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284
A. Stella et al.
Loco-regional anaesthesia was the preferable method and was performed in 84%
of patients.
Short-term results were encouraging, both regarding the technical success
(96.7%) and the absence of 30-day conversions and re-interventions. Technical success was not reached in case of type Ia endoleak that has not inuenced a 30-day
mortality.
The 30-day mortality was 2.5%, and it was lower if compared to literature 30-day
mortality in elderly patients (2.8, 5 and 7.2%, respectively, by Geibusch etal. [16],
Lange et al. [15] and Tsilimparis et al. [17]) but higher if compared to younger
patients (1.4% Paravastu etal. [8]). Mortality was signicantly higher in ASA 4
patients compared with ASA<4 patients (9.4% vs 0.6%).
In our experience, perioperative morbidity was 23.5%, similar to morbidity rate
reported from Tsilimparis etal. [17] (24.7%). Geibusch etal. [16] reported a lower
morbidity rate (11.5%) without considering nephrological complications. If we
consider only cardiopulmonary complications, our morbidity rate is 9.9%.
The mean follow-up was 36±18months, and the overall survival at 1, 2, 3 and
5years was 88±2%, 84±3%, 79±3% and 56±5%, respectively.
Among elderly, we divided and compared the population into two groups on the
basis of the age: survival of patients over 85years was 66.8% vs 64.5% of patients
between 80 and 85years at a mean follow-up of 35months (p:ns). Long-term mortality related to AAA was 3.1% vs 33.3% of total deaths.
Re-interventions rate at 35months of follow-up was 6.2%, slightly lower if compared to the current literature (8.2% Visser etal. [18] and 12.6% Biebl etal. [14]).
Re-intervention rate in elderly was signicantly lower than in patients under 80s
(23.4%). This could be related to the stricter attention offered to elderly.
In our experience, we evaluated other possible variables that can inuence survival (COPD, CKF, PAOD and ASA 3 or ASA>3. At multivariate analysis, PAOD
was one of the variables that affects more midterm survival (2years), together with
ASA>3 score (signal of higher systemic comorbidities). Only patients with one or
no risk factors reached the 5-year follow-up.
Conclusions
Octogenarians are affected by a higher risk of peri-procedural mortality com-
pared to patients under 80s, but this risk is sufciently low to allow EVAR treat-
ment in these patients.
Obviously the decision to treat this group of patients remains controversial
and has to be valued case by case, considering comorbidities, aneurysm dimension and life expectancy of each patient.
With a life expectancy of 6.1years, octogenarians with anatomical and clinical features t for EVAR seem to benet from a preventive AAA treatment.
EVAR in >80-year-old patients is associated with an overall low early mortality
rate of 2% especially in ASA<4 (0.6%).
According to the literature, we can state that age should not be considered rst
as an exclusion criteria for these patients, not even if over 85years.
18 Aortic Aneurysm inElderly Patients
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Exclusion criteria should be clinical conditions of patient, because the survival of patients with none or only one risk factor justies the treatment for
AAA; however, patients with ASA 4 and PAOD had a signicantly higher mortality rate and reduction of life expectancy; therefore, the EVAR treatment could
be justied only in particular cases of AAA with impending rupture.
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5. Greenhalgh RM, Brown LC, Kwong GP, Powell JT, Thompson SG.EVAR trial participants.
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or endovascular repair of abdominal aortic aneurysm. N Engl J Med. 2010;362(20):1881–9.
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BE.Long-term outcomes of abdominal aortic aneurysm in the Medicare population. N Engl J
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A. Stella et al.
Venous Disorders oftheLeg
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Stefanode Franciscis andRaffaeleSerra
Abbreviations
ASVAL Ablation sélective des varices sous anésthesie locale
CDT Catheter-directed thrombolysis
CEAP Clinical-etiology-anatomy-pathophysiology
CHIVA Cure Hémodynamique de l’insufsance veineuse en ambulatoire
CT Compression therapy
CVD Chronic venous disease
CVI Chronic venous insufciency
CVLU Chronic venous leg ulceration
DVT Deep vein thrombosis
ECM Extracellular matrix
EVLA Endovascular laser therapy
GAG Glycosaminoglycan
LMWH Low molecular weight heparin
PAPS Percutaneous ablation of perforators
PAT Percutaneous aspiration thrombectomy
PCDT Pharmacomechanical catheter-directed thrombolysis
PTS Post-thrombotic syndrome
RFA Radiofrequency ablation
SEPS Subfascial endoscopic perforator vein surgery
VAD Venoactive drug
19
S. de Franciscis • R. Serra (*)
Department of Medical and Surgical Sciences, Interuniversity Center of Phlebolymphology
(CIFL), International Research and Educational, Program in Clinical and Experimental
Biotechnology, University Magna Graecia of Catanzaro, Catanzaro, Italy
e-mail: defranci@unicz.it; rserra@unicz.it
© Springer International Publishing AG, part of Springer Nature 2018
A. Crucitti (ed.), Surgical Management of Elderly Patients,
https://doi.org/10.1007/978-3-319-60861-7_19
287
288
b) Lipodermatosclerosis
Healed venous ulcerC6Active venus ulcer
S. de Franciscis and R. Serra
19.1 Introduction
Venous disorders of the leg refer to either chronic or acute conditions related to or
caused by veins that become diseased or abnormal. These problems can include chronic
venous disease (CVD) which involves primarily the supercial venous system and
deep vein thrombosis (DVT) which affects primarily the deep venous system.
CVD and DVT may occur at any age; nevertheless, most of the complications of
venous disorders are more prevalent in the elderly [1].
19.2 Chronic Venous Disease
The prevalence of chronic venous disease (CVD) is <10% for men and for women
younger than 30years and goes up to 57 and 77% in men and women aged >70years,
respectively. The spectrum of CVD can be described using the clinical-etiologyanatomy-pathophysiology (CEAP) classication, and according to the “C” (clinical
classes) of this classication, it ranges from the mild manifestations such as telangiectases/reticular veins (C1) and truncal varicose veins (C2) to the more advanced
signs represented by leg edema (C3) and the serious dermal manifestations
C1
teleangectasies and
reticular veins
ab
Fig. 19.1 Clinical classes (C) of the CEAP classication
C4
a) Venous eczema
C2
varicose veins
C3
edema
C5
19 Venous Disorders oftheLeg
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289
consisting of hyperpigmentation, eczema, lipodermatosclerosis (C4), and chronic
venous leg ulceration (CVLU) (C5–C6) (Fig.19.1).
Clinical manifestations from C3 to C6 pertain to the condition called chronic
venous insufciency (CVI).
Each clinical class is further characterized by a subscript for the presence of
symptoms (S, symptomatic) or absence of symptoms (A, asymptomatic). Symptoms
include aching, pain, tightness, itching, heaviness, and muscle cramps. A particular
subgroup of patients are dened C0s, which means that these patients have no evident sign or instrumental abnormalities, but they complain of venous symptoms.
Loss of calf muscle pump and poor mobility in elderly patients more often lead
to important increase of venous hypertension, with subsequent skin changes formation and, thus, with the risk of venous ulceration becoming even higher. In fact,
venous ulcers occur more commonly in the elderly, the peak prevalence occurring
between ages 60 and 80years. Venous ulceration is a condition that often requires
long-term care. Nonhealing ulcers can be complicated by infection that may require
hospitalization. Furthermore, venous ulcer recurrences are common with rates ranging from 54 to 78%. In the western world, the treatment cost of venous ulcers has
been estimated to require up to 2% of the annual health-care budget.
Mixed arterial and venous disease may also coexist in elderly patients. In fact, in
several clinical studies, the reported incidence of arterial insufciency in patients
with venous ulceration has reached up to 30%, especially in the elderly. This condition is responsible for chronic delayed healing among lower extremity wounds.
From a clinical point of view, venous ulcers are typically supercial and irregularly shaped. Granulation tissue is often present along with the aforementioned
signs of CVI, such as edema and skin changes. These wounds traditionally present
in the lower third of the leg, especially around the gaiter region. Usually, there is no
pain unless the ulcer becomes infected.
On the other side, arterial ulcers can have a punched out appearance with distinct
borders and may involve the foot and/or the toes, and at the end stage, gangrene may
be present. Furthermore, patients with arterial ulcers may complain of more leg pain
compared to patients with venous ulcers alone.
In patients suffering from an ulcer of mixed arterial and venous origin, features
of both ulcer types may be present (Fig.
19.2).
Fig. 19.2 Mixed arterial and venous ulcer
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S. de Franciscis and R. Serra
Although many elderly patients have associated diseases or particular medical
conditions that make them less suitable for a general anesthetic, the full range of
interventions dedicated for the supercial venous disease can be performed safely
under tumescent local anesthetic, often as an outpatient, with considerable advantage for the elderly.
There is no evidence that surgical treatment of CVD in the elderly is less safe or
less effective than in younger people. Conversely, elderly patients with CVD, being
more likely to have complications for their condition, have the most gain from
active treatment.
Apart from classic operations such as saphenectomy, surgery has made important progress in the last 25years. Operations are now more limited, considering the
extension of the segments to treat, and they intend to correct the hemodynamic
alterations, preserving the competent venous segments (hemodynamic surgery).
Furthermore the treatment of varicose veins has also undergone dramatic changes
with the introduction of percutaneous endovenous ablation techniques, including
endovascular laser therapy (EVLA), radiofrequency ablation (RFA), and liquid or
foam sclerotherapy [1–11].
19.2.1 Operating Techniques
The basic indication for the treatment of varicose veins in the elderly is the prevention of possible secondary complications and sequels which are particularly frequent in these patients. Therefore, for these patients, varicose vein surgery is
basically a preventive surgery [7–18].
19.2.1.1 Saphenous Stripping
This surgery involves making incisions (usually the groin and medial thigh, for
the short vein stripping, or the lower part of the leg, for the long vein stripping)
followed by insertion of a special metal or plastic wire into the vein. The vein
is attached to the wire and then pulled out from the body. The incisions are
stitched up, and a pressure bandage followed by elastic stockings is a common
recovery prescription. This procedure may be performed under general or
locoregional anesthetic and more frequently under local or tumescent anesthetic. For this reason and for the risk of saphenous nerve injury, more frequently in the elderly, the reasons explained below are not routinely considered
for elderly people.
Saphenous nerve injury is known for a long time to be a potential complication
of the saphenous vein long stripping. The proximity of the vein and nerve, especially at the level of shank, results in injuries during the vein resection, especially in
the patients, such as the elderly, with advanced varicose veins in this area caused by
a large number of insufcient perforators. Additionally, in the elderly patients suffering from long-lasting varicose veins, it can lead to an accretion of the widened
vein, resulting in the saphenous nerve neuropraxy. This pathology also facilitates in
injury of the nerve bers during the operation [9–12].
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19.2.1.2 Local Phlebectomy andHemodynamic Correction
Surgical treatment for varicose veins had a great and creative improvement with
Muller’s invention of the local stab avulsion method, developing some specic and
useful hooks. Soon after, Franceschi developed a minimally invasive surgical
approach, the cure hémodynamique de l’insufsance veineuse en ambulatoire
(CHIVA), meaning a therapy (cure) which preserves veins and restores the hemodynamics for insufcient veins on an outpatient basis. In fact, CHIVA strategy aims to
perform a hemodynamic correction, more than to a radical avulsion of the varicose
bed, based upon a meticulous preoperative duplex ultrasound examination. CHIVA
treatment corrects the blood ow by using ligatures of specic blood vessels. In
fact, the duplex ultrasound examination allows the physician to create a precise map
of the patient’s venous anatomy and blood ow and, therefore, determine how to
correct it. This technique may preserve the saphenous veins, and most of all, by suppressing the hemodynamic overload, it normalizes the venous ow and make varicose vein disappear. Generally the result is an efcient, cheap, and ambulatory
minimally invasive surgery.
Recently the ablation sélective des varices sous anésthesie locale (ASVAL), based
on the ascending theory, describing the disease process as developing in the lower
most part of the leg and propagating cranially, aims to eliminate collateral varicose
veins, considered at the origin of the disease, under local anesthesia and by means of
multiple micro-incisions, and without treating the saphenous trunk [10,12,13–16].
19.2.1.3 Endovenous Thermal Ablation Surgery
The advantages of endovascular ablation are lower incidence of complications,
shorter post-intervention hospital stays, less postoperative pain, and earlier return to
normal physical activities and, therefore, are particular adequate in the elderly.
The main techniques are represented by endovenous laser ablation (EVLA) and
radiofrequency ablation (RFA) which are performed ultrasonographically guided
and under tumescent local anesthetic.
EVLA is performed by introducing a laser ber into the lumen of the vein to
treat. The heat generated and transferred by the laser energy causes a direct thermal
injury to the vein wall, resulting in the destruction of the endothelial wall, collagen
denaturation of the media, and then followed by brosis. EVLA can be used to treat
both axial veins and collaterals.
RFA is performed by inserting a special radiofrequency catheter into the targeted
saphenous vessel under ultrasound guidance from the knee to the groin, usually up
to the level of the epigastric vein or 1–2cm away from the saphenofemoral junction.
The initial thermal injury is then followed by brosis of the treated vein. This procedure appears to be safe and efcacious, shortening the operation time and preventing patient procedural discomfort. RFA has been initially proposed for the
treatment of axial reux (saphenous veins) but seems to have also a role in the treatment of tributary varices.
The introduction of ultrasonographically guided thermal ablations has also revolutionized the techniques of perforator vein ablation. Percutaneous ablation of perforators (PAPS) consists in the application of an ablative technique (RF, EVLA, or
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S. de Franciscis and R. Serra
even sclerotherapy) within the lumen of the target veins through an ultrasoundguided percutaneous intraluminal port. These techniques seem to get advantages
over the most traditional ablative treatments (Linton and Cockett procedures) and
even over the less invasive subfascial endoscopic perforator vein surgery (SEPS) for
the necessity of simple local anesthesia and for the possibility to be performed
ambulatorially because no dissections and incisions are needed [1,11,17].
19.2.1.4 Skin Grafts
One of the most important surgical procedures for the treatment of CVLUs is skin
grafting, especially when lesions are large and refractory to standard treatments.
Autografts, allografts, or human skin equivalents can be used, with a resulting
healing rate of 73%. Overall, all patients suffering with CVLUs and being considered for skin graft should undergo surgery for venous insufciency in order to correct the underlying venous abnormalities causing the ulcerations and avoid surgical
breakdown. Skin grafting for CVLUs can also be followed by additional treatment
to try to speed up the healing such as long-term LMWH therapy. Also the use of
platelet gel after skin grafting appears to be effective and a safe tool in order to
increase the healing rate of difcult-to-treat ulcers, reaching a healing rate up to
90% at 5years [1, 18].
19.2.1.5 Nonsurgical Treatments
Nonsurgical approaches are mainly represented by compression therapy, medical
treatment, and sclerotherapy that will be briey resumed here for completeness, as
they are not included within the aim and the scope of this surgical chapter, but they
may be used as adjuvant treatments to surgery.
Currently, compression therapy represents the basic and most frequently used
treatment of CVD and its complications. This treatment has been extensively validated. Compression therapy (CT) must overcome the abnormal hemodynamics of
venous hypertension; it is important to achieve the optimal pressure according to the
clinical class of the patient. Therefore, CT has been designed as the primary therapeutic modality for healing venous ulcers and as adjuvant device to supercial vein
surgery and skin grafting in order to avoid also ulcer recurrence. CT may be executed by compression stockings and compression bandages. Depending on the clinical situations, generally the grade of compression may range 10–40mmHg or even
more.
Difculties regarding putting on and removing of the compression stockings
remain signicant in the elderly population, and this may affect the compliance of
this category of patients to these important and useful devices.
Venoactive drugs (VADs) have been employed, along the years, in case of all the
clinical classes of CVD.The most used are avonoids which seem to reduce endothelial alterations and improve the property of smooth muscle cells within the media
of the vein, with phlebotonic effect. Glycosaminoglycan (GAG) drugs seem to
reduce inammation and extracellular matrix (ECM) imbalance which is one of the
major components of CVD.
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Sclerotherapy has become a very popular treatment for varicose veins in Europe.
It consists of the injection of a sclerosing substance into the reuxing vessels. The
sclerosant substance, in the liquid form or in the foam form if it has been mixed with
a gas, such as air, is able to determine chemical endothelial damage and vessel brosis [1, 19].
19.3 Deep Vein Thrombosis
One of the most recent understood aspects of venous deep vein thrombosis (DVT)
risk is advancing age. Incidence rates of DVT increase dramatically at about age 55
and by age 80 are nearly 1in 100 per year, approximately 1000-fold higher than for
those aged 45 or younger. Furthermore, rates of its life-threatening complication
pulmonary embolism (PE) rise faster than DVT in the elderly so that the disease has
greater fatal impact in this population. For DVT (Fig.19.3), prompt, effective, and
sustained anticoagulation is pivotal because of the risk of recurrent events, including PE, and also complications such as post-thrombotic syndrome (PTS) and
chronic thromboembolic pulmonary hypertension, which may greatly affect a
patient’s quality of life, especially in the elderly.
PTS is the consequence of venous valvular incompetence, venous outow
obstruction, and calf muscle pump dysfunction following an acute episode of
DVT.Signs and symptoms of PTS may include lower extremity pain, edema, hyperpigmentation, and CVLU.For PTS, proximal DVT and recurrent ipsilateral DVT
are the two principal established risk factors for PTS, and the best way to prevent it
is to provide optimal anticoagulation for the acute phase of DVT once it occurs.
From this, it follows that most of the treatment of DVT pertains to medicine rather
than surgery.
Fig. 19.3 Deep vein thrombosis
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