Highlights of the Venous Programme at Controversies & Updates in Vascular Surgery (CACVS) – Saturday 19 January
By Mark S Whiteley
The venous session started with a welcome address by the course convenor, Dr Jean-Luc Gerard.
Session I: Post Thrombotic Syndrome – Atypical Varicose Veins
Peter Neglen gave us some fascinating insight into using IVUS (intra vascular ultrasound) in deep vein reconstruction. He pointed out that it does not require x-rays and is particularly useful in obese patients where other imaging might be very difficult.
He showed that IVUS:
- Can be used to guide stents and filters
- Is very good for assessing obstruction
- Reveals stenosis and compression that are not seen on venogram
- Reveals residual thrombus after clot removal
However it does not give any haemodynamic information and is not good for visualising valve leaflets.
Maria Lugli gave a fascinating talk about the on-going evolution of their neovalve technique for making new veins in the deep venous system.
She told the audience that since the year 2000, they had moved from forming a bicuspid to monocuspid valve. This allows a deep valve pocket to be formed. Also the neovalve is fixed in the semi-open position to reduce re-adhesion. She showed that in thin veins a bovine pericardial patch can be used to close the vein, and also explained that the valve formation in an area near an opening from a tributary could be selected to increase flow competition.
The neovalve technique is used in C3 – C6 disease – and she stressed that they only treat symptomatic disease.
Peter Gloviczki gave an authorative talk on incompetent perforating veins (IPV) and stated that 70% are haemodynamically significant and 45% do not go with saphenous surgery.
When it comes to which IPV need treatment, using a diameter of 3.9 mm, misses 1/3 of significant IPV.
Therefore the recommendations are to treat IPV in:
- C5 and C6 disease
- if there is no deep vein obstruction
- there is outwards reflux on manual compression of >500ms
- diameter > 3.5mm
He reported information from the North America SEPS registry showing rapid ulcer healing rates after SEPS. Also some patients had healing with SEPS alone, similar to healing with stripping and SEPS.
He showed the minimally invasive TRLOP technique, invented by Mark Whiteley and adopted by others subsequently, which shows results of IPV occlusion similar to SEPS.
Atypical Varicose Veins from Gluteal Source
Philippe Lemasle gave a fascinating talk about the origin of gluteal varicose veins. He showed the inferior gluteal vein drains the sciatic nerve, draining into the internal iliac vein.
He showed that embryologically the vein was a persistent sciatic vein and there can be veins both in the sciatic nerve sheath, or a large persistent vein might be visible on ultrasound running alongside the sciatic nerve.
He cautioned that if such veins are found, they may be associated with hypoplasia or absence of the deep veins in the leg and so the deep vein must be checked before any treatment is planned.
Milka Greiner continued the discussion about the incompetent inferior gluteal vein and pointed out that varicosities of the tributaries may form in multiparous women or may arise embryologically due to lack of valves in the inferior gluteal vein. She also pointed out the high risk of deep vein hypoplasia in such people, and also the association with the valve less inferior gluteal vein and venous anomalies such as Klippel-Trelawney Syndrome.
She suggested that when the embryological type was found in children, it should be treated before any limb length problems developed. She pointed out that coil embolisation might irritate the nerve and so suggested glue embolisation of the veins.
Annouk Bisdorff gave an account of the different types of sclerosant that can be used for venous lesions. Some of the gems that she shared included using Aethoxysclerol foam for lesions that were small ( < 2cm) and ethanol injection for larger venous malformation. For lesions draining into the brain from around the orbit, glue can be used to close the draining vein and then the superficial vein can be sclerosed using a sclerotherapy liquid.
She explained that the semi-liquid products such as glue or Onyx should only be used in deep lesions as they can form lumps. There is also a new Ethanol gel, but this has a maximum dose of only 2ml per session. In the pelvic veins she preferred glue.
Session II: Treatment of the Small Saphenous Vein.
Debate: The Safest or the Most Efficient
Denis Creton-Nancy gave an excellent account of open surgery for the small saphenous vein (SSV), showing that in his practice stripping can be safe if performed under local anaesthetic in an outpatient setting. He showed flush ligation is not always necessary and he leaves the Giacomini vein open for venous drainage.
He also said that complete stripping of the SSV is not always needed and said that using a pin stripper meant there was a very low risk of complications.
James Lawson spoke about using radiofrequency ablation (RFA) to treat the SSV. He attested that treating the SSV is more challenging than GSV and reports of stripping the SSV showed widely varying reported incidences of nerve damage, from 1.7 – 34%.
He explained that ligation alone is not enough and quoted a paper from Samuel reporting the results of a randomised controlled trial showing that recurrence after open surgery was higher at 1 year than treatment with thermal ablation.
Manj Gohel was asked to support foam sclerotherapy for treatment of the SSV although he pointed out that he had reservations about doing this in his own practice. He showed the cost of foam sclerotherapy is low and complications reduce as the dose reduces.
Foam sclerotherapy is best for smaller veins and Bradbury has reported a long term outcome of 91 % closure at 22 months. He did point out that if foam is to be used, it is essential to aspirate any thrombus if thrombophlebitis occurs.
Jean Luc Gerard supported the use of endovenous laser ablation (EVLA) for the treatment of the SSV. He pointed out that with open surgical stripping, although some experts get good results, this is not the usual course of events. After stripping of the SSV in France, figures show the average time taken off of work is 26 days. He pointed out the large number of medico-legal claims particularly related to nerve damage following SSV stripping.
He showed that when comparing EVLA with open surgery (stripping) for the SSV, there was a higher success, earlier return to work and lower paraesthesia rate.
Session III: Competence or incompetence of the terminal and pre-terminal valve: does it change your mode of treatment?
Massimo Cappelli discussed “stump evolution” and “non-evolution” and Oliver Pichotdescribed the variability of tributaries and valves at the Sapheno-Femoral Junction (SFJ), saying there was a need for a protocol for investigating the SFJ with duplex ultrasound.
There were further presentations about the subject, but one question was asked that seemed most pertinent: if there was any clinical relevance when the vein was ablated. The answer was that with ablation, the pattern of valves makes little or no difference to treatment.
Session IV: Miscellaneous
Armando Mansilha discussed patient reported outcomes and quality of life tools. He explained that he uses these as part of his patient assessment and follow up and suggested it would be something that every vein clinic could do.
Inga Vanhandenhove provided fascinating insight into how the environment of the hospital or clinic has a huge impact on patient satisfaction. She explained that evidence based design (Hamilton 2003) improved recovery and got the patient home earlier. Those in single rooms with good views had lower infection rates, and those in private rooms suffered fewer drug errors, had lower noise levels with beneficial effects on blood pressure and anxiety, as well as staff burn-out.
Michel Perrin gave a very well researched review of the randomised studies in the endovenous treatment of varicose veins. Although many of the outcomes were as expected, that the endovenous techniques have lower pain and faster return to work than stripping, he did point out that technology is moving so fast that when the longer term results are published, the techniques that they relate to have moved on and aren’t used in that form any more.
Session V: Thermal Techniques
Lars Rasmussen presented the five year results of his study comparing open surgery, endovenous laser ablation, radiofrequency ablation and foam sclerotherapy. The primary endpoint was closure of the great saphenous vein and so interestingly, in this study, a great saphenous vein reopening of 5 cm or more was regarded as a failure. As such the success rate of EVLA at five years was only 85%. Some notable findings were that in the endovenous laser group, the anterior accessory saphenous vein was more commonly the cause of recurrence. In the stripping group, incompetent perforators were commonly cause of recurrence.
Manj Gohel gave a presentation suggesting that the technique of performing the procedure, and the strategy of which order the procedures were performed in, and where the procedures are performed together, are probably at least as important if not more important than which procedure is used.
Lowell Kabnick gave an overview of his experience with endovenous laser. He showed that as the wavelength had increased from the haemoglobin absorbing wavelengths to the longer water absorbing wavelengths such as the 1470 nm, patients had experienced less pain and bruising. He also showed that moving from bare-tip fibres to jacket covered fibres also reduced perforations and hence pain and bruising.
Giorgio Spreafico also discussed his experience of the evolution of endovenous laser ablation. He pointed out that moving on from the jacket tip fibre to the radial firing endovenous laser fibre had further reduced pain by spreading the energy around the whole of the vein and not allowing concentration of energy at a single point of contact. He also suggested that this reduced carbon formation within the vein which is another potential cause of pain after endovenous laser ablation.
Thomas Proebstle then gave the first of two talks. He compared the five year results of VNUS Closure FAST with its hot end, with the original VNUS Closure catheter which although was much slower, use bipolar radiofrequency ablation. Although the older technique was much slower, the results were very similar with both techniques.
Thomas Proebstle then gave a talk about the new Venaseal “superglue” cyanoacrylate closure of veins. He reported excellent results without the need of any tumescent anaesthesia in two early multicentre studies. The talk stimulated a lot of questioning of this innovative new procedure.
Mark Whiteley presented the advantages of radial firing endovenous laser over the radiofrequency ablation techniques. He pointed out that there are several different devices under the banner of “radiofrequency ablation”: including the VNUS Closure FAST in which a 7cm or 3cm end are heated by radiofrequency but the final contact with the tissue is thermal only, without any radiofrequency current involved; the bipolar techniques such as RFiTT which induce thermal destruction in the wall (and therefore truly are radiofrequency ablation); and the new generation of monopolar radiofrequency ablation devices techniques for which there is very little research available at present.
Dr Y Alimi presented the early results of using steam to close the Great Saphenous Vein (GSV) and the tributaries. At 6 months there was a 96% closure with 92% closure at 12 months with a consequent improvement in quality of life measures. The study showed less skin pigmentation than treatment of the tributaries with foam sclerotherapy (4/20 v 12/20).
Claudine Hamel Desmos discussed her clinic’s experience with the RFiTT bipolar radiofrequency system. She explained how the technique had changed to try to increase the linear endovenous energy (LEED) passing into the vein, to try to ensure closure. She claimed that using a power of 18 – 20 Watts and a pull-back averaging >2.5 secs per cm there were no failures. However it might take several passes of the catheter to achieve this LEED.
Dr Leopardi assistant to Carlo Spatera discussed the evolution of EVLA in their department. They had instituted quite rigid exclusion criteria for veins not suitable for EVLA and so concluded that with their self-imposed restrictions on vein size, in their unit EVLA was not an alternative to stripping.
A vote was taken before and after this session, using the interactive voting system, asking the audience which of the endovenous technique they would prefer.
The results showed an initial result before the talks and then the change of audience opinion after the vote:
RFA and EVLA vote same about 40%
Written by Mark Whiteley, Consultant Vascular Surgeon at The Whiteley Clinic (www.thewhiteleyclinic.co.uk) in Guildford, England. Update 22/01/13