VENOUS DISORDERS
| NEW TECHNOLOGIES FOR TREATMENT OF SYMPTOMATIC VARICOSE VEINS —Jeffrey L. Ballard, MD, Clinical
Professor of Surgery, University of California, Irvine, College of Medicine
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| Venous reflux: primary treatment target for patients with varicose veins (VV); primary cause—incompetent valves;
symptoms—pain; VV; leg heaviness and fatigue; swelling; skin changes; risk factors—multiple pregnancies; family
history; obesity; standing profession
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| Patient evaluation: document history; perform clinical examination; speaker performs cursory office examination with
continuous-wave Doppler to confirm greater saphenous vein (GSV) reflux; duplex ultrasonography (US)—primary
tool; abnormal reflux defined as >0.5 sec
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| Treatment options: no treatment; compression stockings reasonable first choice for patients with mildly painful varicosities
or edema and no significant varicosities; semi-rigid support no longer used; sclerotherapy effective for small VV, telangiectasias,
and reticular varicosities
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| Surgical options: sclerotherapy; phlebectomy if patient does not have venous reflux or if GSV obliterated and patient has
recurrent VV; GSV or lesser saphenous vein (LSV) obliteration; add subfascial endoscopic perforator surgery (SEPS) for
severe cases of chronic venous insufficiency; ligation of GSV—does not work; over time, collateral flow around ligation
results in reflux; vein largely preserved; saphenous stripping—early procedure worked well but was painful, had extended
recovery time, and groin dissection difficult
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| Surgical liabilities: saphenous or sural nerve injury; absence from work; worsening of edema; scarring; significant pain;
small risk of deep venous thrombosis (DVT)
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VNUS Closure
| Procedure: radiofrequency (RF) catheter inserted into saphenous vein (SV) and positioned near saphenofemoral junction
using US; slow removal of catheter closes SV; speaker recommends using 6 F catheter, because 8 F catheter can clog
with thrombus; manufacturer recommends generator temperature of 85°F; speaker uses 90°F, which enables faster catheter
removal (takes 13-17 min to close length of SV); advantages—relief of symptoms; short recovery time (patients resume
normal activities 1 to 2 days after surgery); outpatient procedure; good cosmetic outcome
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| Data registry: large number of patients (1120 limbs) from 30 centers; mean reflux duration 3 sec; predominantly women
(75%); average age 40 to 49 yr; efficacy—some cases of recanalization of GSV at 4 yr, but unusual; some cases of open
GSV detected on US 3 days after surgery; 95% of patients reflux-free at long-term follow-up
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| Complications: very unusual; pulmonary embolism; DVT; skin burn can be problematic if insufficient tumescent anesthetic
used; infection unusual; occasional lymphedema; paresthesias—likely due to insufficient tumescent anesthetic
creating inadequate heat sink, enabling catheter heat to injure saphenous nerve; saphenous neuralgia improves with time
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| Tumescent anesthesia: needle should be placed deep to fascial layer surrounding SV to allow fluid to spread along SV;
large amount of anesthetic can be injected without using large amount of fluid
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| Study: RF obliteration (RFO; VNUS closure) vs stripping and ligation; VV recurrence rate—same for both groups; patient
recovery—much quicker with RFO; quality of life—improved with RFO, compared to stripping; hemodynamics at 2
yr—91% of patients reflux-free in both groups; significant decrease in incidence of neovascularization around treated vein
with RFO, compared to stripping
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Endovenous Laser Therapy
| Disadvantages: can cause severe bruising; increased incidence of ecchymosis
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| Procedure: laser catheter inserted into vein; laser energy causes blood to boil, resulting in collagen contraction and endothelial
damage
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| Manufacturer’s data: 96% closure rate of SV; few required retreatment; speaker doubts claim that no skin burns, paresthesias,
or other adverse reactions associated with procedure
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| Risk factors for treatment failure: large body mass index (BMI); patients on anticoagulants; technically unsatisfactory
procedure (eg, difficulties with catheter, generator)
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Foam Sclerotherapy
| Procedure: causes immediate spasm of vein; can be used to treat GSV, although procedure lengthy; speaker uses it to
treat VV; foam sclerosant remains undiluted and persists in vein
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| Sclerosant foam: causes more early SV closures, fewer recanalizations, and fewer total recanalizations than liquid sclerosant;
made from sodium tetradecyl sulfate (Sotradecol) and polidocanol (laureth 9); made from detergent solution (hypertonic
saline does not work); 1 part agent to 4 parts room air; 10 syringe passages usually required to make <100-µm
foam
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| Ultrasound guidance: can be directed into varicosities and significant perforators; foam in deep venous system can be
cleared by foot flexion and extension; foam guided proximally using thumb; raising leg directs foam distally
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| DIAGNOSIS AND MANAGEMENT OF INTESTINAL ISCHEMIA —Bruce L. Gewertz, MD, Dallas Phemister Professor
and Chair, Department of Surgery, University of Chicago, Pritzker School of Medicine
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| Role of reperfusion: Granger et al—in animal model, 3 hr of ischemia without reperfusion resulted in small decrease
in mucosal thickness; 3 hr of ischemia and 1 hr of reperfusion resulted in severe decrease in mucosal thickness; 3 hr of ischemia
and 1 hr of reperfusion resulted in greater decrease than 4 hr of ischemia; reperfusion with saline caused less injury
than oxygenated blood
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| Ischemic cascade: ATP broken down to primary modalities; in presence of calcium and protease enzyme, xanthine dehydrogenase
converted to xanthine oxidase; oxygen reintroduced during reperfusion generates oxide and superoxide, which
in presence of iron liberates hydroxyl free radical, leading to accumulation of granulocytes and associated injurious enzymes;
microvascular injury results
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| Intracellular mechanisms: hypoxia—injury reflects severity of blood flow restriction; central mechanism involves disruption
of junctions joining capillary cells; injury leads to increased permeability, transudation of fluid, and activated granulocytes;
reperfusion—during time of hypoxia, cytokines liberated and reperfusion reactive O2 species generated, which
upregulate cell-adhesion molecules on endothelial layer and result in accentuation of neutrophil aggregation; secondary injury
superimposed on hypoxia; zona occludens—gateway protein with hourglass configuration; pore size regulated by
ZO-1 and ZO-2 proteins; mechanical block formed using actin, cadherin, and other proteins; ischemia results in breaks in
actin barrier and dissolution of ZO-1 from normal guardian role; transendothelial electrical resistance studies—with
no hypoxia, endothelial permeability stable; with hypoxia, permeability increases (resistance decreases); studies show epsilon
effective in preventing drop in resistance and subsequent increase in permeability; neutrophil migration—at hypoxic
O2 concentrations (10% and 3%), reactive O2 species still generated and neutrophil migration to endothelial surface
occurs; at 0% O2 concentrations, neutrophil migration returns to normal
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Acute Mesenteric Ischemia
| Diagnosis: abdominal pain with minimal physical findings represents classic diagnosis; not well differentiated by bowel
sounds; early in course, may have high-pitched bowel sounds in parts of bowel still marginally revascularized; leukocytosis
not safe indicator; radiographic signs—tend to be soft; occasionally see absence of intestinal gas because ischemic
bowel expels gas; plain film x-ray excludes other causes, eg, ureteral stones, free air under diaphragm; barium studies—
contraindicated; do not give diagnosis and obscure angiography; angiography—best done in selective fashion; diagnostic
and therapeutic for nonocclusive disease and, occasionally, in situ thrombosis
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| Embolic occlusions: >80% originate in heart; superior mesenteric artery (SMA) most common site; minority lodge at ostia
of SMA; 50% migrate or fragment and move distally within artery, giving variable presentation dependent on affected
collaterals; 15% of patients have synchronous multiple emboli; operative approach—use midline incision; incise SMA
to expose and extract embolus; important to fully extract any fragmented emboli or discontinuous thrombus; close with
interrupted sutures or patch to avoid narrowing
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| In situ thrombosis: patients less frequently have atrial arrhythmias and may be slightly older; 50% of patients have preexisting
symptoms of chronic mesenteric ischemia; SMA most common site
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 | Graft reconstruction: option 1—sew graft on backward, with heel toward distal portion of artery; perform distal anastomosis
first; pull graft taut because distance shrinks when viscera returned to abdomen; sew into most accessible portion
of aorta; option 2—take long length of graft and place in c-shaped configuration; lie flat in retroperitoneum; studies
show good long-term patency; graft can kink, and it can be difficult to find area for proximal anastomosis; option 3—
retrograde technique with less risk of kinking; if celiac artery being revascularized, tunnel behind head of pancreas and
duodenum (Kocher maneuver); option 4—can be used for isolated lesions; perform medial-visceral rotation to expose
SMA; cut through SMA into aorta, perform endarterectomy, and apply patch; prevents kinking
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| Venous thrombosis: patients present with diffuse abdominal pain and nausea; thrombus may begin peripherally in mesenteric
veins and extend centrally to portal vein (PV) or may begin at junction of mesenteric veins and PV;
pathophysiology—massive fluid sequestration within bowel and peritoneum; intraluminal fluid sequestration from
venous pressure; causes—prothrombotic states; inflammatory bowel disease and other abdominal inflammatory disorders;
cirrhosis; dehydration; diagnosis—doughnut sign of thrombus in PV on computed tomography (CT); treatment—
for thrombus within PV, enter PV transhepatically and perform thrombolysis; speaker advocates aggressive treatment
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| Nonocclusive ischemia: classically, presents in patients with cardiac problems and moderate-to-severe peripheral atherosclerosis;
patients often being treated with digitalis (digitalis impairs normal vasoreactivity and response to increased
venous hypertension in mesenteric circulation) and may be taking vasoconstrictive agents; diagnosis—arteriography
shows pruned vessels; treatment—vasodilators (papaverine, tolazoline) and antibiotics generally indicated; low-molecular-weight
dextran sometimes administered to decrease capillary sludging; indications for operative therapy—
perforation; peritoneal signs that persist despite angiographic evidence of vasodilation; leukocytosis; hemorrhagic stools
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Chronic Mesenteric Ischemia
| Presentation: patients often receive diagnosis of hypochondria; celiac ischemia—early satiety; gas-bloat symptoms; patients
often treated for gastroesophageal reflux; SMA ischemia—postprandial pain and food fear associated with weight
loss; inferior mesenteric artery (IMA) or hypogastric vessel ischemia—may present with bleeding
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| Diagnosis: deep abdominal imaging can clearly identify origin and extent of disease; angiography required to confirm diagnosis
and plan for operative therapy
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| Epidemiology: study—majority of patients women (80%), of relatively young age, and low body weight (often emaciated);
symptoms include abdominal pain and weight loss; food fear less common; smoking strong risk factor; 100% of 24 consecutive
patients had SMA involvement, with ≈100% celiac involvement, and much lower IMA involvement, reflecting nature of
proximal aortic atherosclerosis
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| Operative management: endarterectomy—surgeon’s experience determines whether appropriate; aortomesenteric
bypass—simpler operation; speaker uses multiple grafts
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| Endarterectomy technique: option 1—good exposure obtained with medial-visceral rotation; generally used when
patients have renal atheroma; option 2—easier technique; expose suprarenal aorta by taking down diaphragmatic crus;
lysis of celiac-neural plexus provides good aortic plane for anastomosis; perform proximal anastomosis first; use completely
occlusive clamp because most aortas not big enough for side clamp; place clamps on limbs to restore antegrade
flow down aorta; sew one limb of bifurcated 12 x 6 or 14 x 7 Dacron graft to celiac axis past lesion; tunnel other limb parallel
to SMA; speaker’s technique—cut flange off aortobifemoral graft and sew into supraceliac aorta; plug celiac axis
into side of graft; run graft down to SMA; speaker has achieved 100% patency; Moawad et al—24 patients underwent
surgery using speaker’s technique; minimal blood loss and limited transfusion and fluid administration; majority of complications
pulmonary related; one complication of aggravated pancreas; patients with complication of nonocclusive ischemia
received large-volume conduit to stimulate spasm of infantile vessels; smaller graft limbs, calcium channel
blockers, and avoiding angiography may prevent occurrence of nonocclusive ischemia; good patency (2 failures); good
patient survival
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| Mesenteric angioplasty: study—technical success achieved in virtually all of 19 patients (18 lesions involved SMA); 1
fatal failure; high recurrence rate at 2 yr; Cleveland Clinic study—of >100 patients, 28 received endovascular treatment
and 85 received open surgery; incidence of coronary artery disease higher in endovascular group; postoperative complications
fundamentally same, although ileus occurred significantly more often in surgery group; mortality rate same for
both groups; comparable patency for grafts and angioplasty (65% at 3 yr); >80% of surgery group symptom-free at 3 yr;
failure rate twice as high in endovascular group
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| Celiac axis compression: often presents as abdominal pain in anxious young patients; angiography reveals compression
of celiac axis by diaphragmatic crus; 3 times more common in women; considerable number of recurrences despite surgical
therapy; speaker’s criteria—foregut ischemia; negative gastrointestinal workup; celiac artery and SMA involvement
with crus compression and appropriate collateral development; etiology—theory that repetitive trauma from
diaphragm causes lesions in some patients
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Educational Objectives
| The goal of this program is to educate the listener about venous disorders. After hearing and assimilating this program, the
clinician will be better able to:
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| 1. Use new technologies for the treatment of varicose veins.
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| 2. Discuss VNUS Closure therapy for varicose veins.
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| 3. Review the mechanisms of hypoxic and reperfusion injury.
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| 4. Diagnose and manage acute mesenteric ischemia.
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| 5. Diagnose and manage chronic mesenteric ischemia.
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Discussed on This Program
Digitalis [Digifortis, Digiglusin]
Papaverine HCl [Pavabid Plateau Caps, Pavagen TD]
Polidocanol (laureth 9)
Sodium tetradecyl sulfate [Sotradecol]
Tolazoline HCl [Priscoline HCl]
Suggested Reading
Abularrage CJ et al: Chronic mesenteric ischemia: treatment of recurrent disease. J Vasc Surg 42:1026, 2005; Arumugam
TV et al: The role of the complement system in ischemia-reperfusion injury. Shock 21:401, 2004; Bergan JJ,
Pascarella L: Severe chronic venous insufficiency: primary treatment with sclerofoam. Semin Vasc Surg 18:49, 2005;
Bountouroglou DG et al: Ultrasound-guided Foam Sclerotherapy Combined with Sapheno-femoral Ligation Compared
to Surgical Treatment of Varicose Veins: Early Results of a Randomised Controlled Trial. Eur J Vasc Endovasc Surg
31:93, 2006; Brown DJ et al: Mesenteric stenting for chronic mesenteric ischemia. J Vasc Surg 42:268, 2005; Edwards
MS et al: Acute occlusive mesenteric ischemia: surgical management and outcomes. Ann Vasc Surg 17:72, 2003; Fassiadis
N et al: Ultrasound changes at the saphenofemoral junction and in the long saphenous vein during the first year after
VNUS closure. Int Angiol 21:272, 2002; Hinchliffe RJ et al: A Prospective Randomised Controlled Trial of VNUS
Closure versus Surgery for the Treatment of Recurrent Long Saphenous Varicose Veins. Eur J Vasc Endovasc Surg Aug
30, 2005 [Epub ahead of print]; Karwowski J, Arko F: Surgical management of mesenteric ischemia. Tech Vasc Interv
Radiol 7:151, 2004; Lurie F et al: Prospective randomised study of endovenous radiofrequency obliteration (closure)
versus ligation and vein stripping (EVOLVeS): two-year follow-up. Eur J Vasc Endovasc Surg 29:67, 2005; Lurie F et
al: Prospective randomized study of endovenous radiofrequency obliteration (closure procedure) versus ligation and stripping
in a selected patient population (EVOLVeS Study). J Vasc Surg 38:207, 2003; Menon NJ et al: Acute mesenteric
ischaemia. Acta Chir Belg 105:344, 2005; Mundy L et al: Systematic review of endovenous laser treatment for varicose
veins. Br J Surg 92:1189, 2005; Nicolini P; Closure Group: Treatment of primary varicose veins by endovenous obliteration
with the VNUS closure system: results of a prospective multicentre study. Eur J Vasc Endovasc Surg 29:433,
2005; Puggioni A et al: Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: analysis of
early efficacy and complications. J Vasc Surg 42:488, 2005; Razavi M, Chung HH: Endovascular management of
chronic mesenteric ischemia. Tech Vasc Interv Radiol 7:155, 2004; Schoots IG et al: Systematic review of survival after
acute mesenteric ischaemia according to disease aetiology. Br J Surg 91:17, 2004; Sreenarasimhaiah J: Diagnosis
and management of intestinal ischaemic disorders. BMJ 326:1372, 2003; Teruya TH, Ballard JL: New approaches for
the treatment of varicose veins. Surg Clin North Am 84:1397, 2004; Landis MS et al: Percutaneous management of
chronic mesenteric ischemia: outcomes after intervention. J Vasc Interv Radiol 16:1319, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship
with the manufacturer or provider of any commercial product or service discussed. For this issue, the speakers reported
no conflict.
Dr. Ballard was recorded January 28, 2005, at the 33rd Annual Phoenix Surgical Symposium, sponsored by the Maricopa
Integrated Health System and the Phoenix Surgical Society and held in Scottsdale, Arizona. Dr. Gewertz was recorded
October 6, 2004, at the 22nd Annual UCLA Symposium, A Comprehensive Review and Update of What’s New
in Vascular Surgery, sponsored by the the David Geffen School of Medicine at the University of California, Los Angeles,
and held in Beverly Hills, California. The Audio-Digest Foundation thanks the speakers and the sponsors for
their cooperation in the production of this program.
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