Endovenous Treatment of Venous Diseases:
Preprocedural assessment, indications and
contraindications
Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS
Professor of Vascular Surgery
Faculty of Medicine, University of Thessalia, Greece
Chairman, Dept. of Vascular Surgery, University Hospital of Larissa
Larissa, Greece
GSV Before Treatment
Image courtesy of Olivier Pichot, MD, CHU de Grenoble, France.
GSV After Treatment
Image courtesy of Olivier Pichot, MD, CHU de Grenoble, France.
CEAP Clinical Classification
Class
0: Asymptomatic; no visible or palpablesigns
1: Spider veins, reticular veins, telangiectasias
2: Varicose veins
3: Edema
4a: Skin changes with hyperpigmentation and
eczema
4b: Skin changes with lipodermatosclerosis and
atrophie blanche
5: Healed ulcer
6: Active ulcer
CEAP Clinical Classifications
Clinical Etiology Anatomy Pathophysiology
Varicose Veins
CEAP 2
Swelling
CEAP 3
Skin Changes
CEAP 4
Skin Ulcer
CEAP 6
Is pre-op duplex
assessment
important for
varicose vein
surgery?
Ultrasonic assessment
Explanation

Information provided by DS will have
significant impact on the selection of
appropriate treatment

Failure to identify all sources of venous filling is
likely to result in early recurrence
Indications for Duplex Scan
Recommendation: both limbs should be studied
 Primary uncomplicated GSV VVs
Debated whether all pts – if not 30% of important connections between
deep and superficial veins will be missed
Primary uncomplicated LSV VVs Essential
 Non-saphenous & Recurrent VVs Essential
 CVD with complications Essential
 Surveillance after treatment the only way to obtain level I

evidence as to outcome in the future

Venous malformations
anatomical information about the extent of the malformation and its
relationship to other vessels
may be used to guide treatment by sclerotherapy
Position of the patient
Greater saphenous
Position of the patient
Lesser saphenous
Anatomy of superficial veins of the
lower limb
Important anatomical details
Anatomical structures on B-mode
GSV
 Bound anteriorly by superficial fascia &
posteriorly by deep fascia
 Often called “saphenous eye”
Fascial layers creating “saphenous eye”
Images courtesy of Olivier Pichot, MD
GSV Variables
Tortuosity
Images courtesy of Olivier Pichot, MD
Side branches
GSV Variables
Aneurysmal segments
SFJ Tributary Veins

SCI: Superficial Circumflex Iliac

SE: Superficial Epigastric

SEP: Superficial External Pudendal

AASV: Anterior Accessory
Saphenous

PASV: Posterior Accessory
Saphenous
Image adapted from: Chandler JG et al. Defining the role of extended saphenofemoral junction ligation: A
prospective comparative study. JVS 2000;32:941-53
Initial Catheter Tip Positioning

Position catheter tip
approximately 2.0 cm distal to
SFJ
◦ Confirm with measurement
calipers
◦ Distance does not need to be
precise at this time because
catheter position may shift during
tumescent fluid infiltration
Final Tip Position Verification
 Recommendation is 2.0 cm distal to SFJ
 Confirm tip position with ultrasound:
◦ In both transverse and
longitudinal imaging planes
◦ Use measurement calipers to
confirm distance to SFJ

Important step to avoid
misaligning catheter
relative to deep venous
system
Image courtesy of Pranay Ramdev, MD
Anatomical structures on colour facility
Small Saphenous Vein (SSV)
Courses from lateral ankle up
posterior calf
 Terminates in popliteal fossa at
Saphenopopliteal Junction (SPJ)

◦ Variable confluence with Popliteal Vein
(PV)
◦ Proximal portion lies between
superficial & deep fascial layers
SPJ
Pop V
SSV
Figure adapted from: Weiss RA, et al eds. Vein diagnosis and treatment: A comprehensive approach. McGraw-Hill Companies, Inc.; 2001.
Anatomical structures on colour facility
Detection of reflux on colour facility
Detection of reflux on colour facility
Detection of reflux on colour facility
Detection of reflux on colour facility
Perforating vein
If reflux is present measure the diametre but this cannot distinguish competent from
incompetent
Duration of reflux
Detection of reflux on Doppler
Reflux is present when retrograde flow
lasts for at least 1 sec
Patient selection for Endovenous Alation
 Identification of all refluxing venous segments and their
ablation is the key to minimise recurrence
 Diametre of central GSV > 15 mm may be associated
with thrombus extension to CFV
 Uncorrectable coagulopathy
 Liver dysfunction limiting local anaesthetic use
 Immobility
 Pregnancy
 Breastfeeding
Contraindication

Thrombus in the vein segment to be
treated
Choosing the Closure Candidate

Preoperative ultrasound evaluation
◦ Reflux > 0.5 seconds in superficial venous
system
◦ Assess GSV, noting:
 Vein depth and maximum diameter
 Presence of tortuous or aneurysmal segments
 Other significant anatomy
 Duplicate systems
 Large side branches
 Incompetent perforators or tributaries
Vein depth from the skin: Why is so
important?
The aim of ablation procedures is to damage the inner
vein wall without causing a full-thickness burn, which
could lead to perforation of the vein resulting in bruising
or haematoma formation
If vein lies superficially, close to skin the
ablation may cause burn
Pre-op Ultrasound Assessment

Map and mark
◦
◦
◦
◦
Maximum diameter
Tortuous segments
Aneurysmal segments
Areas where vein is very
close to skin
◦ Large branches or perforators
◦ Potential access sites
Infiltration Technique

Do not leave any vein
segments unprotected
◦ Re-scan to ensure:
• >10 mm distance between skin
surface and vein wall
• Circumferential black “halo”
appearance in fascial
compartment

Perivenous vs.
subcutaneous infiltration
Image courtesy of Carolyn Menendez, MD
Vein Mapping
Make indentions in skin using a straw
 Remove US gel from leg


Connect marks on leg with marker to identify
pathway of vein and important anatomy
Image courtesy of Nick Morrison, MD
Pre-op Descending Venography
Selective descending ovarian and hypogastric venogram
Significant ovarian vein reflux but
No hypogastric vein reflux was detected
Hypogastric vein reflux
Ovarian vein reflux
Descending Ovarian Venogram 4 weeks after
embolisation
Hypogastric vein embolisation
CT venography
Chronic Venous Obstruction
DP=8 mmHg
DP=22 mmHg
DP=2 mmHg
IVC filter placement
Indications

DVT and covtraindication
for anticoagulation

Reccurent PE being on
adequate anticoagulation
Pre-procedural evaluation
 MR or CT venography is
required for IVC and iliac
vein patency and IVC
diametre measurement
Thank you for your
attention