Transcript Case Presentation Gastrocneimus Perforator

Case Presentation
Gastrocneimus Perforator
It’s All About Veins Conference- 2011
Phoenix, Arizona
Peggy Bush, APN, CNS, MSN
Disclosure
Disclosure: Peggy Bush, APN, CNS, MSN
I have no disclosures concerning this
presentation.
Results of Studies
• Gastrocnemial vein reflux was present in 10%
of limbs (Labropoulos)
• Incompetence in these veins has been
reported in several studies with a prevalence
ranging from 10%-29%
(Labropoulos, 2000) (Juhan, 1993) (Hobbs,
1988) (Vandendriessche, 1989)
Gastrocteimus Perforators
Not rare, but we
see this in 2-3
cases a month
Schematic Drawing of Perforators
(online, 2011)
CASE STUDY
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46 years old
6’4” / 260#
Farmer/Supervisor
Married
(Midwest Vein & Laser Center, 2011)
Medical History is Unremarkable
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Compression stockings for 4 years
Reports no health issues
Reports no medications
NKA
Past phlebectomy opposite leg
Past foam sclerotherapy opposite leg
(Midwest Vein & Laser Center, 2011)
Initial Exam
• Chief complaint: Pain in legs
• Symptoms: heaviness, itching, aching,
burning, swelling, and pain
• Reflux gastroc perforator & posterior branch
of saphenous
• Varicosities posterior calf
• Normal deep system
(Midwest Vein & Laser Center, 2011)
Ultrasound Image
SSV
Varicosities
Gastroc
Perforator
Popliteal Vein &
Artery
(Bush Venous Lectures, 2011)
Gastrocneimus Perforator Reflux
(Bush Venous Lectures, 2011)
Video of Gastroc
Perforator
Video of Gastroc Perforator
(Bush Venous Lectures, 2011)
Abnormalities- Pathologic!
• Left gastrocneimus perforator with 4 sec.
reflux
• Multiple varicosities
• Marked stasis changes
(Midwest Vein & Laser Center, 2011)
Plan
• Endovenous ablation of the posterior branch
of the saphenous
• Foam injection of large incompetent
perforators
• Multiple stab avulsion phlebectomies
• To be done in 2 sessions due to the two
systems of pathology that were present
(Midwest Vein & Laser Center, 2011)
Surgery Day 1
• Endovenous ablation of the posterior branch
of the saphenous vein left leg
• Stab avulsion phlebectomy of a varix leading
into a Cockett’s perforator
• Laser fired at 8 watts with pullback of 2
mm/firing
• Sutures & compression dressing
• No complications
(Midwest Vein & Laser Center, 2011)
Surgery Day 2
• Preoperative Diagnosis: Gastrocnemius
perforator with multiple varicosities
• Procedure: US-guided foam injection of the
large peforator with tumescent application
around the perforator & multiple stab avulsion
phlebectomies
• (2 cc of 1% Sotradecol® mixed with C02)
Midwest Vein & Laser Center, 2011)
Procedure
• Veins marked with patient in standing position
• Gastroc perforator cannulated
• Under US-guidance injected 1.5 cc 1%
Sotradecol® foam
• Tumescent applied around the injected
perforator
• Calf massaged to make sure all foam was
removed from the deep circulation
Midwest Vein & Laser Center, 2011)
Procedure Cont.
• Compression dressing applied
• No complications
Midwest Vein & Laser Center, 2011)
Conclusion
• Follow-up US 1 week, 1 month, 6 months, and
1 year
• To date, at Midwest Vein & Laser Center, no
recurrent reflux in over 20 patients treated for
incompetent gastrocneimius perforator
Midwest Vein & Laser Center, 2011)
References
Gastrocneimus image. Retrieved online from http://odlarmed.com/?p=1316, January 23, 2011.
Hobbs JT. The enigma of the gastrocnemius vein.Phlebology 1988;3:19-30.
Juhan C, Barthelemy P, Alimi Y, et al. Prevalence of gastroc- nemius vein insufficiency using color-coded Doppler
ultra- sound. Bull Acad Natl Med 1993;177:233-9.
Labropoulos N, Giannoukas, A, Kelis K, et al., The impact of isolated lesser saphenous vein system
incompetence on clinical signs and symptoms of chronic venous disease. Journal of Vascular Surgery.
2000;32:954-960.
Midwest Vein & Laser Center. Patient’s Medical Record. 2011.
Vandendriessche M. Association between gastrocnemial veininsufficiency and varicose veins.
Phlebology1989;4:171-84.
Peggy Bush, Advance Practice Nurse
[email protected]
Thank you!