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Chapter
https://t.me/med1917
9
Clinical Methods for Sclerotherapy of Varicose Veins
A
Figure 9.42 Case Study 15. A, At presentation, multiple bilateral ulcers.
B, 4 months after treatment with sclerosant microfoam, the varicose veins
are reduced and the ulcers closed.
B
nights, then for 7 days only during daytime. The patient was
evaluated with duplex ultrasound at days 1 and 7 and at
months 1, 3, 6, and 12. No complications occurred. Minor
ecchymosis at the access site for 1 week resolved
spontaneously. Complete sclerosis of the desired segment
occurred. Vein size was 1.2 mm (almost not visible) at 12
months (Fig. 9.41D).
The ultrasound images are from 12 months post treatment:
you may see the epigastric vein patent (Fig. 9.41E) and the GSV
with firm sclerosis and echogenicity similar to surrounding
tissue (a little more dense) (Fig. 9.41F). The femoral vein is
patent.
Case Study 15
Varicose veins and venous ulcers treated with
sclerosant microfoam
DDI Wright, JC Cabrera
Elderly patients with leg ulcers frequently remain uninvestigated
and untreated, as the prospect of surgery in the presence of
open ulcers is discounted and often not acceptable to the
patient. Microfoam sclerotherapy offers an effective and
acceptable alternative in appropriate cases.
A 64-year-old woman presented with bilateral leg ulcers open
for 1 and 2 years (right and left, respectively). She had bilateral
varicose veins which had been severe for in excess of 20 years
(Fig. 9.42A). Previous treatment was confined to compression
and local antiseptics.
Duplex scanning revealed bilateral GSV incompetence from
groin to ankle and incompetent perforating veins near the left
ulcer. The SPJs were competent, but distally both small
saphenous veins were incompetent. The deep venous systems
were normal.
Initial treatment consisted of 19 mL of 1% POL microfoam (1%
POL mf) injected under ultrasound guidance through a
20-gauge cannula into the right GSV and an additional 4 mL
injected directly into varicose veins. Two weeks later, the left
GSV was injected with 15 mL of 1% POL mf in the same
manner, and further injections of 15 mL to the varicose veins
and IPVs were administered. At review 1 month later,
recanalization of the proximal segment of the right GSV was
observed and reinjected with an additional 6 mL of 1% POL mf.
By this visit, all ulcers had healed and the varicose veins were
occluded.
Photographs taken 3 months later show the healed ulcers and
greatly reduced varicose veins (Fig. 9.42B). Two years later,
recanalization of both GSV with narrow lumens was detected,
but the ulcers remained healed. A further 12 mL of 1% POL
mf was injected into recanalized segments. There were no
complications following any of the treatments. At last review 43
months after the first treatment, the ulcers remained healed, no
varicosities were visible, and there was no reflux.
This case illustrates that microfoam sclerotherapy can be a
simple, effective, and durable treatment for patients with
venous hypertension and ulceration caused by superficial vein
and perforator incompetence. Minor recanalization can be
retreated and normal venous function restored.
Case Study 16
Microfoam sclerotherapy in Klippel-Trenaunay Syndrome
(KTS) and a patent foramen ovale (PFO)
P Redondo, G Bastarrika, A Sierra, A Martinez-Cuesta, J Cabrera
A 25-year-old women presented with KTS manifested as
widespread venous varicosities and a segmental port wine stain
affecting the left leg with associated intralesional pain.
Multidectector-row computed tomography (MDCT) revealed
that the aberrant vessels originated from the superficial
venous system with a normal deep venous system. Duplex
ultrasound demonstrated incompetence in the superficial
system. She was then treated with polidocanol microfoam
(POL mf) injected into the marginal, great saphenous, and
peripheral small veins via 20, 23, and 25-guage needles,
respectively, under ultrasound guidance with limb elevation for
15–20 minutes followed by graduated compression with a
Struva 23-mmHg stocking for 7 to 15 days (Medi-Bayreuth,
Bayreuth, Germany). Eight separate treatment sessions over 12
months with injection of 20 to 80 mL of POL mf at 0.25 to 2%
concentration was required. A migraine headache after the
second session resulted in a work-up which demonstrated
bubbles in the middle cerebral artery. Magnetic resonance
imaging at 24 hours showed no evidence of cerebral damage
and all subsequent treatments were without incident.
Examinations 6 months after the final sclerotherapy session with
MDCT revealed significant clinical improvement and reduction
in the number and size of the percutaneously treated aberrant
veins (Fig. 9.43).
274
References
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A
D
Figure 9.43 Case Study 16. Clinical and multidetector-row computed tomography venography images from a 25-year-old women with Klippel-Trénauny
Syndrome. Upper row, initial images; lower row, follow-up images. A and D, Anterior views (left); B and E, lateral views; and C and F, posterior views.
(Extracted and used with permission from Arch Dermatol 145:1147, 2009).
B
E
C
F
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References
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Chapter
Distal sclerotherapy and/or Muller’s phlebectomy
Ultrasound-guided foam sclerotherapy
‘Classical’ surgery
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9
sodium sulfate allergy with general
symptoms. Soc Fr Phlebol 1972;25:19.
210. Stroncek DF, Hutton SW, Silvis SE,
et al. Sodium morrhuate stimulates
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211. Duffy DM, Garcia C, Clark RE. The
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Chapter 9: Appendix
Schematic principal types of varicose networks, schematic treatments
Surg 1999;104:1474.
sclerotherapy for vessels involving the
hands and face. Aesth Dermatol
Cosmet Surg 1999;1:91.
Clinical Methods for Sclerotherapy of Varicose Veins
Varicose
reservoir
Appendix 9.1
• 1 + 2 = ‘Classical’
• Fill up network through
2 only = ‘new trend’
Source of reflux
Long/high reflux
Source
High reflux
Short reflux
Varicose
reservoir
1
No long/truncal reflux
Appendix 9.2
Crossectomy
Stripping
2
Appendix 9.3
280
Muller
phlebectomy
Appendix 9.4
With preservation
Laser and radio-frequency
ASVAL and peripheral foam therapy
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of junction and
last/upper tributaries
Additional
treatment
of reservoir
required
Secondary
reduction of
short reflux
Varicose reservoir
Ablation/sclero
Source
High reflux
Chapter 9: Appendix
Appendix 9.5
Appendix 9.6
281
10
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C H A P T E R
Role of Surgery in the Treatment of Varicose Veins
Michael Perrin
Background
Surgery for treating varicose veins (VVs) has been advocated
for centuries. The first description is attributed to A.C. Celsus
from the Roman era and consisted of hook extraction of varicose veins, double ligation and phlebectomy. Modern surgery
based on supposed hemodynamic treatment started at the
beginning of the 19th century when T. Rima performed a
high ligation (HL) of the upper great saphenous vein (GSV),
although F. Trendelenburg is usually credited as having been
the first to do it in 1890. Complementary saphenous trunk
stripping came some years later with W.L. Keller in 1905
(internal stripping), C. Mayo in 1906 (external stripping) and
W.W. Babcock in 1907 (flexible stripper). Various alternative
techniques to conventional HL plus trunk stripping were
proposed in the second half of the twentieth century (Van
der Stricht, Muller, Large, Milleret, Franceschi, Lane, Yamaki,
Pittaluga, etc.).
The first to suggest interruption of perforators to treat VVs
was probably Remy in 1901.
Duplex ultrasound (DUS) investigation was the cornerstone to our changing knowledge and attitude in the management of VVs; nevertheless it must be emphasized that there is
presently no consensus regarding the best procedure for the
operative treatment of VVs when taking into account their
various patterns of clinical and hemodynamic presentation.
Basis and Aim of Surgery
In theory, surgery, as with other operative methods (e.g.
thermal and chemical ablation), aims to suppress or reduce
reflux in the standing position (orthostatism) in the incompetent, enlarged and tortuous superficial veins.
In practice the aim is twofold:
• To eliminate reflux originating from the deep venous
system (DVS) into the superficial venous system (SVS) by
suppressing abnormal leak points, which result from calf
pump muscular systolic pressures being higher in the
DVS than in the SVS. In healthy subjects, terminal valves
of the saphenous trunks and perforator valves prevent
reflux from deep into superficial systems. Reflux occurs
when these valves are incompetent.
• To suppress the reflux in the incompetent superficial
veins which are visualized as varices.
The Different Surgical Procedures
Procedures depend on the different concepts of VV disease
progression and evolution as well as on the principles of
hemodynamic anomalies correction, which are currently con-
troversial and are reviewed below. The procedures discussed
can be performed alone or in combination:
• Resection of all the refluxing veins
• Resection of the incompetent ‘reservoir’
• Ligation of the leak points between the DVS and SVS at
the saphenofemoral junction (SFJ), saphenopopliteal
junction (SPJ) and perforator
• Redirecting reflux from the SVS into the DVS.
As this book is not an atlas of venous surgery, the different
procedures will not be described in detail. However, the
advantages and inconveniences of the different surgical
methods will be underlined.
Surgery without saphenous
trunk preservation
Conventional surgery includes GSV and/or small saphenous
vein (SSV) termination ligation flush to the corresponding
deep vein, plus saphenous trunk stripping with or without
incompetent tributaries phlebectomy and/or incompetent
perforator interruption.
Principle and Controversies
This method is based on the VV descending progression
hemodynamic concept that was established at the beginning
of the 20th century. It was believed that reflux always started
at the SFJ and/or the SPJ, due to incompetence of the terminal
valve, and extended progressively in a distal direction within
the saphenous trunk and into the suprafascial accessory or
tributary veins in which the varices developed. Consequently,
SFJ and/or SPJ ligation completed by trunk stripping and/or
phlebectomy of tributary varices was the ‘cure all’ method. But
the systematic use of DUS for investigating VVs has shown that
this concept was wrong in many cases:
• Reflux and dilatation are frequently segmental in any
location of the saphenous and nonsaphenous systems.
• Onset of the VV can occur in any segment of the
superficial veins without incompetence of the SFJ, SPJ
and saphenous trunk itself.
• The VV reservoir volume favors magnitude and extension
of reflux. Compression of an incompetent tributary
vein termination can reduce or suppress reflux in the
saphenous trunk when they are not dilated beyond 6 to
8 mm in diameter (Fig. 10.1)
• Furthermore we have learned that leak points between
the DVS and the SVS can disappear after ablation of the
VVs even though they have not been treated. After VV
ablation 80% of previously incompetent perforator veins
became competent.
• More surprisingly, incompetent terminal valves can
recover their normal function after ablation of the
refluxing varices.
9,10
1–8
1
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2
A
Figure 10.1 Reservoir reduction capacity allows reduction or suppression
reflux in the main trunk. A, Reflux of the main trunk drains in an
incompetent tributary. This siphon effect increases reflux volume in the
main trunk. B, Compression at the termination of the incompetent tributary
suppresses reflux in the main trunk.
superficielle: notions fondamentales. EMC (Elsevier Masson SAS, Paris), Techniques
chirurgicales
– Chirurgie vasculaire, 43-161-A, 2007.)
B
(Adapted from Perrin M. Insuffisance veineuse
All of these findings have enhanced development of new
surgical procedures that will be described later.
Technical Information
• Ligation of the SFJ and SPJ can be performed by using a
4 to 6-cm transverse incision without cosmetic prejudice,
particularly when the incision is made within the groin
crease.
• Saphenous trunk stripping is most frequently performed
using the endoluminal technique, with invagination or
pin stripping, and is credited with causing fewer
neurologic complications (Figs 10.2 and 10.3).
• Extension of trunk resection depends more on operator
conviction than on the extent of reflux.
• Incompetent tributary phlebectomy is performed
through a very small skin incision, usually 2 to 3 mm in
length.
• Surgical perforator ablation can be performed directly
by skin incision overlying the perforator in the absence
of overlying skin pathology. In the presence of
lipodermatosclerosis, subfascial endoscopic perforator
surgery is strongly recommended, at least for medial leg
perforator veins.
Conventional surgery variants
Saphenous Trunk Stripping with Preservation of
Saphenofemoral Confluence, with or without
Incompetent Tributary Phlebectomy and/or
Incompetent Perforator Interruption
Non-flush ligation at the SFJ and/or SPJ was, until recently,
described as a technical mistake responsible for in situ recurrence in all cases as reflux through the incompetent terminal
valve persisted. But preoperative ultrasound investigations
have proved that in GSV varices the terminal valve is competent in approximately half the patients.
In this situation it looks obvious that high flush tie is not
recommended as tributaries of the saphenofemoral confluence
can drain in a physiologic way into the common femoral vein.
Besides neovascularization, elimination of normal physiologic
reflux is the main cause of recurrence after flush ligation,
rarely identified after confluence conservation.
11,12
13
14
but
3
4
5
Figure 10.2 Invagination stripping. 1. Vein is catheterized from the ankle to
the groin. 2. A thread is fixed on the stripper. 3. The rigid stripper is pulled
up from the ankle to the groin. 4. The thread is fixed on the vein at the
groin. 5. Pull on the thread allows the removal of the vein by the
invagination technique.
veineuse superficielle. Principes. Techniques. R
Techniques chirurgicales
(Adapted from Perrin M. Chirurgie à ciel ouvert de l’insuffisance
ésultats. EMC (Elsevier Masson SAS, Paris),
– Chirurgie vasculaire, 43-161-B, 2007).
When the terminal valve is incompetent, non-flush ligation
was thought to promote recurrence, as previously stated (Fig.
10.4). However, one prospective study has demonstrated that
this concept is wrong. In this large series neither postoperative
outcome nor clinical and diagnostic evaluation found a difference in terms of recurrence if the terminal valve was competent or not.
14
The explanation for this may be that suppression of the
reservoir represented by an incompetent saphenous trunk
and tributaries allows the terminal valve to recover its
competence.
Cryostripping
The only difference with cryostripping in comparison to classical surgery is the ablation modality of the saphenous trunk.
After HL, the saphenous trunk is catheterized downward with
the cryoprobe until reaching the lower limit of the vein to be
stripped. The generator is activated and when the vein is
attached to the cryoprobe (by freezing to it) the vein is broken
off easily. No distal ligation is needed and the vein attached
to the probe is progressively pulled up and extracted through
the groin incision (Fig. 10.5).
Cryostripping is said to cause less postoperative bruising
and hematoma along the path of the saphenous trunk than
The Different Surgical Procedures
283
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