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