Chapters Transcript Video Q&A and Closing Remarks Back to Symposium Alright, we're gonna have the members of our esteemed faculty that are still here. There are 5 of them left. Unfortunately, 2 had to race off to the airport to try and beat Snowmageddon to the east coast. Um, so we're gonna do a question and answer. We'll walk around with the microphones. If you have a question, please feel free to raise your hand or just grab our attention. Um, if you all have a question for each other based on what you saw, please have a discussion, and then right after this, I'm gonna do one last, uh. Uh, housekeeping slide, and then we'll head to lunch. So, uh, what, uh, brand of superficial laser is that? So it's, uh, can you guys hear me? Yeah, it's, uh, Cyon, which is, uh, US made, uh, in California, and it's, I again, I'm, I'm a speaker for them, so there's a bias there, but I truly, truly believe that it is the Bentley of lasers out there. I mean the, the technology is, is absolutely amazing that one's. Specifically that I use is uh uh 1064 nanometer wavelength which is uh vascular specific but um I don't necessarily use it for like I still think uh I'm sure I mean sclerotherapy is the gold standard for aesthetics but um I do feel that there's a role for it especially when there's not. You know all of that extensive disease that sometimes we see superficially, but it has allowed me to do all other sorts of, uh, vein treatments. I'm doing vascular malformations. I'm doing even just small venous lakes and dry veins is like the most satisfying thing to do. So it's, it's just nice to have that kind of a tool and you do trainings, yeah, yeah, yeah, to come to Florida. Yeah, sweet, yep. Anyone in the audience? Was anyone else scared by some of those IVC filter videos? Oh man, that's, uh, yeah. Um, I have a, I, I have a question for these panelists here. Um, so in a patient who has ulcer disease, venous ulcer disease, but who either has chronic infra inguinal DVT or unreconstructible. Iliofemoral DVT with chronic occlusion, how will you treat the superficial disease and will you treat the superficial disease and what does that conversation look like? They have a wound or they don't. They have a wound. I'm, I'm a, I go low hanging fruit first. It depends on chronicity. It depends on the size of the wound. I think some of these superficial wounds that if you ablate the, the inflow or the perforators that are right near it, I, I think you can interrupt and, and you reach that threshold of venous hypertension, and they can heal. Recalcitrant disease is a different story than we're talking about reconstructing the deep system. And I, I really, I, I believe that Venus patients, it's shared decision making. So everything that I talk about with them is a lot of conversations about what to expect. Um, this may not work, this may not be enough. We may have to do more things. So I think it's doing that. It allows me to do, I think the easiest thing first and allows them to buy into if things need to then progress they're ready for it. Yeah, I'm, I'm more selective in, in the the superficial ablations I'll do usually they get a venogram first, see if you can improve something. But I, I mean, I'll be, I'll be very limited in what I treat. I do think you can do the perforators and, um, you know, straightforward ablations on a blood thinner in those patients in the setting of a wound, um, or a limited like ultrasound guided sclero under the wound, but I do think you need to recognize the risk you're in and bring them back for follow-up ultrasound and be more conservative. And I don't take them off for the big varicose veins and things like that. Thank you, um, I have a question for you like uh as you know, um, Mae Turner anatomy is pretty common, uh, but Mae Turner syndrome, uh, you know, may have a difference for you. I, I wonder what, what is your decision making process for you to decide on putting a stand on patient with Mae Turner syndrome? how would you consider that aside from the obvious patient that has, uh, an ulcer. So, so in, in my practice, um, I treat, I would say on the minority, uh, May Thurner patients. Um, mostly I do post-thrombotic patients. Um, May Turner, you have to really convince me. I, I'm only going to treat it if it's at least 80% or higher. It's unilateral. Um, in my opinion, May 3rdner can't cause an ulcer. Um, I've not seen that happen. Um, so, you know, I check those patients for. Superficial disease, I check them for, you know, how bad is the iliac. I get CTs, I get duplex ultrasounds, I get reflex studies. Um, often I try those, uh, you know, if there's anything superficial that's being treated first. Um, if the patient has, you know, thigh swelling or whole calf swelling, also pretty rare to have that just from a Maurner. Um, so those patients, I try them on the veno active meds, I tried compression, I tried lymphatic. Pumps, um, because what I don't want to happen is treat a May Turner and have them say, oh, I'm no better, and then I'm trying the pumps and the other stuff. So I want to make sure that I've tried everything so that, and I warn them like, hey, you're in a kind of iffy category if we do this, you know, it's, it's kind of 50/50. Like it's 60% blockage, uh, in the, uh, video trial. Only half of those patients improved. That's why that was the threshold, but half didn't. Um, and then in the operating room, I do breathing maneuvers. Um, my patients are generally asleep because I do more complex work, so I have anesthesia there. Um, so for them, it's, um, you know, Valsalva. If your patient's awake, you have to do Valsalva and breath hold. Sometimes they'll solve that patients use their abdominal muscles and they collapse the cava. And so you'll think you're seeing something you're not. So I do both maneuvers if they're awake, um, and make sure that it doesn't just pop open. If it pops open, that's a normal compliant vein. That's not a scarred, you know, pathologic vein. Yeah, I'll, I'll echo that. I, I think it's really important to avoid the ocular stent reflex, right? So just because you see it, um, especially as an interventional radiologist, you know, I see a ton of patients who've got portal vein thrombosis, cirrhosis, uterine fibroids, and they. Their iliac veins are compressed completely asymptomatic, has nothing to do with why they're seeing me. So we see it all the time, just like a renal vein stenosis. I see it all the time in patients who do not have nutcracker, um, so really, you know, I think in the arterial world we say a claudicin has to beg you for an intervention to some degree. I think a May Thurner patient almost has to, you know, really make an argument why this is the thing that is causing my life to be, um, affected. Yeah I mean if they have a, I think you ask a great question because that's a tough one for us too you know if somebody has a DVT I'm more likely to do a venogram and look for whatever the root cause was like in the patient that I showed, um. Young patient, even if I see it, truthfully, uh, if they have a lot of varicose veins, I'm gonna treat their superficial veins and see if it improves them. If you have, I mean, I have patients that are 2025, I mean, even if it, you know, 8 years, the patency of the stent is 91% for a non-occlusive lesion. They have 60 years left to live, right? So I'm very selective in, in the people that I do venous stenting on because I mean is it 40% of people have, uh, May Turner's OCT? 30 I think yeah, it's a massive percent of people have it but don't have symptoms. I just wanna add one thing that complicates, at least in our system, patient centric, uh, radiology reports are now available, so a patient will say, I know what's wrong with me. Look at the CT scan. I have nutcracker syndrome. I have May Thurner syndrome, right? And I think the most powerful slide that we saw was the one that was in 1958 when they said women that present with these are. Histrionic and all these type of things, a lot of people have been in chronic pain for so long they're looking for an answer, and they do tend to push. So I think that kind of conversation is, is challenging to have with them and saying I don't think it's this for these reasons, but it's always a challenge, you know what can be more challenging I feel because I do do see quite a bit of those are the ones who, and unfortunately in Florida, I don't know how it is here or where you guys are, but it's like the wild west. So like we'll get a ton of patients who have had stents placed for no good reason and and that is I mean it's just really really hard to see um because you know potentially you know they literally symptoms did absolutely nothing patients who are not evaluated well their symptoms were coming clearly from a superficial system they could have saved themselves from from that stent and so um that that is even harder so. Uh, the patient education and for sure those that come like almost demanding it because yeah it's patients that are unfortunately are sometimes in desperate situations from pain and discomfort and, uh, life altering kind of situations but but we gotta be very judicious in our decision making. It is very, very important. And uh I think you hinted on it. You hinted about it earlier, is it is a lot harder to cross an occluded venous stent than it is to cross a native occluded venous lesion, and I don't know if it's the vein size or what. I mean, that's why you're using 4 layers of, you know, catheters and things, but you really wanna make sure that you've exhausted other things before you do these things, especially in somebody who's young. Now somebody comes in with an ileofemoral DVT. You do a thrombectomy, you're gonna I us afterwards, uh, they're getting a stent, right? I mean, I'm not. And they, and they do great. But there's some argument, you know, well, I'll see an outpatient and do it, but the problem is if you're lucky, like we have a great nurse practitioner, we have a great nurse, we send everything every day when we're round to get follow up set up while they're still in the hospital, you still lose 50% of people at least that never follow up, right? And then they just come back worse at some point. So in my experience stenting it at the time of the thrombectomy, they do great. You had a question on the table. I had a question. I was gonna ask Doctor Haskell, but maybe one of you about pelvic congestion, and I've had a mentor tell me, uh. Uh, initially, when you, uh, cannulate the gonadal vein or ovarian vein, and you shoot your venogram, um, before, uh, my theory was if it refluxed or cross-filled or went down and filled the pelvis, and they had symptoms, you know, obviously, uh, that you embolize it, but I had a mentor tell me that actually if it washes out very fast and crossfills the other side, that that may be a collateral outflow for the kidney potentially in a nutcracker syndrome, but I find that kind of. Hard to believe, given they were devoid of any nutcracker syndrome, no hematuria, no flank pain or anything like that. So, I guess now in my practice, I shoot the dye. If it's not going down at all in the pelvis, then they likely, that's probably not the cause of their symptoms. If it is going down the pelvis and sitting there, I've been embolizing it. But in the situation where I've had fast washout and cross to the other side, and they do have either an ibis or on balloon occlusion, whatever a technique you use to evaluate the renal vein, have any sort of compression, I've been a little bit more hesitant. About embolizing the ovarian vein, does that make, does that make sense, or can you even talk about that thought process? Yeah, I mean, so the first thing to realize is when you're doing your procedure that's not physiologic, right? The patient is completely uh supine, um, that does not represent their symptoms and so I think it's a little bit hard to use the hemodynamics on the table to make decisions um, that said, I don't necessarily um. If the patient has symptoms and they have reflux, the degree of washout does not influence my decision to embolize. Um, that's kind of the same conversation I was trying to, I was starting to have about. Superficial veins in the setting of DVT, the argument is don't ablate them. The patient doesn't have a deep system. But then the other argument is, right, but it's refluxing. It's not really contributing to venous return that much anyway. What it's, it's not working. And so that's sort of how I think about gonadal, that it's not working anyway, um, especially if the patient doesn't have a nutcracker physiology symptom. Um, so I would have no hesitation to embolize it, but I don't know if anyone feels differently about that. I think it's interesting. I have a partner of mine that, that will do the ovarian that they, he has a pullback. Pressure that he'll check the pressure in the renal vein. He will then embolize and he checks the pressure again and it never changes. I mean, I think I really do believe that the, the spectrum goes from pelvic or I should say from nutcracker syndrome and that kind of venous hypertension in the kidney, flank pain, hematuria, things like that, and I think it decompresses through the ovarian, the iolumbar, and then up into the adrenal, and I think the ovarian vein is an important conduit, but there's certainly other outflows of the kidney. I mean we routinely during an aortic aneurysm ligate the left renal vein without any problems um so that's the one thing I'm, I'm very aggressive about and these poor people come in and they've had their uterus out they've had their ovaries out, they've had endometriosis, you know, all these different, these different, uh, diagnoses and a lot of them are just suffering from significant pelvic congestion so I, I'm pretty aggressive about that and I think that. The comments about sandwich technique and about foam sclero therapy, I think is right on too. Perfect. Thank you. I, uh, I agree. I thought it was a little bit too nuanced and I'm like this person has no symptoms of nutcracker, etc. So thank you. At least in Texas you're in San Antonio, right? I mean, uh, maybe it's in Houston. It is hard to get it approved everywhere. It is extremely hard. I had a lady I did fixed all of her symptoms, right, but then it got rejected for payment. They only paid for the venogram. But uh she was so happy she was like yeah whatever but the the point is they wanted uh her insurance it was like Blue Cross I mean it was some it was a good insurance said that she had to have a laparoscopy before they would pay for it, which is crazy, right, a diagnostic laparoscopy. Yeah, so I've referred patients who, um, who have had hysterectomies for this. Like that's crazy, right? The whole thing's crazy, but they do have, um, Gloria Salzar, Ron Whitaker, they're running, uh, um, I think Cushate are running the Embolize trial. You guys are familiar, um, so that, uh, they've started enrolling. Uh, it was a slow uptake, but, um, hopefully, you know, it's, it's 40 patients, it's double blind, it's well funded. Um, so hopefully that'll make us, you know, some room with some of these insurance companies because they'll just say experimental, um, so I don't know how they're gonna say experimental when we give them randomized control double blind, you know, trial. I don't know. The one thing that's helped me is, uh, I mean, it's a he'll find a way, I mean, it's a venogram, so it's pretty low risk overall, is I'll just take them for a diagnostic, and then if it's positive, I'll get it approved for the embolization, and then I'll bring them back. Have you found that when you say you'll start treating pelvic congestion or Nutcracker or May Thurner that all of a sudden you are flooded with patients? Yeah, there's Facebook groups. Yes, yes, absolutely, yeah, uh, pots, beware, uh, yeah, I think I've made it onto one. All right. Are there any other questions? I'm trying to keep you all. Thank you all so much. Can you put 7 back down please? I got it. Thank you. Sorry. Um, so I want to thank all of you up here. We really appreciate your time, uh, all the information that you gave all of us. I learned a ton, um, just going through all of your decks. It was amazing to be able to go through all of it. Published Created by
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