Welcome to the Vein Experts Online Educational CME Program. Original Release Date: 10/11/13 Termination Date: 1/31/2016 Price: 25.00 for Vein Experts Members & $40.00 for Non-Members Processing/CME Fees Accreditation:
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of The University of Toledo and VeinExperts.org. The University of Toledo is accredited by ACCME to provide continuing medical education for physicians. The University of Toledo designates this enduring activity for a maximum of 1.00 AMA PRA Category Credits™. Physicians should claim only credit commensurate with the extent of their participation in the activity. For nurses, we are also able to issue a certificate of attendance stating the course is AMA approved, which may be eligible for credit. Nurses are responsible for submitting the certificate to their board. Please note only one certificate can be issued for each purchase.
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Disclosure: Ronald Bush, MD, FACS, faculty and planning member discloses he is on the Speaker’s Bureau for Dornier/Refine USA and is contracted with Water’s Edge Dermatology and Soffer Health. Peggy Bush, APN, planning member, has no disclosures or financial interests and is employed by Midwest Vein & Laser Center. Richard L. Mueller, MD, faculty and planning member, discloses he receives grant/research support from Vascular Insights, LLC Becky Roberts, planning member, has no financial interest or other relationships with any manufacturer of commercial product or service to disclose. Ariel Soffer, MD, FACC, faculty and planning member, discloses he is on the Speaker’s Bureau for Cutera , consults for Angiodynamics, & does research for BTG. Mission: Our objective is to provide current evidence based information, as well as new technology that is being developed for the treatment of venous disease presented in a virtual format. Target Audience: The target audience for this activity includes physicians and other health care professionals in Cardiology, Dermatology, Interventional Radiology, Phlebology, Surgery, Vascular Surgery, Wound Care Specialists who care for patients with venous disease. CME Credit Instructions Steps to successfully complete this activity: CME Credit Instructions Steps to successfully complete this activity: 1. Register for CME activity & pay your CME fees. 2. Read the Vein Journal Chapter 5, entitled ‘Superficial Venous Aneurysms of the Lower Extremity.’Take the post test (score of 80% or greater must be achieved. (A pdf copy of the exam can be emailed to you if requested). 3. Scan and email post test and evaluation to pbush@veinexperts.org or you can fax completed paperwork to 937-281-0200. 4. You will be contacted by the University of Toledo CME office for instruction of how to sign on and print your certificate. !
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Technical Support Email your questions/concerns to pbush@veinexperts.org or you can call us at 407-900-8346 and we will respond in 24 hours. ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !
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! ! ! ! Superficial!Venous!Aneurysms!of!the!Lower!Extremity! ! 9/1/13! ! Ronald!Bush,!MD,!FACS! ! Peggy!Bush,!APN,!CNS,!MSN! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !
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Superficial Venous Aneurysms of the Lower Extremity This activity describes the etiology, treatment, and possible complications of superficial venous aneurysms of the lower extremity. Learning Objectives: As a result of this activity, the participant should be able to:
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Recognize the pattern of superficial venous aneurysms.
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Recognize potential complications based on anatomical locations.
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Identify appropriate treatment, based on location.
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Identify the etiology of venous aneurysms.
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Saphenous aneurysms (GSV, AAGSV, SSV) may be asymptomatic and only found on ultrasound (US) when scanning the leg. Aneurysms can manifest themselves as the source of pulmonary emboli. Aneurysms of the GSV, SSV, and AAGSV have all been documented as sources of pulmonary emboli. 1,2, Just as importantly, a benign condition may become malignant with improper treatment. In this CME chapter, we will examine superficial venous aneurysms from many aspects including histology, classification, presentation, and treatment. There is no concise consensus on the definition of an aneurysm. Pascarella et al., defined an aneurysm as a dilated area of the vein 1.5x the size of the contiguous vein.3 However, this is in actuality the definition for an arterial aneurysm. Strict criteria and consensus should be developed. My personal criteria for aneurysm inclusion is a vein diameter 3x the normal size and 2x the size of the contiguous vein, similar to, but not identical to Gabrielli.4 Histologic evaluations have been done. There is some variability in findings. This confusion may result in including deep venous aneurysms with those of the superficial system. The etiology and histologic findings in deep venous aneurysms is considerably different.
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Findings reveal in most cases a hypertrophied muscle layer and a thickened intima. The internal elastic membrane is usually disrupted and depending on the duration of venous hypertension; the external elastic membrane may also be interrupted
Fig. 1 - Aneurysmal Wall
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Fig. 2 - Desmin Stain
The etiology of venous aneurysm is venous hypertension. More specifically, there can be an aneurysm only at a valve. The exact sequence is not determined, but probably relates to a defective valve with turbulent flow resulting. Gradual asymmetrical focal dilatation occurs. This phenomenon increases with time.
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Figure 3 Figure 3 shows the histology of a varicose vein. These are by definition minor aneurysms. In fact, the histology is the same for the most part. These varicose branches will never be classified as true venous aneurysm due to the fact that they lie outside the axial branch of the GSV, AAGSV, and SSV. These valvular dilatations are rarely 2x the size of the contiguous undilated vein. Valvular dilations of peripheral veins are never 3x the size of the normal saphenous veins, so the criteria are not met. Classification of aneurysms should be changed to include two distinct types at the SFJ and the aneurysms of the AAGSV branch. The two distinct types at the SFJ (Ia and Ib) are related to the terminal and preterminal valve. Aneurysms distal to the terminal valve and proximal to the preterminal valve (junctional branches are involved) should be ligated to prevent the possibility of clot
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propagation and pulmonary emboli. If a very small neck is present, then other modalities can be considered. I have personally used foam in this situation. This anatomical occurrence is rare.
Fig. 4 - Type Ia Aneurysm – Note Wide Neck Present
An aneurysm distal to the preterminal valve may be treated with thermal ablation or foam sclerotherapy (Careful injection of foam at this point with the majority of foam directed distally). It is necessary to keep normal blood flow (by branches) at the SFJ.
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Fig. 5 - Type Ib – Branches Not Involved
Aneurysms of the distal saphenous (Usually at the valve in Hunter’s Canal or in the region of Boyd’s perforator, II) are treated according to distance from the skin. Those very superficial should be removed by invagination stripping or segmental phlebectomy. Segmental removal will require larger than usual incisions. If the aneurysm is deeper, then ablative techniques as normal are appropriate.
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Fig 6 - Type II Aneurysm
Aneurysms involving both the junction and distal GSV (Type III) are treated as described previously based on each aneurysms characteristic proposed classification. Aneurysms of the SSV (IV) are treated according to location. If the SPJ is involved (more commonly) then ligation is necessary. These can mimic popliteal venous aneurysms. Careful and meticulous dissection is necessary.
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Fig 7 - Type IV Aneurysm
If the aneurysm is distal (mid SSV) then thermal ablation or resection is appropriate depending on distance from skin. Recently just described, an aneurysm of the AAGSV may be the source of pulmonary emboli. In our clinic, in a two-year period, I personally treated six patients with aneurysms of the AAGSV. The incidence was less than aneurysms of the GSV, but far greater than those of the SSV. Three of these patients presented with symptomatic thrombosis. The treatment of AAGSV aneurysm depends on the size of the connection to the GSV. For large diameter necks, ligation should be considered. I have also treated those aneurysms with thermal ablation and in one case with no distal AAGSV trunk, foam sclerotherapy. Those previously rarely documented aneurysms should be given the classification V.
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Fig. 8 – AAGSV Aneurysm Conclusion •
Aneurysms of the SFJ are of two types – Treatment depends on relationship to terminal and preterminal valves.
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Aneurysms are related to locations of valves in truncal vessels.
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SSV aneurysms at or close to the SPJ are ligated.
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AAGSV aneurysms frequently present with thromboembolic phenomenon.
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Treat appropriately to prevent complications.
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References Marcucci G, Accrocca F, Antignani P, Siani A. An isolated aneurysm of the thigh anterolateral branch of the greater saphenous vein in a young patient presenting as an inguinal hernia. Interact Cardio Vasc Thorac Surg 2010;10:654-655. Gabrielli R, Rosati S, Vitale S, et al. Pulmonary emboli due to venous aneurysm of extremeties. Eur Jour Vasc Med 2011;40:327-332. Pascarella L, Al-Tuwaijri A, Bergan J, Mekenas L. Lower extremity superficial venous aneurysms. Ann Vasc Surg 2005;19:69-73. Gabrielli R, Rosati M, Siani A, Irace L. Management of symptomatic venous aneurysm. The Scientific World Journal 2012:1-6.
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Complete the exam & evaluation below and email your results to pbush@veinexperts.org along with your contact information. A score of 80% or greater, must be achieved on the post-test and be completed in less than 3 attempts. Exam 1. For aneurysms of the SFJ, treatment depends on a. Size b. Symptoms c. Flow characteristics d. Location in reference to terminal valve 2. AAGSV aneurysms a. Are innocuous b. Associated with thromboembolic phenomenon c. Should always be treated surgically 3. SSV aneurysm at the SPJ a. Mimic popliteal aneurysm in potential complications b. Can be treated with thermal ablation c. Can be easily dissected without injury to the tibial nerve 4. Venous sneurysms are always associated with a. Wall thinning b. Thrombi c. Defective valve d. No symptoms
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Evaluationჼჼ ჼ 1. How well did this activity present the objectives? Excellent
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2. How do you rate the overall usefulness of the online material to meeting your needs? Excellent
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3. How do you rate the overall presentation material? Excellent
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4. Was any commercial bias presented in the material? No
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____________________________________________________ 5. I will be able to change my clinical practice as a result of participating in this activity. Yes
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6. What topics about venous disease would you like to hear about in the future? ____________________________________________________ 7. Additional comments/recommendations: ____________________________________________________ ___________________________________________________
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Contact Information Name & Credentials_______________________________________________ Address ________________________________________________________ Phone Number ___________________________________________________ Email address ___________________________________
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