Page 1. Ruling out deep venous obstruction prior to superficial vein treatment. Disclosures. Indications for saphenous vein ablation (SVA)

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1 1 Ruling out deep venous obstruction prior to superficial vein treatment Deepak Sudheendra, MD, RPVI Assistant Professor of Clinical Radiology & Surgery Disclosures No financial disclosures Indications for saphenous vein ablation (SVA) Leg pain and swelling Symptomatic varicosities Lipodermatosclerosis Venous stasis ulcers Page 1

2 Contraindications for SVA Saphenous vein thrombus (i.e. SVT) Deep vein obstruction Sciatic vein reflux Hypercoagulable state Raju S, Easterwood, L, Founrain T, et al. Saphenectomy in the presence of chronic venous obstruction. Surgery. 1998;123: Evaluation of Deep Venous System History & Physical Exam Noninvasive Testing Invasive Testing History & Physical Exam History of iliofemoral DVT History of IVC filter Bilateral lower extremity edema Pelvic congestion syndrome May-Thurner Syndrome Abdominal wall/groin/vaginal varicosities Scrotal edema Page 2 2

3 3 Noninvasive Testing Duplex Ultrasound Intraluminal echoes No flow with pulsed/ color Doppler No compressibility Loss of phasicity Least expensive Heather L. Gornik, and Aditya M. Sharma Circulation. 2014;129: Noninvasive Testing CT/MR Venogram Caliber of vessels & extent of occlusion Better delineation of IVC and iliac vessels Assists w/procedure planning May reveal pathology IV contrast issues More expensive Invasive Testing Venogram Gold standard Diagnostic & therapeutic IV Contrast issues Most expensive Page 3

4 4 54 yo F h/o LLE DVT 8 yrs ago s/p EVLT of left SSV 3 wks prior 54 yo F with LLE DVT after EVLT of SSV Venogram Left peroneal vein access All calf veins & popliteal vein thrombosed Acute on chronic DVT GSV is primary collateral 54 yo F with LLE DVT after EVLT of SSV Venogram 24 hour lysis Recanalization of left peroneal & popliteal veins Recanalization of left femoral vein Page 4

5 1 month 10 months 3 years Conclusions Saphenous vein closure can be done in patients with a prior history of DVT only AFTER a thorough evaluation of the deep venous system has been performed. Always open deep venous system (especially iliac veins) prior to superficial venous ablation If deep venous procedures are not offered in your practice, team up with a vascular specialist who has expertise in complex deep venous disease and post thrombotic syndrome Thank You Deepak Sudheendra, MD, RPVI Deepak.Sudheendra@uphs.upenn.edu Patient Education Venous Blog Page 5 5

6 Imaging of Recurrent Varicose Veins This presentation focuses on the patterns of recurrence. --Treatment planning is made easy by understanding the patterns involved. Neil Khilnani, MD Vascular and Interventional Radiology Associate Professor of Clinical Radiology NY Presbyterian-Weill Cornell Medicine VuMedi January 27, 2016 Imaging of Recurrent Varicose Veins This presentation focuses on the patterns of recurrence. --Treatment planning is made easy by understanding the patterns involved. Neil Khilnani, MD Vascular and Interventional Radiology Associate Professor of Clinical Radiology NY Presbyterian-Weill Cornell Medicine Recurrence patterns Saphenous Tributary Other 3 1

7 Relevant Disclosures None Imaging methods for recurrence DUS usually all that is needed Scope- understand the recurrence mechanism Beyond the IAC/ACR protocols Imaging methods for recurrence DUS usually all that is needed Scope- understand the recurrence mechanism Beyond the IAC/ACR protocols Advanced imaging (CT, MR, IVUS) Rarely, and in select cases 2

8 Saphenous recurrence Disease progression Saphenous recurrence Incomplete treatment Diagnostic or Tactical error Saphenous recurrence Disease progression Incomplete treatment Diagnostic or Tactical error 3

9 Technical error / failure: Inadequate treatment Proximal recurrent reflux after thermal ablation Remnant saphenous segments Seen after Surgery Thermal ablation Recently after Foam Mechanico-chemical ablation Remnants after ablation Pre-treatment 4

10 Tactical or diagnostic error persistent rather than recurrent varicose veins Concurrent reflux pathways not treated Another refluxing saphenous vein Non saphenous reflux Pelvic derived external pudendal veins Pre-treatment 2 years after SFJ to lower thigh ablation SSV recurrence patterns Most often at the upper end SPJ derived varicose veins True after SPJ ligation Ablation Thermal Chemical 5

11 Less common observation Diagnostic error leading to tactical error 6

12 Tributary vein recurrence Persistent Never treated Possibly progressed Recurrent New pathway of recurrence Tributary reflux Often not treated Only ablation is done Not really a recurrence Anterior accessory saphenous vein ablation alone Pre-treatment New GSV reflux: re-pressurizes VV 7

13 Incompetent perforating vein Persistent untreated pathway Progressive disease Recurrent IPV derived varicose veins after sclerotherapy or microphlebectomy Pre-treatment Early post-treatment Late post-treatment Other Veins 8

14 Neovessels Neovessels at SFJ (or SPJ) Varicose veins Fill directly Remnant saphenous segments Fill directly or via varicose veins Source of lower varicose veins Neovessels Useful to find these remnant segments Careful DUS over the entire length of treated veins Target for treatment Neovessels Treatment of outflow of neovessel pathway Neovessels Often get smaller May no longer reflux May not need to be treated 9

15 Neovessels without prior surgery Lymph node Occasionally see varicose vein networks near the SFJ Often involve pathways passing through lymph nodes Usually these are small veins May enlarge in multiparous women Lymphoganglionic venous network connect GSV/AA GSV with Junctional veins CFV and FV Tributary veins Lymphovenous network reflux Can cause Subterminal GSV or AA GSV reflux Peri-saphenous VV Direct varicose vein filling near groin Lymph nodes are often seen in some cases of post-sfj ligation neovessel pathways Neovessels lead to saphenous space and then to visible lower varicose veins In the GSV space after GSV ablation In GSV space In the AA GSV space 10

16 Right AA GSV space varicose veins AA GSV is normal Saphenous space varicose veins treatment with x-ray guided sclerotherapy US guided puncture X-ray guided treatment monitoring and management 11

17 Unusual sources Sciatic related recurrent varicose veins Left popliteal fossa Leg veins gone but symptoms persists Iliac vein obstruction Persistent leg pain Non healing VLU Persist swelling DUS Imaging Normal CFV waveform Post thrombotic and non-thrombotic 12

18 Leg veins gone but leg still hurts Pelvic venous incompetence Persistent leg pain Labial or vaginal pain Groin pain Labial and vaginal varicose veins Catheter Venogram L renal venogram L ovarian vein venogram 13

19 Conclusions: Imaging of recurrence Patterns Treat better, based on the anatomy 14

20 Treating Venous Disease in the Setting of Active Ulcers Anne Giuliano MD, CWSP, RVPI Medical Imaging Associates Billings MT Disclosures None Venous Leg Ulcers More than 2 million people affected annually in the US. VLU account for 70-90% of lower leg ulcers. Up to 1/3 of treated patients experience 4 or more episodes of recurrence. Total cost of care for patients with VLU is estimated at $15 billion annually. VLUs result in loss of 2 million work days annually. San C, et al. Human skin wounds: A major and snowballing threat to public health and the economy. WRR 2009: 17(6): Rice JB, et al. Burden of Venous Leg Ulcers in the United States. J Med Econ 2014:

21 Urban Myth You don t treat the venous reflux till the ulcer is healed. Clinical Practice Guidelines Society of Vascular Surgery/American Venous Forum Management of Venous Leg Ulcers: Clinical Practice Guidelines of the Society for Vascular Surgery and the American Venous Forum J Vasc Surg 2014;60:3S 59S (August 2014 Supplement) Society of Interventional Radiology None that I could find American College of Phlebology Brief mention of ulcers only and in association with treating perforators Definition of Evidence Strength 2

22 SVS/AVF Guidelines DEFINITION VENOUS LEG ULCER Guideline 1.1: Venous Leg Ulcer Definition We suggest use of a standard definition of venous ulcer as an open skin lesion of the leg or foot that occurs in an area affected by venous hypertension. [BEST PRACTICE] SVS/AVF Guidelines COMPRESSION: Guideline 5.1: Compression Ulcer Healing In a patient with a venous leg ulcer, we recommend compression therapy over no compression therapy to increase venous leg ulcer healing rate. [GRADE - 1; LEVEL OF EVIDENCE - A] Guideline 5.2: Compression Ulcer Recurrence In a patient with a healed venous leg ulcer, we suggest compression therapy to decrease the risk of ulcer recurrence. [GRADE - 2; LEVEL OF EVIDENCE - B] Guideline 5.3: Multicomponent Compression Bandage We suggest the use of multicomponent compression bandage over single-component bandages for the treatment of venous leg ulcers. [GRADE - 2; LEVEL OF EVIDENCE - B] SVS/AVF Guidelines OPERATIVE/ENDOVASCULAR MANAGEMENT Guideline 6.1: Superficial Venous Reflux and Active Venous Leg Ulcer Ulcer Healing In a patient with a venous leg ulcer (C6) and incompetent superficial veins that have axial reflux directed to the bed of the ulcer, we suggest ablation of the incompetent veins in addition to standard compressive therapy to improve ulcer healing. [GRADE - 2; LEVEL OF EVIDENCE - C] Guideline 6.2: Superficial Venous Reflux and Active Venous Leg Ulcer Prevent Recurrence In a patient with a venous leg ulcer (C6) and incompetent superficial veins that have axial reflux directed to the bed of the ulcer, we recommend ablation of the incompetent veins in addition to standard compressive therapy to prevent recurrence. [GRADE - 1; LEVEL OF EVIDENCE - B] 3

23 SVS/AVF Guidelines PERFORATOR VEINS Guideline 6.5: Combined Superficial and Perforator Venous Reflux With or Without Deep Venous Reflux and Active Venous Leg Ulcer In a patient with a venous leg ulcer (C6) and incompetent superficial veins that have reflux to the ulcer bed in addition to pathologic perforating veins (outward flow of >500 ms duration, with a diameter of >3.5 mm) located beneath or associated with the ulcer bed, we suggest ablation of both the incompetent superficial veins and perforator veins in addition to standard compressive therapy to aid in ulcer healing and to prevent recurrence. [GRADE - 2; LEVEL OF EVIDENCE - C] Guideline 6.7: Pathologic Perforator Venous Reflux in the Absence of Superficial Venous Disease, With or Without Deep Venous Reflux, and a Healed or Active Venous Ulcer In a patient with isolated pathologic perforator veins (outward flow of >500 ms duration, with a diameter of >3.5 mm) located beneath or associated with the healed (C5) or active ulcer (C6) bed regardless of the status of the deep veins, we suggest ablation of the pathologic perforating veins in addition to standard compression therapy to aid in venous ulcer healing and to prevent recurrence. [GRADE - 2; LEVEL OF EVIDENCE - C] SVS/AVF Guidelines PROXIMAL OCCLUSION Guideline 6.14: Proximal Chronic Total Venous Occlusion/Severe Stenosis With Skin Changes at Risk for Venous Leg Ulcer (C4b), Healed (C5) or Active (C6) Venous Leg Ulcer Endovascular Repair In a patient with inferior vena cava or iliac vein chronic total occlusion or severe stenosis, with or without lower extremity deep venous reflux disease, that is associated with skin changes at risk for venous leg ulcer (C4b), healed venous leg ulcer (C5), or active venous leg ulcer (C6), we recommend venous angioplasty and stent recanalization in addition to standard compression therapy to aid in venous ulcer healing and to prevent recurrence. [GRADE - 1; LEVEL OF EVIDENCE - C] Guideline 6.15: Proximal Chronic Venous Occlusion/Severe Stenosis (Bilateral) With Recalcitrant Venous Ulcer Open Repair In a patient with inferior vena cava or iliac vein chronic occlusion or severe stenosis, with or without lower extremity deep venous reflux disease, that is associated with a recalcitrant venous leg ulcer and failed endovascular treatment, we suggest open surgical bypass with use of an externally supported expanded polytetrafluoroethylene graft in addition to standard compression therapy to aid in venous leg ulcer healing and to prevent recurrence. [GRADE - 2; LEVEL OF EVIDENCE - C] SVS/AVF Guidelines IN SUMMARY: Treat the underlying problem. Treat as soon as reasonable. Do not wait for ulcer to heal to start therapy. 4

24 Literature Review Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR): Randomized Controlled trial. Gohel et al, Bmj 2007;335: legs randomized to compression or compression plus saphenous surgery Ulcer healing at 3 years was 89% for compression group and 93% for intervention (P=.73) Ulcer recurrence at 4 years was 56% for compression and 31% for intervention group (P<0.01) Conclusion: Surgical intervention in addition to compression did not improve ulcer healing, but did reduce recurrence at 4 years. Literature Review Healing and Recurrence Rates Following Ultrasound-guided Foam Sclerotherapy of Superficial Venous Reflux in Patients with Chronic Venous Ulceration, Pang et al, European Journal of Vascular and Endovascular Surgery, 40:6: , 12/ consecutive patients underwent USGFS as part of their treatment for CVU Healing was observed in 82% at a median of 1 month following their first USGFS treatment 4.9% ulcer recurrence at 2 years Literature Review Endovenous Laser Treatment for Varicose Veins in Patient with Active Ulcers: Measurement of Intravenous and Perivenous Temperatures during the procedure, Viarengo et al, Dermatologic Surgery, 33:10: , 10/ patients with varicose veins and ulcers for more than 1 year divided into a compression group and EVL plus compression. Patients followed for 12 months At 12 months 24% of compression group healed vs. 81.5% of Laser group. Ulcer recurrence was zero in the laser group. 5

25 Urban Myth You don t treat the venous reflux till the ulcer is healed. How I Do It Upon presentation I asses for any arterial disease. If there is none, than I obtain venous reflux studies as well as evaluation of central pelvic veins if there is a history of ileofemoral DVT or my suspicion is high. I rely on standard wound care techniques to handle edema and possible infection. Once ulcers have quieted down, edema and infection are managed than I treat the underlying venous disease. Obstruction Reflux How I Do It I do not wait for ulcer healing to treat. This requires coordination with the wound care center for dressing changes I often do concurrent foam sclero at the time of ablation especially of the veins refluxing into the ulcer bed. I follow the patient up at the Wound Care Center. If there isn t rapid improvement in the ulcer in the following 2-3 weeks than I will reevaluate and treat residual disease as needed. 6

26 Finally Thank you for your Attention 7

27 1/26/2016 CHALLENGES AND OPPORTUNITIES IN THE TREATMENT OF SUPERFICIAL VENOUS DISEASE THE INTEGRATION OF MULTIPLE VARICOSE VEIN TECHNOLOGIES INTO YOUR PRACTICE David M Liu MD FRCPC FSIR Managing Director EVA Vein Care Vancouver BC Canada Our Practise Profile Socialized Health Care (Canada) IR, Vasc Surgeon, 2 Phlebology Nurses Fully accredited Ambulatory Surgical Center (ASC) Self pay/cash Pay Only Part time practice 1

28 1/26/2016 A minimally invasive procedure that uses an innocuous, medicalgrade adhesive to treat varicose veins. CURRENT APPROACHES TO CVI TREATMENT IMPROVEMENTS HAVE BEEN MADE TO THERMAL ABLATION? Eliminate need for tumescent anesthesia Eliminate need for compression stockings Significantly reduce post-procedure pain and bruising Improve current treatment closure rate of >90% Compression Stockings Pain & Bruising Tumescent Anesthesia Images courtesy of M. Madsen 2

29 1/26/2016 EVLT Venefit Venaseal + Well Established Most cost effective Well Established Most cost effective Non tumescent No stockings Non thermal Rapid Recovery - Tumescent Tumescent Can case skin burn Can case skin burn Compression stockings Compression stockings Bruising / discoloration Bruising / discoloration Less published data Chemical dermatitis Small ball can form COMPRESSION STOCKINGS (Class II) Reduces discomfort Reduces phlebitis Critical to outcome CONSIDERATIONS FOR USE OF NTNT Clinical indication Vein close to skin/close to nerve Patient not tolerant of compression stockings Phobia of needles Open ulcer precluding tumescent Lifestyle Active/busy lifestyle: can t afford or don t want the downtime Desire rapid return to activities Innovative Technology Preference for cutting edge technology Desire different experience 3

30 1/26/2016 PATIENT EMPOWERMENT EVA: OUR PHILOSOPHY Each patient receives personalized care plan All therapies are available in our clinic (sclero, ClosureFast, Venaseal, surgery, Clarivein) We provide objective information and combine them to reach our goals. WHY DOES SELF PAY MODEL WORK FOR US? Clientele Freedom Choice Brings in a specific type of clientele that is looking for quality and concierge service Gives us the ability to choose what is best with the freedom of selecting the most appropriate therapy Provides the patient with the ability to choose rather than be told 4

31 1/26/2016 Whatever you choose will be better than stripping Better outcome Faster recovery Less invasive Personalize your plan You re going to have a great result Its whether you want to get there by first class or premium economy THE PATIENTS THAT PREFER NTNT I only want to get the best I want the latest technology I have a busy lifestyle and can t afford or don t want the downtime I don t want bruising and I hate needles OR I can t tolerate compression I have a anatomical situation that can benefit with the use of NTNT 5

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