Chapters Transcript Video Second Opinion- Superficial Treated, I Have Deep Concerns - Ray.mp4 Back to Symposium I was never scared to put in IVC filters, but I kinda am now, to be honest, so. This this is a fun one, OK? So, uh, the second opinion, OK, they've had their superficial veins treated, so maybe they have a deep problem. Let's figure it out. So what do you do when someone presents after prior superficial treatment somewhere else, but they've got continued or recurrent symptoms? You do the same thing you do for every patient. Good H&P, venous insufficiency study, and honestly, I also usually order an arterial duplex unless they have strongly palpable pedal pulses. So your H&P, what are their current symptoms? How long has it been going on? Did they have any improvement at all after their prior treatments? What's her physical exam show us? You ask them what treatments they had, but again, they rarely know and truthfully, the venous insufficiency study is gonna show us anyways, so I wouldn't waste too much time figuring that out. Have they had a venogram before? Have they had venous stenting? Have they had a filter? I mean, you can always get a KUB. It's a few bucks if there's any, if there's any concern, you know, it's a cheap study. And then where were they performed? That may not seem important, but if you practice long enough in a part of town and you find out who did some of their work, you, you can kinda have an idea. That there may be some some significant issues to expect. So for the clinical assessment you guys have seen this enough, but again you need it for your note and that's why I mention it. If you wanna get cases approved for venous ablations or venograms, you gotta list what their, their CAP as just honestly you just need the C, so you need to write it down and now they want you to put if it's A, B, or C, if it's C4. Something important, if somebody has a venous ulcer, it's healed. If it's C5 or C6, you rarely have problems getting approval, but you just always gotta put this in your note. So you know you're gonna repeat the venous insufficiency study and you gotta look at it yourself. You can't just get a report you don't wanna send it somewhere you need to look at the pictures. And again you gotta have a tech that you trust because especially in someone who's had prior procedures you might be treating tributary veins you might be treating very, you know, tortuous things you need to look at the pictures so that you can make a plan and you can get them approved for the appropriate things. Again, this is our protocol. The whole point is. You need a good protocol if you guys are starting something um I'll send that to you if you want, um, but you need to know you gotta tell somebody what to look for if you expect them to look for it. So, you got to look at the common femoral vein. You gotta look at all the deep veins. Is there evidence of prior DVT? Is there deep reflux? You're gonna see what veins are refluxing, what's been treated. You can see if there's a recurrence. So if you have a recurrence, uh, after treatment, you know, it's gonna be more torturous. You're gonna have to approach it in a different way. In general for your protocol, you want them to tell you any vein that's refluxing. Do you have to treat every single vein? No, but you have to look at the patient. You have to see what's hurting them. You have to see what the root, you know, what the root of their complaint is, and then you need to have those veins noted so that you can then address them and get them approved. So again, if you wanna treat somebody's veins, they gotta map it, they gotta have the size, they gotta tell you what it looks like. So both you can make a plan and you can get it approved for the appropriate thing. And again, the venous insufficiency study is gonna show you what they had done. Again, just look at the study, it's gonna tell you what you need. And the thing is, if they've had prior superficial treatments, and you don't see a lot of superficial veins that have recurred, but they've got significant leg swelling, history of DVT or really they had all their superficial veins ablated. And they're still not better, then maybe they need a venogram. So here's our clinical case. 37-year-old female, she presents. She recently moved to town. 9 years ago, she'd had a DVT in her left leg. She's had significant intentional weight loss and despite that she just has worsening pain in her leg. She really, she does CrossFit, she just really can't do it afterwards her legs hurt. She's wearing compression, but it's just not helping. She's getting worse and despite somebody you know working on her, it never really made any difference. She had a prior hematology workup and it was negative. Um, as far as her past medical history, she's got 2+ pedal pulses. She's got varicose veins in the left leg and then significant edema on the left leg, but not the right. So, 2nd opinion patient, I was 20 minutes late. Do you all think she was mad? Of course she was mad They're, they're usually when you see the second opinion patients, uh, you still need to do a thorough evaluation and don't let your, you know, preconceptions, uh, you know, harm your evaluation of them. They're frustrated because they've already seen somebody they didn't make any difference. Now you walk in late, they think, oh jeez, why am I at this guy's place? You know, I think I was the 4th person that she'd seen. So, I'd be mad too. So we got our venous insufficiency study. Somebody had done GSV ablations, OK? But what we saw is that she had significant deep reflux in her left common femoral vein, and she had evidence of an old, old DVT in the femoral vein. You can look at the pictures here, so a lot of reflux in the femoral vein. And then the GSV in the calf also had some reflux, a little bit in the small, but it's her whole leg is hurting, right? Evidence of prior DVT. Of course, she has some small saphenous reflux and some reflux below the knee, but her, her symptoms are really the entire leg. So you gotta think, what do you wanna do? I mean, in this case, history of a DVT has had prior venous ablations that made no difference. I think it's time to do a venogram. Cause it's really just the left leg. She had bilateral superficial reflux, so. Looking at all of that, we decided to do a vinegar. And things that really push you to do a venogram is, especially somebody with a prior DVT, somebody who has deep reflux, somebody that has symptoms that didn't improve with superficial things, or really somebody you've treated their superficial veins, they come back a few years later and they just have worsening, like significant recurrence of vein, like, uh, superficial veins. So you're concerned that you just have like a very pressurized deep system. So in this case, I had plenty of reasons to do a venogram, so we decided to do it. And then if she didn't get better, we said we'd treat some of the other veins if it didn't completely fix her. So for venogram, different approaches. The main thing is here she had superficial femoral vein, uh, Prior DBT, so honestly, usually we go bilateral popliteal vein access on everybody, um. Bilateral lower extremity venogram, IVC venogram, and then II from both sides. The thing is, it's a vein, right? You can put an aid to 10 front sheath. You're using ultrasound, right? I mean, the truthfully, the risk of accessing a vein and putting a 10 front sheath is nothing. It's low, right? If you visualize it, I do a micropuncture. I take a little venogram, I'm happy. I watch the needle go in. I mean, I try to be cautious because I don't wanna cause problems, but you don't see problems with this. At the end, I take like a 30 monocryl, so an absorbable suture, so I don't have to take it out. I just put like a U stitch, pull it out, tie it down, hold pressure for a couple of minutes, wrap their legs, send them to the recovery, they go home in like an hour. So, low risk. Can we play these? So I access uh. Uh Where's the mouse? I see the mouse on the other side over there. Oh, there we go, look at that. Is it working? Perfect. OK, so if you look at this, uh, at the micropuncture in in the far left, if you look, you can see and, can you play the far left one? So if you look at that, you see an abnormality in the femoral vein. You can kind of see like a little bit of a line. And that's her chronic, that's her chronic DVT. So the thing with DVTs is they usually, your body breaks a lot of it up, but you get some. You know, post thrombotic changes. So go to the next one. This is just higher in the leg. You can see it. It's kind of slow emptying from her leg. OK, next one. And this kind of highlights the importance of IIS. So you can see there's some narrowing, right? You don't see a lot of collateralization, but you can see that it empties pretty slow. So watch out one more time. You can see it's a little bit slow, so go to the next slide, so now we'll look at the other leg, we'll see. Oh, my bad. It's not going. Oh, look at that. So if I click it now, is it gonna play the video? Oh my God. I'm not a good PowerPoint guy, sorry. I don't think I've made one since I was in residency, so, so if you look at the right side, uh, here, let's see if it goes. So if you look at the right here. You see how briskly it uh it empties. Like, watch this. I mean it flies through there if you compare the two. I mean, that's vastly different, right? But the point is if you're doing Venus cases, you gotta do Ibis, gotta do it. So what do we see? Left versus right, so you see some. Non-occlusive postthrombotic changes. You can see them highlighted in that representative, uh, image. You can see delayed emptying in the venous in the veins of the left leg. You can see some left iliac narrowing, but we really got to do IVIS to make the final call. Oh man. So just to pull back, so that's the right leg. Uh, actually, no, they switched my slides around, so that's the left leg. So here's a pullback. So you're in the IVC you pull back. Yeah, this is, you can see there's a very significant compression. You can actually see the artery overlying it. It's pretty cool. And then I think the other one is actually the wrong. The wrong image Basically, the thing is on her right, everything was completely normal. No, no significant compression, and somehow this got put on here twice. The point is, though, if you watch one more time for the. For the left side, just watch it pull back, so you're in the IVC. Again, the orientation based on the catheter, you can see it gets significantly compressed, and you can again see the pulsating artery above it. So then you can see the vein open up to like a normal size. So this is, you know, classic May Turner, and it's honestly probably what led to her DVT so many years ago, and she just never really had a thorough workup. So we ended up using a Lenovo. And hopefully, this has the right picture now. We'll see. Oh baby, look at that. All right. So, excellent uh expansion, good wall acquisition. And. Completion venogram. It's just ripping through there. So you can see, you know, whenever you look at it, you really don't see, um, you can see that's not covering the other side. Honestly, that's why I always do bilateral access. I don't really want it hanging out there. And the other nice thing is if you have bilateral access, again it's a vein, it's low risk. If you end up, it ends up encroaching into the IVC too much. You can just put a stent up the other side. If you need to raise the bifurcation, you can. You're not worried about trying to cross stent inter interstices and things. It's just trying to make your life easy. So, key takeaways, prior treatment doesn't mean somebody did it right, doesn't mean they don't have disease now, doesn't mean that they even did a thorough workup. So do what you normally do. Um, venograms again, venous cases overall it's low risk high reward, uh, you gotta use IIS. And then if you're interested in doing this stuff, BD has an excellent team to help you grow your practice, and we also do courses for deep and superficial venous stuff if you guys are ever interested in doing it. Published Created by
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