Multimodal Treatment of Small Saphenous Vein Incompetence - PDF Document

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  1. Multimodal Treatment of Small Saphenous Vein Incompetence Michael Wyatt Sandip Nandhra Freeman Hospital, Newcastle upon Tyne, UK

  2. Disclosure Speaker name: Michael Wyatt I have the following potential conflicts of interest to report: Consulting Employment in industry Stockholder of a healthcare company Owner of a healthcare company Other(s) I do not have any potential conflict of interest Munich Vascular Conference (MAC) 2018 2

  3. Superficial Venous Incompetence (SVI) ● Major vascular service workload ● 1/3 have SSV incompetence ● Sural nerve damage with surgery ● Less aggressive approach adopted ● Multimodal treatment options attractive 3

  4. Evidence suggests ● Intervention for SSV incompetence offers ○ Increased performance in terms of PROMS ○ Reduced recurrence ○ No significantly worse neurological outcomes (especially EVTA) ● What are the options? 4

  5. Surgery ● Sapheno-popliteal ligation and stripping superior outcome to ligation alone ● Offers effective & durable improvements in PROMS ● Systematic review 2016 ○ Anatomical success – 58% ○ Neurological complications – 19.8% ○ Better results with EVLA/RFA & FS Boersam et al. J Endovasc Ther 2016; 23(1): 199-211 ● Surgery superseded by newer modalities 5

  6. Endovenous Thermal Ablation ● Studies suggest ○ Lower neurological complications (EVTA 7.5% v Surgery 26.4%) ○ Reduced recovery time Samuel et. Al, Ann Surg 2013; 257(3): 419-426 ○ 6

  7. Cochrane Review – 2016 Moderate to low quality evidence that persistent reflux at 6w and recurrence at 1y is reduced with EVTA 7

  8. Single RCT – 2 year results • EVTA offers comparable outcomes to surgery without the short- term neurological complications • EVTA current fore-runner for robust, medium/long-term data • Mainstay modality for SSV intervention • Little data on steam vein sclerosis • small numbers and mainly GSV 8

  9. Foam Sclerotherapy ● Cochrane 2016 – unable to comment due to paucity of data ● Systematic review 2016 ○ Safe but less effective treatment than EVTA ○ Success rates 63% for foam versus 98.5% for EVTA Boersam et al. J Endovasc Ther 2016; 23(1): 199-211 ● CLASS Study – inferior results for ○ Disease specific QoL health gains ○ Cost-effectiveness ○ Truncal ablation rates ○ But, more rapid return to normal activity (15% has SSV SVI) • DVT concerns not supported by the evidence ○ No DVT in 331 patients from 22 centres Gillet et al. Phlebology 2014; 29(9): 600-7 9

  10. Mechanico-chemical Ablation (MOCA) ● Non thermal non-tumescent (NTNT) modality ● Endothelial abrasion (agitator) and liquid chemical sclerosant 10

  11. Office Delivered Treatment ● Local anaesthetic ● Limit of 12cc of sclerosant ● Systematic review – 2017 ○ 254 SSV : 1267 GSV ○ 1 year occlusion rate - 92% ○ 5 year - 87% (single study) ○ 4.8% - sural nerve/paraesthesia ○ Efficacy and QoL compare well with EVTA Witte et al. Phlebology 2017;32(10):649-657 ● LAMA study – results awaited, but focused on GSV 11

  12. Cyanoacrylate Adhesive (CA) ● Non thermal non-tumescent (NTNT) modality ● Similar applications in AVFs and varices ● Catheter delivered US guided adhesive with segmental US pressure to ‘seal’ the refluxing vein 12

  13. Evidence for Glue in SSV • 8 SSV patients (48 GSV) • 100% success • Improvements in QoL, patient satisfaction and lack of compression 13

  14. ● Retrospective comparative study ○ - 16 SSV patients / 47 GSV ● 8 week data - 100% closure on duplex US ● Revised venous clinical severity scores improved ● ‘Phlebitis’ in 23.5% ● No neurological complications 14

  15. ● Retrospective review of CA and RFA – Canada ● CA 148 (16% SSV) , RFA 328 (9% SSV) ● Success 100% CA and 99% RFA ● Phlebitis 5% CA and 16% RFA ● Numbness 0% CA and 1.5% RFA ● Conclusion: CA offers similar results to RFA with lower mid term complications 15

  16. Conclusion ● SSV incompetence - greater detriment to QoL (than for GSV) ● Intervention – improves results ● EVTA – safe and effective with low sural nerve injury rate ● MOCA – early data suggests it may challenge EVTA ● CA – promising but little data on SSV ● Research is continuing 16