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Treatment failures after successful GSV ablation- Root cause analysis and management Raghu Kolluri, MD, Director – Vascular Medicine OhioHealth | Riverside Methodist Hospital Columbus, OH

Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

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Page 1: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

Treatment failures after successful GSV ablation- Root

cause analysis and management

Raghu Kolluri, MD, Director – Vascular Medicine

OhioHealth | Riverside Methodist Hospital Columbus, OH

Page 2: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

Disclosures

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

Page 3: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

DEFINE – “TREATMENT FAILURE”

•  GSV/ SSV not closed •  GSV/SSV partially closed •  GSV/ SSV closed but clinical status is Status

Quo (i.e, Patient Reported Outcomes suck!) –  Pain continues –  Swelling continues –  Ulcer not healed –  Just plain unhappy -X

•  Neovascularization - X

Page 4: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

GSV/ SSV open/ partial ablation

•  Equipment malfunction •  Technical error

–  Vein spasm –  Large diameter –  Obese –  Could not pass wire (post thrombotic) –  Simply not a good operator/ Newbie –  Wrong vein ablated/ duplexed –  SSV – lower success than GSV

•  “God only knows” – AKA “Idiopathic”

Page 5: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

No improvement in clinical status

•  Technical error – Technologist/MD error in scanning

•  Errors in Judgment •  Errors in Diagnosis

Page 6: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

Technical error

•  Errors in scanning – Most common in my practice – Most sonographers do not like to perform

venous incompetence duplex scans and mapping

–  Info is handed to you

Page 7: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

Errors in judgement

•  Not identifying the pathologic vein •  Not identifying refluxive connections

between the deep and superficial system •  Incomplete treatment

Page 8: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

Errors in judgement

•  Patients with or without contributing co-morbidities may require additional considerations: – Deep venous reflux –  Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

•  Ovarian insufficiency – Morbid obesity with CALF PUMP

DYSFUCTION

Page 9: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

Errors in judgement

Page 10: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

Errors in judgement

•  S/p GSV ablation •  No improvement •  Pelvic and profunda

source

Page 11: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

Errors in judgement

•  S/p GSV (thigh only) ablation

•  Venous eczema unresolved

•  Intersaphenous vein from SSV thigh extension to the venous eczema

Page 12: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

Errors in judgement

•  S/P Right GSV ablation

•  Severe cellulitis •  Placed on

clindamycin and referred to PCP for further care

Page 13: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

Errors in Diagnosis

Page 14: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

Pseudo-Kaposi Sarcoma

“Acroangiodermatitis of Mali”

Page 15: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

LIPEDEMALYMPHEDEMA

Page 16: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

Errors in diagnosis

•  S/P bilateral GSV ablation

Page 17: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

VEIN/ VASCULAR SPECIALIST

Pain/ Swelling

VENOUS THERAPIES

Page 18: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

Pulsatile flow in the veins

Page 19: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

Hemodynamics

Page 20: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

Other causes of “edema”

Arch Intern Med. 2000;160(15):2357-2362

Page 21: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

Data on prevalence of RHF/ OSA in CVI

Page 22: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

Errors in diagnosis

•  Sleep apnea

Page 23: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

OSA and compression Rx

Am J Respir Crit Care Med Vol 184. pp 1062–1066, 2011

Page 24: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

OhioHealth prospective study… •  Prevalence of Right Heart Failure in patients

referred for venous insufficiency •  Prospective observational, single center– 300

patients (102 to date) •  All patients receiving Venous Incompetence

Study ! Right Heart Echo Evaluation, by RVT/ RDCS certified sonographers – RV / RA – Size and function – TR – TAPSE – RVSP

Page 25: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

Our study…

•  Venous incomp and Echo findings reviewed by 2 vascular medicine MDs and a 2 Cardiologists respectively

•  Patient characteristics – BMI/ VTE History/ OSA etc

•  CEAP/ VCSS •  “STOPBANG” Questionnaire for patients

without OSA

Page 26: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

Neuropathic pain

•  22% of patients referred to our vein clinic have + EMG/ NCS studies

Page 27: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

Errors in judgement - ulcer

•  Ulcer Healing –  Inappropriate compression – Ablation – AK level

Sullivan, LP

Phlebology 2014

To determine the efficacy of MOCA in below the knee GSV in patients with persistent venous ulcers following above the knee GSV ablation

•  Mean time to heal was 28 days •  MOCA can be delivered directly to the veins

feeding the ulcer

Phlebology. 2014 Dec;29(10):654-7

Page 28: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

Sickle Cell Ulcer Diabetic/ Neurotrophic

MYOSITIS

CREST

Pyoderma Gangrenosum

Page 29: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

Pretibial Myxedema

Necrobiosis Lipoidica Diabeticorum

APLA Bartonella

Levidoid vasculitis Martorell’s

ulcer

Page 30: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

Large B Cell Lymphoma

Basal cell ca

Page 31: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

Root cause analysis

Page 32: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

Thank you

Page 33: Treatment failures after successful GSV ablation- Root cause … · – Iliofemoral or popliteal DVT, or a History of DVT – May-Thurner Syndrome – Pelvic insufficiency or congestion

Treatment failures after successful GSV ablation- Root

cause analysis and management

Raghu Kolluri, MD, Director – Vascular Medicine

OhioHealth | Riverside Methodist Hospital Columbus, OH