DR. ABBAS CHAMSUDDIN

1. The MIGHTY Greater
Saphenous Vein
Abbas A. Chamsuddn, M.D.
1-Clinical Associate Professor, Department of Radiology
AlBalamand University-School of Medicine
Beirut, Lebanon
2-Chief, IR Service, Quantum Medical Radiology
Atlanta, GA
3-Director, The Center for Laser and Interventional Surgery,
Beirut, Lebanon

2. Disclosure:
 Bard:
– Honoraria
– Research Grant
 Angiodynamics:
– Honoraria
 Abbott:
– Research Grant

3. Background

4. VENOUS ANATOMY:
SUPERFICIAL VEINS
• The veins of the lower extremity
that are superficial to the muscular
compartment
• Include innumerable draining
veins as well as the GSV and LSV

5. Lower Extremity Venous
Anatomy
 Superficial Veins
 Deep veins
 Great Saphenous Vein: Replaces “Greater”
or “Long”
 Small Saphenous Vein: Replaces “Lesser”
or “Short”
 Anterior and Posterior Accessory GSVs
 Giacomini Veins
 Truncal veins

6. Varicose Veins: Venous
Anatomy
 SFJ: Saphenofemoral
junction
 SPJ: Saphenopopliteal
junction

7. The Great Saphenous Vein
 Begins on the dorsum of
the foot
 Ascends along the medial
aspect of the leg
 Drains in the femoral vein
 Resides in a space deep to
the superficial fascia and
superficial to the deep
fascia

8. The Small Saphenous Vein
 Begins along the lateral aspect
of the foot
 Ascends up the midline of the
calf
 In 2/3rd of cases drains in the
popliteal vein
 In 1/3rd of cases it drains more
cephalad in the posterior thigh
 Also resides in the saphenous
space

9. Anterior and Posterior
Accessory GSVs
 Located in the
saphenous space
and travel parallel
anterior/porterior to
the GSV
 Anterior AGSV is
more common

10. Giacomini Vein
 The intersaphenous
vein
 A communication
between GSV and
SSV

11. Perforators

12. Venous Anatomy
 Deep Veins:
– Femoral and Popliteal Tibial Veins
 Superficial Veins
– Small Saphenous Vein
– Great Saphenous Vein
 Perforators: Connectors of the deep veins to the
superficial veins
 Reticular Veins: Tributaries to the saphenous
vein-connecting branch veins to deep, superficial
or perforators
 Telangiectasia: Spider Veins

13. Venous Anatomy

14. How Do Leg Veins Work?
 Blood Travels Easily
downhill!
– pumped by the
powerful action of
the heart from above
– aided by the elastic
recoil of the artery
walls
– and of course, by the
effect of gravity

15. How do Veins Work?
 In the standing position:
– blood has to be actively
pumped up the column of
veins
– this is achieved with our
calf muscles which
squeeze the venous
sinuses
– when the muscles relax,
the blood tends to rush
back into the leg

16. Venous Insufficiency
 Occur because:
1-Problem with the veins
themselves
2-Weakness of the pumping
mechanism of the calf:
 Reflux of the column of
blood through the leaky
valve
 Strain on the vein wall
 Stretching and weakness at
various points
 End result: Varicose veins!

17. Venous Insufficiency
 Varicose Veins:
– Dilated, protruding, tortuous saccular superficial veins.
– Develop in the superficial veins of the leg and mainly affect the long
saphenous vein
– Are higgledy-piggledy, dilated veins whose valves have failed allowing
increasing amounts of blood to reflux the wrong way down the limb
 Reticular Veins: Dilated, tortuous, non-protruding superficial veins
 Telangiectasia: Spider appearing, tortuous, non-protruding or dilated

18. Varicose Veins
 Symptoms:
– Often unrecognized by patients and physicians
– Aching pain
– Night cramps
– Fatigue
– Heaviness
– Restlesness

19. Varicose Veins
 A health issue: Left untreated:
– 50% will develop symptoms of severe venous
insufficiency:
 lower-extremity swelling
 eczema
 pigmentation
 hemorrhage
 ulceration

20. Venous Insufficiency
 As the vein dilates the wall
stretches in both width and
length so that the vein becomes
tortuous
 As the situation gets worse the
veins become so dilated that
large sacs form at the bends
 Turbulent flow occurs with
areas of stagnation like extreme
bends…
 …in an otherwise fast running
river and the vein can
sometimes thrombose leading
to inflammation called
superficial thrombophlebitis

21. Complications
 Skin discoloration
 Hemosiderin deposition
 Edema
 Lipodermatosclerosis
 Skin ulceration
 DVT
 SVT
 Thrombophlebitis
 Hemorrhage

22. Complications: Skin discoloration

23. Complications: edema,
“corona phlebectasia”

24. Venous Ulcers
 constitute 90% of
the ulcers seen in a
busy specialist clinic
 ulcer will never heal
unless the chain of
events which led to
it are reversed

25. Complications of Venous
Insufficiency

26. Indications for Treatment
 Absolute Indications:
– Complications from venous reflux
 Relative Indications:
– Desire to have legs without blemish
– Personal body image
– Sexual motives

27. Evaluation for Venous Reflux

28. Evaluation for Venous Reflux

29. Evaluation for Venous Reflux

30. Evaluation for Venous Reflux

31. Evaluation for Venous Reflux

32. Current Treatments
 I-Ultrasound guided sclerotherapy:
– Effective short term but no long term
durability:
 Neglen P, et al: J cardiovascular surgery 1993;
34(4): 295-301:
– Compression Slerotherapy (CST): 5 year failure rate: 51%
– Stripping: 5 years: 60% “cured”, 35% “improved”
– High ligation and CST: 5 years failure rate: 84%

33. Current Treatments
 II-Surgical Treatment:
– High ligation
– High ligation and stripping

34. Surgical Treatment

35. Surgical Treatment:
Stripping/SEPS

36. Surgical Treatment
 Dwerryhouse S et al, J Vasc Surg, April
1999; 29(4): 589-592:
– 100 pts randomized to ligation or stripping
– After 5 years, 78 pts available for duplex scan:
 29% SFJ incompetence in the stripping group
 71% SFJ incompetence in the high ligation group

37. Surgical Treatment
 Fisher R, et al, J Vasc Surg 2001; 34
(2):236-40
– 602 pts underwent high ligation and stripping
– 125 limbs in 77 pts available for duplex scan 34
years after ligation and stripping
– 60% limbs showed SFJ reflux by US
– Neovascularization accounted for identified
failure

38. Varicose Veins: Venous
Anatomy
 AL: AAGSV
 PM: PAGSV
 SEP: Superficial
External Pudendal
 SE: Superficial
Epigastric
 SCI: Superficial
circumflex iliac

39. “Mini” Surgical: Ambulatory
Phlebectomy
 Permits removal of nearly any incompetent
vein below the saphenofemoral and
saphenopopliteal junctions
 Major tributaries; perforators; and reticular
veins, including small reticular veins
associated with telangiectasias
 The procedure is well tolerated by patients
and produces good cosmetic results

40. Ambulatory Phlebectomy

41. Ambulatory Phlebectomy

42. Cyanoacrylate glue for
saphenous ablation
Nick Morrison
 Approved in Europe
 Not FDA approved
 92% GSV occlusion at
1 month
 Clot extension to SFJ
in 21%

43. Other Techniques:
 Coil Embolization
 Combined Coil/Foam embolization

44. Current Treatments
 III-Endovascular ablation of saphenous
vein:
– New treatment out of necessity:
 Trauma of surgical treatment
 High morbidity of surgical treatment
 Minimally invasive treatment
 A new “gold standard”??.....YES!

45. Endovascular ablation of
saphenous vein:

46. Radiofrequency Closure
 Received FDA clearance in 3/99
 Largest collection of published data
 Longuest F/U regarding endovenous
therapy

47. Radiofrequency Closure

48. Radiofrequency Closure

49. Covidien ClosureFast™

50. RF Closure of the GSV:
Dr Rosenblatt
 139 limbs treated in 124 patients
 Mean F/U 17.5 months (34-854 days)
 Symptomatic improvement in 97%
 Persistent and complete occlusion of the
vein in 132 limb (95%) by duplex U/S

51. RF Closure of the GSV:
Dr Rosenblatt
 Complications:
– 12.4%
– Transient paresthesia 11% (resolved in all by 4
months)
– Focal skin burn 1.4%
 No DVT

52. Endovenous Laser Therapy
 FDA Clearance:
– Diomed Jan 02
– Biolitech Jun 02
– Angiodynamics Nov 02
– Dornier Nov 02

53. Precision980
Diode Laser

54. 980nm Diode Laser
Wavelength
How it works
 Water makes up over 80% of blood & Endothelial Cells
 The precision of the 980 Wavelength Targets the water to create
a “Steam Bubble”
 Resulting Heat Destroys
endothelial wall to cause
Thrombosis & Vessel
Occlusion
 Safer more precise treatment
with less chance of collateral
damage to surrounding
tissue or nerves

55. 1470nm Diode Laser
Wavelength

56. Endovascular Laser
Treatment

57. Endovenous Laser Therapy
 Robert J. Min et al, J Vasc Interv
Radiol 2003; 14:991–996
– Large published series to date
– 499 limb in 423 patients
– Successful occlusion of GSV in 490
patients (absence of flow by duplex U/S),
98.2%

58. Procedure Steps:
1-Vein Puncture

59. Procedure Steps:
2-Placement of Vascular
Sheath

60. Procedure Steps:
3-Positioning of Vascular
Sheath

61. Procedure Steps:
4-Placement of Laser Fiber

62. Procedure Steps:
5-Tumescent Anesthesia

63. Procedure Steps:
5-Laser on, Pull Back at 3-
4mm/sec

64. Procedure Steps:
Final Touch

65. Before/After

66. Procedure Comparison
 Vein Stripping
– Overnight Hospital stay
– Significant Patient discomfort
– Risk of Infection and Complications of Surgical
– Long Recovery time
– Surgical Suite cost
 Laser/RFA (Minimally Invasive)
– 45min out patient procedure
– Minimal Patient Discomfort
– Minimal Complications
– 95% Efficacy
– Radiology/Office Suite Cost

67. Conclusion:
Beware The Power of Her
Majesty
The Mighty GSV…

68. Thank you for attending
PAIRS 2014
See you at PAIRS 2015,
March 12-15, Dubai UAE