RECENT ADVANCES

DR.MATHISEKARAN.T

RECENT ADVANCES IN MINIMALLY INVASIVE SURGERY FOR VARICOSE VEINS

INTRODUCTION
VARICOSE VEIN AFFECTS A SIGNIFICANT PERCENTAGE (40%) OF MIDDLE AGED POPULATION. ITS IMPORTANT TO LOCALIZE THE PROBLEM BEFORE SURGICAL MANAGEMENT. CLINICAL EXAMINATION 90% SENSITIVITY FOR SAPHENOFEMORAL JN 61.5% SENSITIVITY FOR PERFORATOR INCOMPETENCE

 ENDO-VENOUS THERAPIES KEYHOLE THERAPYSCLEROSE OR BURN THE LEAKY VEIN CLOSE TO VALVE JUNCTIONS. HEAT SOURCE

LASER

RADIOFREQUENCY

 DIVISION OF INCOMPETENT PERFORATING VEINS REGARDED AS APPROPRIATE APPROACH FOR TREATMENT OF VENOUS STASIS ULCERS. NOW,SEPS SUB FASCIAL ENDOSCOPIC SURGERY IMPORTANT PART OF SURGICAL ARMAMENTARIUM FOR VENOUS ULCERS.

PATHOGENESIS

Pathogenesis

MAIN CAUSE : Persistent chronic ambulatory venous HTN. Prevalence of venous ulceration:0.1 0.3%. Cutaneous venous hypertension occurs as a consequence of primary valvular incompetence in 60% of patients.

Clinical features
Clinical classification is based on CEAP reporting system
C0 C1 C2 NO VISIBLE SIGN OF VENOUS DISEASE TELANGIECTASES AND/OR RETICULAR VEINS VARICOSE VEINS

C3
C4 A B C5 C6

EDEMA
CHANGES IN SKIN AND SUBCUTANEOUS TISSUE

PIGMENTATION OR ECZEMA
LIPODERMATOSCLEROSIS OR ATROPHIC BLANCHE

HEALED ULCER ACTIVE ULCER

Clinical features
Sensation of heaviness and itching Cramps and aching Visible varicosed vein Cutaneous skin breakdown over medial malleolus Complications :
Bleeding Phlebitis ulceration

Indications for surgery

-cosmetic reasons -chronic venous insufficiency -superficial thrombophlebitis -bleeding -anxiety

Contra-indications

Previous deep vein thrombosis Major lower limb fracture Prolonged immobilization white leg of pregnancy Arterial insufficiency -relative

Surgical aspects
Informed consent Warned of possible complications
Minor hemorrhage Track thrombophlebitis Hematomas Infections Lymph leak.

Injury to sural or saphenous nv Permanent lymphoedema Thromboembolism

Common surgical procedures

Sapheno-femoral ligation Stripping of long saphenous vein Multiple avulsions Sapheno-popliteal ligation Perforator ligation

Sapheno-femoral ligation
Identification of long saphenous vein Superficial tributaries dissected Followed back to secondary branches Divided and ligated

Stripping of long saphenous vein

Reduces rate of recurrence Not universally performed

Multiple avulsion
-Small 3-5 incisions made -vein retrieved with phlebotomy hook -avulsed. -avulsions may be closed with steristrips

Sapheno-popliteal ligation
-location of sapheno-popliteal is very variable -pre-operative Doppler or duplex scanning is important.

Perforator ligation:
-significance of this surgery remains unclear -surgery designed to divide perforating veins COCKETT and LINTONconsiderable morbidity.

RECENT ADVANCES

Recent Advances
Endo-venous therapies (keyhole therapies)

Recent Advances
Endo-venous therapies(keyhole therapies)
Sclerosing or burning the leaky vein close to valve junctions. The heat for burning the vein is provided by laser or radio frequency. Less painful procedure. The results are good and better than surgery. The endovenous thermal ablation restores the normal blood flow towards the deep system. The success rate is 93 -95%

Subfascial endoscopic surgery(SEPS)

Procedure: The patient in supine position Esmarch bandage is tightly applied and a sterile tourniquet is inflated high up on the thigh.The esmarch is then removed. A 10 mm endoscope is laid on the leg A 13 mm skin incision is made 3cm from the medial margin of tibia. 10mm opticview port with the scope is inserted.

 It is rotated to reach the white fascia Then the underlying muscles are exposed. At this point, the subfascial space has been entered. It is angled towards the patients foot and advanced into this space. The scope and the inner cannula are removed And CO2 insufflated to 30mm/hg pressure. The scope is then reinserted into the port. The second port is placed 5-10cm from the first and approximately the same level.

 The endoscissors are inserted through 2nd port and subfascial space opened. After creating the optical cavity, larger perforating vein is clipped and divided. Space is opened from medial tibial border to midline posteriorly From the level of port to as far distally as dissection can comfortably proceed Paratibial fossa should be opened sharply so that additional perforating veins can be divided in deep posterior compartment. Caution to avoid injury to postr tibial art,vn and tibial nerve

DISCUSSION
CLASSICALY VASCULAR SURGERY REMAINED RELATIVELY AWAY FROM ENDOSCOPIC TECHNIQUES
SEPS represents a safe,easily mastered technique for vascular practitioner to enter ENDOSCOPIC world. LINTON PROPOSED: Patients with perforator incompetence treated directly by dividing offending perforators. Long incision had to be made85% patients enjoyed ulcer free recurrence in long term. Complicationsinfection, flap necrosis, delayed healing. Minimally invasive surgery re-evaluation of the procedure

HAUER IN GERMANYmechanical system for endoscopic subfascial surgery to date has the greatest experience. ODONNELL OF USAemployed saline infusion adequate optical space.
GLOVICZKI OF USAemployed CO2 insufflation

APPROPRIATE PATIENTS FOR SEPS: Active ulcers Recurrent ulcers Healed ulcer present >4months.

Underlying pathophysiological process is best documented by color flow duplex scanning It is advisable to synchonously treat superficial reflux by stripping while also perrforming SEPS,if perforater competence was documented.

LASER/RADIOFREQUENCY ABLATION SYSTEMS

 ELVeS Endo Laser Vein System is a minimally-invasive laser treatment for Incompetent Saphenous and Accessory Veins a problem which often leads to the formation of varicose veins. ELVeS takes approximately 30 minutes and requires only local anesthesia allowing patients to walk home after treatment. With virtually instant relief from Venous Reflux and Venous Hypertension, patients can return to their normal lifestyle and activities immediately following treatment.

 Benefits of ELVeS for varicose veins & spider veins: Endovenous Laser Therapy ELVeS is a minimally invasive laser vein treatment for damaged incompetent veins. ELVeS requires no incisions, leaves no visible scarring and with minimal postoperative pain recovery periods are quick and minimal. Treatment in less than an hour in office with no general anesthesia or hospitalization. Up to 98% success rate. Immediate relief of symptoms. Return to normal activity immediately with little or no pain. No scars.

CONCLUSION
SEPS represents a promising new approach to ulcer management in patients with perforator incompetence
-minimal morbidity. -out patient basis.
NASEPS committee is warranting continued evaluation, focusing in incidence of recurrent ulceration and ultimately standard evaluation of ulcer therapy

THANKYOU