Techniques and Specific Treatment Modalities for the Active Non-Healing Wound Luke Maj, MD, MHA Assistant Professor of Radiology University of Miami, Miller School of Medicine Director of The Vein Center at Water s Edge Dermatology, Florida
Disclosures None
OVERVIEW Deep veins Superficial veins Perforator veins
PERFORATOR VEINS Why are they important? Perforator damage can cause significant pathology and patient symptoms Veins (spider and varicose), skin changes, ulcers, edema, pain, other symptoms. To me perforators are the most important: They cause signs and symptoms of CVI They (at times) can be the single culprit of patients problem Many providers miss them and patients return symptomatic Treatment no longer covered by insurance (in FL) except when beneath an active or healed venous ulcer You MUST treat to completion = treating perforator veins.
How Do I Do It? Treat axial reflux (CVI) and Pelvic Outflow Obstruction (POO) first. I take the US myself and scan the patient. I m an old school radiologist, I want to see myself I focus on areas that I can see on the skin which demonstrate skin changes. I ask the patient to specify where the symptoms are when I scan over them THIS WILL TELL YOU WHICH PERFORATORS ARE CAUSING THE PROBLEM. The patient will actually point to the area where the symptoms are. Place probe there and look. Then I compare it to the US map by my tech and see if it was identified (PS. Good way to check how good your tech is) I close the perforator (RFA, Laser, UGS) and anything that it gives off. ****BECAREFUL Majority of the time there is an arterial branch next to the perforator CLUE: Take a moment and hold the US steady and watch for pulsating tissue That s an artery.
How Do I Do It? What do I use to close perforators: 1. RFA 3 or 7 cm catheter If I can get away using 3 or 7cm catheter across a T-Bone perforator that is my #1 choice. 2. RFA Stylet Bit cumbersome and closure rate for me has not been as good as catheter or laser 3. Laser I prefer this method as it is quick and good success rate. Get a IV kit ($1.50), 18 or 16 gauge and insert into perforator like you are placing an IV. Or use a regular large bore needle. Through there place the laser into the IV sheath, pull back on the IV sheath so you don t burn it off. Alternative is premeasure the length of the IV sheath and get a doohickey which holds laser fiber and screws on to IV sheath. 4. Clarivein It could be done but for me there is no reimbursement so I don t use it. 5. Venaseal Likely a great method but you have to make sure that you can compress this area for 3 mins. I don t use it on perforators at this time. 5. Foam Varithena or home made The foam will go everywhere! Into perforator and into deep space. Be cautions of DVT risk. I use this method 1% Polidochanol when the insurance wont pay for Laser or RFA or they don t meet guidelines. You may have to do it more than once. Make sure that you press with US probe to close the perforator and obtain spasm of the perforator. DO not go into the perforator further than the fascia when using laser of RFA. WATCH out for artery next to perforator it should move away when you use tumescent. When finished sclerose the tributary varicosities.
Case 458831 Nonhealing ulcer (10 years).
Massive perforator with overlying tributaries
Case It just wont go away. Ulceration that never completely healed and skin keeps forming a new scab for years.
No identifiable perforator. Only tributary veins that need to be closed. Tx: Sclero
Case
Watch out for the fascial plane depth
Case 399612
T-BONE: Easily treated even across the perforator. Laser or 3cm RFA catheter
Treat up to fascial plane LEFT RIGHT
Case JZ Reflux: BL GSV BL SSV BL Perfs BL Tribs L Femoral L Pop R Femoral L: 2x DVT
Pelvic Outflow Obstruction (May Turners Syndrome)
LEFT
RIGHT
Case Z Refluxing L GSV Refluxing L Posterior Tibial Perf L GSV Ablated No significant change. L Posterior Tibial Perforator Closed using 1% Polidochanol Foam WHY?
Artery?
Take Away. Treat to COMPLETION (including perforators, tributaries and skin veins) I quote ($) the patient and do it during other ablation procedures if no insurance coverage Lower cost to patient, Less visits (FL must have C5 of C6 to insurance coverage) Look for perforators on patients who come back with symptoms Consider IVUS for Pelvic Outflow Obstruction in patients with CEAP 3 or higher or Hx of DVT. Watch out for ARTERIES If anyone is looking to relocate to Florida or looking for a job please see me or email me lukemaj@gmail.com
THANK YOU
Techniques and Specific Treatment Modalities for the Active Non-Healing Wound Luke Maj, MD, MHA Assistant Professor of Radiology University of Miami, Miller School of Medicine Director of The Vein Center at Water s Edge Dermatology, Florida