Does All Saphenous Reflux Need Ablation?
Paul M. McNeill, MD FACSCapitol Vein and Laser Center
Bethesda, MarylandFrederick, Maryland
Does All Saphenous Reflux Need Ablation?
Who will benefit from ablation?
When ablation is best deferred?
Sound treatment algorithms consider a range of options for patient care
Does All Saphenous Reflux Need Ablation? What is the natural history of venous reflux?
Are there anatomic differences in saphenous reflux?
What affects progression of disease?What are the risks of treatment of reflux?What are the risks of observation?Does observation have a role in every CEAP
Class?
Saphenous Vein Reflux
Saphenofemoral Junction Variation
Does All Saphenous Reflux Need Ablation?
Anatomy of Saphenous RefluxAssociated SFJ
refluxCompetent Terminal
Valve Proximal source
GSV above kneeGSV below kneeGSV above + below
knee
Does All Saphenous Reflux Need Ablation?
Reflux patterns should be consideredReflux patterns and risk factors in
Primary Varicose Veins’ Clinical Severity. Phlebology 2011;28:153-161GSV reflux associated with SFJ incompetence
more likely to be associated with C4-6 GSV reflux with a competent SFJ
More likely associated with C1-3GSV reflux above and below the knee is more
likely to be associated with C4-6 disease
Does All Saphenous Reflux Need Ablation?
Reflux patterns and progression of diseaseProgression of reflux patterns in
saphenous veins of women with chronic venous valvular insufficiency. Phlebology 2012;27:25-32Stable reflux pattern was common with initial
segmental reflux not affecting the SFJ and not extending to the ankle
Great Saphenous Vein
Great Saphenous Vein
Does All Saphenous Reflux Need Ablation?
Anatomy of Saphenous RefluxWhat is the status of
the deep system at the time of presentation?
Progression of disease may be more likely in the face of deep vein reflux
Does All Saphenous Reflux Need Ablation?
C1 TelangiectasiaC2 Varicose VeinsC3 EdemaC4 Skin ChangesC5 Healed UlcerC6 Active UlcerCA,S Symptoms
CEAP 1 and Saphenous Ablation?
Does All Saphenous Reflux Need Ablation?
Weak association: telangiectasia and Saphenous reflux.Ruckely et al. Telangiectasia and venous
reflux in the Edinburgh Study. Phlebology 2012;27:297-302
Little evidence to support saphenous ablation prior to treating telangiectasia
Mixed CEAP 2 and 1
C2 Observation80F, varicose veinsGSV refluxAsymptomaticUrged by others to
be evaluatedObserve!
C3 ObservationGSV Reflux and mild
edemaMild discomfortInactiveNon compliant with
hoseFairly stable clinical
course
Observation of C4 disease
Observation of C5 disease
Segmental refluxPrior vein surgerySFJ ligation and
partial strippingDVTStableCo-morbid
conditions
Observation of C6 diseaseConsider the high risk
patientImmobile and infirm
patientMorbid obesity and no
clear cut venous symptoms
Multiple issuesAdjunct measures
Does All Saphenous Reflux Need Ablation? Patients can come in seeking treatment
they believe they needArticle: The relative impact on leg
symptoms of fears of getting varicose veins and of Great saphenous vein reflux. Phlebology 2013; 28:347-352Healthy patients with fears of getting
varicose veins experience feelings of leg swelling and heaviness
Does All Saphenous Reflux Need Ablation? Patients can present with other etiologies
for leg pain and swelling – particularly Knee painMuscle sorenessLipemia – not edemaObesity related symptomsFibromyalgia
Develop a planObserve the refluxImprove health parametersOrthopedic or Other evaluation
Does All Saphenous Reflux Need Ablation?
Lifestyle Factors
Physical activityTravel - remoteFamily PlanningSymptoms
Occupational hazardsTravelLong commuteStandingPhysical labor
Does All Saphenous Reflux Need Ablation?
Lifestyle Factors
Physical activityTravel - remoteFamily PlanningSymptoms
ConverselySedentaryHome boundMedical issues
Occupational hazardsTravelLong commuteStandingPhysical labor
ConverselyRetiredSedentaryContent
Saphenous Reflux That Needs Ablation?
SummarySaphenous Reflux Observation
Asymptomatic or stable disease C1-6Anatomy of the reflux is consideredInfirm or clinically content patientAlternative explanation for symptomsLow likelihood of benefit
Saphenous Vein AblationSymptomatic diseaseExtensive refluxMedical and lifestyle benefit
Does All Saphenous Reflux Need Ablation?
Expertise in vein care extends beyond our technical skills
Patients respect your credentials
Admiration for a discerning physician who considers a range of therapeutic options best suited to the patient
Thank you
Paul M McNeill, MD FACS