 Thank you to ma'am. That was the illustration of the procedure Your window was open though. Did you realize that the window in the office was open the cars were parking? Thank God you're on the third floor, right? People outside they cannot see. Oh, you're right. Yes All right, so let's say you have a patient who have venous insufficiency and The insufficiency is in the great softness vein But also it's in the tributaries of the softness vein because you know softness vein give branches Snubber stays just in the softness vein. So you do the ultrasound you diagnose both and The ma'am ablates the softness vein Well, some of the tributaries that you see on the skin will go away But most of them will not especially the larger one more than five millimeter So what do you do with that the patient come back saying? Oh my god What did you do you made me go through this procedure with the window open and people watching and And the veins are still there. What do I do and I say well, let's do what we call sclerotherapy Or you can do microflibectomy depends on how big the vein is microflibectomy is tab wound Fleabectomy we take pieces of that vein out and it's all done in the office Okay, his procedure was done patient is fully awake in the office. No journalist is here. No IV and patient walk out of the office instantly So the next presentation, I'm going to show you Briefly what sclerotherapy is all about the most common agents in the US and actually the world Right now our polydecanol and Sotra the call polydecanol is a fatty alcohol as alcohol in it It's basically local anesthetic. That's how it was invented in the 50s it has much less pain even if it leaks in the tissue and Causes less pigmentation than STS the sort of the cold the second one Okay, the sort of the call is much more powerful. It's actually the most powerful agent If you want a vein to go away inject them with sort of the call the STS Okay, it's a long chain fatty acid. It's actually a soap made like soap. That's what injecting soap, okay, and The problem with it when you have powerful medicine you cause more problem more problem if you are not doing the right way So if you go too high in the concentration You'll have skin necrosis if you leak in the tissue and it goes also and also is not pretty patient will be very unhappy Okay, and you have more pigmentation on the skin after you do it So, how do we do injections? Well, it all depends on the vein you injecting So let's start with the simplest the telangiectasis, which is what we call spiders. Okay use 32 gauge needle Okay, so it's very tiny tiny the patient barely feel it and the concentration is very low point two percent Polydeconol or point one STS and when you inject you inject it till you see the vein blushing away Or you see blip in the skin, which means the vein ruptured and don't So I'm gonna show you brief videos about each scenario. Okay, we have a patient here who has What looks like telangiectasis Separated by venal ectages the blue ones are venal ectages the red ones are telangiectasis You can see the blue ones are slightly larger and frequently you will realize that they are very connected So I'm going to inject them with point three five percent form polydeconol Mixed in this three-way stop clock. We just put it like that and we mix it Like this because white and milky Then we choose the largest vein We injected and see how the form spread So we go in the vein we make sure we got blood in The needle hub here before we inject you don't inject We see no blood and we inject in you can see it spreading Together in a lot bigger area than you anticipate That's because they connected you can see it spreading slowly and I'm injecting very slowly You don't want to rush it because you rupture the vein And you may create an ulcer if you inject under the skin We did several injections for this gentleman here a minute ago, but you can see how the area has cleared We came free of veins instantly and a few minutes you will see some veins coming back and they'll be very red That's because of the inflammation and irritation We can keep going and injecting all those other veins around it, but that's a great example of how Cyclotherapy using foam is very efficient and very effective Actually, I like it more than liquid sclerotherapy for areas like this because it spreads more and the success rate with it Is more than liquid Cyclotherapy with the same medicine polydacanol Thank you Okay, so you can see here that You know you can cover a lot of areas when injection I mean that ankle probably take me three four And it's done. You'll see the veins getting red. Okay, because they're in plain But the process is it at the intimate destroys the intimate Okay, expose the collagen underneath the intimate that causes five process The five process closes the vein. That's how sclerotherapy works or chemical obligation That's true for small veins or big things So can you play that please? This is another So You know what let's skip. Let's skip this video. It's the same thing. Can you skip the video? Yeah So now reticular veins which are a little bit bigger veins They are like a green flat veins about two to four millimeter So you go a little bit higher on the concentration. I put your concentration recommended But in reality I use like point four percent on this. Okay, you want to give them more powerful medicine and Next please You know we always worry about treating the medical veins first and Then the cosmetic ones second and let's admit it. We all care about our appearance. We want to look good So you can see this spider going away You will still see the branches that they are very red and angry right now With time the body absorbs them and this whole thing took maybe five minutes or so And then finally the large vericose veins the one that are bulging. That's what people come to us most commonly for Those are the tributaries. I was talking about from usually great softness vein or short softness vein Thy from lateral lateral sub dormic plexus of Albanese. This is congenital network of veins that Becomes insufficient sometimes and give you vericositis in lateral thigh and knee So in this case, of course, you go to higher concentration again bigger veins acquire higher concentration And we inject them with the handmade form the one I showed you before or we can inject them with vericina Which is form made with co2 by a manufacturer and we mix it in In the office she has been having leg pain especially with standing She had insufficiency in the great softness vein, which is on the Inside of the leg that we have plated with radio frequency all the way from here to here now She has this big tributary. We call it which is a branch of it Still giving her discomfort in the legs. So it's extend from the mid thigh area all the way down To here. So the treatment is going to be injecting this vein with medicine called vericina and Vericina is a foam that is approved by FDA and was approved a couple years ago The advantage of it is that it's very effective But also does not leave much staining on the skin like the old foam medications do so this is vericina that manufactured by the company We take foam from it as needed per patient The advantage of it is that the bubbles are very tiny and small compared to a traditional foam which is handmade Has variable size of bubbles Which makes it a little bit less effective So you can see on the matter over there where I'm injecting With the bubbles the white bubbles are and I inject quite a bit and then Laura is going to trace it and see the foam is moving Down still Will be coming to the veins below So one injection could cover a large area. You can see the foam arriving there and we wait for it a little longer and Then wherever it stops will inject again. So you can see it coming in here Nicely closing the vein making it spasm and those big Black spots become tiny So you can see that from where we injected the vein cleared all the way down to here and I still see it here So we will restart Second injection here to see how long it will cover The results are instantaneous. You see it right away You can see the vein went away right away and We're going to keep watching this segment to see if it clears up and you can see very slow clearance where the vein becomes white visibly Wow, it looks very nice You don't see anything anymore Okay, so that's an example of Foam takes me 10 minutes in the office and it solves the whole issue This way needs to be stripped and can you imagine the surgeon stripping this vein? How many it will take to to do and scars and I've seen patients who had previous stripping and the scars are like Two or three centimeter long all over the legs. It's not a very pleasant sign All right. This is I think the last video. This is briefly Basically, you can inject the way I showed you previous videos You're directly in the vein with the needle this one you put an IV like butterfly and from one butterfly You elevate the leg to empty the vein I use method one. There is a big bulky vein because you want to empty them from blood completely by elevating like 30 degree 40 degree on a wedge and then you inject and in this case you inject very small amount because the vein has no blood It's collapsed and you'll have fantastic results. Okay without significant incidents of pigmentation or Fluvitis, okay, which is a common complication. So I'm not going to show this video because a sake of time Oh, can you go back one slide? Okay, so last slide side effects of sclerotherapy should be aware of it. Okay hyper pigmentation meaning there is brown pigmentation over the vein area It's cosmetic. It's not really a medical problem But you can do aspiration of those veins because usually there's a clot of blood inside them I put a needle. I sprayed the clotted blood. We call the coagulant. It's liquid and the vein improve instantly You cannot flip by this because some branches may not be ablated equally and some blood stays in them become inflamed telangiectatic matting means some Tiny little spiders form in the area of injection, but they go away within a year if you leave them alone Ulcers could happen and it happens if you inject in a small tiny artery that you don't realize you're injecting in could be next to a vein or If you inject too much in the tissue and the medicine across the full thickness of the skin Ulcers will require a plastic surgery if they are more than one centimeter Okay, otherwise they don't heal because full thickness of the skin and will cause ugly start a scar if you leave them alone And that are very rare and athletic reaction but have epinephrine on hand in your office in case, okay It's very rare now DVT is very rare one in 2000 or so usually below the knee and if you give them anticoagulant Usually it was all within days. I don't know what it is about those DVT's that one, you know You're supposed to do ultrasound within Three to five days after your procedure So you diagnose it very fresh and you give them One of the new anticoagulant and you repeat the ultrasound in a week is gone. Okay. I continue for six weeks, you know total anyway But preference now last thing is visual disturbances The IS and CVAs happen in people usually have PFO patent for a man who valley and you don't know that they have it For that reason you have to do two things Limit your phone volume to less than 11 cc per session That is a volume showed to be more safe than anything higher than that number two Elevate the leg for about five to ten minutes after you finish injecting because the air will make the foam float in the leg Not go back up to the heart So if you do those two things do you minimize that effect and if the visual changes happen or TIA Almost always transient goes away within half an hour