On the Order and Timing of Venous Interventions

Part of the art and the beauty of venous surgery is tailoring your approach to treatment for each patient who seemingly presents with the same problem. However, like most artistic endeavors, fierce debate and research on the “correct” approach endures.  Should I perform phlebectomy at the same time as the truncal ablation to avoid painful thrombophlebitis? Or should I stage the phlebectomy to minimize procedural pain, time, and potentially the number of stabs after ablation? Worse still, if there is iliac vein compression, should I treat that before I perform the ablation?  Will the patient suffer a catastrophic DVT if I don’t treat this first?  Essentially the same questions I had even as a trainee still have no clear answer, but each practitioner has their camp and defends it with the honor and rigor of a matador.

On one side of the bullring, you have the “always simultaneous phlebectomy with ablation” camp. The bulk of their experience has taught them that if they wait to do the phlebectomy, especially in those patients with large varicose veins, the risk of thrombosis of these varicosities and subsequent patient pain and discomfort, and now necessary delay in removing them, is not worth the risk. After all, most patients come in wanting those uncomfortable and unsightly veins gone, and now they feel worse off.  Quel horreur. All it takes is one unhappy customer to validate this. Alternatively, on the other side of the bullring, the “always stage your phlebectomy” camp, they will opine that they have never seen this complication happen, and most of their patients have regression of some of their varicosities rendering the phlebectomy easier, with fewer stabs and happier patients. A less trivial question on the choice to stent or ablate first in patients with multilevel disease has vexed our community with the implied risk of a venous thromboembolic event. In the “stent first always,” they implore us that it is the safest approach to avoid a potentially catastrophic VTE.  Some go even further to suggest it will improve the venous hemodynamics enough that additional ablation may not be required to achieve symptom relief. The “ablate first always” will parry that the risk of a VTE is extremely low, and in fact, they have never seen one before and perhaps ablation will also obviate the need for stenting : a much more invasive approach,  involving a permanent implant!  Quel horreur.  To paraphrase our former president, there are fine people on both sides.  But most importantly:  what do most patients think and how do they actually do by-and-large with either approach? Serious intellectual rigor has gone into attempting to figure this out and the anti-climactic conclusion thus far; they do just fine.  Olé!

Consensus Emerges:
Drop the Term “Accessory” for the Anterior Saphenous Vein

The American Venous Forum (AVF), the American Vein and Lymphatic Society (AVLS), and the Union International of Phlebology (UIP) have endorsed the findings of an international consensus panel convened to address the terminology surrounding the anterior accessory saphenous vein (AASV). It has long been established that the great saphenous vein (GSV) and small saphenous vein (SSV) are truncal veins given their envelopment in their own fascial compartment.   There has remained, however, confusion surrounding the term “anterior accessory saphenous vein,” resulting in misconceptions regarding its anatomy, clinical significance, and treatment implications.  The term “accessory”’ has perpetuated this misunderstanding about the true nature of this vein and its clinical relevance. This is because accessory implies it is a branch of the GSV and not a true truncal vein in its own right.  

Unfortunately, this lack of clarity has significant implications for patient treatment and long-term outcomes following intervention.  For example, if the anterior accessory saphenous vein is mistakenly considered a branch tributary vein, the need for treatment could be overlooked or the type of treatment provided could be inadequate, leading to the incomplete resolution of the symptoms that led the patient to seek treatment.  Further, this can lead to denied payer coverage, also resulting in the same undesirable outcomes for patients. Properly identifying the vein’s role as a truncal vein is essential in developing an appropriately targeted and effective treatment plan to optimize long-term outcomes.  

This has implications for many patients suffering from chronic venous insufficiency as more than 1 in 5 patients initially presenting for the treatment of superficial venous insufficiency have ASV reflux.  Additionally, the ASV is becoming the most common source of recurrence in patients who have had prior GSV reflux ablation.

The panel considered that it has long been convention in both the terminology literature (which is established by clinicians) and the nomenclature literature (which is established by anatomists) that truncal veins are those enclosed within fascial saphenous compartments that drain extra fascial tributaries and are often the origin of tributary reflux.  In contrast, tributary veins are not enclosed in a fascial envelope and drain into truncal veins from the subcutaneous venous network.  As part of this collaboration, Alberto Caggiati, MD, Professor of Anatomy at the University La Sapienza in Rome, led the review of the anatomical considerations, advocating that the ASV should be recognized as a truncal vein and not a branch tributary given its clear and distinct envelopment in its own fascia in the upper leg.

From this process the panel unanimously suggest the name of the vein be changed from Anterior Accessory Saphenous Vein (AASV) to Anterior Saphenous Vein (ASV) to more accurately reflect its anatomic features and clinical importance.  This collaboration culminated in the simultaneous publication of a series of four manuscripts in Phlebology and the Journal of Vascular Surgery: Venous and Lymphatic Disorders that were endorsed by the sponsoring societies. These publications delve into the anatomy, a systematic review of the literature, evaluation of current payer policies, and explore treatment considerations pertinent to the anterior saphenous vein.

Figure 1:  The saphenous compartment. D: dermis. MF: muscular fascia. SF: saphenous fascia. GSV: great saphenous vein. ASV: anterior saphenous vein.

https://www.jvsvenous.org/article/S2213-333X(24)00145-8/fulltext

Figure 2. https://www.jvsvenous.org/article/S2213-333X(24)00145-8/fulltext

Endovascular Procedures Should Be Conducted in the Office –Or Should They?

In the last two decades there has been a transition in performing vascular procedures from an inpatient setting to an outpatient setting. This largely has been based on venous procedures transitioning from open to minimally invasive procedures. This endovenous revolution started with radiofrequency obliteration of the great saphenous vein, followed by EVLA and the present era of non-tumescent nonthermal technology. Recently, the cost of venous procedures has increased and procedure revenue has decreased, while the income for vascular surgeons practicing in an outpatient setting has remained relatively unchanged.¹ This has affected practitioners in the outpatient setting who are struggling financially to support their practice’s revenue and quality of care.¹ As a result of the challenges faced by vascular surgeons practicing in outpatient settings, practices are closing or being bought out by hospital systems and large companies.

Alternative approaches to support outpatient practice revenue and enhance the quality of care are being explored to address financial circumstances faced by practitioners. Marketing strategies and developing a brand for practices can promote the services offered by practitioners.