Non-Saphenous Vein Treatments. Jessica Ochs PA-C Albert Vein Institute Colorado Springs and Lone Tree, CO

Transcription

1 Non-Saphenous Vein Treatments Jessica Ochs PA-C Albert Vein Institute Colorado Springs and Lone Tree, CO

2 I have no financial disclosures

3 Types of Veins Treated Perforator Veins Tributary Veins Varicose Veins Spider Veins

4 Perforator Veins

5 Perforator Veins Methods used: 1. SEPS (subfacial endoscopic perforator surgery) 2. Open Ligation 3. Thermal Ablation 4. Radiofrequency Ablation 5. Cyanoacrylate Glue 6. Ultrasound Guided Injection 7. Combination of cyanoacrylate glue and sclerotherapy of the tributaries associated with the perforator

6 SEPS

7 Radiofrequency and Laser Ablation Similar technique as with the saphenous vein ablations, but different sized equipment GUIDELINES FOR ABLATION: 1. >3.5mm beneath a healed or active ulcer 2. Demonstrate reflux >.5ms 3. CEAP class Axial reflux already treated 5. Failed compressive management Not always covered by insurance for being experimental Ozsvath, Kathleen, et al. Current techniques to treat pathologic perforator veins. Journal of Vascular Surgery: Venous and Lymphatic Disorders, vol. 5, no. 2, 2017, pp , doi: /j.jvsv

8 RF Catheter Ablation

9 Ultrasound Guided Injection Injection of the vessel done distal to the perforator and watch for a deep flush (with foam). Need good communication with RVT to know where exactly you are injecting Vessel usually needs to be at least 3.5mm and reflux must be demonstrated. Check with each of your carriers to determine what the requirements are for injection

10 Complications Ozsvath, Kathleen, et al. Current techniques to treat pathologic perforator veins. Journal of Vascular Surgery: Venous and Lymphatic Disorders, vol. 5, no. 2, 2017, pp , doi: /j.jvsv

11 Cyanoacrylate Glue Considered experimental and not covered by most insurance plans Does not have a CPT code for which to bill

12 Cyanoacrylate Glue with Sclerotherapy A recent study was performed by Prassad et al in which cyanoacrylate glue was injected into perforator veins and then the associated tributaries were injected with sclerotherapy There were 63 patients with 83 procedures performed 100% occlusion rate at 6 months 4 non-clinical significant DVTs The authors warn of only using this method if you have a lot of experience with glue given the it s ability to cause permanent deep venous occlusion Bp, Krishna Prasad, et al. Treatment of Incompetent Perforators in Recurrent Venous Insufficiency with Adhesive Embolization and Sclerotherapy. Phlebology, 2017, p , doi: /

13 Occlusion Rates

14 Tributaries Methods Used: 1. Laser Ablation 2. Radiofrequency Ablation 3. Mechanochemical Ablation (MOCA) 4. Ultrasound Guided Injections

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16 Laser Ablation/Radiofrequency Used when a vein has it s own entrance into the deep system (anterior accessory vein going directly into the common femoral junction) 5.0 mm and refluxing Considered to be experimental by some carriers Can only be done after all other saphenous veins have been treated Demonstrate functional loss

17 MOCA Now has a CPT code and a second vein code for tributary veins Still considered experimental and not covered by many carriers

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19 Ultrasound Guided Injection Great for veins that lead into a saphenous vein that has already been ablated mm demonstrating reflux

20 Varicose Veins Phlebectomy Sclerotherapy Injections

21 Phlebectomy PROS Most patients have a better medical and cosmetic outcome if the vein is appropriate for phlebectomy Decreased healing time Decreased risk of hyperpigmentation CONS Patient pain tolerance Patient demographics Patient body habitus Previous or current STP Vein location Unable to remove vein Technique Takes more set up

22 Instruments

23 Set Up

24 Sclerotherapy Pros Less painful Small vessels confirmed treated Good for patients with scarring or partially thrombosed veins Decreased chance of arterial or nerve damage Easier set up/ less equipment Cons Hyperpigmentation and possibly multiple I&D sessions Matting May not close completely if large vein Multiple treatments Months to resolve Decreased pt sun exposure

25 Spider Veins Sclerotherapy Topical Laser

26 Conclusion There are many modalities for treating nonsaphenous veins available today. However, be aware of the different requirements, techniques, and insurance approved methods before selecting your treatment plan.