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ANZSVS Conference 2023
ANZSVS Conference 2023
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VENOUS

Session Program

8:09 am

The overall goal of this paper is to provide a high level, practical approach to managing Venous Outflow Obstruction (VOO) in Australia and New Zealand (ANZ) METHODS A group of vascular surgeons from the ANZSVS with specific interest, training, and experience in the management of VOO were surveyed to assess current local practice. The results were analyzed, and areas of disagreement identified. Following this, the group performed a literature review of consensus guidelines published by leading international organizations focused on management of chronic venous disease, namely the Society for Vascular Surgery (SVS), the American Venous Forum (AVF), the European Society for Vascular Surgery (ESVS), the American Vein and Lymphatic Society (AVLS), the Cardiovascular and Interventional Radiology Society of Europe (CIRSE)and the American Heart Association (AHA). These guidelines were compared against the consensus statements obtained through the surveys to see how they relate to ANZ practice. In addition, selected key papers as well as reviews and meta-analysis on venous stenting were discussed and added to the document. Lastly, a selection of statements with a 100% agreement was voted on and barriers in the guidelines’ applicability identified. SUMMARY OF RECOMMENDATIONS • Patients with a CEAP score 3 or above, a VCSS pain score 2 or above or both, and evidence of > 50% stenosis on venography/CTV/MRV/IVUS should be considered for venous stenting. Level of recommendation IB • Patients undergoing clot removal treatment for acute ilio-femoral DVT, in whom a culprit stenotic lesion has been uncovered, should be considered for venous stenting. Level of recommendation IB • Patients with chronic pelvic pain, deep dyspareunia, post-coital pain affecting quality of life, when other causes have been ruled out, should be considered for venous stenting. Level of recommendation IC • Asymptomatic patients should not be offered venous stenting. Level of recommendation IIIC

8:33 am

OBJECTIVES Post Thrombotic Syndrome (PTS) can cause significant long term sequalae affecting a third of patients following major iliofemoral DVT. With the advent of dedicated venous stents, venous angioplasty and stenting has become a recognised treatment for venous outflow obstruction with low complication rates and high efficacy rates reported in the literature. However, the business model and workflow required to set up a complex DVT service is not well reported, this is what we report. METHODS Data were collected over two years for patients treated for major iliofemoral and inferior vena cava (IVC) deep vein thrombosis (DVT). Information on patient demographics, pattern of disease, procedures, follow up and reinterventions were recorded. Venous stenting was performed under GA and directed by IVUS. Post operative protocol included duplex ultrasound or CT the next day with follow up at 2,6 and 12 weeks then 6 monthly. Those with in-stent stenosis > 50% underwent repeat IVUS and angioplasty as required. RESULTS 22 patients were included. 14 presented with acute major iliofemoral DVT and 7 presented with PTS, 1 presented with IVC atresia. In the acute DVT group (IVC (5) or iliofemoral (9)) thrombolysis was performed in 11 patients and aspiration thrombectomy in 6 patients (3 both). Median acute length of stay was 4 days (range 1 – 31) with a total of 65 venograms performed. Venous stenting was performed in the acute setting in 12 patients and as an elective procedure in 10 patients. A total of 37 stents were placed, average length of lesion covered was 221mm (80mm – 430mm). Overall, there were 34 repeat interventions (venoplasty) in 17 patients of whom 5 patients required repeat interventions within 30 days of stenting. Overall (assisted) patency rate was 90.9% with two stent occlusions both of whom only had profunda femoral vein inflow. CONCLUSION Venous stenting in complex DVT management requires a high degree of vigilance and workload. Detailed follow up is essential as reintervention is common.

8:38 am

Background: Varicose veins surgery is a common elective vascular procedure in the public hospital setting. As it is typically categorised as a lower priority procedure, many patients suffered from prolonged wait times during the COVID-19 outbreak. Latest guidelines recommend endovenous approaches such as radiofrequency or laser ablation, but this still requires significant hospital resources. VenaSealTM is a new non-thermal endovenous closure technique with several advantages including minimal patient discomfort during procedure, no need for tumescent anaesthesia, improved postoperative symptoms, and an increased suitability to perform in the outpatient/clinic setting. The aim of this study was to compare the costs and benefits (closure rate) of VenaSeal™ closure system versus open varicose vein surgery. Methods: This is a retrospective, multi-site study conducted between January 2020 and June 2022 for patients treated for symptomatic varicose veins using the VenaSealTM system in the private outpatient setting. This was compared to average cost of varicose veins stripping and stab avulsions at the local public hospital. Closure rates, procedure wait times and complications were also compared. Results: 90 patients were treated in outpatient rooms with VenaSealTM during the COVID pandemic, at a time of significant strain on hospital resources, resulting in 100% closure of target veins at 4-month follow-up. Outpatient endovenous closure with VenaSealTM was significantly cheaper and had less waiting time than in hospital public surgery. There were no major complications for VenaSealTM treated outpatients (DVT, bleeding, admission to hospital). An in-depth cost-benefit analysis is currently underway. Conclusion: In rooms varicose vein VenaSeal™ closure is a safe and effective alternative to traditional varicose vein surgery and is significantly cheaper with shorter wait times. This is particularly important to provide high quality sustainable surgical care in the setting of the COVID-19 pandemic.

8:43 am

Purpose: Venous leg ulcers (VLU) are a common problem affecting 1 in 300 people over 65 years old. The EVRA RCT suggested that two thirds of patients may have underlying venous insufficiency (varicose veins) and that treating varicose veins improved ulcer healing and reduced recurrence, However, patients with obesity have traditionally been excluded from studies. The aim of this study was to determine the pattern of varicose veins in patients with morbid obesity. Methodology: We conducted a retrospective cross-sectional student on patients with VLU who attended the leg ulcer clinic in a major tertiary metropolitan hospital during 2019. Patients were classified as having morbid obesity with a BMI >=40. Duplex ultrasound findings determined insufficiency of the superficial veins (great or short saphenous vein) and/or deep veins insufficiency. Insufficiency was defined as a measured vein reflux time of > 0.5 seconds. Results: Overall, 156 patients with venous leg ulcers who were included. Median age was 72.7 (ISR 65.0-83.0). There were 41 patients (29.3%) with morbid obesity, mean BMI of 51.1m2 (SD 9.0). Patients with morbid obesity were equally as likely to undergo ultrasound investigation (73.2% vs 75.8%, p.748). There was no difference in the proportion of patients with morbid obesity who had potentially treatable superficial venous incompetence (70.0% vs 78.9%, 0.497). Conclusion: We found no difference in the proportion of patients with venous leg ulcers and morbid obesity that could potentially be treated with endovascular treatment. Further studies are needed to determine if treatment of venous insufficiency in patients with VLU and morbidly obesity translates to improved ulcer healing.

8:48 am

Other Suggested Sessions

Cocktail
21 October 2022 4:30 pm
Federation Ballroom
WELCOME RECEPTION (TICKETED EVENT)

Scientific Session
23 October 2022 9:30 am
Grand Ballroom 2 & 3
AVF/IMAGING
Dr Cameron Robertson, Dr Judy Wang

Speciality Dinner
23 October 2022 6:00 pm
CONFERENCE DINNER (TICKETED EVENT)