34 yrs old female with history of varicose vein. 5 years ago she had Radiofrequency ablation (RFA) for the right GSV after recurrent episodes of bleeding. She presented this time with recurrent VV along the lateral aspect of the leg and the anterior thigh associated with brown pigmentation and dry skin around the lower leg. Doppler scan showed ablated GSV, segmental reflux in the superficial femoral vein, incompetent anterior accessory saphenous which was 4 mm in diameter, 3 mm distance from the skin and with tortuous course. There were other tortuous tributaries in the leg.
Q1: What is CEAP class described in this scenario if no history of ulceration?
Q2: What is your management? If you are offering an intervention, please mention an alternative intervention.
Q3: What are the risks you will mention to the patient when offering an intervention. Q4: Can you please support your proposed plan with an evidence?
Thank you for your comments.
Q2: catheter based intervention ( RFA,EVLT, glue, cather directed foam) are all non-suitable options given the turtuousity and superficial location of the vein.
Suitable option for turtuous AASV would be foam sclerotherapy or phlebectomy.
Q4: Evidence that supports superficial ablation in the presence of segmental deep reflux is ESCHAR trial.
Q1: C4a Ep As,d Pr
Q2: based on the given information, It is a symptomatic recurrent VV with superficial and deep system reflux. I will offer the patient option 1; multiple avulsion +/- foam sclerotherapy. option 2; compression therapy.
Q3: bleeding, recurrence, sensory nerve injury, scar, DVT and PE
Q4: the evidences
for ASV intervention
ESVS recommendation 46 class IIa C
ESVS recommendation 47 class IIb C
for recurrent non truncal VV
ESVS recommendation 57 class IIa C
reasonable approach and answer
C4a Ep Asd Pr
after exclude pelvic leak as cause of recurrence the plan of managment is;-
Thermal ablation
US cath guided sclero
Cynoacrylate
With or without phlebectomies
Redo surgery due to tourtousity of veins
Compression
Recurrence, EHIT, skin burn, Eccymosis, allergy, thrombophlebitis, infection is redo surgery
For patients with symptomatic recurrent varicose veins due to saphenous trunk incompetence, endovenous thermal ablation or ultrasound guided foam sclerotherapy with or without phlebectomy should be considered class IIa B
I believe there is a very close resemblance to Dr Abdullah answer
We need to follow the course instructions to avoid copy/paste answers, using AI or pilgrism please (this is very important to take care of)
Q1. C4a Ep Asd Pr
Q2 after exclude pelvic leak as cause of recurrence the plan of managment is;-
Thermal ablation
US cath guided sclero
Cynoacrylate
With or without phlebectomies
Redo surgery due to tourtousity of veins
Compression
Q3. Recurrence, EHIT, skin burn, eccymosis, allergy, thrombophlebitis, infection is redo surgery
Q4
For patients with symptomatic recurrent varicose veins due to saphenous trunk incompetence, endovenous thermal ablation or ultrasound guided foam sclerotherapy with or without phlebectomy should be considered class IIa B
Thanks for your answer
C4b