the perplexing perforator seps paps nothing savs postgraduate course 2008 n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
The Perplexing Perforator: SEPS, PAPS, nothing? SAVS Postgraduate Course 2008 PowerPoint Presentation
Download Presentation
The Perplexing Perforator: SEPS, PAPS, nothing? SAVS Postgraduate Course 2008

Loading in 2 Seconds...

play fullscreen
1 / 40

The Perplexing Perforator: SEPS, PAPS, nothing? SAVS Postgraduate Course 2008 - PowerPoint PPT Presentation


  • 119 Views
  • Uploaded on

The Perplexing Perforator: SEPS, PAPS, nothing? SAVS Postgraduate Course 2008. Bill Marston MD Division of Vascular Surgery University of North Carolina at Chapel Hill Jan 2008. Introduction. Incompetent perforating veins have been demonstrated in the majority of patients with severe CVI

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'The Perplexing Perforator: SEPS, PAPS, nothing? SAVS Postgraduate Course 2008' - lane-gillespie


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
the perplexing perforator seps paps nothing savs postgraduate course 2008

The Perplexing Perforator: SEPS, PAPS, nothing?SAVS Postgraduate Course 2008

Bill Marston MD

Division of Vascular Surgery

University of North Carolina at Chapel Hill

Jan 2008

introduction
Introduction
  • Incompetent perforating veins have been demonstrated in the majority of patients with severe CVI
  • Class 3 52%
  • Class 4 83%
  • Class 5/6 90%

Stuart et al, J Vasc Surg 32:138

diameter reflux relationship of perforating veins
Diameter-reflux relationship of perforating veins
  • Sandri et al J Vasc Surg 1999;30:867-75
  • As diameter enlarges, increasing incidence of outward flow on compression
the perforator as gate keeper to the skin
The perforator as gate-keeper to the skin
  • Perforator should only allow inward flow from superficial to deep
  • Competence of valves in perforators critical to protecting superficial tissues from transiently elevated deep venous pressures
critical perforator vein questions
Critical perforator vein questions
  • What is the definition of a clinically significant incompetent perforator?
question 1 definition of a clinically significant incompetent perforator
Question #1: definition of a clinically significant incompetent perforator
  • We don’t know
  • Perforators of larger diameter are worse
  • Personal favorite
    • > 3.5 mm diameter at fascia
    • > 0.5 seconds of outward flow
2 when should we attempt to correct perforator incompetence
2. When should we attempt to correct perforator incompetence?
  • Whenever they are diagnosed if the patient has significant symptoms
  • Only after correcting other sources of venous insufficiency if limb remains symptomatic
repair all ipvs
Repair all IPVs
  • Tawes et al J Vasc Surg 2003;37:545
    • 832 patients with IPVs identified and SEPS
    • 55% concomitant saphenous surgery
    • 92% of ulcers significantly improved
    • 4% incidence of ulcer recurrence
  • “Until level 1 evidence is available, SEPS is advocated as optimal therapy for CVI”
slide11

How can we separate effect of saphenous surgery from potential effect of perforator ligation?Ablate/Remove superficial system first, then treat IPVs if still necessary

stuart et al edinburgh uk
Stuart et al, Edinburgh, UK
  • 62 limbs with superficial and perforator incompetence
  • 21% also demonstrated deep insufficiency
  • Performed superficial surgery only
  • Postop duplex evaluation of perforators
    • 80% of patients with mainstem reflux abolished had no IPVs remaining
    • If mainstem reflux (deep or superficial) remained after surgery, 72% still had IPVs

J Vasc Surg 1998;28:834

stuart et al
Stuart et al
  • Most IPVs are found in association with superficial venous reflux
  • Although the presence of IPVs is associated with venous ulceration… many of these may be corrected by saphenous surgery alone

J Vasc Surg 2001;34:774

hemodynamic results when ipvs not ligated
Hemodynamic results when IPVs not ligated
  • Mendes et al, Univ of N. Carolina
  • 24 limbs with both superf and perf incomp
  • IPV defined as > 3mm and >0.5 sec reflux
  • Superficial surgery performed
  • IPVs not ligated
  • APG and Duplex performed pre and post-op

* JVS Nov 2003

mendes et al results
Mendes et al: Results
  • On post-op Duplex, 71% of IPVs were no longer incompetent after superficial surgery

Normal < 2 ml/sec

6.0

2.2

Preop Postop

P < 0.001

randomized trial of seps vs conservative treatment
Randomized trial of SEPS vs conservative treatment

Dutch SEPS trial: Wittens et al

200 patients randomized, 97 to ambulatory compression, 103 to SEPS + saphenous surgery when indicated

Deep venous insuff present in 55%

Mean follow-up 29 months

slide18

Dutch SEPS trial conclusions:

-In selected cases with larger ulcers or longer duration

surgery did influence healing and recurrence rates

-Overall, SEPS did not influence healing or cure

question 2 when should we attempt to correct perforator incompetence
Question #2When should we attempt to correct perforator incompetence?
  • Cannot yet answer this question based on available evidence
  • Effect of superficial venous surgery or ablation typically confounds assessment of role of perforator procedures
3 what is the best method of treating ipvs
3. What is the best method of treating IPVs?
  • SEPS
  • PAPS
  • Extrafascial ablation of perforator outflow tract
seps results
SEPS: Results
  • North American SEPS registry
  • 146 patients, 84% CEAP class 5 or 6
  • 71% concomitant superficial procedures
  • 88% of ulcers healed 1 year after surgery
  • Ulcer recurrence
    • 28% at 2 years
    • 46% in post-thrombotic limbs
    • 20% in limbs with primary valvular incomp

Gloviczki et al, J Vasc Surg 1999;29:489

comparative trials of seps vs linton procedure
Comparative trials of SEPS vs Linton procedure

Pierik et al

39 patients prospectively randomized to SEPS or Linton

comparative trials of seps vs linton procedure1
Comparative trials of SEPS vs Linton procedure

Sybrandy et al, J Vasc Surg 33:1028-32.

Deep venous insuff increased incidence of new IPVs but not recurrent ulcers

slide25

PAPS

Percutaneous Ablation of Perforators

rfa perforator ablation
RFA perforator ablation
  • US guided access
  • Confirm intraluminal site with impedance 150-350 Ohms
  • Local tumescence
  • Apply energy at 85o to 4 quadrants I min each
  • Withdraw I-2 mm and repeat
laser perforator ablation
Laser perforator ablation
  • Use 400 micron fiber
  • Micropuncture needle access under US at or just below fascia
  • Aspirate to confirm placement
  • Tumescent anesth
  • Ablate at 14-15 W for 4-5 seconds
  • Withdraw 1-2 mm and repeat
paps results
RFA

Lumsden SCVS

34 IPVs treated intravascularly

91% occlusion rate at 3 week f/u visit

2 asymptomatic tibial vein thromboses (6%)

Laser

Elias et al (submitted)

50 IPVs treated with average 120 j energy per segment

90% occlusion rate at 1 month f/u

No significant DVT noted

PAPS - results
3 what is the best method of treating ipvs1
3. What is the best method of treating IPVs?
  • SEPS
    • Success at perf interruption well established
    • Typically requires OR setup
  • PAPS
    • Early results encouraging
    • Rapid office based procedure
  • Extrafascial ablation
    • 70-80% of IPVs will correct
how can we determine the hemodynamic significance of ipvs
How can we determine the hemodynamic significance of IPVs?
  • Difficult to determine due to frequency of coexistent superficial and/or deep insufficiency
  • Which perforators require correction in absence of superficial disease?
  • Which perforators should be corrected in the face of uncorrected deep venous insufficiency?
delis et al jvs 2001 33 773
Delis et al: JVS 2001;33:773
  • Proposed that all perforators that demonstrate reflux are not equal
  • Must look at reflux patterns for hemodynamic importance

Diam 3.1 mm

consider significance of each ipv in transmitting pressure
Consider significance of each IPV in transmitting pressure

Potential differentiators

  • Size
  • Reflux velocity and duration
  • Volume flow of reflux
slide37

Incompetent perforator in symptomatic patient

Size > 4mm

High V reflux

Size < 4mm

Low velocity reflux

slide38

Incompetent perforator in symptomatic patient

Size > 4mm

High V reflux

Size < 4mm

Low velocity reflux

Leave alone unless

No other cause of

Venous symptoms

identified

slide39

Incompetent perforator in symptomatic patient

Size > 4mm

High V reflux

Size < 4mm

Low velocity reflux

Correct IPV reflux

Leave alone unless

No other cause of

Venous symptoms

identified

SEPS

PAPS

EF ablation

slide40

Incompetent perforator in symptomatic patient

Size > 4mm

High V reflux

Size < 4mm

Low velocity reflux

Correct IPV reflux

Leave alone unless

No other cause of

Venous symptoms

identified

SEPS

PAPS

EF ablation