perforator veins why and how to treat them
TRANSCRIPT
Cees H.A.WittensCees H.A.Wittens
European Venous Centre European Venous Centre Aachen-MaastrichtAachen-Maastricht
Perforator veins: why Perforator veins: why and how to treat themand how to treat them
E CVEuropean Venous Centre: Maastricht-AachenEuropean Venous Centre: Maastricht-AachenTurkish Society of Vascular Surgery Antalya 2011Turkish Society of Vascular Surgery Antalya 2011
Why treat Incompetent Perforator Why treat Incompetent Perforator in:in:
Venous ulcers CVenous ulcers C6 6 and healed ulcers Cand healed ulcers C55 ? ? Lipodermatosclerotic legs CLipodermatosclerotic legs C44??
Recurrent varicosities CRecurrent varicosities C2,32,3??
E CVEuropean Venous Centre: Maastricht-AachenEuropean Venous Centre: Maastricht-AachenTurkish Society of Vascular Surgery Antalya 2011Turkish Society of Vascular Surgery Antalya 2011
Perforator treatment:Perforator treatment:pathophysiologypathophysiology
High ‘systolic’ intravenous pressures High ‘systolic’ intravenous pressures in calf veins are transmitted through in calf veins are transmitted through incompetent perf. veins to the skin incompetent perf. veins to the skin circulation circulation (200 mmHg) causing;(200 mmHg) causing;
White cell trapping and capillaryWhite cell trapping and capillary
cuffingcuffing Impairing nutritional skinflowImpairing nutritional skinflow
E CVEuropean Venous Centre: Maastricht-AachenEuropean Venous Centre: Maastricht-AachenTurkish Society of Vascular Surgery Antalya 2011Turkish Society of Vascular Surgery Antalya 2011
Perforator treatment CPerforator treatment C5,65,6::clinical outcomeclinical outcome
.. Depending oncompliance
Subgroup analysesQuality of SEPS
Turkish Society of Vascular Surgery Antalya 2011Turkish Society of Vascular Surgery Antalya 2011
Perforator treatment CPerforator treatment C66::clinical outcomeclinical outcome
E CVEuropean Venous Centre: Maastricht-AachenEuropean Venous Centre: Maastricht-AachenTurkish Society of Vascular Surgery Antalya 2011Turkish Society of Vascular Surgery Antalya 2011
SEPS-trial: SEPS-trial: residual and/or medial ulcersresidual and/or medial ulcers
223150576873 314258677885N =
non-primary and/or medial ulcer
period (6 months)
654321
ulc
us
pre
sen
t (%
da
ys)
100
90
80
70
60
50
40
30
20
10
0
TREAT
CH
CO
P= 0.045 (ANOVA)
E CVEuropean Venous Centre: Maastricht-AachenEuropean Venous Centre: Maastricht-AachenTurkish Society of Vascular Surgery Antalya 2011Turkish Society of Vascular Surgery Antalya 2011
Perforator treatment CPerforator treatment C66::clinical outcomeclinical outcome
Influence of the quality of the SEPS procedureInfluence of the quality of the SEPS procedure
E CVEuropean Venous Centre: Maastricht-AachenEuropean Venous Centre: Maastricht-AachenTurkish Society of Vascular Surgery Antalya 2011Turkish Society of Vascular Surgery Antalya 2011
Influence on Healing of the quality of the SEPS Influence on Healing of the quality of the SEPS procedureprocedure
months
60483624120
he
alin
g (
%)
100
90
80
70
60
50
40
30
20
10
0
SEPS
non succesfull
succesfull
NSNS
Compliance highCompliance high
Perforator treatment CPerforator treatment C66::clinical outcomeclinical outcome
E CVEuropean Venous Centre: Maastricht-AachenEuropean Venous Centre: Maastricht-AachenTurkish Society of Vascular Surgery Antalya 2011Turkish Society of Vascular Surgery Antalya 2011
Influence on Recurrence of the quality of the SEPS Influence on Recurrence of the quality of the SEPS procedureprocedure
months
60483624120
recu
rre
nce
(%
)
100
90
80
70
60
50
40
30
20
10
0
seps
not succesfull
succesfull
P<0.007P<0.007
Influence of perforator Influence of perforator incompetence !!incompetence !!
Compliance lowCompliance low
Perforator treatment CPerforator treatment C66::clinical outcomeclinical outcome
E CVEuropean Venous Centre: Maastricht-AachenEuropean Venous Centre: Maastricht-AachenTurkish Society of Vascular Surgery Antalya 2011Turkish Society of Vascular Surgery Antalya 2011
C C 5,65,6
medial ulcersmedial ulcers recurrent ulcersrecurrent ulcers large ulcerslarge ulcers
(around 90 % of patients with venous ulcers)(around 90 % of patients with venous ulcers)
E CVEuropean Venous Centre: Maastricht-AachenEuropean Venous Centre: Maastricht-Aachen
Why treat Incompetent PerforatorWhy treat Incompetent PerforatorBecause of improved clinical outcome in:Because of improved clinical outcome in:
Turkish Society of Vascular Surgery Antalya 2011Turkish Society of Vascular Surgery Antalya 2011
YESYESCC5,65,6 (medial, recurrent and large) (medial, recurrent and large)
????Lipodermatosclerosis CLipodermatosclerosis C4 4
Recurrent varicosities in CRecurrent varicosities in C2,3 2,3
NoNoPrimary varicosities CPrimary varicosities C2,32,3
E CV
European Venous Centre: Maastricht-AachenEuropean Venous Centre: Maastricht-Aachen
Why treat Incompetent PerforatorWhy treat Incompetent PerforatorBecause of improved clinical outcome in:Because of improved clinical outcome in:
Turkish Society of Vascular Surgery Antalya 2011Turkish Society of Vascular Surgery Antalya 2011
Open methods Open methods (Linton)(Linton)
Pierik 1996 (due to woundproblems >50%/0% trial stopped ) = Pierik 1996 (due to woundproblems >50%/0% trial stopped ) = ObsoleetObsoleet
Half blind methods Half blind methods (Edwards phlebotoom) = (Edwards phlebotoom) =
ObsoleetObsoleet
How to treat IPVHow to treat IPV
E CVEuropean Venous Centre: Maastricht-AachenEuropean Venous Centre: Maastricht-AachenTurkish Society of Vascular Surgery Antalya 2011Turkish Society of Vascular Surgery Antalya 2011
SEPS one port systemSEPS one port system
Olympus scoopOlympus scoop
CO2 insufflationCO2 insufflation
Bloodless fieldBloodless field
Mechanical space (force)Mechanical space (force)
E CVEuropean Venous Centre: Maastricht-AachenEuropean Venous Centre: Maastricht-Aachen
How to treat IPVHow to treat IPV
Turkish Society of Vascular Surgery Antalya 2011Turkish Society of Vascular Surgery Antalya 2011
SEPS two/three port systemSEPS two/three port system lap. equipm.lap. equipm.
CO2 insufflationCO2 insufflation
spacemakerspacemaker
no mech. space no mech. space
E CVEuropean Venous Centre: Maastricht-AachenEuropean Venous Centre: Maastricht-Aachen
How to treat IPVHow to treat IPV
Turkish Society of Vascular Surgery Antalya 2011Turkish Society of Vascular Surgery Antalya 2011
Sclerotherapy of IPV:Sclerotherapy of IPV:
intraluminalintraluminal 98 % succesfull occlusion immediately after 98 % succesfull occlusion immediately after
the procedure (cave: spasm)the procedure (cave: spasm) 33.3 % recurrence after 1 month33.3 % recurrence after 1 month
FutureFutureFoam ??Foam ??
Masuda et al; J Vasc Surg 2006Masuda et al; J Vasc Surg 2006E CV
European Venous Centre: Maastricht-AachenEuropean Venous Centre: Maastricht-AachenTurkish Society of Vascular Surgery Antalya 2011Turkish Society of Vascular Surgery Antalya 2011
Cryo Perforator Surgery (CPS):Cryo Perforator Surgery (CPS):
ExtraluminalExtraluminal Initial succes 100 %Initial succes 100 % Recanalisation after Recanalisation after
20 weeks 57 %20 weeks 57 %
ObsoleetObsoleet
Klem and Wittens; Vasc Endovascular Surg 2008/2010Klem and Wittens; Vasc Endovascular Surg 2008/2010E CV
European Venous Centre: Maastricht-AachenEuropean Venous Centre: Maastricht-AachenTurkish Society of Vascular Surgery Antalya 2011Turkish Society of Vascular Surgery Antalya 2011
Radiofrequency ablation of IPV: Radiofrequency ablation of IPV: IntraluminalIntraluminal Initial succes 96%Initial succes 96% 1 year1 year
VNUS: 60-80%VNUS: 60-80%RFITT: 75-90%RFITT: 75-90%
Future: Future: One hand procedure ?One hand procedure ?
Peden and Lumbsden ; Perspect Vasc Surg Endovasc Ther 2007Peden and Lumbsden ; Perspect Vasc Surg Endovasc Ther 2007E CV
European Venous Centre: Maastricht-AachenEuropean Venous Centre: Maastricht-AachenTurkish Society of Vascular Surgery Antalya 2011Turkish Society of Vascular Surgery Antalya 2011
Laser ablation of IPV:Laser ablation of IPV: IntraluminalIntraluminal Initial succes 96 %Initial succes 96 % 1year1year
60-80%60-80%
Future:Future:Length and energy level changeLength and energy level change
Proebstle et al.; Dermatol Surg 2007Proebstle et al.; Dermatol Surg 2007
E CVEuropean Venous Centre: Maastricht-AachenEuropean Venous Centre: Maastricht-AachenTurkish Society of Vascular Surgery Antalya 2011Turkish Society of Vascular Surgery Antalya 2011
Coil embolisation of IPV:Coil embolisation of IPV:
IntraluminalIntraluminal Initial succes 67 %Initial succes 67 % Recanalisation 75 % Recanalisation 75 %
after 1 yearafter 1 year
Future:Future:Obsoleet!Obsoleet!
Van Dijk and Wittens; J Vasc Interv Radiol 1999Van Dijk and Wittens; J Vasc Interv Radiol 1999 E CVEuropean Venous Centre: Maastricht-AachenEuropean Venous Centre: Maastricht-AachenTurkish Society of Vascular Surgery Antalya 2011Turkish Society of Vascular Surgery Antalya 2011
Duplex directed interruption of Duplex directed interruption of IPV:IPV:
ExtraluminalExtraluminal Initial succes 100 %Initial succes 100 % Recanalisation ??Recanalisation ??
Future Future ??
Siewert et al; poster AVF 2006Siewert et al; poster AVF 2006
E CVEuropean Venous Centre: Maastricht-AachenEuropean Venous Centre: Maastricht-AachenTurkish Society of Vascular Surgery Antalya 2011Turkish Society of Vascular Surgery Antalya 2011
All techniques:All techniques:
SEPSSEPS (cannot reach them all; short stay)(cannot reach them all; short stay) 60-9060-90 SclerotherapySclerotherapy (high recurrence; cheap)(high recurrence; cheap) 40-7040-70 CryoPSCryoPS (obsoleet)(obsoleet) <60<60 RFARFA (feasable; expensive)(feasable; expensive)
VNUSVNUS 60-8060-80RFITTRFITT 75-9075-90
Laser Laser (feasable; expensive)(feasable; expensive) 60-8060-80 Coil embolisationCoil embolisation (obsoleet)(obsoleet) <60<60 Duplex interrupt.Duplex interrupt. (extraluminal;distance, cheap)(extraluminal;distance, cheap) ????
E CVEuropean Venous Centre: Maastricht-AachenEuropean Venous Centre: Maastricht-Aachen
Succes %Succes %
Turkish Society of Vascular Surgery Antalya 2011Turkish Society of Vascular Surgery Antalya 2011
Why:Why:• Because it improve clinical outcome in CBecause it improve clinical outcome in C5,65,6
How:How:• SEPSSEPS• Quality control !!Quality control !!• New minimally invasive techniques:New minimally invasive techniques:
• which: trials!which: trials!Turkish Society of Vascular Surgery Antalya 2011Turkish Society of Vascular Surgery Antalya 2011
E CVEuropean Venous Centre: Maastricht-AachenEuropean Venous Centre: Maastricht-Aachen
Perforator veins: why and how to Perforator veins: why and how to treat them:treat them: