 Thank you, Stephanie, for this wonderful introduction. So as most of you know, I've given a lot of talks here and everywhere else, primarily related to endovascular treatment of aneurysmal disease, abdominal aortic aneurysm, thoracic aneurysm, and so on, carotid disease. But I have never given a presentation here to this audience related to this particular topic, which is chronic venous insufficiency. And I call this the forgotten part of circulation, because as you fellows know, very little is done as far as education is concerned at our institution and at many cardiology fellowship programs related to this particular problem. Those few of you that were lucky enough to rotate with us at Leachman Cardiology Associates had an opportunity to see plenty of patients with this condition and also a variety of treatment modalities that are available, including the latest technology that we have. So I have really nothing pertinent to disclose no connections with any companies that are related to this particular field, other than my personal bias that those patients are neglected and need to be treated. So as all of you know, venous pump, as far as the lower extremities are concerned, is related to muscle contraction in your lower extremities. So it's a passive type of a pump. And inspiration also helps in moving the blood flow from the lower extremities upward towards your heart. So inactivity makes this pump inefficient and all of us that are performing international procedures, international cardiologists and also surgeons are at risk of having this pump malfunction because we stand for a long period of time and do not necessarily contract our muscles on a regular basis. And therefore we are also prime candidates for chronic venous insufficiency syndrome. So here you can see a normal vein where the valves open and valves close. And that should be standard. However, when you have a dilated veins due to a variety of reasons and some of it's just inactivity and the other ones are from pressures compressing the veins above, you will get dilatation of the veins and you will have a lack of closure of the valves so you'll have actually retrograde flow or stasis that stays in the lower extremities. So obviously this condition is caused by failed venous valves. Now venous reflux in saphenous vein is most common underlying cause of painful varicose veins in the lower extremities. There are other conditions but reflux is the major cause. Hypertension can be three times above normal at the ankle level while we are standing in a calf lab. So I don't know how many of you and doesn't matter what age you are. Very frequently at the end of the day you feel a little bit of burning, tingling sensation and maybe some degree of numbness in the lower extremities and that is related to venous stasis and lack of circulation of the venous blood. The venous blood is very acidic from metabolites so a lot of lactic acid is in there and that lactic acid causes all of those symptoms. So it's a serious condition and it's almost invariably a progressive disease if you follow patients over a long period of time you will see that this disease progresses. Now how big and how prevalent is chronic venous insufficiency disease? I'm absolutely positive that a lot of you will be astonished by the numbers that I will show you. It is estimated that somewhere between 30 to 40 million in the United States suffer from symptoms of chronic venous insufficiency. However, only 1.7 million roughly seek treatment on an annual basis. So we have somewhere close to 30 or 28 million that do not receive treatment. And so they basically remain untreated and suffer with symptoms. As you can see here it can manifest itself just with varicose veins like in this particular case which is relatively mild type of a finding to a more advanced non-healing wounds in the lower extremity with infection. So it affects all age groups and I'm looking at you fellows you are not exempt from this at all. Now, another very important fact that I'm sure a lot of you are not aware of that chronic venous insufficiency is twice as common as the incidence of coronary artery disease, okay? And 10 times more common than prevalence of peripheral arterial disease in the lower extremities. So about pathophysiology of this condition related to venous hypertension. You get leukocyte trapping that do harm to those valves and the venous wall. You get release of proteolytic enzymes, destruction of cellular membrane, leakage of the plasma proteins and leakage eventually of the red blood cells and destruction of tissue. You get hemociderin and hyperpigmentation as you can see here. And then you get tissue hypoxia, dermatitis and lipodermatosclerosis and eventually ulcer formation, infection and bleeding. So this is what I would call the most advanced stage that we can see. So chronic venous insufficiency facts that a lot of us are not aware of is the most under diagnosed condition to the best of my knowledge. It is the most ignored condition and most misdiagnosed condition. What I mean by that is that some other condition is blamed for this, whether it's peripheral arterial disease or diabetes or whatever else. There are many other conditions you will see in the threshold diagnosis that can mimic this condition. It's also the most under treated medical condition that I know. The question is why? Why is this happening? Well, there is a misconception that this is just a cosmetic disorder, particularly in early stages when you see varicose veins and oral orbit of leg edema. There is so little awareness among population in general and also among healthcare providers of various specialties. And a lot of providers are unaware that in right hands with appropriate treatment, the resolution of this condition is very rewarding for our patients. And there is also a general failure to realize a link that exists between venous insufficiency and lower extremity swelling or edema, nocturnal leg cramps, restless leg syndrome and venous ulceration. There is also a failure to consider the symptoms burden and the tremendous suffering that those patients experience. And this is not to blame only us, but also to patients as well. And very frequently, you will hear from patients, well, I think it's probably related to my old age or it's probably related to my arthritis or it's probably related to my obesity and variety of other things and symptoms and diagnosis. But also the providers have the same misconception where they contribute to this condition due to some other conditions or are not able to differentiate between other conditions and this particular condition. A lot of people that restless leg syndrome is something related to a neurosis, anxiety or whatever. No, it's basically sub-conscious way of treating this condition by contracting muscles and pumping the blood upward. So, and this is one of the most common early stages of presentation of this condition. Hence, venous disease remains a major cause of preventable morbidity and mortality. I call it for that particular reason, the forgotten side of circulation. So, look at variety of things that can manifest itself as chronic venous insufficiency. Very frequently it is aching or leg or foot cramping. I have frequently encountered experience with my patients where you'll ask them a question, do you have leg cramps? And they will say no. It's the same thing if you ask your patient, do you have angina? And they don't know what angina mean. They'll say no. Do you have chest tightness or pressure? They'll say yes. So, ask all the pertinent questions that can explain patient's condition. So, they'll say no, I don't have leg cramping, but I have foot cramping, okay? Sometimes they just experience heaviness at the end of the day, pain, burning sensation, itching, tingling, swelling, numbness, restless legs. Now, about numbness, a lot of patients are misdiagnosed to have peripheral neuropathy. And actually they don't have a peripheral neuropathy. They have numbness related to chronic venous insufficiency. And if you treat chronic venous insufficiency in a lot of instances, you can relieve the symptom of numbness and many other symptoms as well. Once you are more advanced, as far as chronic venous insufficiency concerned, you get ulcers, you get thrombosis, bleeding, cellulitis and infected wounds. So, pay attention to that because it's not infrequent that the patient will present to you with both conditions, peripheral disease of the lower extremities, particularly in diabetics and also chronic venous insufficiency. And you have to be able to differentiate which one is causing the primary problems because sometimes arterial interventions are riskier and more complicated while the venous interventions might be more rewarding for certain subsets of patients that present with this problem. So, it is important therefore to remember that varicose veins is more than simple or cosmetic problem. And you can see there are a variety of categories in the COAP categories that will delineate how advanced this condition is. C6 is the most advanced condition. This will be C6, okay? You never want to get to this stage and then start treatment because this is only a palliative phase. You have to treat them very early. In this stage or this stage and then you have cure and excellent results and very rewarding results for your patient. So, what's important now, this is one of the main messages for you guys that are in fellowship program training that nearly 80% of non-healing leg wounds are related to chronic venous insufficiency, not to peripheral arterial disease. What are the risk factors for varicose veins and chronic venous insufficiency? There are many of them and I listed some of them. It's impossible to list all of them, but the most important ones as we get older, we all will get certain degree of chronic venous insufficiency and regurgitant and incompetent venous valves. Family history is a very strong factor, strong indicator and that could be due to a variety of reasons whether it's obesity, whether it's lifestyle or inactivity, whether it's incidence of May Turner syndrome that's familial and so on. If you have a prior history of DVT, almost invariably you will get a certain degree of valve deformity or destruction and you will develop a certain degree of valve insufficiency. History of phlebitis is very important. Ask your patients about it. Previous trauma of whatever kind that patient suffered from, you can also anticipate there will be certain degree of venous insufficiency. May Turner syndrome, now why we call it May Turner? There were two individuals. One was May, the other one was Turner. We'll describe it, we'll talk a little bit more about it in detail, okay? And then obesity standing occupation, we mentioned that inactivity, sedentary occupation, those secretaries that don't get up for eight hours a day, they are certainly at risk and that's why they have restless leg syndrome because they're smart. They know what helps them to relieve the discomfort. Pregnancy, of course women primarily, right? Nowadays. And for that particular reason, female gender and I have nothing against female gender but because of all of those conditions, pregnancy, birth control pills, certain degree inactivity, weight gain at all the age, all of those things will contribute to that and also May Turner syndrome as well. There are several other possible risk factors that are probably less likely to be connected with it but anyhow they certainly should be considered. When would additional diagnostic evaluation be of importance as far as differential diagnosis concern? Low back pain, sciatica, I had a lot of patients that were referred to me because they underwent back surgery and the symptoms didn't improve. And the reason for it is because the primary problem was chronic venous insufficiency and not any lumbosacral spine disc disease. The genitive joint pain, a lot of patients will have problems with arthritis, hip joint and they think it's causing all of those symptoms which is impossible related to that and actually it's chronic venous insufficiency. Fibromyalgia is difficult because those patients have all kinds of complaints. Vascularitis, also another factor, arterial ischemia, peripheral arterial disease. We talked a little bit about it. Lymphedema is a problem because a lot of patients with lymphedema will have exactly the same symptoms as swelling. So you have to be able to differentiate those things but that doesn't mean that you should not treat chronic venous insufficiency in patients that have lymphedema. You will be able to improve their symptoms that are related to chronic venous insufficiency and then you'll have to address another problem which is lymphedema. So a significant number of those will improve. Peripheral arterial disease and arthritis of various kinds. Neuropathy, okay? I mentioned peripheral neuropathy and interestingly enough, a lot of those patients will improve. So you have to make sure that you're treating proper condition. Heart failure, congestive heart failure will give you leg edema and some of those symptoms. Liver failure, hypertension, obesity, particularly morbid obesity, surgical trauma and previous injuries. All of those things play a significant role. Now let's talk a little bit about anatomy because we have to know the anatomy to be able to diagnose and to be able to treat this condition appropriately. So there are three venous systems. There is a deep venous system, there is a provisional venous system and there are perforators connect those two. When I talk to my patients, I try to explain to them in a layman terminology because it's difficult for them to explain in any other way, why are we doing certain things and what will happen? A lot of patients will worry, well doctor if you close that vein, what will happen? I'm not gonna have a good blood flow and so on. Then you have to explain to them as long as your deep venous system is working well, there shouldn't be any problem by closing or removing the superficial venous system. I explained to them, this is like a backup mechanism. I tell them if you are a skydiver and see those that well and you have a parachute and you have a spare parachute. Spare parachute has a lot of holes. You're not gonna use a spare parachute, you're gonna use your main parachute and so the superficial venous system that's inefficient or regurgitant is like a spare parachute. Or I tell them you have a four lane highway, you have a feeder road, feeder road is full of potholes, forget about a feeder road, just stay on a four lane highway and then they understand this concept really well. And I tell them the surgeons use those superficial veins for bypass surgery in thousands and hundreds and thousands of patients and nothing bad happens. So you have to explain to them because otherwise they become very skeptical. So superficial venous system is basically you have a greater saphenous vein which is on the inner aspect of your leg and then you have a lesser saphenous vein or a smaller saphenous vein that's positioned posteriorly from the knee down to your ankle. And then you have a communicating veins between those two system and you have lateral system. Of course you have perforators that also connect the deep and superficial system. A little bit about deep veins other than what I already mentioned is that deep veins usually do not cause ulcerations in the lower extremities, okay? It's primarily due to superficial venous system problem and the perforators. So deep venous reflux will very frequently disappear after you treat the superficial venous system. Why is that? Because you decrease the flow that returns through the deep venous system. So therefore do not worry about deep venous system even though it might be incompetent at a certain degree and a lot of those patients will actually improve and the incompetence of the valves in the deep system will disappear after you treat the deep venous system. Evaluation, that's extremely important. So how do you do it? There are many different techniques that you could use. A lot of times the best is in standing position. You have to use some augmentation maneuvers like at the saphenofermal junction valve salva to see if that incompetence is occurring there. That is a must. A lot of insurance companies will not approve the procedure of any kind that you intend to do unless you have incompetence of the principal saphenofermal junction vein. And so pay attention to that. Now, so what is a reflux of significance and what is a reflux of no significance? We should have less than 0.5 seconds of a reflux. That will be physiologic type of a reflux but in a common femoral vein it's more than one second, okay? So pay attention to that. Now perforators is more than half a second. So those are the things and numbers that you have to remember because the insurance companies will require this information from you. This is something that absolutely is astonishing to all of us that are involved in this field. If you send your patients to any of the labs, vascular labs, including this our lab here, 94% of the vein disease will be missed by standard ultrasound. If you order just a venous ultrasound study, you will not get any information related to valvular incompetence, particularly related to greater saphenous, less saphenous vein or perforators. And I don't know how many of you that are practicing here have sent your patients to the peripheral vascular lab here and you'll get a report. This is a report that I get on a deep basis. No evidence of thrombophobiasis, no evidence of DVT, minimal or no valvular incompetence of the deep venous system and that's it, nothing else. So how do you know what's happening with the superficial venous system? You have to do it in a lab that is trained, technologies that are trained in doing that. 94% of labs are not trained to do that. So this is what you get in a regular lab, those two things, but you don't get nothing about greater saphenous vein reflux, less of saphenous vein reflux, accessory vein reflux or perforated vein reflux, nothing, okay, embarrassing. Now treatment options, there are a variety of treatment options available. There are conservative methods that you could use and it's almost mandated by insurance companies. They will not allow you to do any other aggressive mode of treatment until you try conservative therapy, which is compression stockings, leg elevation while you're sitting at your desk, exercise, weight reduction, very important, and analgesic as needed. So this is something that you need to document to be able to get approval from the insurance companies. Typically they will require three months of treatment. Now none of those things work on a long-term basis. They work if you achieve certain goals. For instance, compression stockings work only while you wear them, but you will not correct the problem. And in a lot of instances, this is an absolute nuisance, particularly for those high-heeled persons in the fashion type of situations where you wanna show off your beautiful legs and also because of the climate that we live in here. It's uncomfortable. So most of the patients will have a difficult time in tolerating compression stockings on long-term basis. Okay, surgical interventions that have been well-tested in the past is primarily vein stripping, which is nowadays rarely used because we have other modalities that are more rewarding and less traumatic and less aggressive. And those are the endovascular interventions. There is a thermal to mess in the ablation. I will mention about that. It's basically heat-generated ablation of the vein that you achieve by injecting to mess anesthesia, which means local anesthesia to relieve the discomfort that is generated with those particular devices. RFA ablation is one of them. Laser ablation, EVLT is another one, a variety of lasers available. And then more recently, we have been using less invasive, less aggressive and more rewarding as far as discomfort is concerned, non-thermal, non-fumicent therapies like foam, sclerotherapy with a variety of what we call detergents that are being used for that. Vertina is one of them, mocha is another one. And more recently, vena-seal, which is an acrylate that in my opinion is probably the most rewarding for a great majority of patients. This does not necessarily mean that the other modalities treatment are obsolete. Not at all, but that certainly is an option. So vein stripping, I don't know how many of you have seen that. And this has made me a little bit exaggerated, but it is a certainly aggressive procedure is typically done under general anesthesia. There are several incisions made and it's for robust individuals like Bill Godley here that's standing and observing this particular procedure. So stab fluectomy for varicositis is where you use hemostats and hooks and you tease that venous segment out as you can see. So this is done obviously with domestic anesthesia. You sometimes make 30 or 40 different stabs with 11 blade to remove those varicositis. And that is occasionally needed and useful is certainly less uncomfortable than vein stripping. And this is done again with local anesthesia. But this is sometimes the picture for stab fluectomy that you have to do. So obviously this is a gruesome type of a thing if you show this to your patient and this is what you have to do to remove all the varicositis. So that's why more pleasing less invasive modalities are becoming more and more popular. And so many of the invasive alternatives offer you faster recovery. Basically it's done typically on outpatient basis. If any of the physicians perform this type of procedures under general anesthesia in a hospital environment that is totally obsolete, totally inappropriate and they are ignoring the cost issues and they're ignoring patients benefits and that would be embarrassing to do that but it's still happening in a lot of instances even in neighboring institutions here, anyhow. So procedural details with RFA and laser procedures. RFA means radio frequency and there are several products available. It's an outpatient procedure. You use an ultrasound guided. So you better know or you have to have a good sonographer to guide you through this procedure because it cannot be done without ultrasound guidance. You can resume normal activities immediately. I tell our patients to start walking right away as much as they tolerate the same day. So that is encouraging and rewarding for the patient. I tell them for the ladies to go to Neiman Marcus first and the day like that. And it's covered by Medicare and CMS which is very important. So that is an approved procedure. So what laser radio frequency do, they basically shrivel the vein to a string, okay? And that is generated by heat by denaturating the cells in the intima and basically I tell the patients like welded vein into a string, okay? Now, so let's talk about benefits, advantages and advantages of one versus the other. Vain stripping is a useful procedure. It is successful in a lot of instances but again, it's aggressive modality. Now EVLA or radio frequency, when we look at the meta analysis in 34 randomized controlled trials is basically equivalent efficacy. That means that they are equally successful, okay? The problem with vein stripping is a blind procedure. So you're basically removing the vein without seeing how much and what segment are you moving? So sometimes there are segments that are not removed and they can eventually cause through coladoles, further problems with valuing incompetence and further symptoms. So EVLA and radio frequency and terminal ablation. So when you look at the outcomes with the radio frequency ablation, 92% success rate and occlusion at five years which is very good. 2.7% of patients have symptoms after that length of follow up. And as far as laser is concerned, one year occlusion rate is 93% which is very close to this one but there is a little bit higher instance of nerve injury. Now this is relatively low if it happens to somebody else but if it happens to you, then it's a significant problem because you could have a permanent peristasia, even weakness in that extremity if this is very aggressive. And the reason for it is the laser generates more heat and that is probably the reason. And it also depends how you treat it and where you treat it. Now meta analysis between RFA and laser because there are some proponents of laser and there are some proponents of radio frequency but we use both of them and have experience with both of them. I don't think there is a tremendous difference other than post laser you have a little bit more pain and you have more acrymosis and a little bit higher incidence of nerve injury and that's why we use it relatively infrequently. So over the last several decades to mesent thermal ablation therapies have basically replaced surgery for treatment of chronic venous insufficiency. And again, the procedure can be done in a simple setup in your office and on outpatient basis under local anesthesia. Now, what are the disadvantages of thermal ablation therapies? Because all therapies have certain disadvantages. You heard about elastic stocking disadvantages. Now let's talk about thermal ablation disadvantages. It cannot treat all venous segment due to potential nerve damage. Like you have a Fremont nerve that goes very close to the greatest saphenous vein and the further down you go below the knee, the closer they are. So when you generate a temperature of 120 or 140 degrees of centigrade you will invariably cause some damage to the nerve unless you use the mesent anesthesia which is called sailing mixed with lidocaine, bicarbonate and epinephrine. And what you're trying to do you're trying to separate or isolate the vein from the nerve but it's almost impossible to do it below the knee. So for those of us that are using RFA or laser we will go just below the knee and stop right there. So if the patient has a viral incompetence further down all the way to the ankle we have to find some other modality to treat this particular problem because we cannot safely treat this with thermal ablation therapy. There is also potential risk of skin burn and stain for superficial veins. So we try to do a variety of things to prevent that, but it's very difficult in those what we call supra-facial veins that are just underneath the skin and that should be avoided. So they all require to mesent anesthesia and again, and you have to gain experience to know how to do appropriate to mesent anesthesia and to know what is enough and what is not enough as far as to mesent anesthesia. There is a considerable amount of training required to gain proficiency for those type of treatments and there is a very frequently intra-procedural discomfort particularly with laser therapy and there is a post-procedural bruising primarily because of to mesent anesthesia and many sticks but also if you hit the vein inadvertently you will have bleeding. So there will be bruising with that and requires post-procedural compression posed for several weeks and this is particularly a nuisance in warmer climates like here and it's very difficult for some patients to do that particularly morbidly obese patients that cannot pull up their stockings or frail patients or patients that have a significant peripheral arterial disease of the lower extremities because you'll compress coladones and they'll have more symptoms. So this is why the non-to-mesent, non-thermal therapies became popular and there are a variety of what we call detergents so-called polygocanol is one of them and then there is a Sotrdecal that we use more frequently and then a variety of devices where you have nitrogen mixed with them or CO2 mixed with them or if you mix just air with it those are a variety of techniques and more recently cyanoacrylate adhesive so cyanoacrylate has been extensively used for aneurysms, brain aneurysms, AV malformations some of you have seen me using it for treatment of type 2 endolics and so on so this particular product has been well tested in the past in variety of applications and it has been proven to be safe and so we obviously have options available as far as this is concerned so non-to-mesent, non-thermal therapies have basically evolved to eliminate the risk of thermal ablation there are less needle sticks okay because you don't have to give it to mesent no sedation is required no to mesent anesthesia you can treat superfacial veins very superficial veins you can treat the whole saphenous vein either greater or lesser saphenous vein without fear to cause nerve damage and you can significantly lessen procedural and post-procedural discomfort there will be less bruising there is no reason for bruising unless you are doing something inappropriate and no risk of bleeding so for our patients we actually treat them while they are on anticoagulants and it is truly minimally invasive modality of treatment for this particular condition so vena-sil is the only one that's using cyanoacrylate that is by Metronic and as I mentioned it has been well tested there is a required technique to learn how to prevent embolization of that material by compressing the vein and obviously this has to be done under ultrasound guidance what are the results when you compare a variety of non-to-mesent therapies polydocanol, sotridechol in variety of forms or shapes and versus vena-sil as you can see vena-sil offers you excellent results as far as follow-up occlusion rates 99% of six months and 94% at 36 months if you do it appropriately which is lower than with other modalities and pretty comparable I would say to radiofrequency ablation but this one obviously can avoid certain things that can occur with radiofrequency ablation mentioning a little bit about polydocanol and vanish-2 trial results there was in this particular study risk of thrombus extension it was a femoral junction in about 4% of patients and incidence of proximal TBT in 2.6% or distal TBT in 3% and 50% of patients were treated with anticoagulants because of the concerns and potential risk with vena-sil we do not at any point of time for any patients give any anticoagulants so that is another benefit here wanted to share few patients with you that came to me for treatment of chronic venous sufficiency this is almost embarrassing to mention that this particular patient was 76-year-old vascular surgeon that totally neglected his health and care diabetes, peripheral tear disease, hypertension, hyperlipidemia and chronic venous failure and non-healing ulcers we treated this patient with venous seal from the ankle all the way up and one week after that this wound looks dramatically better it was dry and healing real well so that was certainly very rewarding now when you would look at this young lady that came to me you would say she has the most beautiful legs she could be in a glamour magazine or wherever else why would you even consider doing anything for her? there is no varicose veins and so on but she had all the classical symptoms so first we established a diagnosis she was only 27 years old that she had developed a devotee during pregnancy diagnosis of meternal syndrome was established then she had a placement of the iliac stent she had a placement of the iliac stent because of 90% residual stenosis and she was at significant risk of occluding that vein again and she had significant valvular incompetence of the greatest affinous veins bilaterally because meternal can present with your symptoms bilaterally and no problems with deep venous system and this is how it looked this leg looked at the end of the procedure so just one bandaid no elastic stocking, nothing and she flew back to Mexico the next day and this is how it looked treating both legs so venous seal procedure one stick, local anesthesia, not to medicines no sedation, no elastic stockings this is what I like this is what I call minimalist approach to treatment of any kind of condition here's another patient had a totally incompetent greatest affinous vein from the ankle all the way up okay so you treated the ankle you would use a radio frequency you would use laser you could not do that because you would run the risk of damaging the nerve a little bit about meternal syndrome because this is very important about 25% of us here in the audience have meternal syndrome and you don't know about it now 30% of female population has it and about 20% of the male population has it okay and why again I'm complaining that the females have more problems with this well because they have a different anatomy as far as pelvis is concerned the angle of the pelvis and the way the vessels bifurcate and so on so this was described by May and Turner in the etiology in 1957 on pathological specimens but we're called in 1800s last surgeon from Germany from Berlin was the first one to describe everybody knows about work of triads but very few know that actually he was the first one to describe the compression of the ilium veins so it's also called iliocaval compression syndrome or Crockett syndrome that occurs secondary to the compression of the ilium veins by overriding ilium carter it could be common, it could be external or whatever and this is how we look angiographically you see anyhow now what's important is who gets it well it is seen in more than 25% of as I mentioned healthy individuals but it can vary tremendously among patients that have a left-sided EVT so if you see a patient in your office a young patient that's very pronounced or middle-aged or all the patients pronounced veins varicose veins in the left leg only nothing on the right side consider May Turner syndrome anyhow so pay attention to this particular feature it is easily diagnosed just with a ultrasound as you can see here you can see the velocity difference you can see the compression you can see the compression here or the compression here you have a variety of other modalities with the ultrasound available to establish the diagnosis reversal of the flow collateral flow all of those things can be used and you have to make sure that you send the patient to the appropriate vascular lab that knows how to evaluate for this condition MRI and CTN geography is also very useful as you can see here you can see here clearly showing the compression it's very infrequently used you have to talk to your radiologist what are you looking for and you have to make sure it's MRV not MRA because if you order MRA they will miss the Venus phase so make sure that you inform your radiologist what are you looking for so pre and post venous seal as you can see in this patient very rewarding for venous ulcers we can use also sclerotherapy for varicose veins or greatest aphid veins that were left untreated after radiofrequency ablation we can treat telangiectasis with sclerotherapy and spider veins but the important thing is address the main problem first so it means treat the greater saphenous or lesser saphenous vein first in a lot of instances the problems with spiders and telangiectasis will disappear or improve to a significant degree but this is not a cosmetic condition I have seen patients with this type of condition actually still having symptoms or burning sensation, tingling and numbness so in a lot of instances actually it should be treated okay so what can you expect related to endovascular treatment of chronic venous insufficiency you can expect in the great majority of your patients resolution of their symptoms related to chronic venous insufficiency you can dramatically reduce the incidence of complications if you treat this early prevent DVT, venous ulcerations unnecessary hospitalization and also unnecessary antibiotic treatment you can stop a lot of medications that the patients have taken for a variety of conditions that are actually not causing this problem and your patients would be much happier if you would give them the optimal treatment for this particular condition so endovascular treatment of chronic venous insufficiency depends on your knowledge and your experience and common sense and then you gain excellence but lack of knowledge and lack of experience can lead to disastrous complications as seen here and those are my patients that will refer to me too late so knowledge ladies and gentlemen you see only what you look for and you recognize only what you know thank you very much for your attention