Managing the challenging patient: Ancillary procedures for … · Managing the challenging patient:...
Transcript of Managing the challenging patient: Ancillary procedures for … · Managing the challenging patient:...
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Managing the challenging patient: Ancillary procedures for
complex anatomies
Raghu Kolluri, MS, MD, RVT, RPVIDirector | SYNTROPIC CoreLab – Vascular and Wound Imaging
System Medical Director | Vascular MedicineOhioHealth Vascular Institute
Columbus, Ohio
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Disclosure
Medtronic – Consultant
Bard – Research Consultant
Philips/ Volcano – Consultant
Boston Scientific – Consultant
Inari – Consultant
Spectranetics – Consultant
BTG – Consultant/ Research Grant
Vesper Medical - Consultant
Innovein – ConsultantBrand names are included in this presentation for participant clarification purposes only. No product promotion should be inferred.
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Fowler et al, JVU 38(1):34–40, 2014
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Simple Decision Making
• Signs/ Symptoms + or Cosmetic improvement
• GSV/SSV reflux
• GSV/SSV anatomy –Straight, adequate depth and no tributary reflux
Thermal/ Non Thermal GSV/
SSV+/- Compression Rx
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Simple Decision Making –Aneurysmal disease
• Aneurysmal superficial venous disease
• Surgical Rx
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• 67 yr old female with Hx of Right LE edema and venous claudication.
• Prior Hx of DVT in the RLE.
• Recommended GSV ablation
• Second opinion
GSV
SSV
FV
Pop V
Rx – Perforator ablation + Phlebectomy of
Varix.
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Complex
• 53 yr old male with bilateral ankle ulcers
• Left GSV ablation last yrdid 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
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Ulcer
PASV
Thigh ext
Inter-saphenous
vein
GSV
Not so simple – Prior ablation
• SSV ablation + Foam Sclerotherapy of the branch varicosities
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Not so simple – Prior ablation + tortuousity
Severe painful lipodermatosclerosis
Prior GSV ablation
Reflux in tortuous intersaphenous vein - AASV toBelow knee GSV
AASV/ SFJ Reflux – AASV straight – 8cms
Prior GSV ablation
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Options
AASV Ablation/ Venaseal – straight portion
Foam Sclero of tortuous vein
Below knee GSV ablationOr Venaseal
? Perforator ablation/ Foam
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Options
? Clarivein – Mechanico Chemical Ablation
Clarivein – Mechanico Chemical Ablation
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Options
Varithena Foam/ ?Regular foam
Varithena Foam/ ?Regular foam
Varithena Foam/ ?Regular foam
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Polidoconol Microfoam Ablation for challenging situations
In Press
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FOAM ASSISTED DUPLEX ULTRASOUND GUIDED PHLEBECTOMY
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Traditional Vs Foam Assisted DUS guided phlebectomy
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Advantages of the new technique
• EBL < 5cc in all cases
• Can be performed with concomitant anticoagulation
• No nerve injury
• Precise – Incision, hooking and exteriorizing less traumatic
• Segments not exteriorized Sclerose
• Small veins distal sclerosis
• Venous eczema improvement
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Summary
• VEIN MAP/ REFLUX TEST first step in stratification
• Venous insufficiency is NOT just from GSV and SSV
• Important to assess the state of deep and superficial veins and perforators in severe venous disease
• Consider iliac vein obstruction in patients with venous ulcers/ severe venous disease and deep venous reflux
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Summary
• Complex venous anatomy can often be overcome with several simple techniques
• Polidoconol microfoam or traditional foam sclerotherapy for complex small to medium sized tortuous veins
• Foam Assisted DUS guided Phlebectomy for larger veins and for people who seek best cosmetic outcome
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Managing the challenging patient: Ancillary procedures for
complex anatomies
Raghu Kolluri, MS, MD, RVT, RPVIDirector | SYNTROPIC CoreLab – Vascular and Wound Imaging
System Medical Director | Vascular MedicineOhioHealth Vascular Institute
Columbus, Ohio