Chapters Transcript Video Combined Venous Disease and when-how do I treat Back to Symposium So, um, Lina Vargas. I'm a vascular surgeon, and I have a private practice in Windermere, Florida, and I have the honor of actually presenting a case of a combined superficial and deep treatment from Doctor Armstrong who unfortunately cannot join us here for a personal reason and then at the end I'm gonna get to share a little bit of my insights on the specifics of my practice as we dive into practice development, which is something that I think a lot of you are interested, so. Uh, these are my disclosures. Um, again, this is a case, uh, of a patient of Doctor Armstrong, and this is what I got from him. He was treating a 78 year old male who had a history of a complex left hip replacement. His, his initial surgery was complicated with an ipsilateral DVT. He that was treated with standard anticoagulations anticoagulation with oral medications for 3 months. Unfortunately he did go on to require another hip replacement that was complicated, needed some local uh reconstruction. And after that, the patient, uh, Doctor Armstrong was following him long term. He noticed that he started developing worsening swelling of both legs but definitely worse on the left, uh, but he also started having some chronic changes of the skin as we noticed with deeper superficial venous insufficiency, lipodermatosclerosis, thickening of the skin, and eventually unfortunately progressed to developing an ulcer on the distal lip lower extremity. So again, like we've heard multiple times today, it is really important to do a thorough evaluation starting with the patient's history, do a, a physical examination and of course a really high quality venous ultrasound that allows you to really see what's going on, maybe initially just with the superficial system, but I would say definitely in patients who have that level of advanced disease and ulcer, it is always a good idea to start thinking about the deep system from the get go, someone with that history of a hip. Reconstruction that's very, very important. So I don't have any ultrasound images available, but he reported that the patient had, uh, reflux of both the deep system, uh, the great saphenous vein on the left, as well as uh an incompetent and patent perforator in the area, um, around the ulceration. These are the images uh that I have available so he has, uh, reference images as you can see as well as, uh, evidence of significant compression of both common iliac veins. So he brought him to, uh, the cath lab essentially to do a venogram, which is, you know, it doesn't really tell us much except for that sort of like kink or compression or stenosis on that left, uh, common femoral vein as you can see. And he proceeded during that index procedure to do stents of. Uh, stents of both common iliac veins as he deemed these were necessary to alleviate his symptoms, the patient's symptoms. So then, as you can see on this venogram, unfortunately these are all static images. There's, uh, adequately placed stents on both common iliac veins, but there is that still that area around the left common femoral vein that he, um. Was not very excited to treat with a stent again I know there's some hesitation out there so he just angioplasty and you know was hoping that you know hopefully this would make a difference for the patient. Unfortunately, the patient continued to have issues, a non-healing ulcer and ongoing swelling left on the right, on the left, sorry, so he decided to treat him back thinking that this lesion was probably causing issues. Angioplasty alone had not done it, so on a second, uh, intervention he decides to extend with a de novo stent across that common femoral vein, and I think thankfully at this point we should all be comfortable, uh, with that understanding that these. Stents are actually OK and safe to place into the common femoral vein like we've heard earlier today we need to make sure that we what really matters most to me for example is just making sure that we have good inflow whether from your profunda, your, uh, superficial femoral or both, um, but sometimes if you have a lesion that is significant even down across the inguinal ligament, it is important that we treat that angioplasty alone is probably not gonna cut it, so this really made a difference, um. Treating his deep uh system was very, very important, but again this is we're talking about someone who has advanced disease C6 with chronic changes, significant swelling, uh, this is someone you can potentially follow long term and kind of see what how they're gonna do about that deep, you know, after that deep intervention but I think having a low threshold, especially if your ultrasound shows you. That your superficial insufficiency is just not it's it's not insignificant like it is significant it's a large vein you have long time of reflux you should probably have a low threshold of go ahead and just treating that. Close to if not immediately following uh your deep venous treating uh system. So these are some of the ultrasound images that we have and so as you can see his left great saphenous vein is about as we go down you'll see it's 7 millimeters 6 about 6. 5 or greater and he has about 8.8 seconds, 0.6 seconds as we move down into the uh mid-thigh and then above the knee still 0.6 seconds of reflux. So this is something that is significant on someone who continues having an open wound. This is very important to treat so. He proceeds to do a um ablation of his incompetent right grade saphenous vein with the vein closed device, radio frequency ablation. He accessed above the knee or around the proximal calf area, which is, I absolutely agree with that. It is my personal preference to do combination of treatment. I like to stay right at the knee or above for my thermal ablation, and then I continue in the distal aspect with, uh, chemical ablation with Baritina. In this patient who has a patent perforator that is incompetent in the area of this wound, you have to treat that perforator. I see patients getting treatment of perforators for a lot, you know, not indicated, but in a patient where you have an ulcer, you have those skin changes, you know that patient is at risk of progressing to a wound you definitely need to make sure that you are addressing that instead of waiting a lot of time to see if what you've done so far is going to be helpful. So I, uh, do my perforators as well with. The MAVE device, um, like Erin said, this, there's, um, a learning curve, but it's actually not very steep, but I personally have had great experience using this catheter to close these incompetent perforators in patients with advanced C4, C5, definitely C6 disease. So this patient, of course, wants to treat everything that is significant. The chances of them not improving are extremely extremely low and what is very satisfying is actually these patients start turning the corner relatively fast. He reported to us that this patient actually had. Um, started that wound started turning the corner within 3 weeks. Sometimes we even see it sooner once you address all of those issues that are driving that increased pressure in that area, you're going to start seeing changes, and this is essential to make sure that we change the patient's life with this treatment, so. Really, really good case that I think uh makes us think about when we go with superficial first, when we go with deep first, and I think there's not a right or wrong answer but every patient is different and we cannot have a cookie cutter approach. We need to take every patient individually and gotta figure out what's more significant is it the superficial? I mean sometimes we'll have patients at the superficial system, yeah, sure they have some reflux, but it's not significant. Don't spend a lot of time on that. You can always come back to that, but some patients are just screaming deep vein reflux obstruction. Those patients need to be addressed from that standpoint first. Majority of patients are gonna be a superficial first. That's low hanging fruit, but please, please, please do not ignore those that are screaming deep insufficiency. So that's the case that I go to share with you guys. I hope we can get to talk about it a little bit more now. We're Gonna switch gears to more of the practice development and this gets me very, very excited because I think um you know we all have so many different practices some of our some of us are vascular surgeons we have interventional radiologists I know we have uh vein specialists from. Cardiology backgrounds nowadays we even see, you know, just family doctors emergency doctors kinda like diving into this and I think that there is enough space for all of us, but we need to make sure that we are doing things right, that education is at the forefront of what we do and so, uh, my history is kinda like a little different. I trained at Cleveland Clinic. I used to practice a whole spectrum of vascular surgery. Um, initially at Duke after I graduated from Cleveland Clinic and then when I moved to Orlando again, just general vascular surgeon doing absolutely everything and I was dealing with a little bit of frustration with administration at the same time my husband is a spine surgeon, he's really busy, we have two little girls and it was my goal. To try to find a better work-life balance and so at that point I decided screw the hospital. I don't wanna do this anymore. I wanna go on my own. I wanna be my own boss. So if any of you guys are feeling that way and you can do it, I would highly encourage that. So I decided to quit back in 2018. I opened my practice. I've been my own boss since 2018. I have not taken calls since then. I do not answer phone calls after 4 p.m. They just don't come through, so it is possible and it is incredibly satisfying. So you know I decided to open this beautiful clinic and I built an OBL and I was just kind of waiting for the numbers to justify getting the CARM table, getting, you know, the CR and the tech and the nurses and the beds for recovery and guess what happened in 2020, yes, so we never really got to see those numbers make it up there to justify the investment. But what happened was actually pretty cool is that things from the aesthetic standpoint and again just being a female I've always even when I was in the hospital and couldn't do sclerotherapy I was really, really hoping to be able to do that for my patients because that's what they were asking that was one of the reasons why I wanted to kind of like go on my own anyways but in in starting to be someone who is not only treating bad. Vascular disease from the medical standpoint but also from an aesthetic standpoint it was very important for me to have a laser that allowed me to do transdermal treatments of vascular lesions so that's kind of my segue into aesthetics and this has grown and taken off in ways that I would have never imagined. So it's all about kind of like listening to those signs that life is throwing at you, uh, but it's been really, really cool because, um, it has allowed me to kind of like. Completely transitioned my practice where you know I had patients who were patients of my old practice and they were having sclero therapy by some of my partners and they were like we never want to go back there because we don't want to be in the same waiting room with the patient who has a gangrenous leg and. That's valid. I may not necessarily agree with that, but there are some patients who are, you know, the, the main patients can be a little different, and if that's kind of what you decide to do, then, you know, for me it was necessary to rebrand and just kind of like reimagine the space to be more aesthetically pleasing, not necessarily as medical. I got rid of the fishbowl reception kind of thing that we had going on at some point, so. This completely kinda like shifted gears we had to make lots of adjustments. I'm not gonna dive too much into this for the sake of time but essentially the way we approach things is I have been able to kinda like shift most of the aesthetics to my PA who is also from she comes from the vascular world which is amazing. I still want to do the veins. I'm still a vascular surgeon who is very passionate about sitting down with all my patients and understanding their history and taking the time to understand not only their symptoms but their motivation, their lifestyle, what they're doing, how this is impacting them. And this is what I get to do. So my approach is, you know, we'll, we'll see them potentially do an ultrasound on a first or second visit, talk about lots of education, lots of, um, just the importance of conservative measures, even though I don't necessarily love compression stockings. I do feel there's a role for them. Um, we do majority of our patients, I would definitely say they are superficial. I still. Have privileges and I still do some of the the procedures in the hospital but every day I'm kinda like staying away from that, not because I don't want to unfortunately it doesn't make sense to me financially to go to the hospital and get pennies for all the time that I spend doing those cases and the time that it takes me takes me so but I, I, you know, thankfully in Orlando I have great referral, uh, people and they take care of my patients exactly how I would take care of them so. I'm focusing mostly on treatment of superficial, uh, veins, and a lot of my patients do cross over, so I get patients who come from aesthetics and they end up transitioning to aesthetics and vice versa. Get patients who come for aesthetics and they're like, oh my gosh, you guys are amazing. Uh, my mom has horrible varicose veins. She once saw this doctor, she didn't like him at all. She, he didn't care. I'm definitely bringing them to you so we get lots of referrals just from family members, friends, definitely lots of local doctors and just creating those relationships is very important for those of you wanting to try to do this on their on your own it's possible and just build a strong network so. The other thing that I think it's important to share for any of you wanting to try to do this this way is um it's very important to get comfortable with um having conversations about financing or paying out of pocket so I always say that um my dream when I grow up is um I want to completely get rid of insurance companies. I hate them viscerally I don't want to deal with them. And my dream is that one day I'm gonna be say if you want me to do your veins, you're gonna have to pay for them. Um, just like plastic surgeons and dentists do nowadays, unfortunately we are in a situation where we are getting crushed by insurance companies, and it is not fair for me as a business owner aside from a vascular surgeon and physician that I have to put all the risk and the investment up front with my staff, my lease, my devices, my catheters, my all of that, and then have to pray that insurance companies are gonna pay me back, so. We are physicians we're not comfortable having that conversation those conversations, but if you are in a place where you have a private practice, please start having these conversations and getting comfortable because actually patients appreciate it. Uh, sometimes patients don't want to wait months for insurance to say, OK, you tried compression. Oh, you know, OK, I'm going to approve this. We're gonna do one vein at a time now. You have to only do your GSV or your or your SSV. Choose, or you can only do RF, but you cannot do our thing. I mean, bullshit. Like that is not what we were taught in vascular surgery training. Like this is not what we're supposed to do. This is not right for patients. And so I am. Very honest with them and if I have a patient who their insurance is not going to cover, I'm gonna tell them, listen. These are the options and we have financing options and we have all of these things just to make it work for them. But um it is very, very important that you do this if you have a private practice. The other part that is, uh, important, obviously photography is very important, I think even more so for when there's aesthetics and then when there's cash, uh, cash uh based payments, um, it is very, very important. But even as we were hearing before, I mean we're all human beings, we literally forget. I, I'm sure we've all had the patients who have the massive varicose veins. We're like how could you ever forget that you had that for like. A ton of time, like years, and then they're like, oh yeah, I don't know, you know, I'm, I'm still kind of feeling the same. I'm like. Yeah That thing is gone and you're not gonna tell me you're not better and you're not excited with these results so that part is very, very important, um, again if you have a private practice really really investing in or or setting it up so that you can sell products, you can sell stockings. I sell Dermaca. I don't know how many of you are familiar with Dermaca but I absolutely love it, um, just selling that because you are going to get a 50%, at least 50% profit margin for that and for a private practice that is absolutely key. Um, and then again just for me personally and professionally this had allowed this has allowed me to really continue practicing medicine, continue being a vascular surgeon who cares deeply about the patients that can change lives, but I can do it in a way that is, um. Personally, like very successful. I have beautiful relationships with my patients and again my goal is to try to step away from depending from insurance as much as I can as I as quickly as I can. So, um, this is a very, very powerful combination and I literally as much as I miss doing carotids and I miss aneurysms, I definitely don't miss PAD as much. I'm gonna confess. Um, but, uh, I wouldn't trade any of what I have and what I've built in my independence and what I bring to the table in terms of changing patient's life for any of that. So for any of you guys who are interested in learning, you know, more vein disease. And that aesthetic part, you know, I do lots of preceptorships and trainings at my clinic. Uh, we do have the business portion of it integrated as well. So if you guys are on social media and you wanna scan the QR code, let's connect. If not, I'll be happy to share my information, my phone number with you, and, uh, talk some more offline. Thank you. Published Created by
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