1. Advances In Varicose Vein Treatment Louis Grella, MD, F.A.C.S. Medical Director Advanced Vein Care Louis Grella, MD F.A.C.S. www.Advancedveincare.org

2. Vascular Training Experience Stony Brook Medical Center SUNY Syracuse: MD Degree Flushing Hospital Medical Center : General Surgery SUNY Stony Brook: Vascular Surgery Fellow North Port VA: Vascular Laboratory training Jersey Coast Vascular Institute: Vascular Surgery practice Advanced Vein Care: Medical Director Louis Grella, MD F.A.C.S. www.Advancedveincare.org

4. Found running along the arteries

5. Predictable anatomy

7. Medical Management

8. Anticoagulation

9. Thrombolytic therapy

10. Systemic vs. Catheter directed

11. Elevation and Compression Louis Grella, MD F.A.C.S. www.Advancedveincare.org

13. Greater saphenous

14. Small saphenous

15. Perforators connect superficial and deep systems

16. Highly variable anatomy

17. Many unnamed branches and Tributaries Louis Grella, MD F.A.C.S. www.Advancedveincare.org

18. Venous Disease Superficial System Varicose Veins Spider Veins Venous Malformation (birth marks and others) Venous Reflux Leg Swelling Venous Ulceration

20. Calf Muscle Pump Just like the in heart we have diastole and systole This is why stretching your legs or walking improves circulation

22. From the foot up to the heart Superficial vein disease always starts with abnormal valves and interruption to normal flow called venous reflux

23. Abnormal flow = Venous Reflux Damaged Valves Blood flows to the skin Blood is pushed distally and proximally Close loop recirculation Blood is retained in the leg Increased volume of blood (heaviness Fatigue) Increased venous pressure Veins Dilate (varicose veins)

24. Causes of Venous Reflux

25. Symptoms of venous reflux Leg Fatigue Leg Heaviness Itching and pain along veins Varicose Veins Spider veins (not always 2nd to reflux) Leg swelling( think DVT 1st) Skin Discoloration (lipo dermatosclerosis) Venous ulceration

27. Remember this is only a manifestation of the underlying disease

28. Mild Disease is cosmetic issue

29. Advanced Disease significant medical problem

30. Pain

31. Swelling

33. Females to male 3 to 1

35. Single layer endothelium, minimal muscle

36. Can be Red or Blue in color depending on the origin

37. Do not cause major medical complications

38. Appears earlier than varicose veins (4% of teenagers , and 13 % in 18 to 20 year olds

39. More common in females

41. Venous Stasis Ulcers Differential Diagnosis Venous ulcerations 50% on non healing ulcers Arterial ulcers in about 10% Malignancy : basal and squamous cell, lymphoma Infections: HIV, fungal Collagen vascular disorders: Lupus ec. Lymphatic obstruction Affects over 1 million people in the US 100,000 are disabled from this More common in elderly population

42. Venous Stasis Ulcers Etiology Venous Hypertension Venous reflux DVT Varicose veins Edema Biological factors Leakage of proteins impedes diffusion O2 Aggregation of white cells Block capillary flow Release on inflammatory proteins

43. Diagnosis of venous disease Physical exam Appearance Trendelenburg test Palpation Hand Doppler Duplex Examination R/O DVT Size of veins Map out superficial veins Locate the site of reflux Reflux 0.5 sec in GSV and 1 sec in deep system Find refluxing perforators

44. Venous Duplex R/O DVT Scan deep system in cross section, look for total compression of the vein in B mode Examine from the femoral vein to the below the pop Check flow characteristics with Doppler Sharp up stroke with calf compression Small or No flow with relaxation R/O DVI This must be done with patient upright Reversal of flow of > 1 sec with Valsalva or after calf compression

45. Duplex Anatomy Locate GSV Junction(FSJ) Look for Mickey's hat Normal venous flow Look at valve Venous flow is opposite the artery

47. Look for compressibility

48. Filling defects

49. Echogenicity of defect

50. Fresh

52. Anatomy of Great Saphenous Femoral junction has multiple branches Runs on medial side of leg down to ankle Found in a facial sheet Perforators connect it to deep system

53. Anatomy of Great Saphenous From Jose Almeida, MD, IVC talk

54. Anatomy of Great Saphenous From Jose Almeida, MD, IVC talk

56. Duplex Mid Thigh

57. Treatment of Varicose Veins Conservative management Exercise Leg elevation Compression stocking Surgical treatment Standard Ligation and stripping Phlebectomies Minimally invasive procedures (Currently accepted standard) Laser Ablation Radio Frequency ablation Sclerotherapy

58. Surgical ligation and Stripping Standard treatment for a century General anesthesia Pain Long recovery Some complications Good cosmetic results

60. Done under local anesthesia

61. One needle puncture at the level of the knee

62. Takes about 1 hour

64. EVLA Results Images from http://venacure-evlt.com/

65. EVLA Results Images from http://venacure-evlt.com/

66. EVLA Results Images from http://venacure-evlt.com/

67. Sclerotherapy Cumulate vein with needle Inject Sclerosing Solution Sotradecol (Sodium tetradecyl sulfate) Pilodocanol Hyper tonic Saline Foam (Mix STS with air and make bubbles) Intravenous injection causes intima inflammation and thrombus formation

68. Sclerotherapy Use Neovascularization Perforators Clean up after Phlebectomies Spider veins Reticular veins GSV: can closure the, but has high recurrence rate

69. Sclerotherapy results

70. Thank you for your attention