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22 Venous Disease Management intheLimb Salvage Patient: Diagnostics, Compression, andAblation
Fig. 22.6 Effect of compression on venous macrocirculation. (Reprinted with permission: http://creativecommons.org/
licenses/by/4.0/ [34, 66])
293
(IPC). However, elastic graduated compression is
the hallmark of conservative management for
C0-C4 disease, which improves calf muscle
pump function and thus reduces venous pressures
and edema (Fig.22.6) [16, 31]. Most importantly,
the degree of compression must be medical-grade
to be considered clinically signicant in the treatment of venous hypertension. While further
research is needed to evaluate the benet of elastic compression directly on venous valve function, what is well established in the literature is
the improvement in venous hemodynamics with
compression use. Venous hemodynamics can be
directly evaluated via air plethysmography
(APG), which measures volume changes in the
leg and calf- pump effectiveness with ambulation.
The residual volume fraction (RVF), a direct
reection of ambulatory venous pressure, is signicantly reduced in patients with CVI with the
use of graduated elastic compression. APG has
also demonstrated that compression garments
exerting a higher pressure on the calf versus the
ankle demonstrate a greater efcacy in increasing
the venous ejection fraction from the leg [35–37].
The SVS and the AVF recommend a minimum
pressure of 20–30 mmHg for C2 disease and
above [17].
Compression stockings are the most common
form of compression. The main disadvantage of
stockings is that they produce less extrinsic pressure increases compared to compression bandages when standing up and walking and,
therefore, are less effective with respect to their
hemodynamic effects. However, compression
stockings have been shown to be effective in
reducing edema and pain versus no stockings and
are thought to have anti-inammatory properties
[31]. Patients should be advised of the
recommendation to replace compression stockings at 3–4 month intervals to promote optimal
pressure and avoid overstretching the elastic
compression gradient [16].
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B. Cutler et al.
If elastic medical-grade compression socks
(Fig.22.7) cannot be tolerated due to difculty
donning or discomfort, non-elastic compression
(such as bandages and adjustable Velcro bands)
can be considered, although non-elastic compression is not as clinically effective as elastic compression systems. Compression bandages are
multilayer and have been shown to promote the
wound healing rates of ulcers when compared to
standard wound care without the utilization of
compressive therapy [16].
Common compression bandages include the
Unna boot, Profor, Comprifore, and Coban. An
important consideration with bandage compression is to avoid applying the dressing too loosely,
which results in an ill-tting, non-effective
dressing.
Another non-elastic compression system consists of Velcro bands, which facilitate higher
compression levels during ambulation, thus
reducing venous stasis and edema. Compliance is
improved with Velcro wraps due to ease of donning and can be easily adjusted as leg edema is
reduced or loosened as discomfort occurs.
Adherence to treatment recommendations is
particularly low in patients requiring long-term
management. Compression therapy is essential
to prevent the recurrence of ulcers, and the most
benet is derived from high-grade compression.
The main concerns reported by patients include
difculties donning and dofng stockings,
improper tting bandages that are loose, and
concerns for hygiene, as dressings are often
worn for extended periods of time. Hence, the
technical ability for patients to don and doff
must be considered in compression treatment
choice.
Signicant peripheral arterial disease is a contraindication to compression therapy use, but
unfortunately may be concomitant in many
patients with venous ulcers or venous disease.
Compression can compromise arterial perfusion
to limbs, and it is recommended to limit compression use in patients with an ankle brachial
index of less than 0.5 or if absolute ankle pressure is <60mmHg [31].
Fig. 22.7 Medical grade compression. (Reprinted with permission: Lim CS, Davies AH. Graduated compression
stockings. CMAJ. 2014;186(10):E391–E398. doi:10.1503/cmaj.131281 [38])
22 Venous Disease Management intheLimb Salvage Patient: Diagnostics, Compression, andAblation
295
Treatment ofSupercial Reuxing
Veins
The era of open ligation and stripping of reuxing supercial saphenous veins has been replaced
by more minimally invasive safe and effective
endovenous closure techniques to decrease
venous hypertension. These endovenous closure
techniques can be done without general anesthesia and are often performed in the ofce. Although
open ligation and stripping continues to be appropriate for supercial saphenous veins (>1 cm)
from the skin, dilated >2.5 cm, etc., regular
advancements in endovenous closure techniques
have broadened indications for venous
treatment.
Thermal Endovenous Closure
Either laser or radiofrequency can accomplish
thermal closure of reuxing supercial veins.
Both techniques require access to the vein under
ultrasound guidance after local anesthetic is
administered. With regard to the GSV, access is
performed slightly below the knee to avoid thermal injury to the saphenous nerve in the distal
calf. Similarly with the small saphenous vein,
precautions should be taken to avoid the sural
nerve. A microwire is used to gain access into the
vein through the access needle. Once conrmed
to be intraluminal by ultrasound, the catheter is
introduced, often through a sheath, into the vein
and advanced to a point of 2cm away from the
sapheno-femoral/popliteal junction. Tumescent
anesthesia is then administered around the perivenous tissue, mitigating risks of thermal injury.
Thermal energy is then initiated. For laser ablation, the ber and sheath are withdrawn simultaneously and continuously, treating the entire
length of the vein in a pull-back fashion. For
radiofrequency ablation, the catheter treats a segment (3 or 7cm) at a time. The heat causes irreversible cellular damage of the reuxing vein,
collagen contraction, brosis, and ultimately,
induces collapse of the vein.
With regard to endovenous laser ablation
(EVLA), the treatment was rst approved by the
FDA in 2001, but as it gained popularity through
its minimally invasive convenience, safety, and
efcacy; its technology and procedural modications to power, linear endovenous energy density,
wavelength, and ber type have resulted in
improvements in treatment success. The
International Endovenous Laser Working Group
evaluated long-term outcomes of endovenous
treatment. Failure rates were 7.7% at 1 year and
5.4% at 2 years [39].
Radiofrequency ablation (RFA) of reuxing
supercial veins was introduced in the early
1990s (Fig.22.8). The alternating electrical current emits heat due to its electrical resistance. The
newest iterations can automatically adjust the
power output to ensure consistent treatment
throughout the treating section by maintaining a
target temperature of 120 °C. Several studies
have shown success rates >90% [40–42].
Not surprisingly, comparisons between RFA
and high open ligation with stripping have demonstrated RFA to be less painful, require less time
off work, and increase quality of life, without any
difference in efcacy [41, 43, 44]. Across all
modalities, including thermal and nonthermal
endovenous closure, a meta-analysis demonstrated RFA and EVLA to consistently be more
durable than sclerotherapy at 36months to close
reuxing saphenous veins [45]. A pivotal randomized control trial by Rasmussen etal. demonstrated low procedural failure at 1 year with RFA
and EVLA compared to sclerotherapy [46].
Comparison studies between EVLA and RFA
groups conrmed that post-procedural discomfort is higher in the EVLA group [40].
Mechanochemical Endovenous
Closure (MOCA)
The need for tumescent anesthesia to mitigate
periprocedural pain and thermal injury with RFA
and EVLA techniques has catapulted nonthermal
techniques for endovenous saphenous vein closure
to the forefront of emerging techniques for treatment of chronic venous insufciency since tumescent anesthesia prolongs procedural time and adds
to patient discomfort. Furthermore, thermal tech-
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B. Cutler et al.
Disposable catheter
inserted into vein
Fig. 22.8 RFA catheter. (Reprinted with permission from Medtronic, Inc.)
niques avoid treatment of reux in the distal
saphenous veins due to risk of thermal injury.
MOCA, on the other hand, produces inammatory
changes to endothelial wall, brosis, and subsequent closure by utilizing mechanical injury with
chemical irritation with typical sclerosant without
the need for tumescent anesthesia and can treat the
entire length of the saphenous vein. Furthermore,
sclerosant tends to dissipate into the supercial
varicosities of the vein being treated, maximizing
treatment efcacy.
Access for MOCA treatment with a microneedle and microwire can be at the ankle. The
MOCA device is introduced through the sheath
to the saphenojunction, 1 cm away. The rst
2–3cm is treated with the mechanical ablation to
induce vasospasm and closure of the junction to
limit dispersion of sclerosant into the deep system. The delivery catheter is activated with the
rotating mechanical tip to withdraw at a constant
speed while delivering sclerosant.
MOCA, compared to thermal techniques,
have lower long-term closure rates. Van Eekeren
Controlled heat
collapses vein
et al. published 1-year results of MOCA with
88.2% closure rate [47]. Despite consistent
higher recanalization rates compared to thermal
endovenous closure, MOCA can treat the entire
length of the reuxing vein without risk of thermal nerve injury and does not require tumescent
anesthesia, lending to a more favorable patient
experience. The venous clinical severity score
(VCSS) post-procedure also signicantly
improved, even at 1 year.
In a randomized trial comparing MOCA with
RFA, the MOCA cohort experienced signicantly less post-procedural pain compared to
RFA, and thus, an earlier return to activity [48].
The Maradona trial compared MOCA with
RFA.MOCA was reported to be less painful of a
procedure than RFA with a faster improvement in
venous clinical severity scores. However, more
anatomic failures were reported with MOCA due
to recanalization, but similar clinical success
rates at 1 and 2years between the two techniques
[49]. The LAMA trial compared MOCA to
EVLA.As predicted, the MOCA procedure was
Catheter withdrawn,
closing vein
22 Venous Disease Management intheLimb Salvage Patient: Diagnostics, Compression, andAblation
297
a less painful procedure, though degree of postprocedural pain was similar between both groups
[50, 51].
Adhesive Endovenous Closure
Given the efcacy and safety of cyanoacrylates in
endovascular procedures for abdominal aortic
aneurysms, arteriovenous malformations, and
pelvic congestion syndrome, this chemical adhesive is delivered directly into the lumen of the
reuxing vein to incite an inammatory response
and eventually leads to brosis. The access and
delivery are similar to MOCA, and as it is nonthermal, the use of tumescent is not necessary
and the entire length of the vein can be treated
without risk of nerve injury.
A microwire is inserted into the access needle
and conrmed to be intraluminal under ultrasound guidance. A 7Fr introducer sheath is placed
into the vein over the microwire. The 7Fr delivery
system is also introduced close to the saphenojunction. The delivery catheter, primed with glue,
is inserted through the introducer sheath and is
positioned 5cm away from the saphenojunction.
While putting pressure on the junction, the trigger of the dispensing gun is pulled to deliver the
adhesive, squeezing once to deliver 0.10mL of
adhesive, pulling back 1cm, and the trigger is
squeezed again. Pressure is maintained at the
junction for 3 min. The catheter is then pulled
back 3 cm for another delivery of 0.10mL of
adhesive with manual compression above the
catheter for 30 s. This pull back and adhesive
delivery is continued until the entire length of the
target vein is treated.
The rst clinical trial of cyanoacrylate adhesive closure involved 38 patients. The complete
occlusion rate immediately post-procedure was
100% and at 1 year, 92.1%. Using Kaplan-Meier
life table analysis, the closure rate at 2years was
92% [52]. A multicentered European study
treated reuxing GSVs with cyanoacrylate adhesive. At 1 year, the complete venous closure rate
was 92.9%. Venous Clinical Severity Score
improved signicantly with acceptable safety
prole [53]. A more recent post-market evalua-
tion of the cyanoacrylate adhesive closure system reported a 97.2% closure rate of the great
saphenous vein at 1 year, compared to the nearly
identical closure rate of 97% with RFA. Other
trial studies using cyanoacrylate adhesive have
also demonstrated similar closure efcacy without the need for post-procedural compression.
Mean return to work time was signicantly
shorter for cyanoacrylate adhesive closure [54,
55]. Additionally, a randomized trial comparing
adhesive to RFA showed treatment noninferiority in closure of incompetent GSV at 3months
post- procedure. At 3-months post-procedure, the
closure rate for adhesive was 99% and RFA was
96% [56].
Post-procedural Care
For thermal and MOCA endothermal closure
techniques, patients are discharged from the
ofce with 20–30mmHg compression stockings
to wear continuously for approximately 48 h.
Subsequently, patients are advised to wear daytime compression for at least 2 weeks. Patients
are encouraged to walk immediately postprocedure and resume normal activities, including daily walking. Post-procedural ultrasounds
should be scheduled within 7–14days.
With cyanoacrylate adhesive closure, postprocedural compression is not required. Patients
should continue to walk immediately postprocedurally and resume normal activities, including daily walking. Post-procedural ultrasounds
should be scheduled within 7–14days [17].
Complications
The advent of minimally invasive endovenous
closure techniques has allowed for supercial
vein treatments to be performed in the outpatient
setting. Though generally safe and well-tolerated, supercial closure techniques carry inherent risks.
Endovenous thermal closure complications
include post-procedural pain, bruising, hematoma,
phlebitis, and adjacent skin burn/discoloration.
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B. Cutler et al.
Post-procedural duplex ensures diagnosis of possible deep vein thrombosis or endothermal heatinduced thrombosis (EHIT) [57]. EHIT is unique
to thermal closure techniques and is referred to a
thrombus that propagates more proximally than
the treated segment, towards the junction. Taking
extra care in treating a safe distance from the
saphenojunction, including distal to the supercial
epigastric vein for GSV treatment, is imperative to
prevent post- procedural thrombus propagation.
In recent years, efforts have been made to
standardize a classication system and guidelines
for treatment of EHIT.Given that an acute thrombus of an EHIT behaves differently than a de
novo DVT, there is some controversy surrounding the treatment algorithm for this complication,
and ongoing research is required for a consistent
consensus on treatment approach. The AVF and
SVS published updated EHIT grading and recommendation guidelines in 2020. The recommendations are summarized below [57]
(Fig.22.9).
Furthermore, unique to thermal closure is
nerve injury. For RFA, focal paresthesias were
noted in 12% of limbs in the rst limb, improving
over time. However, for below-knee GSV treated
patients, the paresthesia rate was 7.7% at 5 years.
Dermody etal. have showed a lower risk of nerve
injury with RFA compared to EVLA (3.8% vs.
5.5%) [58]. Due to the proximity of the saphenous vein to the saphenous nerve below the knee,
most physicians limit RFA treatment to the proximal third of the GSV below the knee and supply
sufcient tumescent uid to separate the vein
from the nerve [58].
MOCA complications include hyperpigmentation, bruising, hematoma, and phlebitis. The
incidence of phlebitis is reported to be lower
than endothermal techniques [46]. The risk of
paresthesia is rare with MOCA as the technique
does not use heat. DVT and PE are also known
complications to MOCA. Neurological side
effects are unique to MOCA.The sclerosant may
travel systemically and can potentially cause
Fig. 22.9 Classication and treatment of endothermal heat-induced thrombosis. License #: 5447820045253
22 Venous Disease Management intheLimb Salvage Patient: Diagnostics, Compression, andAblation
299
cerebrovascular accidents or transient ischemic
attacks [59].
Complications of endovenous adhesive closure include bruising and phlebitis. The phlebitis
can sometimes be severe, requiring high dose
NSAIDs, compression, and warm compress therapy. Care should also be taken to ensure there is
no allergy to adhesive, or history of autoimmune
disease, prior to treatment as the cyanoacrylate is
considered an implant. Furthermore, endovenous
glue-induced thrombus (EGIT) also can occur
due to extension of thrombus into the deep system [60].
Treatment ofIncompetent
Perforator Veins
In addition to closure of reuxing supercial
saphenous veins, incompetent perforator vein
closure has contributed to decreasing venous
hypertension, directly near wounds. The Linton
procedure had severe wound complications and
was largely replaced by subfascial endoscopic
perforator vein surgery (SEPS) when introduced
by Hauer in 1985 [61, 62]. SEPS became the procedure of choice due to fewer incisions farther
away from the already compromised area around
the ulcer. However, in recent years, thermal ablations and US-guided sclerotherapy of reuxing
perforators for associated venous ulcers have
become the mainstay.
Societal guidelines have recommended treatment of pathologic perforators near the ulcer
with a diameter of >3.5 mm and with a reux
time of >0.5s.
Percutaneous thermal ablation of incompetent
perforators involves placing the laser or RFA stylet directly into the offending vein under ultrasound guidance. The directed heat damages the
endothelium, collapsing and brosing the vein.
Under RFA, the stylet is directly placed into
the vein 2 mm away from the deep system.
Tumescent anesthesia is administered around the
perivenous tissue. A spot-welding ablative technique is recommended, treating all four quadrants of the venous wall for 60s each. The stylet
is then withdrawn 3–5mm and RF is performed
in all four quadrants. This is repeated throughout
the length of the perforator.
For laser, a 1470nm, 400-mm laser ber is
placed through a micropuncture needle, directly
into the vein, 2.0–3.0 mm away from the deep
system. Perivenous tissue is inltrated with
tumescence. The vein is treated in a pulsed technique at 6W with 50–100J per 2mm through the
entire length of the perforator.
Ultrasound-guided sclerotherapy of perforator
veins involves a 25-gauge buttery needle accessing the perforator vein or a tributary off the perforator vein. Ultrasound-guided compression is
applied to the junction of the deep vein and the
perforator vein while the sclerosant is delivered.
Lawrence etal. reported on a large series of
patients refractory to wound healing and eligible
for perforator treatment. The study demonstrated
a subgroup of patients that may benet from perforator ablation. Forty-ve patients underwent
perforator ablation and healed in 71% of cases at
a mean of 193days [63].
Treatment ofDeep Venous
Obstruction
Patients with advanced venous disease presentation (e.g., CEAP C4-6) have a higher incidence
of concomitant deep venous disease. The deep
venous disease can either be reux and/or
obstruction. In symptomatic patients, both can
occur simultaneously in up to 55% of patients
[16]. Thus, to optimize treatment of venous
hypertension, patients need to be evaluated and
treated for both deep and supercial venous disease. Classication, based on signs and symptoms, can be either “reux dominant” or
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Fig. 22.10 Pre- and post-treatment IVUS of occluded iliac vein
B. Cutler et al.
“obstructive dominant.” This separation can
guide treatment options to maximize outcomes.
Deep venous thrombosis is the most common
cause of venous outow obstruction causing
venous hypertension in the lower extremities.
However, other structural abnormalities such as
May-Thurner’s and retroperitoneal brosis can
also impede venous outow as well. Although
collateralization may occur to mitigate outow
obstruction, its compensation is often inadequate
and can result in chronic venous hypertension.
Current endovascular techniques to recanalize
the inferior vena cava and iliac vein obstruction
to reduce venous hypertension in the lower
extremities rely heavily on preoperative planning
with CT venograms. Peri-procedurally, access is
often antegrade and retrograde. Crossing total
occlusion requires patience by the interventionalist and a myriad of different wires and supportive
catheters. The use of intravascular ultrasound
(IVUS) to diagnose and guide sizing of stents is
critical for optimizing chances of success in
maintaining venous outow (Fig.22.10).
Commercially available venous stents are
self-expanding nitinol stents (Fig. 22.11). Each
venous stent varies in design to offer a balance
22 Venous Disease Management intheLimb Salvage Patient: Diagnostics, Compression, andAblation
301
Fig. 22.11
Commercially available
self-expanding venous
stents. (a) Boston
Scientic Wallstent
Endoprosthesis. (b)
Cook Zilver Vena
Venous Stent. (c) Boston
Scientic Vici Venous
Stent. (d) Bard Venovo
Venous Stent. (e)
Optimed sinus-Obliquis
Venous Stent. (f)
Medtronic Abre Venous
Stent [64]. (Reprinted
with permission:
License Number
5026661464274)
a
b
c
d
e
f
between radial force, exibility, and deployment
accuracy. Long-term clinical efcacy studies of
the various stents are still under investigation.
Venous stenting, however, can be performed
with low morbidity and mortality with acceptable patency rates. Furthermore, it results in
major symptomatic relief in patients with CVD,
including ulcer healing. Neglen et al. demon-
strated a primary, assisted-primary, and secondary cumulative patency rates of 79%, 100%, and
100%, respectively, at 72-months after ileocaval
stenting with signicant decreases in venous
clinical severity score [65]. In an additional
study, sustained ulcer healing was achieved in
60% of all limbs after ileocaval stenting
(Fig.22.12) [66].
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Fig. 22.12 Pre- and post-treatment venogram for ileocaval obstruction
B. Cutler et al.
Conclusion
Venous disease is an often under-recognized but
treatable condition that signicantly impacts
patients’ quality of life. Emerging minimally
invasive techniques to address functional and
structural venous disease have allowed increased
access to treatments with signicantly improved
outcomes for patients suffering with venous
hypertension, who otherwise would rely on compression and elevation therapy alone.
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