatomynatomy P Pathophysiologyathophysiology
Varicose VeinsCEAP 2
SwellingCEAP 3
Skin ChangesCEAP 4
Skin UlcerCEAP 6
![Page 6: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/6.jpg)
Is pre-op duplex assessment important for varicose vein surgery?
![Page 7: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/7.jpg)
Ultrasonic assessmentUltrasonic assessment
![Page 8: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/8.jpg)
ExplanationExplanation
Information provided by DS will have
significant impact on the selection of appropriate treatment
Failure to identify all sources of venous filling is likely to result in early recurrence
![Page 9: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/9.jpg)
Indications for Duplex ScanIndications for Duplex Scan
Recommendation: both limbs should be studiedPrimary uncomplicated GSV VVs
Debated whether all pts – if not 30% of important connections between deep and superficial veins will be missed
Primary uncomplicated LSV VVs Essential
Non-saphenous & Recurrent VVs Essential
CVD with complications Essential
Surveillance after treatment the only way to obtain level I evidence as to outcome in the future
Venous malformations
anatomical information about the extent of the malformation and its relationship to other vessels
may be used to guide treatment by sclerotherapy
![Page 10: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/10.jpg)
Position of the patientPosition of the patientGreater saphenous
![Page 11: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/11.jpg)
Position of the patientPosition of the patientLesser saphenous
![Page 12: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/12.jpg)
Anatomy of superficial veins of the Anatomy of superficial veins of the lower limblower limb
![Page 13: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/13.jpg)
Important anatomical detailsImportant anatomical details
![Page 14: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/14.jpg)
Anatomical structures on B-modeAnatomical structures on B-mode
![Page 15: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/15.jpg)
Images courtesy of Olivier Pichot, MD
Fascial layers creating “saphenous eye”
GSVGSV
Bound anteriorly by superficial fascia & posteriorly by deep fascia
Often called “saphenous eye”
![Page 16: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/16.jpg)
Tortuosity Side branches
GSV VariablesGSV Variables
Images courtesy of Olivier Pichot, MD
![Page 17: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/17.jpg)
Aneurysmal segments
GSV Variables
![Page 18: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/18.jpg)
SFJ Tributary VeinsSFJ Tributary Veins
SCI: Superficial Circumflex Iliac
SE: Superficial Epigastric
SEP: Superficial External Pudendal
AASV: Anterior Accessory
Saphenous
PASV: Posterior Accessory
Saphenous
Image adapted from: Chandler JG et al. Defining the role of extended saphenofemoral junction ligation: A prospective comparative study. JVS 2000;32:941-53
![Page 19: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/19.jpg)
![Page 20: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/20.jpg)
![Page 21: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/21.jpg)
Initial Catheter Tip PositioningInitial Catheter Tip Positioning
Position catheter tip approximately 2.0 cm distal to SFJ◦ Confirm with measurement
calipers◦ Distance does not need to be
precise at this time because catheter position may shift during tumescent fluid infiltration
![Page 22: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/22.jpg)
Final Tip Position VerificationFinal Tip Position Verification
◦ In both transverse and longitudinal imaging planes
◦ Use measurement calipers to confirm distance to SFJ
Important step to avoid misaligning catheter relative to deep venous system
Recommendation is 2.0 cm distal to SFJ Confirm tip position with ultrasound:
Image courtesy of Pranay Ramdev, MD
![Page 23: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/23.jpg)
Anatomical structures on colour facilityAnatomical structures on colour facility
![Page 24: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/24.jpg)
Small Saphenous Vein (SSV)Small Saphenous Vein (SSV)
Courses from lateral ankle up posterior calf
Terminates in popliteal fossa at Saphenopopliteal Junction (SPJ)◦ Variable confluence with Popliteal Vein
(PV)◦ Proximal portion lies between
superficial & deep fascial layers
SSV
SPJ
Pop V
Figure adapted from: Weiss RA, et al eds. Vein diagnosis and treatment: A comprehensive approach. McGraw-Hill Companies, Inc.; 2001.
![Page 25: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/25.jpg)
Anatomical structures on colour facilityAnatomical structures on colour facility
![Page 26: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/26.jpg)
Detection of reflux on colour facilityDetection of reflux on colour facility
![Page 27: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/27.jpg)
Detection of reflux on colour facilityDetection of reflux on colour facility
![Page 28: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/28.jpg)
Detection of reflux on colour facilityDetection of reflux on colour facility
![Page 29: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/29.jpg)
Detection of reflux on colour facilityDetection of reflux on colour facilityPerforating vein
If reflux is present measure the diametre but this cannot distinguish competent from incompetentDuration of reflux
![Page 30: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/30.jpg)
Detection of reflux on DopplerDetection of reflux on Doppler
Reflux is present when retrograde flow lasts for at least 1 sec
![Page 31: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/31.jpg)
Patient selection for Endovenous AlationPatient selection for Endovenous Alation
Identification of all refluxing venous segments and their ablation is the key to minimise recurrence
Diametre of central GSV > 15 mm may be associated with thrombus extension to CFV
Uncorrectable coagulopathy
Liver dysfunction limiting local anaesthetic use
Immobility
Pregnancy
Breastfeeding
![Page 32: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/32.jpg)
ContraindicationContraindication
Thrombus in the vein segment to be treated
![Page 33: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/33.jpg)
Preoperative ultrasound evaluation◦Reflux > 0.5 seconds in superficial venous
system◦Assess GSV, noting:
Vein depth and maximum diameter Presence of tortuous or aneurysmal segments Other significant anatomy Duplicate systems Large side branches Incompetent perforators or tributaries
Choosing the Closure CandidateChoosing the Closure Candidate
![Page 34: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/34.jpg)
The aim of ablation procedures is to damage the inner vein wall without causing a full-thickness burn, which
could lead to perforation of the vein resulting in bruising or haematoma formation
If vein lies superficially, close to skin the ablation may cause burn
Vein depth from the skin: Why is so important?
![Page 35: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/35.jpg)
Pre-op Ultrasound Assessment Pre-op Ultrasound Assessment
Map and mark◦ Maximum diameter◦ Tortuous segments◦ Aneurysmal segments◦ Areas where vein is very
close to skin◦ Large branches or perforators◦ Potential access sites
![Page 36: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/36.jpg)
Infiltration TechniqueInfiltration Technique
Do not leave any vein segments unprotected◦Re-scan to ensure:
• >10 mm distance between skin surface and vein wall
• Circumferential black “halo” appearance in fascial compartment
Perivenous vs. subcutaneous infiltration
Image courtesy of Carolyn Menendez, MD
![Page 37: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/37.jpg)
Vein MappingVein MappingMake indentions in skin using a strawRemove US gel from legConnect marks on leg with marker to identify
pathway of vein and important anatomy
Image courtesy of Nick Morrison, MD
![Page 38: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/38.jpg)
Pre-op Descending VenographyPre-op Descending Venography
![Page 39: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/39.jpg)
![Page 40: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/40.jpg)
Selective descending ovarian and hypogastric venogram
Significant ovarian vein reflux but No hypogastric vein reflux was detected
![Page 41: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/41.jpg)
Hypogastric vein reflux Ovarian vein reflux
![Page 42: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/42.jpg)
Descending Ovarian Venogram 4 weeks after embolisation
![Page 43: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/43.jpg)
Hypogastric vein embolisation
![Page 44: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/44.jpg)
CT venography
![Page 45: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/45.jpg)
Chronic Venous Obstruction
![Page 46: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/46.jpg)
DP=22 mmHgDP=8 mmHg
DP=2 mmHg
![Page 47: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/47.jpg)
IVC filter placement IVC filter placement
Indications
DVT and covtraindication for anticoagulation
Reccurent PE being on adequate anticoagulation
Pre-procedural evaluation MR or CT venography is
required for IVC and iliac vein patency and IVC diametre measurement
![Page 48: Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery](https://reader035.fdocuments.in/reader035/viewer/2022081520/5681572c550346895dc4c6c1/html5/thumbnails/48.jpg)
Thank you for your attention