Complex Vein Interventions

march 14 , 2011

Signs of advanced vein disease can include the following : corona phlebiticum ; eczema below the knee ; lipodermatosclerosis ; skin ulcers ; significant hemosiderin deposits below the knee ; very prominent veins on dorsum of foot with standing ; progressive edema ; etc .

Symptoms of advanced disease include the following : lower extremity cramping ; restless legs ; fullness with prolonged standing _sometime this symptom is immediate upon standing ; edema ; bulging varicosities , often painful that sometimes bleed ; soles of feet burning or feeling of walking on rock chips .

All patients with significant reflux into the greater sapenous vein in the thigh with concomitant symptoms are candidates for ablation of the greater saphenous vein . Mid thigh perforators that reflux toward the skin are pathologic and should be closed with ablation or foam sclerotherapy ustilizing CO2 . Dilated , refluxing short saphenous veins in posterior calf associated with symptoms , skin disease or ulcers should be ablated .Ulcers associated with SSV reflux are often located on the lateral malleolus . Dilated individual superficial veins below the knee should be injected with foam sclerotherapy . Likewise pathologic below the knee perforators should be ablated with foam .

Although controversial , very dilated , refluxing saphenous veins below the knee may require closure with foam . This situation might arise when foam injection at the ankle could lead to possible closure of multiple perforators ; further treat lymphovenous edema ; relieve foot symptoms and treat all dilated superficial veins , thereby ameliorating skin disease and ulcers . Although a potential venous conduit is lost , the combination of drug eluting stent therapy and the availability of arterial conduits for use in coronary bypass surgery negate the significant concern associated with loss of a venous conduit . However one should note this procedure is necessary in only a small percentage of patients. When utilized 40 mm compression stockings should be utilized as edema is commonly seen in the first few weeks and diuretics and elevation may be required . This problem virtually always resolves over a few weeks at which time diuretics can be stopped . Walking and calf pump exercises should be encouraged as shoul water aerobics . If prior lymphedema pumps are available as home therapy and work very well .
As previously noted , complex venous disease is best treated in a dedicated center where this case mix is commonly treated .