XV. Small saphenous and BTK vein treatment
XV. Small saphenous and BTK vein
treatment
Surgery, thermal or non-thermal treatment in the SSV treatment?
Marc Vuylsteke (Belgium)
Incompetence of the small saphenous vein is observed in 10% to 15% of patients with chronic venous insufficiency and 29% of patients with severe chronic venous insufficiency or truncal vein incompetence. The small saphenous vein is located near the saphenous nerve, with an average distance between them of 3 to 4 mm. There are 5 different types of saphenopopliteal junctions. Surgical treatment of small saphenous vein incompetence is characterized by low anatomical success with a high recurrence rate (30% to 50%) at 1 year and neurological damage (19% paresthesia). The results of ultrasound-guided foam sclerotherapy are characterized by an anatomical success rate in 20% to 96% and a higher occlusion rate in veins with a diameter of <5 mm. Using endovenous laser ablation is characterized by a success rate of 91% to 100%, but the paresthesia/ numbness rates of 1.1% to 11%. For radiofrequency occlusion rates of 82% to 100%, the paresthesia rates are 9.7% to 26%. For mechanochemical ablation, the occlusion rate is about 94%; the procedure is safe, feasible, and effective and no paresthesia has been report. For cyanoacrylate glue ablation, the results are the same, with a closure rate of 97.3% at 6 months and 96.8% at 12 months and no report about saphenous nerve paresthesia. The major flaw of thermal tumescence is saphenous nerve neuritis. To prevent this complication, work near the saphenous nerve should be carried out carefully, which is achievable in 100% of cases. If hydro displacement was done, then the frequency of posttreatment neuritis is reduced to 0.8%. Puncturing the small saphenous vein at the mid-calf may decrease postoperative paresthesia, as the risk point is above mid-calf level in 10% of cases.
Small saphenous vein treatment by thermal and nonthermal ablation methods: focus on popliteal fossa, femoral extension and Giacomimi vein atypical
Frantisek Zernovicky (Germany)
The small saphenous vein in the area of saphenopopliteal junction is variable. Treatment results are dependent on the structure of the saphenopopliteal junction. To improve the results of treatment, Frantisek Zernovicky offered the following treatment algorithm. He distinguished three types of saphenopopliteal junction: complete, partial, and absent. A complete (typical) saphenopopliteal junction means that the complete volume of blood is drained to the popliteal vein and it occurs in 50% of cases. This variant of the small saphenous vein is best treated using endothermal ablation methods (out of a rating of 5, endothermal ablation is ranked as 5, and other methods, such as foam, mechanochemical ablation, and glue are ranked as 3). A partial variant of the saphenopopliteal junction means that part of the blood volume is drained to the popliteal vein and part of the volume of blood continues proximally to a thigh-like cranial extension of the small saphenous vein (foam treatment and mechanochemical ablation is ranked at 4 points, endothermal ablation at 3 points, and glue at 2 points). An absent variantof the saphenopopliteal junction means that none of the blood volume is drained to the popliteal vein and complete volume of blood continues proximally to a thigh-like cranial extension of the small saphenous vein. For this type of junction, mechanochemical ablation is the preferable method (ranked as 5), followed by endothermal ablation (ranked as 3 points), foam and glue (ranked as 2). After determining the saphenopopliteal junction type, it is essential to define the site of connection of the small saphenous vein to the popliteal vein. If the type of connection is lateral/medial, then the best option will be sclerotherapy or mechanochemical ablation. How should we perform small saphenous vein surgery in 2019? It is only perfect, if it fits tangibly with every patient.
How to deal with below the knee saphenous vein incompetence
Steve Elias (US)
The treatment of below the knee saphenous vein is difficult and depends on where the vein is located. The potential problems for treatment would be the nerves (saphenous, sural, tibial, peroneal), skin (veins more superficial and skin can be damaged), and stage of disease (in C5,6, the veins are hard to visualize). According to the basic rules of 2019, we have to treat to the lowest point of incompetence, the more advanced disease (meaning you need to go lower and do more [varicose veins, perforating veins]). A study showed that, in the case of above the knee endovenous laser ablation, 41% of patients with persistent below the knee reflux and 89% required treatment of residual varicose veins. Steve Elias suggested that, in 2019, for primary procedures in C2 patients, we can treat at least to mid-calf (maybe lower), in C4, at least to mid-calf, and, in C5-6, to the malleolus, under the ulcer. Relying on these principles, nonthermal and nontumescent methods are easier/safer to go to the malleolus. Another indication for below the knee treatment is persistence of symptoms after endovenous laser ablation of above the knee great saphenous vein (occurs in 40% to 50%), incompetent perforating veins in C6, C5 after great saphenous vein or small saphenous vein ablation.
Current theories on indications and techniques for perforator ablation
Kathleen Gibson (US)
Substantial evidence supports the role of incompetent perforator veins role in chronic venous insufficiency. Approximately two-thirds of limbs with skin changes have incompetent perforator veins as well as superficial or deep reflux. Of the recurrent varicose veins, 63% are associated with incompetent perforator veins. The current guidelines from the Society for Vascular Surgery/American Venous Forum for patients with ulcers suggest ablation of incompetent superficial veins and perforator veins, as well as compressive therapy to aid in ulcer healing and recurrence (2C). For C4b and C5 patients they suggest that perforator ablation can be performed simultaneously or staged if still incompetent on re-evolution (2C). Currently, the treatments used for incompetent perforator veins are subfascial endoscopic perforator surgery, direct perforator ligation, percutaneous radiofrequency ablation, and laser ablation (recently received FDA approval), foam sclerotherapy, and nonthermal ablation. The closure rates for thermal methods are 71% to 86% and lower than for truncal veins. Nonthermal techniques are promising tools in the treatment of advanced venous disease/ulcers and may offer some advantages over thermal techniques.
Foot vein sclerotherapy
Aleksandra Jaworucka-Kaszorowska (Poland)
Little attention has been devoted to the veins of the foot, which are susceptible to vertical pathologies, including corona phlebectatica, varicose veins, venous ulcers, and deep vein thrombosis. Corona phlebectatica appears due to consequences of the venous stasis of the foot due to venous hypertension and is the best predictor of subsequent occurrence of skin changes. Corona phlebectatica is associated with increasing numbers of incompetent venous segments and a higher rate of venous reflux, preferentially in the saphenous vein and perforator territory. Foot perforating veins constitute the anatomical ground for formation of the corona phlebectatica. Foot varicose veins despite the strongest hydrostatic pressure, usually appear late in the progression of the disease. Foot vein dilatations almost exclusively involve the superficial network (unprotected by the superficial fascia) and spare the saphenous-type veins. Foot venous ulcers are often the result of multiple refluxing foot veins. Nearly 9% of foot ulcers have a venous origin. For diagnosis, an ultrasound examination of the foot segment of the great saphenous vein, small saphenous vein, anterior arch veins extending over the foot dorsum and the superficial venous arch. Foot varicose veins have been grossly overlooked; until recently, the treatment of foot varicose veins was avoided for fear of complications.
Foot varicose veins are a continuation of varicose veins in the leg. Isolated treatment of only the varicosities of the foot is therefore contraindicated. A total workup and systemic treatment from proximal to distal is essential for good results. Treatment of foot varicose veins using phlebectomy is safe and effective, but not without the risk of complications. The treatment of foot varicose veins by sclerotherapy contains some disagreements regarding the use of sclerotherapy to treat the foot veins. Now there is not enough data concerning complications after foot varicose vein sclerotherapy and the incidence of complications is largely derived from publications on sclerotherapy of lower limb varicose veins. Aleksandra Jaworucka-Kaszorowska presented here experience with 682 patients: 483 patients with corona phlebectatica, 180 with foot varicose veins, and 39 with foot ulcers. Hybrid procedures (laser+ultrasound-guided foam sclerotherapy) were performed in 279 cases and isolate ultrasound-guided foam sclerotherapy in 403 cases. A total of 592 (86.8%) patients had an additional sclerotherapy session for foot veins. In case of 146 (21.4%) patients, hyperpigmentation was observed, which disappeared in 74% of cases in 6 months. Foot edema occurred in 26 (3.8%) cases, deep vein thrombosis in 1 case, skin necrosis in 19 (2.8%) patients. A total of 96% of patients were satisfied with the treatment results. The results showed that sclerotherapy is a safe and effective method for treating foot veins.
