Chronic Venous Disease Gabor Menyhei MD Ph D
Chronic Venous Disease Gabor Menyhei MD, Ph. D Professor of Vascular Surgery
Classification of venous diseases • Acute superficial thrombophlebitis deep venous thrombosis injuries • Chronic venous insufficiency primary (superficial or deep) secondary (postthrombotic syndrome) arteriovenous fistula(rare)
Etiology of chronic venous insufficiency • Primary Risk factors: long-term standing, multiple birth, adiposity, genetic factors • Secondary Deep venous thrombosis Arteriovenous fistula (acquired or congenital)
Pathophysiology of chronic venous insufficiency Valve incompetence Raised venous pressure Oedema, varicose veins, skin changes, venous ulcer
Teleangiectasia
Varicose veins
Skin changes in CVI
Venous ulcer
Anatomic patterns of CVI • Superficial LSV or SSV reflux • Perforating veins • Deep veins valve incompetence occlusion
Diagnosis of chronic venous insufficiency • • • Physical examination Hand-held Doppler Duplex scan Phlebography Plethysmography Radionuclide venography
Duplex assessment
Treatment of venous insufficiency • • • Compression therapy Sclerotherapy Surgery Local treatment (ulcer) Venotonic drugs
Surgery in superficial insufficiency • High ligation of long or short saphenous vein • Stripping • Multiple avulsions
High ligation
Stripping of LSV
Stripping of LSV
Endovenous laser treatment
Radiofrequency ablation
Surgery of incompetent perforators • Ligation of perforators through small incisions • Cockett operation (one long medial incision) • Endoscopic dissection (SEPS)
Perforator vein incompetence
SEPS
Löfqvist tourniqet for SEPS
SEPS – Two-port technique
Advantages of SEPS • • • Minimally invasiv Less complications Shorter hospital stay Shorter recovery Good cost-benefit
Mid term clinical outcome after subfascial endoscopic perforator surgery CEAP grade C 6 n=40 C 4 -5 n=11 Total n=51 Healed/Improved Unchanged Ulcer recurred 25 (62%) 7 (18%) 8 (20%) 8 2 1 33 (64%) 9 (18%) C 4 : skin changes, C 5: healed ulcer, C 6: active ulcer
Surgery of deep vein occlusion • Palma operation if chronic iliac vein occlusion femoro-femoral crossover saphenous bypass
Femoro-femoral crossover saphenous bypass (Palma operation)
Dinamic radionuclide venography after Palma operation
Long term results of Palma operation (after 6 years) Phlebography findings Improved Unchang ed Total Iliac vein occlusion and intact deep veins below 10 (83%) 2 (17%) 12 Iliac vein occlusion and postthrombotic deep veins below 19 (64%) 11 (46%) 30 Total 29 (69%) 13 (31%) 42
Surgery of deep vein incompetence • Vein segment transplantation • External or internal valvuloplasty • Vein transposition
Primary deep vein incompetence: External or internal valve plasty Ulcer free at 5 years: 65 -83% Kistner, 1996. Raju, 2000.
Secunder (postthrombotic) deep vein incompetence: Vein-segment transplantation Ulcus recurrence at 5 years: - if good patient compliance: 29% - if not: 100% Mayberry, 2002
Vein segment transplantation
Thank you for your attention.
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