Learning points Superficial lower limb venous anatomy Clinical - PDF document

19/08/2019 Learning points  Superficial lower limb venous anatomy  Clinical assessment in OPD Varicose veins – Endovenous  Assessing suitability for EVT therapy  Understanding the procedure  US imaging after EVT Prof Tim Buckenham Consultant Vascular and Interventional Radiologist Monash University and Monash Health Venous anatomy Venous anatomy ANATOMY Saphenous Fascia 1

19/08/2019 Varicose veins the Perforating veins physiology OVARIAN VEIN Relationship between Vulval varicosities Lower limb varicosities and Pelvic congestion INCOMPETENCE • During pregnancy, the vascular capacity of the ovarian veins may increase 60-fold and remain this way for months after delivery. • Left ovarian vein usually affected Treatment of Trans abdominal US Incompetent ovarian vein  Dilated Ovarian vein(>6 mm)  Reverse flow  Incompetent  Para ovarian varices 2

19/08/2019 The Team Physical requirements: Vascular surgeons, Nurses, Sonographers, IR’s, PSA  Good quality diagnostic ultrasound facilities with tilting table  Trained sonographers  Experienced IR nurses  Consultation rooms EVT techniques Interventional room: 1. EVLT  Ultrasound machine 2. RF ablation  Tilting table 3. Cyanoacrylate closure  Sterile facilities 4. UGS  Good lighting CEAP classification of chronic venous disease complications Clinical classification  C0 No visible or palpable signs of venous disease  C1 Telangiectasies or reticular veins  C2 Varicose veins  C3 Edema  C4a Pigmentation or eczema  C4b Lipodermatosclerosis or athrophie blanche  C5 Healed venous ulcer  C6 Active venous ulcer     3

19/08/2019 Advantages of EVT  Ambulatory procedure  No GA  No incision  Immediate activity/work after procedure  At least as effective as surgery Patterns of disease and Patient Flow their treatment  Procedure time laser 30-40min/limb Great and Small saphenous incompetence : Can be treated with EVT  UGS 15/min limb   Application of full length class 2 Contraindications to EVT: compression hosiary Non-occlusive thrombus 1.  Ambulatory recovery period 30 Tortuosity minutes 2. Dilatation > 10mm(relative) 3. Deep Venous incompetence/obstruction 4. Neo Junction GSV Imaging prior to EVT  GSV patent  Possible to treat with EVLT  GSV in the saphenous sheath for at  If there is a trunk least 15cm  Is the GSV cirsoid?  Does GSV have webs  Diameter of GSV 4

19/08/2019 ENDOVENOUS  Percutaneous access seldinger  Sheath advanced over a wire to 5mm short of junction (US control) plus light  Tumescent local  Withdraw laser/RF probe Tip of laser within vein GSV tumescent local EVLT V RFA 5

19/08/2019 Laser safety Managing the AASV 3% fibro vein and Sclerotherapy Tessario foam  1ml of 3% Fibrovein foamed to 4mls   Tessario technique  Maximum dose 8mls of foam  US guided 3 days continuous and 3 Complications weeks during daytime  Scotoma  Pigmentation  Ulceration  Eccyhmosis 6

19/08/2019 Conclusion IR can set up a venous service Utilise existing infrastructure provided by an existing Radiological department with skilled IR nurses Attractive option for patients and Hospital Outpatient treatment 1. Minimally invasive 2. No GA 3. No surgery 4. Very rapid recovery 5. 7