V I U R E V I E W. T h e O f f i c i a l J o u r n a l o f V e n o u s I n s u f f i c i e n c y U n i v e r s i t y

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1 C o m p l i m e n t s o f S a n j i v L a k h a n p a l, M D, J a i m e M a r q u e z, M D, J e r r i l y n J u t t o n, M D, K e l l y O ' D o n n e l l, M D, R a j i v J h a v e r i, M D, L u i s A. D i b o s, M D, T h o m a s C. M i l i t a n o, M D, A r v i n d N a r a s i m h a n, M D, F r a n k S b r o c c o, M D, a n d S h e k e e b S u f i a n, M D V I U R E V I E W T h e O f f i c i a l J o u r n a l o f V e n o u s I n s u f f i c i e n c y U n i v e r s i t y Volume 2, Issue 2 Locations Annapolis, MD Baltimore/Towson, MD Easton, MD Greenbelt, MD Prince Frederick, MD Rockville, MD Takoma Park, MD Waldorf, MD Washington, DC Phone: VEIN (8346) or I N T H I S I S S U E The Importance of Ultrasound During and After Treatment 1-2 T h e I m p o r t a n c e o f U l t r a s o u n d D u r i n g a n d A f t e r Tr e a t m e n t In the last edition of VIU Review, we offered an overview of how ultrasound is a key imaging modality for evaluation of the venous system as it is used to map the anatomy as well as the reflux pathways. A complete venous ultrasound exam is performed to detect if the valves that keep blood flowing back to the heart in the right direction may be damaged (venous reflux), and to rule out deep vein thrombosis (DVT), a condition in which a blood clot forms in a main vein that returns blood flow from the extremities back to the heart and lungs. The ultrasound exam, which includes imaging, compression maneuvers and Doppler analysis, also helps to determine if the patient is a candidate for endovenous ablation therapy. Venous disorders are common medical problems that are associated with multiple symptoms of varying degrees. Many patients seek treatment because the varicosities are cosmetically discomforting but they also frequently experience aching pain, night cramps, heaviness, pressure, swelling and skin changes. If left untreated, most people with chronic venous reflux and varicose veins will eventually develop skin changes and swelling, with some progressing to venous ulceration, says Shekeeb Sufian, MD. T o page 2 Local CME Events: The Diagnostic & Therapeutic Principles of Venous Disease Sclerotherapy The Method of Choice for Treatment of Spider Veins 1 3 Ultrasound of Saphenofemoral Junction L o c a l C M E E v e n t s : T h e D i a g n o s t i c & T h e r a p e u t i c P r i n c i p l e s o f V e n o u s D i s e a s e COMMENTARY: Advancing Standards of Care for Patients with Venous Disorders 3-4 In one evening, you can enhance your understanding of the most current diagnostic and treatment options available to your patients suffering from venous disease. The physicians and allied health professionals of Venous Insufficiency University (VIU) provide a comprehensive program which includes a broad spectrum of treatment options for superficial and deep venous disorders. Physicians and clinical health care providers also earn up to 2.5 prescribed CME credits at no charge while learning what s new for their at-risk patients. RSVP call Bob Howell, MS at or bob@centerforvein.com. CALENDAR OF EVENTS Join us at a complimentary VIU event near you: June 10, 2009 Portofino Ristorante Italiano Easton, Maryland August 27, 2009 Les Follies Brasserie Restaurant Annapolis, Maryland Events begin at 6:00 p.m. To register or for details, contact Bob Howell, MS at or bob@centerforvein.com. Mark your calendar to attend the next VIU event nearest you!

2 V I U R E V I E W Page 2 T h e I m p o r t a n c e o f U l t r a s o u n d D u r i n g a n d A f t e r Tr e a t m e n t Continued from Page 1 In the past, treatment required surgical ligation and stripping of the vein but new treatment methods such as endovenous ablation use a tiny catheter rather than surgery. In addition to being invaluable for pretreatment assessment, ultrasound is used for guidance during endovenous ablation and for follow-up exams. At the Center for Vein Restoration, we couple our knowledge of the deep and superficial venous system with today s advanced ultrasound technology to produce optimal clinical results. The Role of Ultrasound in Endovenous Ablation There are two main techniques used for endovenous ablation both result in a non-thrombotic vein occlusion by heating of the vein wall. The first utilizes a radiofrequency (RF) device to heat the vein wall and seal it closed. This device uses a catheter with retractable electrodes to deliver the RF energy, and these electrodes come in varying sizes to best match vein diameter. The second technique uses a tiny catheter with a laser to heat and contract the collagen within the vein walls and cause the shrinkage and collapse of the vessel. The body automatically re-routes blood flow through healthier veins, and the restoration of normal circulation relieves the distention of the surface veins. The ablated vein becomes scar tissue and is eventually absorbed by the body. The goal of treatment is to heat and seal diseased veins and to address the underlying cause of venous reflux disease. While the greater saphenous vein is the most common vessel involved with reflux, the offending vein may also be a tributary, abnormal perforators or the small saphenous vein. Any of these vessels can be treated with endovenous ablation techniques using ultrasound guidance. Ultrasound assisted vascular access is used to locate the greater saphenous vein or other vessel to be ablated, and to find a straight segment in a superficial location. The vessel is also evaluated with ultrasound for size, distance from the skin line, and tortuosity. The next important role of ultrasound is to guide the application of tumescent anesthesia into the tissue surrounding the length of the vein to be treated. Continued imaging guides the pathway and facilitates maneuvering of the catheter through venous segments and vessel narrowings. Ultrasound demonstrating vein has been successfully closed following endovenous ablation Follow-up Care Endovenous ablation treatments have the advantage of being minimally invasive with fewer complications, reduced recovery time and decreased cost compared to surgery. Following the procedure patients wear support stockings for at least one week, and while vigorous athletic activity is delayed, walking is encouraged with resumption of normal activities. In general, patients return for a follow-up exam 72 hours post-ablation and at this time, post-treatment ultrasound studies are used to check for DVT, confirm resolution of the reflux and successful obliteration of the treated vein. Follow-up exams at three, six and twelve months will demonstrate progressive shrinking of the treated vein and after a year or more, the vein may no longer be detectable by ultrasound. Call VEIN or to schedule a consultation and state-of-the-art ultrasound examination at the Center for Vein Restoration. Ultrasound demonstrating endovenous ablation by use of laser technology

3 Page 3 V o l u m e 2, I s s u e 2 S c l e r o t h e r a p y T h e M e t h o d o f C h o i c e f o r Tr e a t m e n t o f S p i d e r V e i n s Sclerotherapy is the practice of injecting caustic agents, sclerosants, into unwanted veins both large and small to induce closure and eventual resorption. Small vessel sclerotherapy (veins less than 3mm) is primarily cosmetic, but these unsightly veins sometimes produce symptoms of itching and throbbing. Treatment of the small veins is not reimbursable through insurance in either case. Osmotic agents including hypertonic saline and glycerin are frequently employed for vessels 1mm and smaller. Hypertonic saline has the disadvantage of stinging on injection and its ulceragenic potential if accidently injected extravascularly. It is a favorite of some sclerotherapists, however, as it is very effective and reproducible. In addition, hypertonic saline has no allergic potential. Glycerin is painless on injection and also very effective. A second class of sclerosants include polidocanol and sodium tetradecyl sulfate (STS.), the nonionic detergents. Polidocinol is commonly used in the U.S. and elsewhere, but is not currently FDA approved. It rarely produces allergies, is painless, and seldom leads to direct contact ulceration. STS is more allergenic and produces ulceration as lower concentration than polidocinol, but is much less ulceragenic than hypertonic saline. Dilute concentrations of either nonionic detergent may be utilized for eradication of the smallest vessels. Higher concentrations of detergent can be combined with air and agitated to create a foam the consistency of shaving cream. The infusion of foam can be directed to deeper refluxing vessels using ultrasound guidance. Duplex imaging is invaluable but not foolproof as it produces a two-dimensional view. The intravascular migration of foam can usually be visualized, however. Sclerotherapy is tedious and technique dependent. There is no treatment regimen that will be effective on every patient and efficacy of any given treatment may vary in different sites on the same patient. All of the agents described are effective in various concentrations depending on the size of the vessel. Although no magic formula exists, it is recommended to start with more dilute concentrations and evaluate for effect to minimize the potential complications of ulceration and hyperpigmentation. Most agree that optimization of results depends on post-injection compression, but there is no consensus on how much or the optimal duration. Recommendations vary greatly and range from several days to 4 weeks. In general, smaller vessels require less compression for shorter duration. Better results are obtained on larger vessels if the vein is evacuated prior to injection using positioning of the leg above the heart and maintaining significant compression to prevent refill of the vessel. C O M M E N TA R Y : A d v a n c i n g S t a n d a r d s o f C a r e f o r P a t i e n t s Continued from Page 4 In patients with low CEAP classification grades, and no large areas of spider and reticular veins, we do not offer venous ablation therapy. These patients should be treated with sclerotherapy and compression stockings only, however we always recommend a duplex study to determine if patients have any reflux. There has been a significant increase in office practice for venous disease in the past few years as many healthcare practitioners have recognized the benefits of a dedicated venous practice. At The Center for Vein Restoration, our assessment and treatment techniques are unique as they consist of a continuum of care approach, and a commitment to raising and upholding the standard of care for others to follow. Sanjiv Lakhanpal, MD is the Founder of Center for Vein Restoration.

4 VIU REVIEW The Official Journal Of Venous Insufficiency University 7500 Hanover Parkway Suite 103B Greenbelt, MD Phone: VEIN (8346) or Additional locations: Annapolis, MD Baltimore/Towson, MD Easton, MD Prince Frederick, MD Rockville, MD Takoma Park, MD Waldorf, MD Washington, DC C O M M E N TA R Y : A d v a n c i n g S t a n d a r d s o f C a r e f o r P a t i e n t s w i t h V e n o u s D i s o r d e r s The evaluation and treatment methods available today for venous disorders offer patients a level of diagnostic specificity and consequent therapeutic safety that was unattainable just a few years ago. However, regardless of which treatment modality is used, its success depends in part on careful assessment of the problem by a highly-trained, knowledgeable venous specialist. Sanjiv Lakhanpal, MD One of the many factors distinguishing the Center for Vein Restoration from other practices is the training and experience of our physicians. As cardiovascular surgeons with specialized training in venous disorders, we have an in-depth understanding of the cardiac, arterial, venous and lymphatic systems. In addition, we all have demonstrated expertise in treating these intricately related body systems. As a result, we are able to provide comprehensive care to our patients that includes thorough evaluation, early diagnosis, and appropriate selection of the treatment modality whether non-invasive, minimally invasive or a traditional open surgical option for both acute and chronic venous disease. What does our background in cardiovascular surgery mean for our patients at Center for Vein Restoration? It means that above and beyond our ability to deliver excellent results, we use the most stringent criteria to label a vein as insufficient. Having worshipped saphenous veins all of our lives, we take vein ablations very seriously. To further elucidate this point, while most authorities would consider a reflux duration of 0.5 seconds as significant reflux, we would typically wait for a reflux time of one second before offering vein ablation to the patient. Of course, if the vein size is greater than 6mm or the patient has advanced CEAP presentation, this is also taken into consideration. T o page 3

5 C E N T E R FO R V E I N R E STO R AT I O N M e e t O u r P h y s i c i a n s Named Top Doctor" by Washingtonian Magazine, Baltimore Magazine and What's Up Annapolis Local and national media experts on health issues including varicose veins and venous insufficiency Sanjiv Lakhanpal, MD, FACS Board Certified in General Surgery and Cardiovascular & Thoracic Surgery A Member of the Medical Staff at Washington Hospital Center Former Director of Minimally Invasive Cardiac Surgery at Washington Adventist Hospital Former Director of Cardiac Surgery at Prince George s Hospital Center National Media Spokesperson on Vein and Cardiovascular Care Founder of Center for Vein Restoration Jaime F. Marquez, MD, FACS, PA Board Certified in Surgery, Thoracic Surgery, and Cardiovascular & Thoracic Surgery with Extended Studies in Non-Invasive Vascular Surgery Recognized by Washingtonian Magazine as Top Doctor in Cardiovascular Care Expertise in Sclerotherapy Jerrilyn M. Jutton, MD, FACS Board Certified in General Surgery A Member of the Anne Arundel Medical Center Medical Staff Former Chief of Surgery at Anne Arundel Medical Center National Recognition for Surgical Expertise Luis A. Dibos, MD, FACS Board Certified in General Surgery and Cardiothoracic Surgery A Member of the Union Memorial Hospital Medical Staff since 1996 Extensive Training at the Cleveland Clinic Foundation in Re-operative Cardiac Surgery, Valve Repair and Ventricular Assist Devices Specialization in Minimally-Invasive and Beating Heart Surgery Recognized as Top Doctor by Baltimore Magazine Rajiv Jhaveri, MD, MBA Board Certified Physician A Member of the Washington Hospital Center Medical Staff Widely Published for Expertise in Anesthesia, Transplantation, Cardiac, Thoracic and Vascular Care -over, please- Phone: VEIN (8346) or visit

6 C E N T E R FO R V E I N R E STO R AT I O N Thomas C. Militano, MD, FACS Board Certified Cardiothoracic and Vascular Surgeon Chairman and Medical Director, Department of Surgery, Washington Adventist Hospital A Member of the Medical Staff at Washington Hospital Center Selected as one of America s Top Doctor s in 2004 Formerly Chief of Division of Cardiothoracic and Vascular Surgery, Washington Adventist Hospital Shekeeb Sufian, MD, FACS Board Certified and Re-Certified in General Surgery Member of the Society of Vascular Surgery, the Society of Clinical Vascular Surgery, and International Society of Endovascular Surgery Previously Clinical Professor of Surgery at the University of Medicine and Dentistry of New Jersey Chief of Vascular Surgery and Director of Multiple Vascular Labs in New Jersey and North Carolina Published Extensively in General, Vascular and Venous Diseases Specialized Training in the Treatment of Venous Insufficiency Frank Sbrocco, MD Georgetown University School of Medicine and Washington Hospital Center Prepared Physician Medical and Surgical Management of the Female Patient in Southern Maryland for over Fourteen Years Arvind Narasimhan, MD Board Certified Physician Member of Medical Staff of Fort Washington Hospital Specialized Training in the Treatment of Venous Insufficiency Citation from Washington DC for Emergency Rescue at Rock Creek Park Certification in Hyperbaric Medicine with an Interest in Wound Care Phone: VEIN (8346) or visit