By: Paul M. McNeill, MD, FACS Visit VeinGlobal at http://www.veinglobal.com/ for more presentations and videos on this topic, or for more information on venous disease news, education and research.

1. Paul M. McNeill, MD FACS
Capitol Vein and Laser Center
Bethesda, Maryland
Frederick, Maryland

2. Does All Saphenous Reflux Need Ablation?
 Who will benefit
from ablation?
 When ablation is
best deferred?
 Sound treatment
algorithms consider
a range of options
for patient care

3. Does All Saphenous Reflux Need
Ablation?
 What is the natural history of venous reflux?
 Are there anatomic differences in saphenous reflux?
 What affects progression of disease?
 What are the risks of treatment of reflux?
 What are the risks of observation?
 Does observation have a role in every CEAP Class?

4. Saphenous Vein Reflux

5. Saphenofemoral Junction Variation

6. Does All Saphenous Reflux Need Ablation?
 Anatomy of Saphenous
Reflux
 Associated SFJ reflux
 Competent Terminal
Valve
 Proximal source
 GSV above knee
 GSV below knee
 GSV above + below knee

7. Does All Saphenous Reflux Need Ablation?
Reflux patterns should be considered
 Reflux patterns and risk factors in Primary
Varicose Veins’ Clinical Severity. Phlebology
2011;28:153-161
 GSV reflux associated with SFJ incompetence
 more likely to be associated with C4-6
 GSV reflux with a competent SFJ
 More likely associated with C1-3
 GSV reflux above and below the knee is more likely to be
associated with C4-6 disease

8. Does All Saphenous Reflux Need Ablation?
Reflux patterns and progression of disease
 Progression of reflux patterns in saphenous veins
of women with chronic venous valvular
insufficiency. Phlebology 2012;27:25-32
 Stable reflux pattern was common with initial
segmental reflux not affecting the SFJ and not extending
to the ankle

9. Great Saphenous Vein

10. Great Saphenous Vein

11. Does All Saphenous Reflux Need Ablation?
 Anatomy of Saphenous
Reflux
 What is the status of the
deep system at the time
of presentation?
 Progression of disease
may be more likely in
the face of deep vein
reflux

12. Does All Saphenous Reflux Need Ablation?
C1 Telangiectasia
C2 Varicose Veins
C3 Edema
C4 Skin Changes
C5 Healed Ulcer
C6 Active Ulcer
CA,S Symptoms

13. CEAP 1 and Saphenous Ablation?

14. Does All Saphenous Reflux Need Ablation?
Weak association: telangiectasia and
Saphenous reflux.
 Ruckely et al. Telangiectasia and venous reflux in the
Edinburgh Study. Phlebology 2012;27:297-302
 Little evidence to support saphenous
ablation prior to treating
telangiectasia

15. Mixed CEAP 2 and 1

16. C2 Observation
 80F, varicose veins
 GSV reflux
 Asymptomatic
 Urged by others to
be evaluated
 Observe!

17. C3 Observation
 GSV Reflux and mild
edema
 Mild discomfort
 Inactive
 Non compliant with hose
 Fairly stable clinical
course

18. Observation of C4 disease

19. Observation of C5 disease
 Segmental reflux
 Prior vein surgery
 SFJ ligation and partial
stripping
 DVT
 Stable
 Co-morbid conditions

20. Observation of C6 disease
 Consider the high risk
patient
 Immobile and infirm
patient
 Morbid obesity and no
clear cut venous
symptoms
 Multiple issues
 Adjunct measures

21. Does All Saphenous Reflux Need Ablation?
 Patients can come in seeking treatment they
believe they need
 Article: The relative impact on leg symptoms of
fears of getting varicose veins and of Great
saphenous vein reflux. Phlebology 2013; 28:347-352
 Healthy patients with fears of getting varicose veins
experience feelings of leg swelling and heaviness

22. Does All Saphenous Reflux Need Ablation?
 Patients can present with other etiologies for leg
pain and swelling – particularly
 Knee pain
 Muscle soreness
 Lipemia – not edema
 Obesity related symptoms
 Fibromyalgia
 Develop a plan
 Observe the reflux
 Improve health parameters
 Orthopedic or Other evaluation

23. Does All Saphenous Reflux Need Ablation?
 Lifestyle Factors
 Physical activity
 Travel - remote
 Family Planning
 Symptoms
 Occupational hazards
 Travel
 Long commute
 Standing
 Physical labor

24. Does All Saphenous Reflux Need Ablation?
 Lifestyle Factors
 Physical activity
 Travel - remote
 Family Planning
 Symptoms
 Conversely
 Sedentary
 Home bound
 Medical issues
 Occupational hazards
 Travel
 Long commute
 Standing
 Physical labor
 Conversely
 Retired
 Sedentary
 Content

25. Saphenous Reflux That Needs Ablation?

26. Summary
 Saphenous Reflux Observation
 Asymptomatic or stable disease C1-6
 Anatomy of the reflux is considered
 Infirm or clinically content patient
 Alternative explanation for symptoms
 Low likelihood of benefit
 Saphenous Vein Ablation
 Symptomatic disease
 Extensive reflux
 Medical and lifestyle benefit

27. Does All Saphenous Reflux Need Ablation?
 Expertise in vein care
extends beyond our
technical skills
 Patients respect your
credentials
 Admiration for a
discerning physician
who considers a range of
therapeutic options best
suited to the patient

28. Thank you
Paul M McNeill, MD FACS