Anatomy and Physiology of Veins;

Principles of Sclerotherapy

Gerant Rivera-Sanfeliz,MD

Venous Pathology

• > 100 million people with venous disorders in US and Europe

• > 40% women and 20% men living with superficial venous disease

• > One million vein stripping procedures/year in US and europe

Varicose Veins (Rutherford)

• Venous Disorders - 211 of 2032 pages• Varicose Veins - 4 pages

Lower Extremity Veins

• Deep system• Superficial system• Perforator system• Lateral subdermic

venous system (LSVS)

Great Saphenous Vein (GSV)

Previous Long Saphenous Vein (LSV)• Known as “el safin ” by

Arabic physicians, which means the concealed

• Located along the medial aspect of the lower extremity

• True duplication seen in 10-37%, often joining within 10 cm of the knee

• Saphenous nerve• Saphenous compartment• Joins CFV at fossa ovalis (SFJ)

Small Saphenous Vein (SSV)Previous Lesser Saphenous Vein

• Travels, with the sural nerve, along the lateral aspect of the leg

• Joins popliteal vein at SPJ between the two heads of the gastrocnemius

• May extend into the thigh and communicate with the femoral vein or GSV (Vein of Giacomini)

• True duplication rarely reported

Perforating Veins• Communicate the deep

and superficial systems• Horizontal or slightly

upward orientation• Flow normally from

superficial to deep• Common GSV perforators:

- Hunterian (midthigh)- Dodd’s (above knee)- Boyd’s (below knee)- Cockett (distal leg)

Subcutaneous Veins

• When abnormal: - Varicose (> 3mm) - Reticular (1- 3

mm) - Telangiectasia

(spider)

Lateral Subdermic Venous System (LSVS)

• Lateral aspect of leg above and below the knee

• Embryonic superficial vessels fail to involute

• Varicosities at young age, not increasing with age

• Perforators

EpifascialSubcutaneous veins

IntrafascialSuperficial veins

SubfascialDeep veins

Three Anatomical Areas:

Three fully interacting systems: superficial, deep, perforators

Vein Physiology

• Pumps

• Valves

Muscle Pump (Peripheral Heart)

• Contractions propel blood toward heart

• Relaxation draws blood from- superficial veins

- lower deep veins

Thoracoabdominal Pump

• Inspiration decreases intrathoracic pressure promoting venous return

• Expiration reverses the process

• Findings easily seen in US

Valves

• Maintain unidirectional flow- Extremity to heart- Superficial to deep

• GSV and SSV with terminal and preterminal valves

• Terminal (sentinel or first) valve with firm thickened white cusps different from the rest of the valves

PathophysiologyVaricose Veins (VV)

• Histologic studies show the collagen content of primary VV less than normal veins

• Muscle content, although high, shows disorganization with areas broken up by similarly disorganized collagen

• These findings may account for the decreased elasticity of VV

Pathophysiology> 90% LEVI

A. NormalA. Normal

Incompetent Valve ProgressionIncompetent Valve Progression

B. Leaky Valve B. Leaky Valve

Syndrome Syndrome --Valves become Valves become stretched stretched -Allow back flow of -Allow back flow of BloodBlood

C. Superficial Valvular RefluxC. Superficial Valvular Reflux-Vein becomes engorged-Increasing pressure-Thinning walls-Weaken muscle support-Can enlarge vessel diameters greater than 10mm

Patterns of Reflux

1. Truncal or saphenous related reflux

- GSV: 4/6 of VV- SSV: 1/6 of VV

2. Non-truncal reflux: 1/6 of VV

- Pudendal, perforators

- LSVS, Giacomini

SVI – SymptomsBad looks, bad feelings

• Aching• Vague Discomfort• Heat/Burning• Skin changes, bleeding• ? Swelling

All tend to increase with dependency and resolve with leg elevation or

compression

SVI - Stigmata

• Abnormal veins- telangiectasia (spider)- reticular- Non-saphenous VV (perforans varicosis)- Saphenous VV

• Abnormal skin

SVI - Stigmata

• Abnormal veins- telangiectasia (spider)- reticular- Non-saphenous VV- Saphenous VV

• Abnormal skin

SVI - Stigmata

• Abnormal veins- telangiectasia (spider)- reticular- Non-saphenous VV- Saphenous VV

• Abnormal skin

SVI - Stigmata

• Abnormal veins- telangiectasia (spider)- reticular- Non-saphenous VV- Saphenous VV

• Abnormal skin

SVI - Stigmata

• Abnormal veins- telangiectasia (spider)- reticular- Non-saphenous VV- Saphenous VV

• Abnormal skin

Courtesy of Dr. J. Golan

SVI - Stigmata• Abnormal veins• Abnormal skin

- eczema- edema- corona phlebectatica- lipodermatosclerosis- ulceration

Classification Of CVDCEAP

• C - clinical signs0: No visible venous disease1: Telangiectasias or reticular veins2: Varicose veins3: Edema4: Skin changes5: Healed ulceration6: Active ulceration

J Vasc Surg 1995; 21:635-645.

Courtesy of Dr. J. Golan

Courtesy of Dr. J. Golan

Imaging In PVI

• Duplex ultrasonography- Has replaced plethysmography

and venography- 7-10MHz linear array transducer- Examination performed in sitting

and standing positions- Superficial and deep systems

evaluated- Physiologic reflux: < 0.5 sec- Pathologic reflux: > 0.5 sec

Standard Surgical Treatment

• Saphenous vein ligation• Saphenous vein stripping +/-

ligation• Flush SFJ ligation, stripping the

thigh portion of the GSV with excision of its tributaries and stab avulsion phlebectomies of the VV

• SEPS (subfascial endoscopic perforator surgery)

Ligation vs. Stripping

Recurence of VV higher with Recurence of VV higher with ligation when compared to ligation when compared to stripping of the thigh portion of stripping of the thigh portion of the GSVthe GSV (McMullin GM, et al. Br J Surg 1991; 78:1139-1142/ Stonebridge PA, et al. Br J Surg 1995; 82:60-62/ Rutgers PH, et al. Am J Surg 1994; 168:311-315)

Fischer R, et al. The Unresolved Problem of Recurrent Saphenofemoral Reflux. J Am Coll Surg 2002; 195:80-94.

Surgical Complications

• Wound Infection• Hematoma/

severe bruising• Scarring• DVT• Recurrence

Courtesy of Dr. J. Golan

One conclusion is apparent from the surgical literature:

The crucial step in treating VV is removing the thigh portion of the refluxing saphenous vein from the circulation.

Percutaneous Options

• Sclerotherapy• Endovenous Ablation

- Radiofrequency- Laser

A small amount of damage will produce …

… but a thrombosed vessel with intact endothelium will not

sclerose

Volume Dilution

• Zone 1Zone 1: vessel is irreversibly injured

• Zone 2Zone 2: vessel will be able to recanalize

• Zone 3Zone 3: no endothelial injury, dilute sclerosant

Modern Sclerosants

• Detergents• Hypertonic and ionic solutions• Cellular toxins

Detergents• Most commonly used• Sodium morrhuate, sotradecol,

polidocanol, among others• Liquid or Foam

Detergent sclerosants work by a mechanism known as protein theft denaturation, in which an aggregation of detergent molecules forms a lipid bilayer in the form of a sheet, a cylinder or a micelle, which then disrupts the cell surface

membrane and may steal away essential proteins from the cell membrane surface.

Cell Death

Polidocanol (0.5%)

Advantages• Injection is

Painless• Extravasation

No Necrosis

Disadvantages

• Pigmentation Intermediate

Sclerotherapy - Results

• Excellent for small veins: reticular, telangiectasias

• High recanalization rates for larger veins

• GSV: > 50% recurrent reflux by US, which is likely the prelude for recurrence of VV

Sclerotherapy-Complications

• Pigmentation• Matting• Ulceration

Courtesy of Dr. J. Golan

Sclerotherapy vs. Surgery• Prospective 10 year study (121 96)• VV and superficial incompetence• Group A: Sclerotherapy (39)• Group B: Ligation + Sclerotherapy (40)• Group C: Ligation only (42)• No incompetence at SFJ in surgical groups• Sclerotherapy with 20-44% reflux• Sclerotherapy cheaper, surgery superior

Belcaro G, et al. Angiology 2000; 51:529-534.

Sclerosing Foam

• Orbach(1944): the air block technique

• Displaces blood• Induces more

spasm• Tiny bubbles

covered by tensio-active liquid

• Treat larger veins

1ml of 3% STS injected in a vein dilutes with 10ml of

blood

Final drug concentration: 0.3%

1ml of 1% Foam STS injected in the same vein displaces blood

Final drug concentration: 1%

Sclerosing Foam

• Less volume • More potent• Morbidity appears

similar to liquid sclerosants

• Being used clinically since 1997, results in GSV better than liquid ~ 20-30% recanalization

Percutaneous Options

• Sclerotherapy• Endovenous Ablation

- Radiofrequency- Laser