Ambulatory Phlebectomy & Sclerotherapy - The Vein … · Ambulatory Phlebectomy & Sclerotherapy Dr. S. Kundu Medical Director The Vein Institute of Toronto. 2 Definition ... Side

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Ambulatory Ambulatory PhlebectomyPhlebectomy& & SclerotherapySclerotherapy

Dr. S. KunduDr. S. KunduMedical DirectorMedical DirectorThe Vein Institute of TorontoThe Vein Institute of Toronto

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DefinitionDefinition

Other Names:Other Names:Stab AvulsionStab AvulsionMicro ExtractionMicro Extraction

Definition:Definition:Removal of segments of varicose veins of any Removal of segments of varicose veins of any size and from any location, under local size and from any location, under local anesthesia, on an outpatient basisanesthesia, on an outpatient basis

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IntroductionIntroduction

Varicosities of any size in any locationVaricosities of any size in any locationExclusion = reflux at SFJExclusion = reflux at SFJ

Can be combined with other methodsCan be combined with other methodsEVLT/EVLA/ELAS/RFAEVLT/EVLA/ELAS/RFASclerotherapySclerotherapy

Diagnostic workup essentialDiagnostic workup essential

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IndicationsIndications--11

Asymptomatic Varicose VeinsAsymptomatic Varicose VeinsCosmetic purposesCosmetic purposesConcern about Concern about sequelaesequelae of varicose veinsof varicose veinsStrong family history of varicose veins & Strong family history of varicose veins & complicationscomplications

Symptomatic Varicose VeinsSymptomatic Varicose VeinsComplicated Varicose VeinsComplicated Varicose Veins

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IndicationsIndications--22

Large varicosities Large varicosities –– widespreadwidespreadThicker varicose veins (nonThicker varicose veins (non--blue)blue)Side branches GSV & LSVSide branches GSV & LSVYounger active patientsYounger active patientsDorsal foot veinsDorsal foot veinsLipodermatosclerosisLipodermatosclerosis

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ContraindicationsContraindications

Infectious dermatitis or Infectious dermatitis or cellulitiscellulitis of the area to be of the area to be treatedtreatedSevere peripheral edemaSevere peripheral edema

Secondary to:Secondary to:Cardiac diseaseCardiac diseaseRenal diseaseRenal disease

Seriously ill patientsSeriously ill patientsSevere cardiovascular and/or pulmonary problemsSevere cardiovascular and/or pulmonary problemsUncontrolled diabetesUncontrolled diabetes

Very elderly patientsVery elderly patients

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TechniqueTechnique

Rule out reflux at Rule out reflux at saphenofemoralsaphenofemoral or or saphenopolitealsaphenopoliteal junction refluxjunction refluxPreoperative mappingPreoperative mappingSurgical planningSurgical planningLocal AnesthesiaLocal AnesthesiaPhlebectomyPhlebectomyPostoperative dressingPostoperative dressing

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Rule Out RefluxRule Out Reflux

Duplex ultrasound Duplex ultrasound Assess for Assess for saphenofemoralsaphenofemoral and and saphenopolitealsaphenopoliteal junction refluxjunction reflux

If ultrasound positive for refluxIf ultrasound positive for refluxPerform EVLA/ELAS/EVLT/RFA firstPerform EVLA/ELAS/EVLT/RFA first

Always treat proximal to distalAlways treat proximal to distal

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Preoperative MappingPreoperative Mapping

Use surgical pen or permanent markerUse surgical pen or permanent markerHave patient stand for 20 minutes before Have patient stand for 20 minutes before markingmarkingInitial mapping performed in standing Initial mapping performed in standing positionpositionSecondary mapping performed in Secondary mapping performed in TrendelenburgTrendelenburg position using position using transilluminationtransillumination

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TransilluminationTransillumination LightLight

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Local AnesthesiaLocal Anesthesia

Start with 1% Start with 1% lidocaine/xylocainelidocaine/xylocaineInitiation points for tumescent anesthesiaInitiation points for tumescent anesthesia

Use 25 gauge, ½ inch needleUse 25 gauge, ½ inch needle

Tumescent anesthesiaTumescent anesthesiaDilute Dilute lidocainelidocaine with epinephrine 1 in 4with epinephrine 1 in 4

0.25 % 0.25 % LidocaineLidocaine

Volume up to 500 Volume up to 500 mLmLInject slowly using 30 cc syringeInject slowly using 30 cc syringe

Use 20 gauge spinal needleUse 20 gauge spinal needle

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Tumescent AnesthesiaTumescent Anesthesia

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Ambulatory Ambulatory PhlebectomyPhlebectomyInstrumentationInstrumentation

Variety of hooksVariety of hooksMuller, Muller, OeschOesch, , RamletRamlet, , VaradayVaraday, , DortuDortu

Small curved hemostatsSmall curved hemostatsBlunt dissector (may use hooks)Blunt dissector (may use hooks)#11 blade, #11 blade, opthalmologyopthalmology blade, 18 gauge blade, 18 gauge needleneedleSterile gauze, drapesSterile gauze, drapesScissorsScissors

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Ambulatory Ambulatory PhlebectomyPhlebectomyTechniqueTechnique--11

Puncture skin using scalpel or needlePuncture skin using scalpel or needle“Dissection” along long axis“Dissection” along long axisHook or Harpoon adventitiaHook or Harpoon adventitia--attempt to liftattempt to liftVisualize glistening whiteVisualize glistening white

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Ambulatory Ambulatory PhlebectomyPhlebectomyTechniqueTechnique

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Exteriorize vein loopExteriorize vein loopGrasp loop with mosquito hemostatGrasp loop with mosquito hemostatGentle slow pull with lateral massageGentle slow pull with lateral massageHemostats advancedHemostats advancedTraction maintained to guide next siteTraction maintained to guide next site“Skin Tenting” can guide next site“Skin Tenting” can guide next site

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When difficult to extract move to next siteWhen difficult to extract move to next siteMultiple vein loops exteriorized initiallyMultiple vein loops exteriorized initiallyConnected by blunt dissectionConnected by blunt dissectionAvulsion usually in portionsAvulsion usually in portionsBleeding compressed by assistantBleeding compressed by assistant

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Ambulatory Ambulatory PhlebectomyPhlebectomyPostPost--Op CareOp Care

Incisions sealed with Incisions sealed with SteriSteri--stripsstripsNo suturesNo sutures

Gauze pads or other absorbent pads placed over Gauze pads or other absorbent pads placed over incision sitesincision sitesShort Stretch BandageShort Stretch BandageGraduated compression stockingGraduated compression stocking

3030--40 mm Hg40 mm HgDurationDuration-- one weekone week

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Ambulatory Ambulatory PhlebectomyPhlebectomyCasesCases

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Ambulatory Ambulatory PhlebectomyPhlebectomyCasesCases

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SclerotherapySclerotherapy

Types of SolutionsTypes of SolutionsConcentrations based on vein Concentrations based on vein sizesizeEquipmentEquipment

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Types of SolutionsTypes of Solutions

Detergent SolutionsDetergent SolutionsSodium Sodium TetradecylTetradecyl Sulfate (STS)Sulfate (STS)

SotadecrolSotadecrol

PolidocanolPolidocanol (POL)(POL)AethoxysklerolAethoxysklerol

Ethanolamine Ethanolamine OleateOleate ((EthamolinEthamolin))Sodium Sodium MorrhuateMorrhuate ((ScleromateScleromate))

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Types of SolutionsTypes of Solutions

Toxic or Corrosive AgentsToxic or Corrosive AgentsIodine salt (Iodine salt (polyiodinatedpolyiodinated) (P2)) (P2)

SclerodyneSclerodyne

Glycerin (chromium potassium alum)Glycerin (chromium potassium alum)ChromexChromex

AlcoholsAlcoholsMetal CompoundsMetal Compounds

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Detergent SolutionsDetergent Solutions

Mechanism of ActionMechanism of ActionFast ActingFast ActingDissolution of endothelium cell membraneDissolution of endothelium cell membraneModerate penetration depthModerate penetration depthMay have effect up to 20 cm from injection May have effect up to 20 cm from injection sitesiteStimulation of inflammation sequencesStimulation of inflammation sequences

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AdvantagesAdvantagesPainless when intravascularPainless when intravascularEffects beyond injection pointEffects beyond injection point

Affect large networks efficientlyAffect large networks efficientlyLarge amount of territory per treatmentLarge amount of territory per treatment

All size vessels treatableAll size vessels treatableInflammatory component controllable by Inflammatory component controllable by varying concentrationvarying concentrationFDA approval for STSFDA approval for STS

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DisadvantagesDisadvantagesAllergyAllergy

STS dissolves rubber stoppersSTS dissolves rubber stoppersMust use Latex free syringesMust use Latex free syringes

Long length of actionLong length of actionExpenseExpense

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SclerosingSclerosing Solution Solution Matched to Vessel SizeMatched to Vessel Size

TelangiectasiasTelangiectasias/Spider Veins/Spider Veins0.1% to 0.2% sodium 0.1% to 0.2% sodium tetradecyltetradecyl sulfate (STS)sulfate (STS)

NonNon--foamfoamLess than 0.5 Less than 0.5 mLmL volumevolume

Reticular VeinsReticular Veins0.25 to 0.5% sodium 0.25 to 0.5% sodium tetradecyltetradecyl sulfate (STS)sulfate (STS)

Foam: 0.25%Foam: 0.25%Volume up to 0.5 cc per injection siteVolume up to 0.5 cc per injection site

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SclerosingSclerosing SolutionsSolutions--Larger VesselsLarger Vessels

Large Reticular/Small Varicose VeinsLarge Reticular/Small Varicose Veins0.5% to 1% STS conventional0.5% to 1% STS conventional0.5% foam0.5% foamInjection of up to 1cc per site. No more than 10cc Injection of up to 1cc per site. No more than 10cc per sessionper session

TruncalTruncal Varicose VeinsVaricose Veins3% STS conventional3% STS conventional1% STS Foam1% STS FoamUp to 3cc of 3% may be used in one sessionUp to 3cc of 3% may be used in one session

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Maximum Doses per Maximum Doses per SessionSession

10 10 mLmL ruleruleHyperosmolarHyperosmolar = 10 = 10 mLmLDetergent = 10 Detergent = 10 mLmL of 3 % of 3 % (strongest)(strongest)

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EquipmentEquipment

3 cc syringe for spider and reticular veins3 cc syringe for spider and reticular veins5 cc syringe for small varicose and 5 cc syringe for small varicose and truncaltruncalvaricose veinsvaricose veins27” butterfly or 30” needle27” butterfly or 30” needleThree way stopcockThree way stopcockTransilluminationTransillumination LightLightMarkerMarker

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EquipmentEquipment

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Compression Compression GuidelinesGuidelines

Spider Veins & Reticular VeinsSpider Veins & Reticular Veins2020--30 mm Hg30 mm Hg

Reticular & Small Varicose VeinsReticular & Small Varicose Veins2020--30 mm Hg30 mm Hg

TruncalTruncal Varicose VeinsVaricose Veins3030--40 mm Hg40 mm Hg

All compression for two to three All compression for two to three weeksweeks

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Ambulatory Phlebectomy & Sclerotherapy - The Vein … · Ambulatory Phlebectomy & Sclerotherapy Dr. S. Kundu Medical Director The Vein Institute of Toronto. 2 Definition ... Side