Patient assessment and strategy making for endovenous treatment
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1 Patient assessment and strategy making for endovenous treatment Raghu Kolluri, MD Director Vascular Medicine OhioHealth Riverside Methodist Hospital Columbus, OH
2 Disclosures Current Medtronic Consultant/ Speaker Bard Data Safety Committee Cook Consultant Volcano Consultant Boston Scientific Consultant/ Speaker
3 Vascular Lab in venous disease J Vasc Surg 2011;53:2S-48S
4 Clinical Evaluation Clinical examination CEAP classification Venous Clinical Severity Score (VCSS) is used for assessment of clinical outcome after therapy Grade 1 A 1 A 1 B J Vasc Surg 2011;53:2S-48S
5 Saphenous System Anterior Accessory Saphenous vein Posterior Accessory Saphenous vein Small J. Vasc. Surg, 2002 ; 36:416-22
6 Anatomy
7 Small Saphenous System IGV Inferior Gluteal Vein CV Circumflex Vein (Post thigh) ScP Sciatic Perforator IV Intersaphenous vein J. Vasc. Surg, 2002 ; 36:416-22
8 Perforators
9 Non-Saphenous/ Pelvic Varicosities
10 Vascular Lab DVT - Acute/ Chronic Evidence of Iliac Vein Obstruction Superficial Thrombosis Acute Vs Chronic Info regarding recanalization (Rx Decision - Ablation Vs Foam) Reflux Deep, Superficial, Perforator Vein Map
11 GSV Reflux No Reflux Augmentation Augmentation
12 SFJ Tributaries AASV PASV ILIAC OCCLUSION SE Superficial Epigastric (Land mark for ablative therapies) SEP Superficial External Pudendal SCI Superficial Circumflex Iliac
13 Fowler et al, JVU 38(1):34 40, 2014
14 CEAP Classification C = Clinical C0 - no visible venous disease C1 - telangiectasias or reticular veins C2 - varicose veins C3 - edema C4 - skin changes without ulceration C5 - skin changes with healed ulceration C6 - skin changes with active ulceration E = Etiology (primary vs. secondary) A = Anatomy (defines location of disease within (superficial, deep and perforating venous systems) P = Pathophysiology (reflux, obstruction, or both)
15
16 Compression Rx J Vasc Surg 2011;53:2S-48S
17 Endothermal ablations J Vasc Surg 2011;53:2S-48S
18 New technologies Thermal Vs Non Thermal Adjunctive Therapies Foam Vs Phlebectomy Simultaneous Vs Staged
19 Simple Decision Making Signs/ Symptoms + or Cosmetic improvement GSV/SSV reflux GSV/SSV anatomy Straight, adequate depth and no tributary reflux Ablation +/- Compression Rx
20 Simple Decision Making Venous Hemorrhage GSV reflux GSV anatomy Straight, adequate depth + tributary reflux in calf Ablation + Sclerotherapy+ Compression Rx
21 Simple Decision Making No GSV/ SSV Reflux or Post saphenous or other large varix Rx Has reticular veins/ telangectasias and seeks cosmetic Rx Sclero (liquid/ foam Visual or US guided
22 Simple Decision Making AASV GSV Aneurysmal superficial venous disease Recommend surgery
23 Perforator Ablation Against selective treatment of incompetent perforating veins in patients with simple varicose veins (CEAP class C2) For treatment of pathologic perforating veins, - subfascial endoscopic perforating vein surgery, ultrasonographically guided sclerotherapy, or thermal ablations. Grade 1 B 2 C J Vasc Surg 2011;53:2S-48S Tech Vasc Interv Radiol 2014 Jun; 17(2):132-8.
24 Complex situations
25 No junctional reflux Severe lipodermatosclerosis Severe pain No IVC/ Iliac obstruction +/- Obesity +/- OSA +/- Elevated central venous pressure? Sclero +/- Ablation
26 Complex Pelvic Collaterals 53 yr old male with bilateral ankle ulcers Left GSV ablation last yr did not help GSV Reflux, proximal aneurysm IVC Atresia, Iliac veins absent, prominent Azygous / Hemiazygous Deep Vein Reflux Physiologic reversal of perforator into a competent AASV
27 Summary 1 st visit Is this venous disease? Type of presentation Differential Diagnosis Concomitant medical issues that influence outcomes of venous treatments Iliac obstruction Right Heart Failure and OSA Obesity Liver Disease Thyroid Disease Kidney dysfunction Neuropathic pain Arterial disease Formulate a plan: Non-inv/ compression therapy recs for 6-12 weeks
28 Thank you
29 Patient assessment and strategy making for endovenous treatment Raghu Kolluri, MD Director Vascular Medicine OhioHealth Riverside Methodist Hospital Columbus, OH
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