Patient assessment and strategy making for

endovenous treatment Raghu Kolluri, MD

Director – Vascular Medicine OhioHealth | Riverside Methodist Hospital

Columbus, OH

Disclosures

•  Current – Medtronic – Consultant/ Speaker – Bard – Data Safety Committee – Cook – Consultant – Volcano – Consultant – Boston Scientific – Consultant/ Speaker

Vascular Lab in venous disease

J Vasc Surg 2011;53:2S-48S

Clinical Evaluation

Grade Clinical examination 1 A CEAP classification 1 A

Venous Clinical Severity Score (VCSS) is used for assessment of clinical outcome after therapy

1 B

J Vasc Surg 2011;53:2S-48S

Saphenous System

J. Vasc. Surg, 2002 ; 36:416-22

Small

Anterior Accessory Saphenous vein

Posterior Accessory Saphenous vein

Anatomy

IGV – Inferior Gluteal VeinCV – Circumflex Vein (Post thigh)ScP – Sciatic PerforatorIV – Intersaphenous vein

Small Saphenous System

J. Vasc. Surg, 2002 ; 36:416-22

Perforators

Non-Saphenous/ Pelvic Varicosities

Vascular Lab

•  DVT - Acute/ Chronic •  Evidence of Iliac Vein Obstruction •  Superficial Thrombosis

– Acute Vs Chronic •  Info regarding recanalization (Rx Decision -

Ablation Vs Foam)

•  Reflux – Deep, Superficial, Perforator •  Vein Map

GSV

Augmentation

Reflux

Augmentation

No Reflux

SFJ Tributaries •  SE – Superficial

Epigastric (Land mark for ablative therapies)

•  SEP – Superficial External Pudendal

•  SCI – Superficial Circumflex Iliac

AASV

PASV

ILIAC OCCLUSION

Fowler et al, JVU 38(1):34–40, 2014

CEAP Classification •  “C” = Clinical •  C0 - no visible venous disease •  C1 - telangiectasias or reticular veins •  C2 - varicose veins •  C3 - edema •  C4 - skin changes without ulceration •  C5 - skin changes with healed ulceration •  C6 - skin changes with active ulceration •  “E” = Etiology (primary vs. secondary) •  “A” = Anatomy (defines location of disease within •  (superficial, deep and perforating venous systems) •  “P” = Pathophysiology (reflux, obstruction, or both)

Compression Rx

J Vasc Surg 2011;53:2S-48S

Endothermal ablations

J Vasc Surg 2011;53:2S-48S

New technologies •  Thermal Vs Non Thermal

Adjunctive Therapies •  Foam Vs Phlebectomy •  Simultaneous Vs Staged

Simple Decision Making

•  Signs/ Symptoms + or Cosmetic improvement

•  GSV/SSV reflux •  GSV/SSV anatomy – Straight,

adequate depth and no tributary reflux

Ablation +/- Compression Rx

Simple Decision Making •  Venous Hemorrhage •  GSV reflux •  GSV anatomy – Straight,

adequate depth + tributary reflux in calf

Ablation + Sclerotherapy+ Compression Rx

Simple Decision Making •  No GSV/ SSV Reflux or

Post saphenous or other large varix Rx

•  Has reticular veins/ telangectasias and seeks cosmetic Rx

•  Sclero (liquid/ foam – Visual or US guided

Simple Decision Making •  Aneurysmal

superficial venous disease

•  Recommend surgery

AASV

GSV

Perforator Ablation Grade

Against selective treatment of incompetent perforating veins in patients with simple varicose veins (CEAP class C2)

1 B

For treatment of “pathologic” perforating veins, - subfascial endoscopic perforating vein surgery, ultrasonographically guided sclerotherapy, or thermal ablations.

2 C

Tech Vasc Interv Radiol 2014 Jun; 17(2):132-8.

J Vasc Surg 2011;53:2S-48S

Complex situations

No junctional reflux •  Severe

lipodermatosclerosis •  Severe pain •  No IVC/ Iliac

obstruction •  +/- Obesity •  +/- OSA •  +/- Elevated central

venous pressure

•  ? Sclero +/- Ablation

Complex

•  53 yr old male with bilateral ankle ulcers

•  Left GSV ablation last yr did not help

GSV Reflux, proximal aneurysm

Pelvic Collaterals

Deep Vein Reflux “Physiologic reversal” of perforator into a competent AASV

IVC Atresia, Iliac veins absent, prominent Azygous / Hemiazygous

Summary – 1st visit •  Is this venous disease? •  Type of presentation •  Differential Diagnosis •  Concomitant medical issues that influence outcomes of

venous treatments –  Iliac obstruction –  Right Heart Failure and OSA –  Obesity –  Liver Disease –  Thyroid Disease –  Kidney dysfunction –  Neuropathic pain –  Arterial disease

•  Formulate a plan: Non-inv/ compression therapy recs for 6-12 weeks

Thank you

Patient assessment and strategy making for

endovenous treatment Raghu Kolluri, MD

Director – Vascular Medicine OhioHealth | Riverside Methodist Hospital

Columbus, OH