4/18/2015 Disclosures Evidence Based Medicine: • None Concomitant or Sequential Phlebectomy for Varicosities with Venous Ablation? 2015 UCSF Vascular Symposium Warren Gasper, MD Assistant Professor of Surgery UCSF Division of Vascular Surgery Concerning the recent randomized controlled trial in the New History of varicose vein surgery England Journal of Medicine comparing the quality of life in patients with venous disease of the legs following foam, laser and surgical treatment (CLASS study) which of the following is • Greek papyrus (ca 1550 BCE) contains the oldest true? description of varicose veins A. Laser therapy consisted of truncal ablation of • Classic therapy: from Hippocrates to Sir Astley saphenous veins under local anesthetic followed by Cooper foam sclerotherapy of residual varicosities 6 weeks later • “I see the cure is not worth the pain” – Caius 32% 32% B. Foam was applied according to the Tessari technique Marius at a ratio of 0.5mL sodium tetradecyl sulfate to 1.5mL of air to treat both the saphenous veins and the 21% • Saphenous vein ligation and stripping varicosities C. Surgery consisted of proximal ligation and stripping of 11% the GSV with concomitant stab phlebectomies to treat • Sclerotherapy residual varicosities 4% D. Quality of life measures at six months did not differ • Minimally invasive treatments saphenous among the three groups . E. All of the above . . e . . . . v o . . . t o • Thermal ablation (laser or radiofrequency) d . . a d o b o r r s a e p e t c r e s c u h i a o f s s t n d d a f o e o e e m c i t l y p l s l i e A p p s a a n f l i r s o f e c o h a w y y t r r m e t e g l i s a a r u a o u L S Q F Ann Vasc Surg 2010; 24: 426-432 1
4/18/2015 What about the superficial varicosities? • In the era of general anesthesia for saphenous ligation and stripping, concomitant stab phlebectomy was typical • The new paradigm of minimally invasive therapies have brought the procedure to the clinic, hence an interest in a procedure that could be tolerated in an office setting Phlebectomy technologies • Stab phlebectomy / microphlebectomy •507 limbs with truncal reflux and >3mm symptomatic varicose veins •355 (70%) had concomitant phlebectomy • Light assisted phlebectomy •126 (25%) had sequential phlebectomy • Light assisted power phlebectomy • Mechanical phlebectomy • Foam sclerotherapy •86 limbs with truncal reflux and symptomatic All can be done with local anesthesia varicose veins •EVLA first with photographic assessment at 1mo •36 (42%) had sequential phlebectomy 2
4/18/2015 •50 patients randomized to saphenous laser ablation and concomitant vs sequential phlebectomy •16/24 (67%) treated with EVLA alone had subsequent phlebectomy (vs 1/25 in concomitant group) Vasc Endovasc Surg 44(7) 545-549 Br J Surg 2009; 96: 369–375; BJS 2014; 101: 1093–1097 •101 patients randomized to saphenous RFA with concomitant vs sequential phlebectomy •18/50 (36%) treated with RFA alone had subsequent phlebectomy (vs 1/51 in concomitant group) Br J Surg 2009; 96: 369–375; BJS 2014; 101: 1093–1097 Ann Surg 2015;261:654–661 3
4/18/2015 Predicting need for concomitant phlebectomy Conclusions • Varicose vein treatment has gone from a “fool me once…” surgery to an office based, outpatient procedure • Phlebectomies can be safely performed in a concomitant or sequential fashion 38% of limbs (115/302) had complete varicose vein resolution • Consider concomitant phlebectomy for Of patients with C2 disease and residual varicosities, extensive, large (>6mm) varicosities and 85.7% (132/155) requested a secondary procedure especially in C2 disease Of patients with C3-6 disease and residual varicosities, 39.4% (13/33) requested a secondary procedure 4
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