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Endothermal Heat-Induced Thrombosis

Historical Background Endothermal ablation techniques used to treat superficial venous reflux, such as endovenous laser ablation (EVLA) and radiofrequency ablation (RFA), use heat to induce endothelial injury. This results in a combination of thrombosis, fibrosis, subsequent vein contracture, and eventual occlusion of the treated vein. As stated, a component of this mechanism involves thrombus formation, which may vary depending on the modality or technique used. The…

New Concepts in the Management of Pulmonary Embolus

Historical Background Demographics Acute pulmonary embolism (PE) continues to be a major cause of morbidity and mortality worldwide. There are approximately 530,000 cases of symptomatic PE, and almost 300,000 deaths each year from acute venous thromboembolisms. The International Cooperative Pulmonary Embolism Registry (ICOPER), a collaboration between 52 European and North American hospitals, was established to better calculate rates of clinical outcomes, such as the reoccurrence of…

Pharmacomechanical Thrombolysis

Historical Background Venous thromboembolism (VTE) remains a significant health problem with over 900,000 new episodes each year in the United States alone. VTE, which comprises both deep venous thrombosis (DVT) and pulmonary embolism (PE), is responsible for up to 300,000 deaths each year and continues to be a leading cause of in-hospital mortality. Postthrombotic syndrome (PTS) is the most common complication of DVT, with 25% to…

Endovenous Placement of Inferior Vena Caval Filters

Historical Background Venous interruption for the prevention of pulmonary embolism (PE) was introduced by Homans in 1934. Although his initial description involved ligation of the femoral vein, surgical techniques soon evolved, focusing on interruption at the level of the inferior vena cava (IVC). Complete ligation of the IVC was performed in 1959, but the resulting cardiovascular complications and venous sequelae led to the development of alternative…

Thromboembolic Disease

Historical Background and Epidemiology of Acute Venous Thromboembolic Disease The incidence of deep venous thrombosis (DVT) ranges from 5 to 9 per 10,000 person-years in the general population, and the incidence of venous thromboembolism (VTE), defined as DVT and pulmonary embolism (PE] combined, is about 14 per 10,000 person-years. This equates to more than 275,000 new cases of VTE per year in the United States, with…

Endovenous Approach to Recurrent Varicose Veins

Historical Background Recurrence rates of varicose veins of 20% are common, with rates as high as 70% at 10 years. Up to 25% of procedures for varicose veins are performed for recurrent disease, thus placing considerable demands on health care resources. Note that recurrent varicose vein surgery carries a much greater morbidity risk to the patient than primary surgery. This risk seems to be reduced with…

Treatment of Varicosed Tributary Veins

Historical Background Ambulatory phlebectomy (AP) is a minor surgical procedure designed to remove varicose vein clusters located close to the skin surface. Originally performed in ancient Rome, the technique was published by Robert Muller in 1966. In many office-based, venous surgery practices in the United States, AP is performed with the use of local tumescent anesthesia. The six basic features of the technique are as follows:…

Treatment of Perforating Veins

Historical Background Although the role of perforator veins (PVs) in the development of signs and symptoms remains unclear, the number of incompetent PVs and the size of both competent and incompetent PVs have been shown to increase with worsening chronic venous disease (CVD). Furthermore, it was recently reported that the duration of outward flow in these veins was longer in patients with ulcers compared with those…

Nonthermal Ablation of Saphenous Reflux

All endovenous technologies can be classified under two general categories: thermal tumescent (TT) or nonthermal nontumescent (NTNT). The TT technologies include radiofrequency, laser, and steam. NTNT technologies encompass: mechanical occlusion chemically assisted (MOCA), cyanoacrylate closure (CAC), and polidocanol injectable microfoam (PIM), with others emerging. These newer NTNT technologies have some real-world advantages: minimal nerve or skin injury, safety when treating disease to the ankle, decreased patient…

Laser Thermal Ablation: Current Data

Historical Background Endovenous laser ablation (EVLA) therapy arose from a background of managing refluxing truncal veins using open surgical techniques, such as stripping with high ligation. The technology was first introduced in 1999, and following US Food and Drug Administration approval for commercial use in 2002, has exhibited exponential growth in use. This is, in part, because of the ability to perform this endothermal ablation technique…

Radiofrequency Thermal Ablation: Current Data

Historical Background Investigators in the 1960s and 1970s observed third-degree skin burns and saphenous nerve injuries after thermal ablation of the saphenous vein. Low-wattage, bipolar current, and specific electrode designs, coupled with algorithms governed by frequent sampling of wall temperature and impedance, were expected to mitigate thermal damage to adjacent tissues. The use of bipolar electrodes, which concentrate current density along minimal impedance paths between the…

Endovenous Thermal Ablation of Saphenous Reflux

Historical Background Treatment of this disorder has evolved from sclerotherapy to open radical surgery and then to the use of sophisticated technology, such as thermal and nonthermal catheter-based ablation. The exact historical point in time when saphenous vein incompetence was recognized as a source of venous hypertension is unclear; however, Trendelenburg promulgated saphenofemoral ligation in 1891. In the early 20th century, stripping of the saphenous veins…

Venous Diagnostic Tools

Historical Background Of the 25 million Americans with venous disease, approximately 7 million exhibit serious symptoms such as edema, skin changes, and venous ulcers. One million seek formal medical advice annually. Diagnostic testing is used to identify, grade, and follow venous insufficiency and to define deep venous thrombosis (DVT). Because more patients will be presenting for therapy as a result of improved outcomes with endovenous techniques…

Venous Pathophysiology

Etiology and Natural History of Disease Primary Venous Disease Primary venous disease affects two-thirds of patients with chronic venous disease (CVD). The most accepted theory is based on increased venous hydrostatic pressure transmitted to the vein wall, causing smooth muscle relaxation, endothelial damage, and extracellular matrix degradation with subsequent vein wall weakening and wall dilatation. It has also been suggested that valve damage may occur because…

Venous Hemodynamics

Volume-Pressure Curve The volume-pressure (V-P) curve is central to venous hemodynamics. Its effect is manifest in many aspects of venous function. Because veins are thin-walled collapsible tubes, the V-P curve is governed by the Tube law, which is displayed in Fig. 2.1 . The curve is sigmoid. The functionally relevant parts are the horizontal and terminal vertical limbs in the physiologic pressure range of 5 to…

Venous Anatomy

Historical Background Chronic venous diseases include a spectrum of clinical findings ranging from spider telangiectasias and varicose veins to debilitating venous ulceration. Varicose veins without skin changes are present in about 20% of the general population, and they are slightly more frequent in women. References to varicose veins are found in early Egyptian and Greek writings and confirm that venous disease was recognized in ancient times.…

Preoperative Optimization of the Hernia Patient

1 Introduction ▴ Patients presenting for elective hernia repair often possess risk factors for wound morbidity and hernia recurrence that the surgeon cannot mend. Defect size, age, multiplicity of recurrences, and the presence of an ostomy or infected prosthetic are intrinsic variables for which little can be done between the preoperative assessment and operative date. However, certain risk factors are malleable and warrant close investigation in…

Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair

1 Clinical Anatomy ▴ The preperitoneal plane lies between the peritoneum and the posterior lamina of the transversalis fascia. There are two spaces that are of particular interest in the laparoscopic repair of inguinal hernias: the space of Retzius, the most medial of which lies superior to the bladder, and the space of Bogros, which is a lateral extension of the space of Retzius that extends…

Transabdominal Preperitoneal Inguinal Hernia Repair

1 Clinical Anatomy ▴ Inguinal anatomy is notoriously challenging for the most experienced surgeon. The presence of major neurovascular structures in the retroperitoneum can make safe dissection challenging, particularly for the novice surgeon. ▴ This chapter provides a stepwise approach to dissecting an inguinal hernia during laparoscopic repair that provides careful identification and preservation of key anatomic structures during laparoscopic inguinal hernia surgery. ▴ The exact…

Repair of Post-TRAM Bulges and Hernias

The transverse rectus abdominis musculocutaneous (TRAM) flap is a popular option for breast reconstruction. As an autogenous flap, TRAM flap breast reconstruction eliminates the risk of implant-related complications, provides soft tissue that mimics a natural breast, and provides a favorable abdominal wall contour at the flap donor site. However, pedicled or free TRAM flaps have a donor site morbidity of bulging or hernia with a frequency…