Transcript 1540_Morrison_EB3D2x

KTS and Marginal Vein
Insufficiency: Treatment Options
3:40-3:50
Slide Rock, Sedona, AZ
Nick Morrison, MD
President, International Union of Phlebology
Disclosures
Medtronic
Research Grant
Scientific Advisory Board
Speakers Bureau
MediUSA
Speakers Bureau
Educational Grant
Merz
Consultant
Morrison Vein/Training Institute
Medical Director
Northern Arizona, USA
Kleppel-Trenaunay Syndrome
Description
Vascular malformations:
Including venous, lymphatic, capillary
(Not arterial – Parkes-Weber Syndrome)
Boney/Muscular Hypertrophy
Atypical Lateral (Marginal) Varicosity
Patient Presentation
Twenty-year old white male
Diffuse port-wine staining primarily of the right leg, foot,
hemithorax, abdomen
Slight lengthening of the right leg with osseous hypertrophy and
macrodactyly
Extensive varicosities of the superficial venous system in the right
thigh, infragenicular area and the foot
Symptoms of pain, heaviness, and fatigue of increasing severity
Kleppel-Trenaunay Syndrome
Diagnostic Studies
Duplex-ultrasonography
Mild femoral vein hypoplasia
Moderate reflux in the deep system from the CFV to the PTVs
with moderate ectasia of the proximal popliteal and distal
femoral vein and a dilated, dominant profunda vein
Gross reflux of the GSV from the SFJ distally (including an
incompetent anterior accessory GSV and SSV
Confirmed duplex valve presence
Confirmed duplex valve presence
CFV Reflux
Diagnostic Studies
Arterial doppler study
normal with a normal ABI
MRA and MRV of the right leg and pelvis
normal with no evidence of A-V fistula or AVM
Ascending and Descending Venogram
no evidence of AVM
Lymphoscintigraphy
normal lymphatic system
Thrombophilia profile
Hyperhomocysteinemia – 3x normal
Treatment
Endovenous laser ablation of proximal GSV and SSV
Ambulatory phlebectomy of varicosity of the medial
aspect and dorsum of the foot
Foam sclerotherapy of accessory saphenous, distal
GSV, SSV, and infragenicular varicosities
*(always “covered” with LMWH because of thrombophilia)
9-year follow up
2007
Endovenous laser ablation of the right great saphenous veins and
ambulatory phlebectomy below the right knee.
2009
Endovenous laser right marginal vein, left GSV
2012 Right BK AP re-do
2014
Right GSV re-do laser ablation
Right SSV, lateral vein re-do laser ablation (11 months later)
2007-Present
Multiple UGS sessions with Foam
9-year follow up
2016
“He is doing well but is tired of all of the procedures and the expense is a
strong consideration for him. On PE he has recurrent varices over the lateral
patella and proximal calf, as well as the feet. On duplex exam, the right deep
system is patent along its length, mildly hypoplastic, and incompetent at the
CFV and PV. The right SSV is closed, and the right GSV is closed proximally
but wide open from the distal thigh to the ankle, with the exception of a
5cm sclerotic segment in the proximal calf. The left GSV is also partially
patent along its length and the incompetent tributaries are noted from the
knee inferiorly.”
9-year follow up
April, 2016
Right GSV Adhesive ablation (donated by Medtronic)
right ankle to proximal calf – above too sclerotic to cannulate
Right proximal GSV, large tributaries of foot, ankle, and perigenicular UGS foam sclerotherapy
Kleppel-Trenaunay Syndrome
Other treatment options
RF ablation – likely same outcome as laser ablation
Surgical excision of large lateral vein – BLEEDING!!
Compression therapy alone – inadequate symptom relief
Thank you for your kind attention
[email protected]