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Treatment of accessory and non-saphenous
veins
Jose I. Almeida, MD, FACS, RPVI, RVTDirector, Miami Vein Center
Voluntary Associate Professor of Surgery
University of Miami - Jackson Memorial Hospital
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Faculty DisclosureJose I. Almeida, MD, FACS, RPVI, RVT
1. Research grant supportAngioDynamics, Covidien, Sapheon, Vascular Insights
2. Managing PartnerVascular Device Partners, LLC
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Great saphenous vein anatomy
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The Venous Map
Pitfalls
Failure to recognize anatomic variability.
Failure to correlate duplex to the clinical exam.
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Common patterns of VV
GSV DoddPudendal Giacomini
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Surgical failures:
Imaging will identify
the refluxing vein
causing varicosis.
AASV
GSV
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Great Saphenous Incompetence
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The great saphenous vein (GSV) is the most
common source of superficial venous reflux
occurring in up to 70% of patients presenting
with symptomatic varicose veins and venous
insufficiency
Myers KA, Ziegenbein RW, Zeng GH, et al. Duplex ultrasonography scanning for
chronic venous disease: patterns of venous reflux. J Vasc Surg. 1995;21:605-
612.605-12.)
Labropoulos N, Giannoukas AD, Delis K, et al. Where does venous reflux start? J
Vasc Surg. 1997;26:736-742.
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60% 30% 10%SSV Insertions
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Up to 20% of patients with varicose veins have
incompetence of the SSV.
Englehorn CA, Englehorn AL, Cassou MF, Salles-Cunha SX. Patterns of saphenous
reflux in women with varicose veins. J Vasc Surg 2005;41: 645-51.
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Anterior Accessory SV
Drawing courtesy of Olivier Pichot, MDDrawing courtesy of Olivier Pichot, MD
img 27
Image courtesy of Olivier Pichot, MD
img 27
Image courtesy of Olivier Pichot, MD
AASV PASV
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Isolated AAGSV reflux occurs in
approximately 10% of patients with
symptomatic varicose veins
33 patients who underwent EVLT of the
AAGSV had no recanalization of the treated
vein at 1 year.
Patient-satisfaction scores 84%
Theivacumar NS, Darwood RJ, Gough MJ. Endovenous laser ablation (EVLA) of the
anterior accessory great saphenous vein (AAGSV): abolition of sapheno-femoral reflux
with preservation of the great saphenous vein. Eur J Vasc Endovasc Surg. 2009;37:477-
481.
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Almeida, Ann Vasc Surg, 2006
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img 22
Image courtesy of Olivier Pichot, MD
Image courtesy of Olivier Pichot, MD
Dual GSV and AASV reflux
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Dual ablation
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Superficial Accessory SV
Risk of thermal injury
img 51 img 51
Images courtesy of Olivier Pichot, MD
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Post-op staining from epifascial GSV
img 50
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Re-entry via inter-saphenous connections
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Perforators
Drawing courtesy of Olivier Pichot, MDDrawing courtesy of Olivier Pichot, MD
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case 1
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LADS- laser assisted distal saphenectomy
GSV in canalDermal GSV
(sasv)
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LADS- laser assisted distal saphenectomy
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LADS- laser assisted distal saphenectomy
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LADS
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case 2
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Foam
EVL straight remnant
EVL AASV
Recurrent VV s/p saphenectomy
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EVL versatility: fits through micropuncture
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RF 7cm long heating element limits short
length veins
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case 3
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Klippel-Trenauney Syndrome
Pain & non-healing ulcer
Normal deep venogram
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ELT of KTS- 6 superficial axial veins closed over 1 year
period, followed by sclerofoam.
Lateral embryonic vein
R then LLSV
R then L
Anterolateral leg vein
R only
Lateral thigh vein
L only
Now 9 years, UGS once a quarter
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MAP correctly,
& you won’t go astray
Thank you!
Conclusion: