Perforator physician training arbid

training slides for treatment of venous perforators.

1. Physician Training The all Around Solution Perforating Veins; When and how to treat?

2. The venous system of the lower limbs (LL) comprises the deep system, responsible for 85% of venous drainage, and the superficial system, responsible for the remaining 15%. Between these two systems there are perforating veins, between the foot and the groin, that communicate directly or indirectly, enabling flow to drain from superficial veins to deep veins. Perforator veins traverse the deep fascia of the leg while forming communication channels between the superficial and deep venous systems. Physiologically, perforator veins carry blood from the superficial to deep veins. Communicating veins Perforating veins Perforators should not be confused with communicating veins which connect veins in the same plane, and do not penetrate the fascia. THE VENOUS SYSTEM

3. Intersaphenous Vein (vein of Giacomini) Communicating veins Calf plexus LSV SSV Communicating vein SSV LSV CV provide pathways for reflux to be transmitted between the LSV and the SSV SSV to LSV Conversely, reflux of the short saphenous network can induce overload of the veins of the long saphenous network. LSV to SSV The short saphenous trunk can become secondarily incompetent as a result of this overload.

4. Perforator veins allow communication between the superficial and deep venous systems of the legs: they are vessels that penetrate the aponeurosis of the muscle, giving it the name perforator vein.  The aponeurosis is fascial tissue that invests or envelops muscle groups and binds these muscle groups to other muscle groups or to bone. The superficial veins communicate with the deep veins via perforator veins. If you imagine the two legs of the letter "H", the perforator vein is the connection between the two legs of the letter "H". That connection is the part that perforates the muscle fascia and connects the deep veins to the superficial veins. Perforator DEFINITION: Aponeurosis of the muscle Skin

5. Perforating veins   Gasparis , A., Labropoulos , N., (2011) Perforator Vein Incompetence in CVD Patients, Endovascular Today , p.45-49 . Perforator veins were first reported in the Anatomische Tafeln zur Beforderung der Kenntniss des  menschichen Korpers (Weimar, 1794-1803), the main work of the German anatomist Justus Christian von Loder (1753-1832).   There are many perforator systems in each extremity with approximately 150 perforator veins in each lower extremity identified by van Limborgh . They are distributed as follows: 60 perforator veins in the thigh , 8 in the popliteal fossa , 55 in the leg , 28 in the foot . Of these veins, about 30 become incompetent and are identified in clinical practice.

6. Main groups Subgroups Foot perforators Dorsal foot PV or intercapitular veins Medial foot PV Lateral foot PV Plantar foot PV Ankle perforators Medial ankle PV Anterior ankle PV Lateral ankle PV Leg perforators Medial leg PV Paratibial PV Posterior tibial PV Anterior leg PV Lateral leg PV Posterior leg PV Medial gastrocnemius PV Lateral gastrocnemius PV Intergemellar PV Para- achillean PV The  perforating veins of the lower limb  (PV or “perforators”) are numerous veins in variable arrangements, connections, sizes, and distributions. The Terminologia Anatomica (TA)   classifies the perforators in he leg in 6 groups:   Georgiev M. Regarding "Nomenclature of the veins of the lower limbs: an international interdisciplinary consensus statement. (2004) Journal of vascular surgery. 39 (5): 1144; author reply 1144. 

7. Thigh perforators Medial thigh PV PV of the femoral canal Inguinal PV Anterior thigh PV Lateral thigh PV Posterior thigh PV Posteromedial Sciatic PV Posterolateral Pudendal PV Gluteal perforators Superior gluteal PV Midgluteal PV Lower gluteal PV Knee perforators Medial knee PV Suprapatellar PV Lateral knee PV Infrapatellar PV Popliteal fossa PV   Georgiev M. Regarding "Nomenclature of the veins of the lower limbs: an international interdisciplinary consensus statement. (2004) Journal of vascular surgery. 39 (5): 1144; author reply 1144. 

8. New Terminology “Old” term “New” term Greater or long saphenous vein Great saphenous vein (GSV) Smaller or short saphenous vein Small saphenous vein (SSV) Saphenofemoral junction Confluence of the superficial inguinal veins Giacomini’s vein Intersaphenous vein Posterior arch vein or Leonardo’s vein Posterior accessory saphenous vein of the leg (PASV BK) Superficial femoral vein Femoral vein Cockett perforators (I, II, II) Posterior tibial perforators (lower, middle, upper) Boyd’s perforator Paratibial perforator (proximal) Sherman’s perforators Paratibial perforators ‘24 cm’ perforators Paratibial perforators Hunter’s and Dodd’s perforators Perforators of the femoral canal May’s or Kuster’s perforators Ankle perforators Adapted from Mozes G, Gloviczki P. New discoveries in anatomy and new terminology of leg veins: clinical implications. Vasc Endovasc Surg 2004;38:367-74.

9. Proximal perforator of the femoral canal Distal perforator of the femoral canal Paratibial perforator Posterior tibial perforators Old New nomenclature CLINICALLY RELEVANT PERFORATORS, MEDIAL LEG: Hunterian Dodd Boyd Cockett The calf contains four groups of perforators that are clinically most important : the paratibial perforators connecting the great saphenous and posterior tibial veins, the posterior tibial perforators connecting the posterior accessory great saphenous and posterior tibial veins the lateral leg perforators the anterior leg perforators

10. Adapted from Mozes G, Gloviczki P: Vasc Endovasc Surg 2004;38:367-74. great Mendoza et al. (eds.), Duplex Ultrasound of Superfi cial Leg Veins , 19 731-4_2, © Springer-Verlag Berlin Heidelberg 2014] CLINICALLY RELEVANT PERFORATORS, POSTERIOR LEG:

11. Foot Perforators Medial surface of the foot 1. Medial malleolus 2. Navicular bone 3. Posterior group 4. Median group 5. Anterior group Lateral surface of the foot 1. Metatarsal group 2. Calcaneal group https:// www.phlebologia.com /veins-of-the-foot/perforating-veins-of-the-foot/ The foot perforators are unique in that they normally direct flow toward the superficial veins, while all others normally direct flow to the deep system.

12. Average diameters obtained for competent and incompetent perforators in the thigh and calf Sandri JL, et al. J Vasc Surg 1999;30:867-75.) The average diameter of incompetent perforating veins: Varicose veins, CEAP 2-4 3.5 mm Venous ulcers, CEAP 5-6 4.4 mm Several studies have reported that the diameter of incompetent PVs is larger compared with that of PVs without reflux Labropoulos , N, et al. ( J Vasc Surg 2006;43:558-62.) Stuart WP, et al. J Vasc Surg 2000, 32: 138-143.

13. Diameter-reflux relationship of perforating veins Incompetent perforating veins and CEAP: Class 3 52% Class 4 83% Class 5/6 90% Perforator diameter Incidence of reflux 2.0 mm 10% 2.5 mm 50% 3.0 mm 80% 3.5 mm 80% 4.0 mm 88% Stuart et al, J Vasc Surg 32:138 Sandri et al J Vasc Surg 1999;30:867-75

14. TYPES OF PERFORATORS Two types of perforating vein can be distinguished : Direct Perforating veins (classical) : they directly connect superficial veins with the axial deep veins e.g. tibial veins (anterior, posterior tibial veins, and peroneal veins) . Indirect P erforating veins connected to intramuscular veins : they connect superficial veins with the venous sinuses of the gastrocnemius or soleus veins and often have multiple branches. connecting superficial, intermuscular. and intramuscular networks.” Perforators are often accompanied by an artery, and are commonly located in the intramuscular septa Direct perforating veins Indirect perforating veins https:// www.phlebologia.com /short-saphenous-territory/below-the-popliteal-fossa

15. Re-entry points are where superficial lower extremity veins and perforator veins join. Exit veins are refluxing perforators usually associated with clusters of varicose veins and/or important skin changes , such as  hyperpigmentation Re-entry  perforators usually are found distal to major varicose veins and clusters. Their blood flow direction is inward (toward the deep veins) and they are not pathologic but merely competent. NO Skin changes are seen ad jacent to reentry perforating veins P ascarella, L., Mekenas , L., (2007). Ultrasound examination of the patient with primary venous Insufficiency, The Vein Book . TYPES OF PERFORATORS

16. A) Resting phase of pump cycle: blood is filling the deep veins, and deep venous pressure is increasing. B) Contraction phase: muscular compression (black arrows) of the deep veins empties the veins and closes the fascial gate preventing excess retrograde perforator flow. C) Early relaxation phase: muscles relax (black arrows) causing relative low pressure in the deep system promoting flow from superficial to deep direction. NORMAL FUNCTION OF PERFORATORS: In the calf, the flow is mostly inward (flow direction from superficial vein to the perforator) In the foot, the flow in perforator veins is bidirectional but mostly deep to superficial .

17. THE VALVE CYCLE: Opening phase : When the venous flow rate increases distal to the valve, as occurs during foot movements, the velocity of the flow between the valve cusps rapidly increases. The cusps move from the closed position toward the sinus wall. After reaching a certain point, the valves cease opening and enter the Equilibrium phase : The valve is maximally open during this phase. Still cusps maintain their position at some distance from the wall, creating a funnel-like narrowing of lumen. The flow accelerates in this stenotic area resulting in a proximally directed flow jet. The smaller part of the flow turns into the sinus pocket behind the valve cusp. This part of the stream forms a vortex along the sinus wall and the mural side of valve cusp causing a brief interval of retrograde flow before re-emerging in the mainstream in the vein. (< 500 msec.) Closing phase : Rising pressures on the mural side and falling pressures on the luminal side of the cusps initiate their movements toward the center of the vein. Closed phase : The cusps of the valve assume a symmetrical position at an equal distance from the walls on both sides of the sinus remaining in this position during the closed phase.

18. 1- Antegrade overload pattern: Retrograde flow in a superficial varicosity decompresses through a re-entry perforator resulting in perforator dilatation and eventual valvular incompetence. In a severe case, the excess venous load may secondarily cause distension and reflux in the deep veins as well. Typically in CEAP 1 to 3. MECHANISMS OF PERFORATOR INCOMPETENCE: Chronic superficial reflux into a severely dilated perforator with high-volume bidirectional flow and secondary deep venous reflux.  Fan, EM. Endovascular today; July 2015 pp68-74 If an incompetent perforator results from antegrade overload, correction of the superficial reflux alone is often sufficient to normalize perforator hemodynamics and permit return to normal function. As superficial reflux increases and becomes a constant stressor, the perforator begins to dilate, and early perforator incompetence develops Early reflux in the superficial vein, perforator is still competent. Perforator dysfunction is characterized by dilatation with valvular incompetence and retrograde flow.

19. Complete perforator incompetence after longstanding strain, further overload of the superficial vein, which is now also severely incompetent. Retrograde flow from above, antegrade flow from below, and retrograde flow from the IPV combine to create a focal point of severe superficial venous hypertension at the junction of the superficial and perforator vein. Chronic deep venous hypertension stresses the perforator from a retrograde direction causing perforator dilatation, valvular incompetency, and secondary superficial venous hypertension manifesting as varicose veins and inflammatory changes. This pattern typically presents in patients with post-thrombotic obstruction or severe deep venous reflux . CEAP 4-6. 2- Retrograde blow-out pattern: Fan, EM. Endovascular today; July 2015 pp68-74 If the perforator incompetence develops secondarily to uncorrectable deep venous hypertension, eliminating the associated superficial venous reflux does not address the underlying cause of the problem, the perforator cannot recover normal function, and active intervention may be needed Delis KT. Leg perforator vein incompetence: functional anatomy. Radiology 2005; 235:327-334 Chronic deep venous obstruction during muscular contraction (black arrows): venous outflow is diverting to a dilated superficial system, but the perforator at this level is still competent. Chronic deep venous hypertension is causing progressive dilatation of the perforator and some incompetence. Retrograde flow into the already overworked superficial system causes further superficial vein distension and worsening reflux.

20. Retrograde blow out pattern: 27 months later ascending reflux in PV 44 months later - Lower calf medial descending reflux 38 months later – Midcalf reflux in a new location Progression of reflux over time Labropoulos , N., et al. J Vasc Surg 2006:43:558-62

21. PVs run in pairs in >70% cases Ultrasound Assessment Challenges Demonstrates the importance of marking the cm up and over on prior perfs treated One perforator treated successfully, now the twin is incompetent and the perforator artery is still patent The incompetent perforating vein (IPV) often appears to be a single vessel, when it is actually two or more vessels. ( 173 limbs of 152 patients) C lassified into seven types (type N, type O, type I, type II, type III, type IV, and type V) according to the combination of arteries and veins which were presented. Ninety-seven out of 110 IPVs (88.2%) had a concomitant artery. Haruta , N., et al. (2004). Endoscopic anatomy of perforating veins in chronic venous insufficiency of the legs: “Solitary” incompetent perforating veins are often actually multiple vessels. International Journal of Angiology  vol. 13, p. 31–36. “Solitary” Incompetent Perforating Veins Are Often Actually Multiple Vessels”.

22. Type N: normal perforator consisting of a single artery with a pair of normal veins running alongside it. Type O (5%): normal perforator but shows reverse flow. T ype I (25%) : incompetent perforator with thick walls and reverse flow, not accompanied by an artery. T ype II (1%): incompetent perforator , accompanied by an artery T ype III (38 %): incompetent perforator accompanied by an artery and another normal vein,. T ype IV (30%): two incompetent perforators Ty pe V (1%): multiple incompetent perforators. Haruta , N., et al. (2004). Endoscopic anatomy of perforating veins in chronic venous insufficiency of the legs: “Solitary” incompetent perforating veins are often actually multiple vessels. International Journal of Angiology  vol. 13, p. 31–36. Endoscopic Anatomy of Perforating Veins in Chronic Venous Insufficiency of the Legs: “Solitary” Incompetent Perforating Veins Are Often Actually Multiple Vessels”.

23. Duplex Ultrasound (DUS) remains the gold standard in diagnosing CVI including PVI. However, a thorough understanding of the lower extremity venous anatomy is vital in detecting junctional, truncal and perforator incompetence by DUS. Society for Vascular Surgery (SVS) guidelines define a ‘pathological’ perforator vein based on: the anatomical location beneath an active or healed ulcer with a reflux lasting ≥ 500 milliseconds and a diameter ≥ 3.5 mm. https://www.youtube.com/watch?v=4noBuGHsiMI Diagnosis

24. 2- Identifying superficial vein, perforator and deep vein with proper labeling. 1- Upright patient positioning with weight on opposing limb. Note the transverse scanning plane for the first of multiple circumferential sweeps. 3- Wall-to-wall diameter measurement obtained at the level that the incompetent perforator vein is seen crossing the deep muscle fascia. Scanning for a perforator from Pasv

25. Operative report - Perforators Patient: Date: Preoperative parameters (CM from distance over from tibia and up from bottom of foot Intraoperative parameters Perforator #1 R/L->__ Location ↑ floor___ cm diameter ___cm ___zones treated ____cm treatment time________ Temp.____ Perforator #2 R/L->__ Location ↑ floor___ cm diameter ___cm ___zones treated ____cm treatment time________ Temp.____ Perforator #3 R/L->__ Location ↑ floor___ cm diameter ___cm ___zones treated ____cm treatment time________ Temp.____ Perforator #4 R/L->__ Location ↑ floor___ cm diameter ___cm ___zones treated ____cm treatment time________ Temp.____ Perforator #5 R/L->__ Location ↑ floor___ cm diameter ___cm ___zones treated ____cm treatment time________ Temp.____ ____________________________, M.D. ____ Venclose RF perforator catheter

26. 1- Historical description and evolution of treatment In 1917, Homan described the role of PVI in the development of chronic venous ulceration and emphasized the importance of surgical disruption of such perforators. Almost two decades later, Linton first described the medial fascial incision and perforator ligation as a means of managing PVI. This technique remained the gold standard of managing PVI for almost half a century despite the associated morbidities including ulcer recurrence, wound breakdown and neuropathy. However, with the advent of newer less invasive treatment modalities, open surgical ligation has been largely abandoned after Subfascial Endoscopic Perforator Surgery was developed and became widely adopted. Treatment of Perforator Incompetence

27. Hauer in 1985 described the method of SEPS, which eventually displaced the open surgical perforator ligation due to significant reduction in operative morbidity and shorter hospital stay. SEPS was shown to have success rates of up to 78% in closure of perforators during mid-term follow up. TenBrook and colleagues performed a meta-analysis of 20 studies looking at the success of SEPS with or without concomitant superficial vein surgery . They concluded that combination of SEPS resulted in ulcer healing rate of 88% overall with significant improvement in venous clinical severity scores. However, the same study also showed the associated adverse effects of SEPS including wound infection (06%), hematoma formation (09%), neuralgia (07%), and deep vein thrombosis (01%). 2- Subfascial endoscopic perforator surgery (SEPS) These adverse effects along with the need for formal anesthesia to perform SEPS prompted the search for a less invasive treatment modality for PVI. Ten Brook JA, Iafrati MD, O’Donnell TF, Wolf MP, Hoffman SN, et al. (2004) Systematic review of outcomes after surgical management of venous disease incorporating subfascial endoscopic perforator surgery. J Vasc Surg 39: 583-589. Hauer G (1985) The endoscopic subfascial division of the perforating veins - preliminary report (in German). Vasa - J Vasc Dis 14: 59-61.

28. USGS uses chemical agents to treat venous perforators and is the most commonly utilized and oldest minimally invasive ablation method used: US-guided access to the perforator vein is established; with confirmation with aspiration of blood ensure endoluminal position before ablation. Sodium morrhuate , sodium tetradecyl sulfate (STS), and aethoxysclerol are reported sclerosants in the literature. When in contact with the venous walls, these sclerosants cause denaturation of proteins, denude the endothelium, and cause direct tissue damage just beyond the vessel wall. The response is a result of this cell damage with fibroblast proliferation that leads to sclerosis and fibrosis. In addition to fibrosis, agents may produce other effects such as thrombosis. 3- Ultrasound Guided Sclerotherapy (USGS):

29. Early closure rate 80% 20-month closure rate 70% Patients with successfully treated incompetent perforator veins also had a significant improvement in their clinical scores and symptoms, proving the clinical success of this technique. These small adjacent perforators can become insufficient after an initial treatment . New or recurrent perforator disease is a well-described entity and USGS can easily be repeated in these situations. Masuda EM, Kessler DM, Lurie F, et al. The effect of ultrasound-guided sclerotherapy of incompetent perforator veins on venous clinical severity and disability scores. J Vasc Surg 2006;43:551-6; discussion 556-7. 10.1016/j.jvs.2005.11.038 de Waard MM, der Kinderen DJ. Duplex ultrasonography-guided foam sclerotherapy of incompetent perforator veins in a patient with bilateral venous leg ulcers. Dermatol Surg 2005;31:580-3. 10. Outcomes of USGS:

30. 4- Ultrasound Guided Foam Sclerotherapy (UGFS) Jia X, Mowatt G, Burr JM, et al. Systematic review of foam sclerotherapy for varicose veins. Br J Surg 2007;94:925-36. 10.1002/bjs.5891 Perforating vein cannulated with a 23- gauge butterfly needle. One cc of 1% polidocanol (Asclera, Merz Aesthetics, Greensboro, NC) agitated with 4 cc CO2 8 cc maximum foam injected Perforator completely filled, compression is held at the junction of the perforator and the deep vein for 2 minutes Efforts made to push foam into varicosities so to treat all varicosities in relation to an incompetent perforator with a single injection.

31. UGFS - Outcomes 62 patients with C6 disease 189 perforating veins treated with UGFS Overall ablation success per injection was 7 4% 70% healed with successful healed 3 % healed with failed ablation P=.02 J Vasc Surg 2014;59:1368-76

32. Complications of USGS: Allergic reactions to the sclerosant Painful phlebitis Deep vein thrombosis. Neurologic Symptoms from systemic embolization (air or foam particles Inadvertent injection to adjoining arteries with resultant skin necrosis. Outcomes of Ultrasound guided foam sclerotherapy (UGFS) Masuda EM, Kessler DM, Lurie F, Puggioni A, Kistner RL, et al. (2006) The effect of ultrasound-guided sclerotherapy of incompetent perforator veins on venous clinical severity and disability scores. J Vasc Surg 43: 551-557. Early closure rate 90% 20-month closure rate 78% Neurologic complications of USGS: Dry cough Migraine Chest tightness Metallic taste Nausea Dizziness Visual disturbance Panic attack Vagal reaction Stroke

33. EVTA has been performed for perforators using either Radio-frequency or laser. The obvious advantage over conventional surgical techniques and SEPS is the non-requirement for formal anesthesia and the ability to be performed as day case or out-patient procedure. The RF or laser energy thermally damages the endothelial lining of venous structures which will then seal the perforator shut. The perforator will eventually fibrose and remain closed. The reported closure rates have been as high as 95% . The reported short and mid-term closure rates have been excellent 92-94%. 5- TRansLuminal occlusion of Perforators. TRLOP Kuyumcu G, Salazar GM, Prabhakar AM, Ganguli S (2016) Minimally invasive treatments for perforator vein insufficiency. Cardiovasc Diagn Ther 6: 593-598. Hager ES, Washington C, Steinmetz A, Wu T, Singh M, et al. (2016) Factors that influence perforator vein closure rates using radiofrequency ablation, laser ablation, or foam sclerotherapy. J Vasc Surg Venous Lymphat Disord 4: 51-56. https:// www.youtube.com / watch?v =OlyfKYGV9SM

34. 1470 nm, 400um microfiber introduced through direct puncture 21g needle Positioned 2-3 mm from the deep vein Lidocaine infiltrated around the laser tip The generator set at 6 watts and treated with 50-100 joules per 2mm Endovenous Laser Ablation

35. Retrospective analysis of 132 patients who underwent EVLA at a single institution from 2010 – 2011 and compared to conservative therapy Outcomes: Immediate procedural success was 100% 1 year closure rates were 82% Faster median ulcer healing rate was observed (1.4 mo vs 3.30 mo) No DVT / neuralgia EVLA is safe and effective and improves ulcer healing rates EVLA - outcomes Eur J Vasc Endovasc Surg. 2015 May;49(5):574-80. Shi H, Liu X, Lu M, Lu X, Jiang M, Yin M. The effect of endovenous laser ablation of incompetent perforating veins and the great saphenous vein in patients with primary venous disease.

36. Direct puncture and Seldinger technique both used Positioned 2-3 mm from the deep vein After local anesthesia infiltration, 4 quadrants treated for 30 seconds each Catheter withdrawn 3-5 mm and treated again Radiofrequency ablation

37. Analysis of 75 patients who underwent perforator RFA – 60 (80%) CEAP 6 Outcomes: Immediate procedural success was 94% 1 year closure rates were 82% CEAP and pathological clinical score improved in 49.3% No change in ulcer healing rate, but reduced recurrence rates (12% vs. 43%) 2 tibial vein DVT Successful RFA improves CEAP class and pathologic clinical scores and reduces ulcer recurrence rates RFA - Outcomes Phlebology. 2010 Apr;25(2):79-84 Marsh, P, Price BA, Holdstock JM, Whiteley MS. One-year outcomes of radiofrequency ablation of incompetent perforator veins using the radiofrequency stylet device. Phlebology. 2010 Apr;25(2):79-84

38. WHEN ABLATING A PERFORATOR , IT IS CRUCIAL TO PROTECT: Skin: Tumescent to keep heating element .05 to 1.0 cm from the skin to prevent skin burns Bone: Tumescent to protect bone when perforators are close to tibia or malleolus Nerves: Superficial fibular, Deep fibular and peroneal nerves Arteries: Identifies accompanying arteries that may get affected by proximity to perforators Deep Veins: Stay at least two cm away from deep veins to avoid DVT https:// www.semanticscholar.org /paper/Anomalous-intraosseous-venous-drainage%3A-Bone-Ramelet-Cr%C3%A9bassa/52e90fb0de2d69de470d73a28d73c0bce75e1c9b

39. 1 https:// www.semanticscholar.org /paper/Anomalous-intraosseous-venous-drainage%3A-Bone-Ramelet-Cr%C3%A9bassa/52e90fb0de2d69de470d73a28d73c0bce75e1c9b Skin burn from RF ablation Skin ulcer form venous disease Skin burn from Laser ablation Ablation related skin ulcerations tend to heal over 4-6 weeks with proper wound care. If not healed local excision in an elliptical fashion may be required SKIN BURN

40. https:// www.cambridge.org /core/books/applied-anatomy-for- anaesthesia -and-intensive-care/lower limb/C78BDD2A76B3C8FA8648B6139C951928 NERVE INJURIES Foot drop is caused by an injury to the  peroneal nerve . The  peroneal nerve  is a branch of the sciatic nerve that wraps from the back of the knee to the front of the shin.

41. ARTERIAL INJURIES “Ninety-seven out of 110 IPVs (88.2%) had a concomitant artery”. Skin necrosis due to arterial injection is painful, may threaten the limb and will take a long time to heal.

42. Anterior medial leg Anterior medial leg Anterior Tibial Veins & Artery Lateral of tibia Small Scanning tibials and peroneals   https://www.youtube.com/watch?v=q9lOQ3tSnKk   https://www.youtube.com/watch?v=oo0hPKdtFSQ start @3:50 Understand & Protect the Deep Veins- Posterior Lower extremity https:// ultrasoundregistryreview.com /vascularTrial17.html

43. Understand & Protect the Deep Veins- Posterior Lower extremity Posterior Leg *Small saphenous vein can branch below the level of the gastrocnemius muscles * Artery Veins https:// ultrasoundregistryreview.com /vascularTrial17.html

44. Complications of PIV treatment Murad, MH, et al. J Vasc Surg 2011;53:49S-66S

45. Post Operative CARe : Apply compression folded 4x4 over treated perf for pressure Wrap leg from toes up (starting top of foot to avoid pressure points on bottom of foot) (Diabetic?) Recommended 30-40 mmHg gradient compression stocking Patients instructed to maintain or increase their normal activity levels O’Hare et al. (2010) found that “compression bandaging for 24 hours, followed by use of thrombo-embolus deterrent stockings for remainder 14 days, gave results comparable to compression bandaging for 5 days”. Rescan at 72 hours https:// pt.slideshare.net /dra2lg10/varicose-vein-30092018 O’Hare, J.L., et al., Br J Surg. May 2010:97(5):650-6.

46. Successful ablation of IPVs reduces ulcer recurrence and facilitates healing J Vasc Surg 2012;55:458-64 Why treat perforating veins?

47. Modality of Second Procedure Primary closure rates Closure rates after prior UGFS P Value EVLA 6 1 .3% 84.6% .03 RFA 7 3 .1% 89.1% .003 UGFS 5 7 .4% 50% NS Predictor of Success Heat ablation after failed foam sclerotherapy resulted in significantly higher closure rates https:// doi.org /10.1016/j.jvsv.2015.08.004 Hager, E, et al. Journal of Vascular Surgery: Venous and Lymphatic Disorders Volume 4, Issue 1, January 2016, Pages 51-56

48. Variables that did not affect closure rates Anticoagulation Presence of deep vein reflux Perforator size BMI <50 Predictors of failure All modalities: BMI >50 (p=.05) Pulsatility in the treated vein (p=.05) https:// doi.org /10.1016/j.jvsv.2015.08.004 Hager, E, et al. Journal of Vascular Surgery: Venous and Lymphatic Disorders Volume 4, Issue 1, January 2016, Pages 51-56

49. Becoming an expert at treating perforators: Clear and thorough understanding of the venous anatomy Understanding patterns of reflux in the lower extremities Having the right equipment Using the proper technique Providing after care and not ignoring complications Managing expectations at the first visit.

50. Thermal perforator ablation has been associated with significant improvement of venous clinical severity scores when performed in above discussed CEAP class-5 and 6 disease. Thermal ablation with RFA or EVLA have been documented with significantly higher perforator closure rates at follow up compared to UGFS. Closure rates of laser and radiofrequency EVTA after failed USGS were 85% and 89% respectively. MAVEN was the most reliable method of perforator closure at 1-year follow up. Hager ES, Washington C, Steinmetz A, Wu T, Singh M, et al. (2016) Factors that influence perforator vein closure rates using radiofrequency ablation, laser ablation, or foam sclerotherapy. J Vasc Surg Venous Lymphat Disord 4: 51-56. Current guidelines by the American Venous Forum recommends treatment of incompetent perforators especially in Clinical, Etiological, Anatomical and Pathophysiological (CEAP) class 5 and 6 disease. CEAP class-5 refers to PVI in the region of healed previous ulcer while CEAP class-6 refers to PVI in the region of an active ulcer. CONCLUSIONS: At present, there is no conclusive evidence for the simultaneous ablation of incompetent perforators at the time of truncal vein ablation in the absence of active or past venous ulceration.

51. Thank You!