Consultant Vascular Surgeon
London Northwest Healthcare Trust,London
</b> <br>Venous Disease<br> <br>Venous Disease is a chronic as well as an acute problem that has been neglected over the years.<br> <br>In this presentation, I will talk to you about four different venous conditions and how we treat it. Some of these venous problems are very sensitive and people forget to take advice for treatment from the hospitals. In one such condition that I will first describe is varicose vein disease. Varicose vein is highly prevalent about 20-30% of the population suffer from varicose veins. Sometimes people think that it is more prevalent in women than men. But as women are always covered in their legs, we never see them and they are often shy to show their leg, therefore we do not know what is prevalence in this country. But world wide if you take an estimate, it is a very common problem. Why it is important? because untreated varicose vein can develop very serious problem where people develop leg ulcers, posttraumatic syndrome which is a significant burden in the community. These people’s lifestyle is affected by these problems and this is a preventable condition. Why it is preventable? because we can treat them by manually invasive procedures today. We do not have to resort to open surgery that we did 30 years ago and there are several different ways of treating these veins including what is called saphenous glue where you can inject this glue into the vein and you come to my clinic, I will treat you by single middle puncture and let you go home after the treatment. You can imagine if you compare it what was happening in the past with compared to open surgery where people used to spend 6-7 days in the hospital after the treatment. So there are varieties of new ways available apart from this glue and now this is a standard procedure all over the world and which patients are benefitting. The problem is because varicose vein is not a dramatic problem, it does not kill patients therefore it is often neglected. But it causes significant morbidity in the community and a lot of man power is lost because of the disability that is associated with it. So we have got treatments available today and we should accept it or request our doctors to arrange for treatment of such kind of problem. <br> <br>The next topic that I will talk to you is about thrombosis and particularly affecting the upper leg .This is an area where it is again the neglected largely because of the lack of awareness and the awareness about the treatment modalities that is available and finally many of the clinicians are not quite clear about the mechanism of this thrombosis. There are some mechanical problems in our neck which causes compression on the vein which drains the hand into the heart. This compression could be due to bone, due to ligament, due to muscles and due to various other structures and when this vein is repeatedly kept under compression or stretching, it causes damage to the vein wall and it leads on to thrombosis. The standard practice people or the clinicians follow, we used to put them on anticoagulation treatment but unfortunately anticoagulation treatment does not prevent the long term sequelae from this condition called posttraumatic syndrome. As a result the arm remain swollen and that painful particularly when you are using the arm. So the current treatment modality that is being prescribed or we do practice in our day-to-day practice consists of three things. <br> <br> 1. Thrombolysis by dissolving the clot by putting the right kind of medicine through what is called Catheter Directed Thrombolysis. Once we have completely dissolved the clot, you put the patients on antithrombotic treatment. 2. At a second stage, we remove the compression by excising the bone of the rib or excising the muscles of the ligaments which is causing the compression. 3. The third stage in order to keep the vein open, we put what is called a metallic stent. So these are the three stage procedures that should be followed in any of the main thrombosis. <br> <br>During the postoperative period, these patients can be kept on anticoagulation for maximum up to 3 to 6 months in order to prevent recurrence of DVT. The success of this treatment modality is very good. 85% to 90% of the patients do have a patent subclavian vein at the end of this treatment protocol. So I think it is high time that these patients should benefit from this kind of treatment when it is available and the hospital should equip themselves with the facilities so that this kind of treatment can be delivered. <br> <br>My third talk is about what is called pelvic congestion syndrome but this is a problem which occurs in women and is seen by different physicians with different interest. First of all it is the gynecologists who are enrolled in treating these patients. These patients may be treated by the vascular surgeons or sometimes by the interventional radiologist. The problem is recognition of the condition is the problem and many times these patients present with abdominal or pelvic pain and there are so many different causes of pelvic pain and abdominal pain that this diagnosis is often forgotten unless we are have got special interest, unless we have done the investigation to find the cause. Obviously, the gynecologist will definitely exclude the common gynecological cause for this kind of pain. Once they have exhausted all possible investigations, they will start thinking about this particular problem and sometimes the vascular surgeons when they have been treating these patients for their varicose veins, they find that the patients who have got recurrence of varicose vein despite adequate treatment. So in that case these patients undergo investigations only to find out that there are other problems which are causing these things. So what is to be done? <br> 1. High index of suspicion when you do not find a cause, try to look for this cause and the way to develop your investigation modality to identify the cause is as follows <br> These patients should have an ultrasound scan or Duplex scan to see whether there is ovarian vein incompetence. The ovarian vein should be dilated more than 6 mm in maximum diameter in order to cause the problem. Pelvic vein congestion is often called ovarian vein incompetence. The ovarian vein incompetence occurs for various reasons. 1. Due to May–Thurner syndrome which causes stenosis of the iliac vein commonly on the left side. 2. Nutcracker syndrome where the renal vein is compressed by superior mesenteric artery and thereafter) the compression causes venous hypertension in the ovarian vein causing it to dilate and causing the vein grafts to be incompetent and this has got the effect on the pelvic vein congestion. <br> 3. It can happen in conditions where the renal vein goes behind the aorta which causes compression. So all this compression problems lead on to dilatation of the ovarian vein and this may happen on both sides. So if you found that on ultrasound scan the ovarian vein is dilated, the next stage of investigation is to do a CT venogram. The CT venogram is quite clearly will demonstrate the pathology that I described earlier. <br> <br>The third thing to counsel the patient, what kind of treatment we are proposing based on the investigations and what is the outcome of this treatment because at the end of the day, it is the patient who becomes a partner in making this decision. So the treatment that is involved when there is ovarian vein incompetence is to close that vein by using embolization using coil, glue, acrylate or comb. We may have to do treatment for both side ovarian vein and sometimes after this treatment also we may find that these few patients who have got what is called putting the varicosities, varicosities involving the medial side of the thigh and these veins can be treated by foam sclerotherapy but I am sure that the long saphenous vein is not incompetent and if that is the case that should be treated by prepared endothermal ablation. So by this strategy we should be able to close this abnormal congestion which is occurring in the pelvis due to pelvic vein incompetence or ovarian vein incompetence. So what is the outcome of this treatment? I think the outcome is quite good, almost 80% of the patients do benefit from this treatment. The pelvic vein improves within six months, the veins disappear and I would definitely recommend treatment for this condition which is often neglected. But do not forget that you must treat the torn vein incompetence which is the long saphenous vein, may be the putting of drain often drain into the long saphenous vein, if the saphenous vein is incompetent, it will continue to hold the problem, that must be treated. <br> <br>So that is the end of third topic on venous problem. <br> <br>I also did talk about a condition which I described earlier called May–Thurner syndrome or iliac vein stenosis. <br> <br>May–Thurner syndrome was described in the late 1950s but this was not recognized in our clinical practice until this decade. I am sure you realize that deep vein thrombosis affects the left side more commonly than the right side and when it does occur in the past, people always attributed the problem to the intak of oral conceptive pills, pregnancy and other conditions which might account for the development of deep vein thrombosis. <br> <br>As our knowledge improved, as we realize that there must be some other of Indian cause for this kind problem because these are the group of people who have got May–Thurner syndrome that present again and again with recurring DVT despite the treatment, only then we realize that there must be some other reason for them to present with recurrence of deep vein thrombosis and then we start doing the investigations. The common investigation that we perform is the CT venogram. The CT venogram will demonstrate the stenosis of the left iliac vein or sometimes maybe right iliac vein because the iliac vein stenosis can occur on either side and when that is the case, this must be dealt with and some of these patients present with iliac vein thrombosis and if that is the case the iliac vein thrombosis must be treated with thrombolysis, catheter directed thrombolysis or mechanical directed thrombolysis whatever is available at your institution. <br> <br>Once this has been done, the patients’ iliac stenosis mostly treated and the treatment involves venoplasty followed by stenting of the iliac vein stenosis. This modality of treatment has got tremendous success. <br> <br> 1. In preventing recurrence of DVT 2. To prevent the occlusive effect of iliac vein thrombosis and this also improves their quality of life and the vascular evaluation has changed the way we treated our patients from very open surgery to what is called minimally invasive surgery The beauty of this practice is this that the patients workality is reduced, the recovery from surgery is expedited, patients spend less time in the hospital and the outcome treatment has been successful and this principal has been applied to treat a notorious condition called abdominal aortic aneurysm although endovascular treatment can be applied anywhere wherever there is an aneurysm or occlusive disease but I am going talk about this particular serious condition of abdominal aortic aneurysm whether it is elective or is an emergency situation. Because of the need, the development of various endovascular aneurysm devices have evolved over the last 30 years. 30 years ago when we started this experiment, it was very crude and we did not understand the various needs or various principles that we must adhere to in developing a device at this time. I did some research about two years ago to understand the biological behavior of abdominal aortic aneurysm, the geometry of the aneurysm and various forces that act often to the device that we deploy in order to treat the patients aneurysms. We developed simulation to using the principles of competitional prodynamics. What we found that there are three very important things we must answer when you are trying to develop a device. 1. We must have adequate friction course by having a good infrarenal neck. 2. We must have anchoring mechanism by having hooks on the graft. 3. We should have burning edges which will cause the graft to fix to the aorta and prevent migration. <br> <br>So these three principles are very important whenever we are trying to develop any new devices and the finally the geometry of the aortic aneurysm does not stop there. There are various for mutation and combination and modification that happens in the geometry if the abdominal aorta dilates. So we need to address those issues for example it may be a very hostile neck, the conventional device are not suitable in those situations. So we have to think about a suprarenal fixation so that is one way of development <br> <br>The second is many of these aneurysms are very tortuous. They may be tortuous at the infrarenal neck, they may be torturous at the iliac artery on one side or both sides or there may be a suprarenal tortuosity so we need to address this geometrical configuration and many of the devices that are available today ………..