ASVAL Can Save Refluxing Saphenous Veins

Ambulatory selective varicose vein ablation under local anesthesia (ASVAL) can abolish reflux while preserving the great saphenous vein, and benefits can last at least a decade, said Dr. Silvain Chastanet, who helped create the technique and will discuss it Thursday morning.

Historically, a refluxing great saphenous vein was treated by removing it. The ASVAL method preserves the vein by using microphlebotomy to instead remove the varicose reservoir, said Dr. Chastanet of the Riviera Vein Institute in Monaco. “Because each patient is different, this strategy offers tailored, à la carte treatment, as opposed to systematic ablation,” he said. “Doing precise and thorough microphlebectomies is not as simple as one might think, but we will share tips and tricks for performing saphenous sparing venous surgery in an easy and elegant way.”

Dr. Chastanet recently evaluated more than 300 saphenous-sparing ASVAL procedures at his institute and found that 10 years later, 64% of patients remained reflux free, 70% continued to have symptomatic relief, and 66% remained improved cosmetically. Notably, fewer than 1 in 10 patients needed repeat phlebectomy or ablation.

The ASVAL technique is based on the premise that reflux usually ascends from the tributaries toward the saphenous trunk, rather than following the opposite path, said Dr. Chastanet. Although the ascending pattern is not universal, increasing evidence suggests that it is most common. For example, a study of more than 700 consecutive patients with chronic venous disease showed that patients of CEAP category C4-C6 had significantly greater involvement of the saphenofemoral junction and saphenopopliteal trunk than patients with less advanced venous disease. The authors concluded that reflux usually ascends up from the tributaries and accessory saphenous veins (J Vasc Surg. 2010;51(1):96-103).

Thus, when evaluating a patient with saphenous reflux, surgeons should always ask whether they can spare the great saphenous vein, Dr. Chastanet said. Evidence indicates that if the patient is classified as C2 (varicose veins) and the great saphenous vein is dilated less than 10 mm, ASVAL may be a valid option, especially if reflux is localized above the knee, with the varices localized to the thigh.

Techniques such as ASVAL are a major advance, but questions persist about surgically treating varicose disease, Dr. Chastanet noted. For example, although ascending disease appears to be most common, it can convert to descending disease or patients can have a refluxing saphenous trunk without tributaries. “We still do not know which patients are likely to have descending or ascending disease, and why,” Dr. Chastanet said. Likewise, experts continue to debate whether phlebectomy should be performed together with saphenous ablation. “Considering that some varicosities will disappear after endothermal ablation of the saphenous vein, some surgeons consider concomitant phlebectomy to be overtreatment,” Dr. Chastenet noted. “Conversely, if we consider that the disease begins at the tributary level according to the ascending theory, it seems obvious to focus treatment on the varicose tributaries, which are the main concern for the majority of patients.”

Bringing techniques such as ASVAL into community practice involves practical challenges, too. Microphlebectomy is “clearly” the best cosmetic option, but is not taught during surgical or phlebology training, Dr. Chastanet said. “There is a need to develop new tools for treating the varicose tributaries in an easier and faster way.” Such advances could help transition procedures such as ASVAL to outpatient settings, which is not now the norm in most countries, he noted. “Using local anesthesia, mini-invasive surgical procedures with immediate ambulation will enable us to reach this goal.”

Session 63
“Venous Clinical Examination and Hemodynamics”
Thursday 8:13 a.m. – 8:18 a.m.
Trianon Ballroom, 3rd Floor

Ambulatory selective varicose vein ablation under local anesthesia (ASVAL) can abolish reflux while preserving the great saphenous vein, and benefits can last at least a decade, said Dr. Silvain Chastanet, who helped create the technique and will discuss it Thursday morning.

Historically, a refluxing great saphenous vein was treated by removing it. The ASVAL method preserves the vein by using microphlebotomy to instead remove the varicose reservoir, said Dr. Chastanet of the Riviera Vein Institute in Monaco. “Because each patient is different, this strategy offers tailored, à la carte treatment, as opposed to systematic ablation,” he said. “Doing precise and thorough microphlebectomies is not as simple as one might think, but we will share tips and tricks for performing saphenous sparing venous surgery in an easy and elegant way.”

Dr. Chastanet recently evaluated more than 300 saphenous-sparing ASVAL procedures at his institute and found that 10 years later, 64% of patients remained reflux free, 70% continued to have symptomatic relief, and 66% remained improved cosmetically. Notably, fewer than 1 in 10 patients needed repeat phlebectomy or ablation.

The ASVAL technique is based on the premise that reflux usually ascends from the tributaries toward the saphenous trunk, rather than following the opposite path, said Dr. Chastanet. Although the ascending pattern is not universal, increasing evidence suggests that it is most common. For example, a study of more than 700 consecutive patients with chronic venous disease showed that patients of CEAP category C4-C6 had significantly greater involvement of the saphenofemoral junction and saphenopopliteal trunk than patients with less advanced venous disease. The authors concluded that reflux usually ascends up from the tributaries and accessory saphenous veins (J Vasc Surg. 2010;51(1):96-103).

Thus, when evaluating a patient with saphenous reflux, surgeons should always ask whether they can spare the great saphenous vein, Dr. Chastanet said. Evidence indicates that if the patient is classified as C2 (varicose veins) and the great saphenous vein is dilated less than 10 mm, ASVAL may be a valid option, especially if reflux is localized above the knee, with the varices localized to the thigh.

Techniques such as ASVAL are a major advance, but questions persist about surgically treating varicose disease, Dr. Chastanet noted. For example, although ascending disease appears to be most common, it can convert to descending disease or patients can have a refluxing saphenous trunk without tributaries. “We still do not know which patients are likely to have descending or ascending disease, and why,” Dr. Chastanet said. Likewise, experts continue to debate whether phlebectomy should be performed together with saphenous ablation. “Considering that some varicosities will disappear after endothermal ablation of the saphenous vein, some surgeons consider concomitant phlebectomy to be overtreatment,” Dr. Chastenet noted. “Conversely, if we consider that the disease begins at the tributary level according to the ascending theory, it seems obvious to focus treatment on the varicose tributaries, which are the main concern for the majority of patients.”

Bringing techniques such as ASVAL into community practice involves practical challenges, too. Microphlebectomy is “clearly” the best cosmetic option, but is not taught during surgical or phlebology training, Dr. Chastanet said. “There is a need to develop new tools for treating the varicose tributaries in an easier and faster way.” Such advances could help transition procedures such as ASVAL to outpatient settings, which is not now the norm in most countries, he noted. “Using local anesthesia, mini-invasive surgical procedures with immediate ambulation will enable us to reach this goal.”

Session 63
“Venous Clinical Examination and Hemodynamics”
Thursday 8:13 a.m. – 8:18 a.m.
Trianon Ballroom, 3rd Floor

Ambulatory selective varicose vein ablation under local anesthesia (ASVAL) can abolish reflux while preserving the great saphenous vein, and benefits can last at least a decade, said Dr. Silvain Chastanet, who helped create the technique and will discuss it Thursday morning.

Historically, a refluxing great saphenous vein was treated by removing it. The ASVAL method preserves the vein by using microphlebotomy to instead remove the varicose reservoir, said Dr. Chastanet of the Riviera Vein Institute in Monaco. “Because each patient is different, this strategy offers tailored, à la carte treatment, as opposed to systematic ablation,” he said. “Doing precise and thorough microphlebectomies is not as simple as one might think, but we will share tips and tricks for performing saphenous sparing venous surgery in an easy and elegant way.”

Dr. Chastanet recently evaluated more than 300 saphenous-sparing ASVAL procedures at his institute and found that 10 years later, 64% of patients remained reflux free, 70% continued to have symptomatic relief, and 66% remained improved cosmetically. Notably, fewer than 1 in 10 patients needed repeat phlebectomy or ablation.

The ASVAL technique is based on the premise that reflux usually ascends from the tributaries toward the saphenous trunk, rather than following the opposite path, said Dr. Chastanet. Although the ascending pattern is not universal, increasing evidence suggests that it is most common. For example, a study of more than 700 consecutive patients with chronic venous disease showed that patients of CEAP category C4-C6 had significantly greater involvement of the saphenofemoral junction and saphenopopliteal trunk than patients with less advanced venous disease. The authors concluded that reflux usually ascends up from the tributaries and accessory saphenous veins (J Vasc Surg. 2010;51(1):96-103).

Thus, when evaluating a patient with saphenous reflux, surgeons should always ask whether they can spare the great saphenous vein, Dr. Chastanet said. Evidence indicates that if the patient is classified as C2 (varicose veins) and the great saphenous vein is dilated less than 10 mm, ASVAL may be a valid option, especially if reflux is localized above the knee, with the varices localized to the thigh.

Techniques such as ASVAL are a major advance, but questions persist about surgically treating varicose disease, Dr. Chastanet noted. For example, although ascending disease appears to be most common, it can convert to descending disease or patients can have a refluxing saphenous trunk without tributaries. “We still do not know which patients are likely to have descending or ascending disease, and why,” Dr. Chastanet said. Likewise, experts continue to debate whether phlebectomy should be performed together with saphenous ablation. “Considering that some varicosities will disappear after endothermal ablation of the saphenous vein, some surgeons consider concomitant phlebectomy to be overtreatment,” Dr. Chastenet noted. “Conversely, if we consider that the disease begins at the tributary level according to the ascending theory, it seems obvious to focus treatment on the varicose tributaries, which are the main concern for the majority of patients.”

Bringing techniques such as ASVAL into community practice involves practical challenges, too. Microphlebectomy is “clearly” the best cosmetic option, but is not taught during surgical or phlebology training, Dr. Chastanet said. “There is a need to develop new tools for treating the varicose tributaries in an easier and faster way.” Such advances could help transition procedures such as ASVAL to outpatient settings, which is not now the norm in most countries, he noted. “Using local anesthesia, mini-invasive surgical procedures with immediate ambulation will enable us to reach this goal.”

Session 63
“Venous Clinical Examination and Hemodynamics”
Thursday 8:13 a.m. – 8:18 a.m.
Trianon Ballroom, 3rd Floor