Management of incompetent perforators after endovenous LASER ablation or stripping of GSV
Ahmed Fathy Abdel-Aziz AboHadr;
Abstract
SUMMARY
T
he lower extremity venous system is unique in its constant need to overcome the force of gravity while returning blood toward the heart. An elegant calf pump and vein valve system normally accomplish this task efficiently. The thin bicuspid, semilunar vein valves float open in the venous stream during prograde flow. During calf muscle relaxation, retrograde flow and higher supravalvular pressure cause the margins of the valve cusps to move to the midline and oppose so that caudad reflux is prevented. These valves can be disrupted by a thrombotic event (secondary), can be congenitally absent or atretic, or can become dysfunctional over time as the vein wall or valve loses integrity (primary).
Perforator veins perforate the deep fascia of the leg that separates the superficial and deep compartments; they can be classified as direct or indirect. Direct perforators connect the superficial to the deep venous systems, whereas indirect perforators join the venous sinuses of the calf muscles. Furthermore, PVs connect to each other via communicating veins above and underneath the deep muscle fascia.
IPVs can be found in 40% to 60% of extremities with primary CVD and even more frequently in legs with postthrombotic disease .More than 60% of extremities with axial reflux in the great saphenous vein (GSV) have incompetent PVs, as opposed to 38% of extremities with only segmental superficial reflux.
An association between axial superficial reflux and PV incompetence has been shown during the progression of CVD. Within 1 or 2 years of observation, new refluxing segments in the superficial system develop in about a third of legs with varicose veins .In half of these cases, the new IPV also develops during the same time., The observation that correction of superficial reflux leads to resolution of perforator incompetence in most limbs supports the concept that superficial reflux causes an “overload” of PVs resulting in dilatation and incompetence.However, treatment of saphenous reflux by either stripping or ablation results in a significant increase in resistance to outward flow in PVs. Therefore, elimination of PV reflux after such treatment does not necessarily mean that the competence of the PV valves will be regained. The presence of these incompetent perforators without demonstrated reflux may be a reason that “isolated” IPVs are found in previously treated extremities and cause new symptoms and worsening hemodynamics.
Although a significant proportion of limbs with the most severe combination of deep, superficial, and perforator incompetence have no swelling or skin changes, IPVs alone can cause symptoms, affect hemodynamics, and increase the severity of disease .Even more convincing is the fact that successful treatment of an “isolated” IPV is associated with relief of symptoms and improvement of severity scores. In addition to their role in disease progression, IPVs can be a source of recurrent varices after treatment. This concept is supported by consistent findings of a high prevalence of IPVs in extremities with recurrent varices.
GSV stripping is the central component of the classic operation for varicose veins. Recurrence rates are markedly reduced when the GSV is stripped as opposed to when high ligation is performed alone, therefore high ligation is usually performed in conjunction with treatment of the GSV
ELA uses a bare-tipped or jacket-tipped fiber to deliver laser energy to a target area and form thermal energy within the vein lumen. The thermal energy generates heat and steam bubbles within the lumen of the target vessel, destroying the endothelial lining of the vessel. This causes an inflammatory reaction resulting in a thrombotic occlusion that effectively closes off the vein and eventually leads to fibrosis.
The timing and technique of IPV interruption are important. Although procedures can be staged, performing simultaneous saphenous vein ablation and perforator ablation has two major advantages. First, all invasive procedures are performed in one session, which is highly desirable for the patient and reduces the cost of treatment. Second, it has been suggested that any remaining incompetent tributaries and IPVs connected to the saphenous veins can increase the chance of recanalization after thermal and chemical ablation. Thus, treating IPVs at the time of saphenous vein ablation possibly improves the result of the saphenous vein ablation. On the other hand, elimination of saphenous reflux has a profound effect on the global venous hemodynamics of the leg. Segments not specifically targeted during surgery, such as PVs and deep veins, may partially reverse their incompetence when the total venous “overload” of the leg is reduced. In as many as 58% of IPVs, incompetence can be reversed during the 2 years after stripping.
When simultaneous treatment of IPVs and incompetent saphenous veins is planned, selection of the IPV interruption technique is very much dependent on the method of treating the saphenous vein. The less invasive options for saphenous ablation limit the use of open surgical interruption because it may increase immediate postoperative morbidity and negate the advantages of minimally invasive procedures. When IPV interruption is performed alone, selecting a minimally invasive option still has the advantage of minimizing immediate postoperative morbidity, thereby allowing early ambulation and reducing impact on quality of life.
Interruption of PVs through small stab wounds plus avulsion by a vein hook is now preferred among the open surgical methods because this procedure is significantly less invasive and does not require hospitalization. With this technique, duplex scanning is used for preoperative mapping and the IPVs are marked on the skin, which allows performance of a more precise procedure. Ligation of incompetent perforators can also be done by making a short incision directly over the marked sites and ligating them at the fascia with absorbable sutures. Alternatively, vein hook position can be controlled with the use of intraoperative transcutaneous ultrasound to ensure that a targeted IPV is actually interrupted. Selection of an open perforator interruption technique does not guarantee 100% success. Five percent of perforators are usually missed, and 32% recur within 3 years, half of them being incompetent.
T
he lower extremity venous system is unique in its constant need to overcome the force of gravity while returning blood toward the heart. An elegant calf pump and vein valve system normally accomplish this task efficiently. The thin bicuspid, semilunar vein valves float open in the venous stream during prograde flow. During calf muscle relaxation, retrograde flow and higher supravalvular pressure cause the margins of the valve cusps to move to the midline and oppose so that caudad reflux is prevented. These valves can be disrupted by a thrombotic event (secondary), can be congenitally absent or atretic, or can become dysfunctional over time as the vein wall or valve loses integrity (primary).
Perforator veins perforate the deep fascia of the leg that separates the superficial and deep compartments; they can be classified as direct or indirect. Direct perforators connect the superficial to the deep venous systems, whereas indirect perforators join the venous sinuses of the calf muscles. Furthermore, PVs connect to each other via communicating veins above and underneath the deep muscle fascia.
IPVs can be found in 40% to 60% of extremities with primary CVD and even more frequently in legs with postthrombotic disease .More than 60% of extremities with axial reflux in the great saphenous vein (GSV) have incompetent PVs, as opposed to 38% of extremities with only segmental superficial reflux.
An association between axial superficial reflux and PV incompetence has been shown during the progression of CVD. Within 1 or 2 years of observation, new refluxing segments in the superficial system develop in about a third of legs with varicose veins .In half of these cases, the new IPV also develops during the same time., The observation that correction of superficial reflux leads to resolution of perforator incompetence in most limbs supports the concept that superficial reflux causes an “overload” of PVs resulting in dilatation and incompetence.However, treatment of saphenous reflux by either stripping or ablation results in a significant increase in resistance to outward flow in PVs. Therefore, elimination of PV reflux after such treatment does not necessarily mean that the competence of the PV valves will be regained. The presence of these incompetent perforators without demonstrated reflux may be a reason that “isolated” IPVs are found in previously treated extremities and cause new symptoms and worsening hemodynamics.
Although a significant proportion of limbs with the most severe combination of deep, superficial, and perforator incompetence have no swelling or skin changes, IPVs alone can cause symptoms, affect hemodynamics, and increase the severity of disease .Even more convincing is the fact that successful treatment of an “isolated” IPV is associated with relief of symptoms and improvement of severity scores. In addition to their role in disease progression, IPVs can be a source of recurrent varices after treatment. This concept is supported by consistent findings of a high prevalence of IPVs in extremities with recurrent varices.
GSV stripping is the central component of the classic operation for varicose veins. Recurrence rates are markedly reduced when the GSV is stripped as opposed to when high ligation is performed alone, therefore high ligation is usually performed in conjunction with treatment of the GSV
ELA uses a bare-tipped or jacket-tipped fiber to deliver laser energy to a target area and form thermal energy within the vein lumen. The thermal energy generates heat and steam bubbles within the lumen of the target vessel, destroying the endothelial lining of the vessel. This causes an inflammatory reaction resulting in a thrombotic occlusion that effectively closes off the vein and eventually leads to fibrosis.
The timing and technique of IPV interruption are important. Although procedures can be staged, performing simultaneous saphenous vein ablation and perforator ablation has two major advantages. First, all invasive procedures are performed in one session, which is highly desirable for the patient and reduces the cost of treatment. Second, it has been suggested that any remaining incompetent tributaries and IPVs connected to the saphenous veins can increase the chance of recanalization after thermal and chemical ablation. Thus, treating IPVs at the time of saphenous vein ablation possibly improves the result of the saphenous vein ablation. On the other hand, elimination of saphenous reflux has a profound effect on the global venous hemodynamics of the leg. Segments not specifically targeted during surgery, such as PVs and deep veins, may partially reverse their incompetence when the total venous “overload” of the leg is reduced. In as many as 58% of IPVs, incompetence can be reversed during the 2 years after stripping.
When simultaneous treatment of IPVs and incompetent saphenous veins is planned, selection of the IPV interruption technique is very much dependent on the method of treating the saphenous vein. The less invasive options for saphenous ablation limit the use of open surgical interruption because it may increase immediate postoperative morbidity and negate the advantages of minimally invasive procedures. When IPV interruption is performed alone, selecting a minimally invasive option still has the advantage of minimizing immediate postoperative morbidity, thereby allowing early ambulation and reducing impact on quality of life.
Interruption of PVs through small stab wounds plus avulsion by a vein hook is now preferred among the open surgical methods because this procedure is significantly less invasive and does not require hospitalization. With this technique, duplex scanning is used for preoperative mapping and the IPVs are marked on the skin, which allows performance of a more precise procedure. Ligation of incompetent perforators can also be done by making a short incision directly over the marked sites and ligating them at the fascia with absorbable sutures. Alternatively, vein hook position can be controlled with the use of intraoperative transcutaneous ultrasound to ensure that a targeted IPV is actually interrupted. Selection of an open perforator interruption technique does not guarantee 100% success. Five percent of perforators are usually missed, and 32% recur within 3 years, half of them being incompetent.
Other data
| Title | Management of incompetent perforators after endovenous LASER ablation or stripping of GSV | Other Titles | أساليب كي الوريد الثاقب بالتردد الحراري لمريض دوالي الساقين | Authors | Ahmed Fathy Abdel-Aziz AboHadr | Issue Date | 2017 |
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