Steven Elias

Surgical treatment of postphlebitic syndrome with vein valve transplant.

Sequelae of the postphlebitic syndrome can new be treated by direct valve surgery. The present surgical treatment of stasis ulcer, including removal of the incompetent perforators, ulcer excision, and skin grafting, remains essential. Excision of perforators and ulcer care are effective but are associated with a high rate of ulcer recurrence. Experimental studies to restore venous valve function include autogenous or homologous vein valve transplantation, valvuloplasty, and valve transposition. In 23 cases of vein valve transplantation and two transpositions, a normal autogenous vein valve from the arm was used to restore a normal functioning venous valve in the leg. Pre- and postoperative noninvasive and invasive testing indicates hemodynamic improvement of venous function in these legs. Follow-up direct venous pressure measurements did not show normalization and may indicate that more than one competent valve is necessary. Changes in muscle structure may play a role in the maintenance of venous pressure.

Recommended Reporting Standards for Endovenous Ablation for the Treatment of Venous Insufficiency: Joint Statement of the American Venous Forum and the Society of Interventional Radiology

Sanjoy Kundu, MD, FRCPC, FCIRSE, FASA, Fedor Lurie, MD, Steven F. Millward, MD, FRCPC, FSIR, Frank Padberg Jr, MD, Suresh Vedantham, MD, Steven Elias, MD, Neil M. Khilnani, MD, William Marston, MD, John F. Cardella, MD, FSIR, FACR, Mark H. Meissner, MD, Michael C. Dalsing, MD, Timothy W.I. Clark, MD, FSIR, and Robert J. Min, MD, MBA, FSIR, Toronto and Peterborough, Ontario, Canada; Honolulu, Hawaii; Newark and Englewood, NJ; Saint Louis, Mo; New York, NY; Chapel Hill, NC; Springfield, Mass; Seattle, Wash; and Indianapolis, Ind

Minimally invasive vein surgery: its role in the treatment of venous stasis ulceration

Although traditional modalities used to treat venous disease and subsequent stasis ulceration have proved to be effective, they can have associated morbidities, such as postoperative pain, limited mobility, wound infection and dehiscence, as well as missed varicosities and/or incompetent perforator veins resulting in additional procedures. Recent advances have been made in minimally invasive vein surgery (MIVS) techniques that can decrease operative morbidity, number and size of incisions, recovery time, as well as operative time. These techniques are as durable as open procedures. The following procedures will be discussed: transilluminated powered phlebectomy, radiofrequency ablation of the greater saphenous vein closure, subfascial endoscopic perforator surgery, and percutaneous vein valve bioprosthesis. The advent of MIVS techniques allows the surgeon to manage venous pathophysiology associated with all 3 venous systems. MIVS is proving to be an important complement in the overall care of venous stasis ulceration.

Minimally Invasive Vein Surgery: Latest Options for Vein Disease

The goal of treatment for venous disease is to decrease ambulatory venous hypertension. Various strategies are employed. These can be divided into exogenous and endogenous treatments. Exogenous methods concern those employed from the outside of the limb, such as compression and elevation. Endogenous modalities treat from inside the limb the underlying venous pathology due to venous valvular dysfunction or venous obstruction. Traditional endogenous procedures include stripping, ligation, and phlebectomy. All these procedures require incisions, anesthesia, and perhaps hospitalization, and involve significant discomfort. Newer minimally invasive vein surgery procedures now exist. These are all same-day, outpatient procedures, usually involving local anesthesia. Most can be performed percutaneously without incisions. Patients ambulate the day of the procedure. Morbidity is less than 1%. This article summarizes the concept of minimally invasive vein surgery and summarizes new technologies to manage all forms of venous disease. Mt Sinai J Med 77:270-278, 2010. (c) 2010 Mount Sinai School of Medicine.

Venous Ulcers: New Options in Treatment: Minimally Invasive Vein Surgery

Venous disease has a spectrum of presentations. The most advanced state of chronic venous insufficiency (CVI) managed by wound care specialists being ulceration of the lower extremity. The goal of all treatments for advanced venous disease is to decrease ambulatory venous hypertension. Treatment can be divided into exogenous and endogenous methods. Exogenous methods include those applied externally such as compression, elevation, debridement and wound dressings. Endogenous methods treat the underlying venous pathology either due to venous valvular dysfunction or venous obstruction leading to venous hypertension. Recently, significant advances in endogenous methods have evolved. The development of a new concept, minimally invasive vein surgery (MIVS), has improved upon traditional, open, invasive treatments of venous disease. MIVS techniques are performed percutaneously, with minimal anesthesia, no incisions and rarely require hospital admission. This article summarizes the concept of MIVS, describes each method of MIVS and its complementary role in the management of venous leg ulcers patients.

Deep Posterior Compartment Pressure in the Evaluation of Venous Insufficiency of the Lower Extremity — A Preliminary Report

A new method of assessing the extent of venous insufficiency in the lower extremity at the tissue level was tested on thirteen limbs with various degrees of venous insufficiency as evidenced by clinical signs and descending venography. Deep posterior compartment pressures in standing patients correlated well with standing venous pressures in these same limbs. Eighty-three percent of those limbs with deep posterior compartment pressures above 30 mmHg had objective clinical signs of venous insufficiency, namely edema, stasis dermatitis and/or stasis ulcer. Descending venography results were compared in six of these limbs, however, no correlation with compartment pressures could be found from this small sample. With further study, deep posterior compartment pressures using the slit catheter technique may prove to be a valuable aid in the diagnosis of venous insufficiency.

Surgical Treatment of Post Phlebitic Syndrome

Sequelae of deep vein thrombophlebitis, such as post phlebitic syndrome with or without ulceration, can be treated by direct surgery on the valve. Present surgical treatment of stasis ulcer includes removal of the incompetent communicating veins with excision of the ulcer and skin graft. This procedure is usually associated with a high incidence of leg ulcer among the patients with an incompetent deep venous system. Experimental studies to restore venous valve function, such as autogenous vein valve transplant, valvoplasty, homologous vein transplant and synthetic valve procedures, have been tried. It has been shown that the patency rate with autogenous vein graft is higher than with other procedures. The authors have operated on ten patients utilizing autogenous vein valve from the upper extremities to restore a normal functioning venous system of the distal leg. Data on pre- and post-operative, non-invasive, and ascending and descending venography with the results of surgery will be presented and discussed.

External Shunt to Procure and Preserve Venous Endothelium for Arterial Bypass

After the patient is under general or spinal anesthesia, and a routine preparation and drape are done, a longitudinal incision is made in the groin. The common femoral, superficial femoral, and profunda arteries are identified and isolated. A parallel incision is made over the medial aspect of the malleolus to isolate and control the distal saphenous vein. Venotomy is performed, and 5,000 units of heparin are injected. An arteriotomy is performed at the common femoral artery, and a 4 mm internal diameter shunt is inserted.* This tubing is connected to a second one with a side arm and stopcock. The distal portion of the arterial shunt is inserted into the saphenous venotomy incision and secured with a suture (Figure 1). Blood now flows from the common femoral artery, down the external shunt, and into the distal saphenous vein. The saphenofemoral vein is then clamped just distal to its junction. The saphenous vein is then harvested with gentle dissection. The initial blood flow into the saphenous vein is measured, and pressure is obtained. It is apparent that as the division of the

Profundoplasty for the Ischemic Lower Extremity

The profunda femoral artery originates from the common femoral artery below the inguinal ligament (Figure 1). It is usually directed posterolaterally, thus supplying blood to the thigh. More importantly for the purpose of revascularization, the artery forms a number of collateral anastomoses with genicular arteries distally and the hypogastric and lumbar arteries proximally (Figure 2). Stenosis of the profunda artery is usually secondary to atherosclerotic plaque which involves the orifice. Often it is a continuation of the atherosclerotic plaque from the common femoral. As is common in most vessels, the plaque is generally limited to the first few centimeters above and below the bifurcation of the common femoral artery and the superficial and profunda artery. The majority of the plaque is located on the posterior arterial wall.