Chapters Transcript Video Case Review- GSV and ASV Strategies Back to Symposium Good morning. A little early today for me, even though I'm a surgeon, I usually start about 9, so. And try to get us back on track. Alright, so if you're new to venous disease, it is extremely prevalent, 175 million Americans. So if you wanna do venous cases, you can find the pictures. It's an expensive problem, and the point is there's also a lot of patients that have chronic venous ulcers, and these do not heal without some kind of intervention. So let's talk about clinical assessment. So there's a seat classification. It has 4 components. We only talk about the C though. C0 would be no disease at all. That's pretty much no one. C1 means you have spider veins. C2, you're getting varicose veins. C3, usually when they're seeing you, they at least have C3 venous disease, so they're starting to have swelling. C4, if you're seeing these patients, you need to denote if it's C4A, B, or C, and it just denotes the severity. So A, you have some pigmentation, B, it's much more dense pigmentation, and C, you're starting to get it involving the foot. And then C5 and 6, it's either a healed venous ulcer, which is C5, or it's an active venous ulcer. And again, if you see people presenting with active venous ulcers. They need some kind of intervention. It can be arterial, it can be venous, and in our case, we like to look at both. So just kind of a quick overview of arterial versus Venus. Generally venous wounds are located medially. They're not always, but more commonly they are, um. They'll have a, uh, they'll be more dark red. Um, they might be leaking fluid. Arterial tend to be more necrotic appearing and scar, like a bit a black base. Here's some good examples, right? So if you look at an arterial wound, you can see that there's a black scar, it looks dried out. The toe looks ischemic with how wide it is. And then looking at a venous wound. It looks kind of wet. Also here there, there's both a medial and a lateral, but a lot of times you'll see it right where the great saphenous vein ends up near the ankle. Because that's where the venous pressure is the highest in the leg. So if you're gonna do a complete Venus evaluation, you gotta have a good protocol. So the thing is, if you have ultrasound techs, you need to, that are in your office, you need to discuss your Venus protocol with them. Um, but if, if you don't actually have techs, then you can find people who come to do the studies for you, and they're, we found them to be, you know, very high quality studies. The problem with venous, uh, ultrasounds is if you don't tell them what to look for and they don't have a good protocol, then you're not gonna see what you need to treat. We had a big problem whenever we started treating a lot of veins. They were only looking at the great saphenous vein. They were only looking at the small saphenous vein. They weren't noting any perforators. They weren't noting anterior accessory saphenous veins. They were just looking at two things and telling you what it was. They weren't telling us if it was tortuous and, and other things. So you have to sit down with the people that do the studies for you and tell them what you need to see. Because it's gonna change how you treat somebody, so you heard Aaron talking about if you're gonna do glue, you have to get a catheter from wherever you stick it in all the way up to the junction. So if someone has a very tortuous vein, that's not gonna work well, and the problem is in the modern world you have to get things pre-approved. So say you wanted to do um a glue case on someone. And they show up and you say oh my goodness look how tortuous their vein is so now you have to cancel their case, you know, get it approved for something else and then uh you're upset and the patient's more upset because you wasted their time so just make sure that you have a good protocol and honestly the, the BD reps are great, um, a lot of them were stenographers before and they can help you to set up your practice which is very nice. So things that we look at. You gotta look at the deep veins and you gotta look at the superficial veins. So what are you looking for in the deep veins? Make sure they don't have a DVT. If somebody has a DVT or they have very significant reflux and very significant swelling at the common femoral vein, then maybe they need a venogram. Um, Then you're gonna look at the saphenofemoral junction, you have to look at the saphennopopliteal junction. Uh, why? Because insurance requires it, so you have to note these things. You need to say how big the veins are and how long the reflux time is. So, great saphenous vein, small saphenous vein, or lesser saphenous vein, depending on the, whatever the appropriate terminology is now. And then you need to look at the saphennopopliteal junction or you need to note that it does not exist. So we've started getting denials because you don't put the saphennopopliteal junction when they actually have a thigh extension of the small saphenous vein. So the point is. They just need to note everything. If you put too much information, it's usually not going to hurt you. And then also you need to look for any anterior or posterior accessory saphenous veins. You need to look for perforating veins, because again, if you're gonna do, say, varyhena, right? You might want to close that perforating vein first because if you're not careful, you can end up getting a DVT. Um, and then any refluxing tributary veins. So if you're just looking for the main named veins and you don't mark any refluxing tributary veins. If you close down the axial vein that's directly connecting to this vein that they're complaining about, it will decompress it and sometimes it closes it. But truthfully, most of the time for a complete treatment, you're gonna end up having to treat the axial vein, and you're gonna come back and treat that, you know, large vein that's really bothering them, and we'll do a case that shows this. So, in general, just note anything that's refluxing. You don't have to treat them all, but you need to see what's bothering the patient and develop a plan that's gonna fix their problem. And you wanna ask them what were their prior treatments, right? But honestly, they usually don't know. They just say I had some vein treatment somewhere. I mean you can get the records, but truthfully it's kind of a waste of time. Just do a good ultrasound and you can see what they did. Something important to note is, if someone's seeing you. And they've had prior treatments. It does not mean that there's nothing to do. They can have recurrence. The prior treatment might be unsuccessful, um, and there may be some other root cause of what's going on with them. So again, you need to do a thorough evaluation. And truthfully, some people need a venogram. So if they've had every superficial vein ablated, they come back, they've got massive recurrence of very tortuous, uh, veins. Truthfully, they probably just need a venogram. And a lot of times you'll see they have significant deep venous compression, which is leading to a recurrence of the veins. OK, so. Patient comes in, she's 43. She's had 15 to 20 years of worsening veins, really worsened after her pregnancies. Uh, she used to live out of the state, and she had had a vein treatment. She really didn't improve. She always had this vein on her thigh. They treated her great saphenous vein, but it, this other vein that actually was bothering her the entire time, they never did anything about. Her left leg hurts, it swells, and she really just wants a second opinion. As far as medical history, she smokes. She didn't actually know what vein procedure she had had, but we could tell from the ultrasound. And she's really just complaining that her legs hurt, and the vein is worsening, it's painful, hurts when her kids bump into it. This is actually a picture of her leg. So, You see this tortuous vein, it's kind of wrapping around. So we did an ultrasound. And focusing on the left leg. They did a fantastic job treating the great saphenous vein, right? So they treated it above and below the knee, but. Why does she still have this huge painful varicose vein and all this leg swelling? Well, it turns out she actually had a quite large. Anterior accessory saphenous vein, so it's. 6.5 millimeters. I mean, that's a big vein. And it had 3 seconds of reflux, right? So I don't know if the other person didn't look for this or what, but you know she's telling me this is the same vein that she's had bought in there in her for years, so. Let's fix it, right? And then the other thing that we saw is that there was a very large. tortuous vein coming off of it, which again you can see. You know, wrapping around her leg. Yeah, so I mean she's had an ablation. Can we help her? Of course we can. So, we'll, let's plan to treat the left anterior accessory saphenous vein, and then generally what I'll do is for all the tortuous stuff is usually I'll use. Uh, Ver Athena. So here's some videos, so you can see, if you look at her common femoral vein. It's phasic. So you don't just see monophasic flow, you can see as she breathes, there's respiratory variation. Looking at the thigh, what do you see? Well, it's more what you don't see. The vein's ablated, so you don't really see the great saphenous vein. Just to recap of what we said, OK, so, but she still has pain, so what's going on? Well, here is her anterior accessory saphenous vein. So if you watch the, the screen, they're gonna kind of scroll through it. And then you can see the reflex 3 seconds, hoo wee. So if you look at this, this is the segment of the accessory saphenous vein. That's straight. So in this case, especially, you know, it's connecting directly into the deep vein. My go to is radio frequency ablation. And truthfully, one of the greatest things about the BD catheter is, say that it's not a very long segment. I mean, you can treat up as long as you can get in. You could treat a 2.5 centimeter segment. So you can always treat something if it's this long. The problem with some of the other brands is you have to stock both a 7 centimeter or 8 centimeter and a 3 centimeter. It's just kind of silly. Truthfully, you may get some case like this. They've already opened the catheter, you got a 7, you can't get enough, you can't get a long enough runway to safely do it, to have an. Have a barrier between the end of the catheter and the skin, you have to open another catheter. So the nicest thing is with BD you don't have to do that. So what I did is we treated this anterior accessory. So if you look at this, it's just a few more videos that's scrolling down the leg, you can see it becomes quite tortuous. So are you gonna get any catheter to track through that? I mean, you tried hard enough maybe, but why? You just treat the top of it, you decrease the reflux through it and you can come back with varythena. When it's that tortuous, even with the bent tip, it's, uh, it's not gonna make it through. So you know, putting it all together, her leg hurts, she's got a big reflexing vein. And we see that it's emanating from the anterior accessory sapulas. So let's treat that. So the, the plan was to treat the Treat the ASV and then if her symptoms worsen, then we do Veryena, which is what we end up doing afterwards. So how do you do it? Here's the setup. It all comes in a kit. It's easy. Has everything you need except the ultrasound machine. So you do it just like a great staff in Spain it's just quicker because it's a shorter segment. Prep the whole leg, prep the groin. You wanna make sure you prep high enough so that you can, you can see the common femoral vein. You can see the junction and make sure that you're far enough away. Drape the patient, drape the probe. You're gonna get ultrasound access. You're gonna use lidocaine. Place the sheath, place the catheter, do the temescent. Domestic anesthesia is very well tolerated. I, I think some people are scared of it, but I'd say maybe 1 out of 100 people have any issue at all. We give people Valium too, and they, they love that, but about 50% of them take it, half of them don't, and they do fine regardless. I'd probably want the Valium. Um, you treat it, put a bandage, and then they're gonna follow up within the next few days to get an ultrasound. In our practice, less, it's, it's definitely less than a 1% risk of any kind of E hit. I mean it, I mean, it's a fraction of a percent. And most of the time it resolves if you see it. So you can see our post ultrasound. Success. So you can see the vein is non-compressible. There's no flow. She felt great afterwards. We ended up doing the rest of that vein that you saw circling around her leg with Ver Athena. Um, I actually got a picture from her the other day, but I had to turn these slides in early. I mean her leg looks fantastic. I'll show it to y'all if you want just find me. Uh, she gave me permission. Uh, key takeaways, look beyond the GSV and SSV. Vein ablations are low risk. They're fun. They make people feel better. Don't be scared to do them. And then honestly, your rep. Is is a great resource both for building your practice and for doing your cases and uh I think they have a great group of people so if you got any questions let me know if you're new to the Venus space just do it it's fun thanks guys. Published Created by
Content on this site is intended for United States Healthcare Professionals Only
