 Thank you very much Dr. Coulter for the invitation. It's a pleasure to be here with you guys today. The title of my talk is chronic venous disease beyond blood thinners and stockings. In general, in our medicine family practice and even cardiology training programs, we get pretty good education regarding acute venous disease management. Patients that present with acute venous thrombosis, we're pretty good at managing those patients. I think there's some things that I'll talk about later in the talk that we could improve upon. But chronic venous disease management, really, we don't get a whole lot of exposure, partly because we focus so much on inpatient care for patients with venous disease. So we're going to talk, as our objectives are going to be review saphenous vein reflux, which is what you're mostly going to see in an office practice. We're going to talk about non-thrombotic iliac vein lesions, also known as May-Thurner syndrome. And finally, we're going to talk some about our experience here managing chronic deep venous thrombosis. The prevalence of chronic venous disease is really staggering. There's over 30 million Americans that are affected either by varicose veins or some more serious form of venous disease. About 2 million patients present for evaluation every year. This is 10 times more prevalent than peripheral arterial disease. The direct cost of these are staggering, approaching a billion dollars a year. And the consequences of venous disease, we tend to see them as being benign, but many patients can present with pretty debilitating disease that requires hospital admission, about 92 per 100,000 admissions, and most of these are related to venous ulceration where there's about 20,000 new venous ulcers diagnosed every year. What are risk factors and what are the signs and symptoms of chronic venous disease? Well, risk factors, older age, our veins as they age, they tend to dilate and this causes problems with the valve or structure of the veins. And family history is very prevalent in patients who have venous disease. Patients who've had a prior deep venous thrombosis can develop post-thrombotic or post-phlebitic syndrome, history of superficial vein thrombophlebitis, obesity, occupations involving standing, pregnancy, female gender, other risk factors include obstructive sleep apnea, for example, and high impact physical activity which can promote dilatation of the veins. What are the typical signs and symptoms? Well, these are patients that show up to your clinic and say, my legs are cramping at night, they feel heavy, they're burning, they're itching, and a lot of these patients undergo these pretty extensive neurologic work-ups and frequently have venous disease. Many of them don't have obvious varicose veins or telangiectasis or other signs of venous disease that make it obvious. Skin discoloration, particularly at the ankle, if you look at the medial malleolus and you see dark skin changes there, that's usually from greater saphenous vein reflux, spider veins, reticular veins, and varicose veins, of course. Adema, a patient presenting with superficial phlebitis, and bleeding from a vein is another presentation, the latter to require prompt treatment of their venous disease. It's important to understand a little bit about the anatomy of the venous system. The saphenous vein, which is the vein that's used for coronary bypass graft and inferenginal bypasses, is the longest vein in the body. Usually it originates in the foot and courses in the medial malleolus or in front of the medial malleolus, north, and anastomosis in the groin at the saphenofemoral junction. Throughout its course, it does anastomose with the deep venous system in several areas through a system of perforator veins, and those perforator veins can also develop disease. Venous anatomy is highly variable, much more variable than anatomy of the arterial system, so many veins are duplicated in the calf or in the thigh, and it requires really a thorough examination and ultrasound study to assess these patients well. The small saphenous vein can also reflux, and it starts at the lateral malleolus, extends up the gastrocnemius muscles and drains and frequently or usually in the popliteal fossa through the popliteal fossa into the popliteal vein. There's very frequent thigh extensions that may drain into the femoral vein in the thigh or up near the buttocks. And let's talk a little bit about the physiology. So we have several mechanisms, several valves throughout the leg that open during systole and close during diastole to prevent blood from returning. The calf muscle pump that you see contracting and squeezing the vein can empty about 50% of the blood volume of the leg just with one contraction. All of us here stand, this is in your Guyton Physiology book, for several minutes, venous pressure at our ankle increases to almost 100 millimeters in burpee, 90 to 100. Just walking 7 to 10 steps drops that venous pressure down to 22. That's why patients that have chronic venous problems say, I got to move, and they start walking and their legs feel better. They're sitting all day, their legs start turning, they walk a few minutes, their legs feel better. What ends up happening over time to the valve or structures is that the vein, either for many of the risk factors we mentioned or just genetic predisposition, the vein wall, the vein dilates and the valves do not co-apt well. So blood starts refluxing in south towards the foot. And over time you can get changes in the veins below the reflux points and very rare instances you can get venous aneurysms which can thrombose or rupture. And asymptomatic patients frequently have reflux and you can tell because they've got prominent veins or varicostates. We mentioned perforator veins. These are the veins that communicate the saphenous veins to the deep system and they have valves in themselves and if they are big in diameter they have significant reflux and for Doppler study what we look at is more than half a second of reflux to be significant. They can be a source for increased pressure on areas that are ulcerated. So patients that don't, that you ablate their saphenous vein or do a stripping of their saphenous vein, their ulcer doesn't heal, you have to look for these because they can be sources of poor healing for those wounds. There is a classification that we use to communicate between each other and it's important to know. It's called the CEP classification and it involves a clinical, etiologic, anatomic and pathophysiologic mechanisms. We usually use the C and we'll go over what those are as the easiest way to communicate. C1 patients have telangiectasis and reticular veins. We usually are minimally symptomatic. C2 patients have varicose veins. C3 have edema. C4A patients have pigmentation or eczema and you can see this is occurring here mostly around the medial malleolus. I ablated the lady who had the same lesion yesterday. C4B is lipodermatosclerosis or a trophy blanch which are just more significant inflammatory changes. C5 are patients who've had a healed venous ulcer and C6 are active ulcer. These patients obviously require much more aggressive treatment such as wound care, for sure, graduated compression stocking therapy and correction of the reflux as detected. So in your general assessment, you do a general assessment of the patient's condition. The patient's legs are swollen but their wheelchair band, they sit all day. Well, they've lost the calf muscle pump and that's probably the main mechanism of their edema and they should wear stockings, of course. A past medical history, the patient comes in with edema and they've got congestive heart failure. That's probably a major contributor and you can tell a patient that may have reflux and heart failure that their edema probably will not resolve completely because they have another factor to contribute to it and I mentioned the importance of an ultrasound study. That's the most important diagnostic tool beyond the clinical exam to assess these patients. These patients are assessed upright. Doppler probe is put in their leg. The calf is squeezed and you can see the blood going north and then refluxing south through an incompetent valve. It's important for us when we're trying to diagnose this to diagnose this, locate the areas of reflux so that we can target our therapy best. What is the therapy for this condition? Well, there are numerous treatment modalities. The most important thing is to start these patients on graduated compression stockings. We recommend class 2 which is 20 to 30 millimeters of mercury stockings. You can just write that, either calf or thigh. Women tend to prefer calf, men tend to prefer thigh, men tend to prefer calf or knee-high stockings. These make compress the veins more in a graduated fashion compress less north promoting forward flow. In patients that fail graduated compression stocking therapy which should be treated for at least three months, there are several treatment modalities traditionally stripping which is what you're seeing here where the patient is put under general anesthesia and several incisions are made and the vein is essentially removed from the leg. Foam sclerotherapy, this is particularly popular in Europe and South America as a treatment of saphenous reflux and it involves cannulating the vein. In this case, they're cannulating either a vericose vein or the small saphenous vein and a foaming agent in this country, sodium tetrodesal is usually used, is foamed between two syringes and injected in the vein and this vein as it makes contact with the endothelium it damages it and closes the vein. The other techniques that we have are laser ablation and radio frequency ablation which use thermal energy to damage and contract the venous wall and occlude it with a very high success rate and then more recently there's been the addition of venous seal which is approved by the FDA to occlude the vein. It's injecting cyanoacrylate which is the same product that has been used for intracranial aneurysms. Well, this is injected via this cath that are into the saphenous vein. It solidifies in the vein and it closes the vein. The main benefit of that latter modality is that it's pretty painless because you're not delivering any thermal energy compared to ablation. And this is what we mostly use in our practice. We use the benefit procedure with radio frequency energy. Again, you advance this catheter that has a heating element at the end to the saphenofermal junction. We'll see here in this little video where you make a cannulation. This is done in the office. Under ultrasound guidance the heating element is advanced to the saphenofermal junction. We try to stay below this little vein to reduce the risk of DVT. And the catheter is pulled back sequentially. And as you can see, as the catheter generates heat, the vein occludes. We do the entire procedure under ultrasound guidance. You'll see here the catheter moving within the vein. We inject a lot of lidocaine around the vein to protect the adjacent structures to prevent damage to the soft tissues and to the saphenous nerve that can course close to the vein, particularly at the calf level. And this procedure has been studied in longitudinal follow-up. And this data was presented at the Vieth Symposium in 2010 where they took about 300 patients and they performed the benefit procedure. And they saw at three years that there was successful occlusion of the vein and over 90% of patients. This five-year follow-up that was presented at the American College of Phlebolegy in 2012 looked at seep scores in patients that had undergone the benefit procedure. And what you can see is their baseline seep scores were between two, three, and four. And those at five years are shifted over closer to one, suggesting clinical efficacy, not just occlusion, but the patients are still doing well. Are there any studies that compare this ablative techniques? There are. The Rasmussen study is the largest randomized study with over 500 patients. And I know that doesn't sound a lot, but in the setting of... when you look at studies for drug therapy, they've got 18,000 patients. These procedures are very costly and they're procedure-related. And the companies generally don't have the capital, so these generally are not a very large number of patient procedures. They're randomized 500 patients to either RF ablation and the venous laser ablation, ultrasound foam-guided sclerotherapy, and venous stripping. And what you can see is that the clinical efficacy of radiofrequency, laser, and stripping is pretty similar at having a successful reflux free vein at one year. What really is different amongst these is that the recuperation time and the tolerability of the patient is better with radiofrequency ablation and with ultrasound foam-guided sclerotherapy. The only negative for ultrasound foam sclerotherapy is because when you're injecting the foaming agent in the vein, you're dependent on the foam contacting, making contact with all the walls in the vein, and it's not uniform because it's just moving up with flow and so the success rate is not as high. Time to return to normal activities was one day with ultrasound-guided foam sclerotherapy and radiofrequency ablation and higher with laser and with vein stripping. And time to resume the work also echoed those findings. And this is a patient before and after an ablation procedure. This is not immediately after some of these patients who have persistent large varicostinies after the ablated vein is treated may require stab flabectomy or foam sclerotherapy, but basically the vein is decompressed significantly. In a lot of patients, you don't have to remove the veins if they're cosmetically happy and they're not symptomatic after the ablation. What are the risks of saphenous vein ablation? Well, the worst risk, of course, is having a deep venous thrombosis because you're near the saphenofermal junction. Luckily, this risk is fairly low pulmonary embolism because of the same thing. Vessel perforation is more common with laser ablation because of how the energy is delivered. Phlebitis, hematoma formation, infection, skin burn and nerve injury or other potential risks. So now we're going to move and we're going to cover three subjects. We're going to move over to non-thrombotic iliac vein lesions. This is a clinical entity that's been described for over 50 years by May and Turner where patients presented with either leg swelling, discomfort and what was found on pathology was compression of the left iliac vein by the right common iliac artery. This is natural. Maybe 30 to 50 percent of us have this but it's luckily rare that it becomes clinically apparent. The artery which is at higher pressure than the vein creates these choke points. So the artery here is compressing the left iliac vein which is behind it. But other potential choke points are on the right common iliac vein behind. The hypogastric veins may choke the internal iliac veins and more rarely you can get the inguinal ligament to compress the femoral vein. Over time what ends up happening is the repetitive pulsations of the artery over the vein and the vein frequently is compressed against the spine. I'll show you some pictures that show that. You get mural fibrosis, you get web formation within the vein and membranes that can limit flow and also predispose you to deep venous thrombosis. And in the setting of deep venous thrombosis these are areas that have poor resolution of thrombus. So your typical scenario that you can see is a patient that gets put in a female typically as the prevalence of this is higher in females gets placed on oral contraceptives and suddenly develops a left-sided iliofemoral DVT. In that patient if you had no other hypercoagulable state you should at least consider the possibility that she may have may-therner syndrome and how you treat that patient is a little different than just anticoagulant therapy because correcting the lesion may reduce their risk of recurrent deep venous thrombosis and may actually improve their long-term outcome and reduction in risk of post-flabitic syndrome. What's the diagnostic evaluation of these patients? Well clinical findings. Some patients just show up with my left leg is always swollen it's heavy and it bothers me. Typically venography was performed to confirm this diagnosis. Other diagnostic testing, Doppler ultrasound which can be challenging in the pelvis and you have some you need a tech that has expertise in this CT venography and magnetic resonance venography which is what we're seeing here and then finally we'll talk a little bit more about intravascular ultrasonography. This is the left side on an imaging study and this is the right side. This is the right common iliac artery here and this is the left iliac vein. Because the IVC is to the left side in the retroperitoneum the left iliac vein the left femoral vein to get to the IVC as an iliac vein has to cross over the right common iliac artery and you can see how the vein and this is the IVC is compressed by the artery. Here you can see the spine back here and you can see the artery is squeezing the vein against the spine and here in a forward view you can see why the artery is compressing the vein and on venography the accuracy of a diagnosis is not great. So this is a by the group, the biggest group that studied iliac vein intervention is a group in Jackson Mississippi names of the physicians are Dr. Raju and Dr. Neglin and they've published extensively about it in their series the diagnostic accuracy of a venogram is relatively low with over 30% of patients not having a detectable lesion on venography. This is the classic finding you do a venogram and the iliac vein looks squished in the AP view and then you have the IVC this is a patient where really it's not terribly apparent that there's something going on here maybe it's a little wider but it doesn't look too bad and this is an essentially normal looking venogram in a patient that has by intravascular ultrasound pretty significant compression of the vein so the clinical value of intravascular ultrasound is that the spatial resolution is very good so you can see a normal vein here this is a vein that's contracted not round and irregular this is a venous web within a vein this is the external iliac vein this is a common iliac vein again you can see a vein that has pretty dense pervenous fibrosis and compression of the vein and so intravascular ultrasound is very important in patients that you want to consider doing some form of treatment this is not for just someone that has a little bit of aching in their leg this is someone who has really significant clinical complaints with intravascular ultrasound we can make the diagnosis this is a pretty normal iliac vein next to an iliac artery there's a little bit of indentation but it doesn't look too bad and this is a vein that looks compressed and oval and that is possibly contributing to the patient's symptoms so we can use divas not only to diagnose but also to determine the size of a stent which is one of the treatments that we offer these patients this is a patient of mine 60 year old who presented with a popliteal dbt and we went to try to treat the popliteal dbt from the contralateral side and we went up and over and while I was there I said let me take a picture up here and I saw that there was something irregular on the ultrasound and you're going to see here on this on this this is the IVC this is the aorta here we're coming into the vein and you can see how the vein becomes slit like and the artery is compressing it right next to it this hypercoic area is the spine and so this patient underwent stenting and there's several stents available in Europe in this country the most used stent is the wall stent it has good resistance to external compression it provides good scaffolding and more importantly it's the only vein that comes it's the only stent for this application that comes in very large sizes iliac veins are much larger than iliac arteries these are night and all stents that usually don't come in sizes large enough to treat the veins they they don't scaffold as well and they tend to be compressed we have put them in so it's not that we haven't used them and with some success but we've moved towards wall stents because we think the patients do better and this is that patient after we stent it and you can see you don't see that compression and we always perform ultrasound after the procedure just to document and this is the stent now in the vein and you can see that the artery next to it is not compressing it any longer the technical outcomes from the group in Mississippi with over 300 patients with non thrombotic iliac vein lesions they've had a primary patency of 79 and 100% patency out to 6 years with assisted primary and secondary patency if you compare that to post thrombotic patients patients who've had a DVT that's acute or chronic the patency rates are much lower because you're treating a much more diseased vein that now has a space occupying lesion of clot and scar interestingly when they looked at their patients clinical outcomes according to whether or not they had not only a Nivels lesion but also greater saphenous vein reflux and compared that to patients who this is patients they stented who had Nivels without reflux the success rate the clinical success rate was very similar without treating the saphenous vein reflux so they went and stented the iliac veins left the saphenous veins didn't ablate them alone they found this lesion and they saw that both the patients with reflux and without reflux improved significantly with a good or excellent clinical outcome in 75 of the patients with reflux and 79 of the patients without reflux and what this suggests is that either the reflux in the veins below the groin is caused by this superior lesion or that just addressing one of the problems is enough to really significantly improve the patient so now we're going to shift over to chronic venous disease chronic DVT DVTs are a huge burden to society about how many million occur in the U.S. and in European cities up to 40% of patients that have a DVT develop a condition called postphlebitic syndrome or post thrombotic syndrome and this can be anywhere from very mild symptoms of edema to lifestyle limiting claudication and extreme cases patients can get ulceration and another thing is when your patient gets a DVT and you put them on blood thinners you immediately put them on graduated compression stalking therapy and they should wear them daily for the next two years that has been shown to reduce the risk of post thrombotic syndrome by over 50% in patients that have common iliac vein or common femoral vein involvement this is where everything in your training to the common femoral vein and the common iliac vein patients that have involvement in those veins have the worst outcome they have the highest risk of recurrent DVT and they have the highest risk of developing postphlebitic syndrome so those are the patients that should be treated most aggressively depending on the hospital protocols where you're at if the patient has any femoral DVT and they're a reasonable candidate for thrombolytic therapy or thrombectomy then you should consider having the radiologist or whoever the vascular specialist is at your facility treating that there's patients that aren't candidates have high bleeding risk the vascular specialist frequently can help in discerning whether they're too risky for that type of treatment about 4 to 15% of patients develop have involvement in the fear of vena cava and those patients are particularly challenging to treat and I like showing this slide because we tend to hear that one of the reasons that patients develop postphlebitic syndrome is because they have damage to the valvular structure so they develop leaky veins in the legs and this is easy to see why this is how delicate a valve in a vein looks as you can imagine any thrombus and the healing process of the thrombus can be a problem but look at what a vein looks like inside after a chronic DVT you develop significant scarring this is evident on intravascular ultrasound and this is inflating balloons in a patient with iliac veins stenosis you can see how tight those lesions are and these do not respond well to stents or to balloon angioplasty in the groin up in the iliac veins the stents do pretty well but the best thing is to treat these patients aggressively and I like showing this slide because we tend to hear that the American Heart Association in their scientific statement of 2011 recommended graduated compression stocking therapy as we mentioned and they also now recommend angioplasty for femoral vein lesions and stent placement for iliac vein lesions in patients who have chronic DVT to reduce post thrombotic syndrome symptoms and to help with healing of venous ulcers and this is a case an interesting case where we use the wall stents that we mentioned before and we use the large stent called the palm moss stent to crush an inferior vena cava filter this patient was 55 years of age had chronic DVT and a prior simon nitinol filter all this stuff is hardware for back surgery Dr. Eunice you know this patient very well and the patient had a vena cava filter that had occluded and the IVC which should be larger than the aorta had become a tretic and this is a vena gram after we've crossed his iliac vein occlusions but I show this mainly to show the extensive network of collateral veins that these patients develop in order to drain the leg and in order to drain a 16mm vein which is what an iliac vein is we need about 16mm 8mm collateral I mean you need a lot of collateral to drain a leg so these patients can be very very symptomatic and this is the filter right here and this is the stent pushing the filter to the side this is the filter now crushed by the stent and here by intravascular ultrasound we can see that the vein is open and this is a before and after stents to reconstruct this patient's iliofemoral system in cava this is another patient where we double barreled just wall stents this lady had acute on a chronic DVT a lot of these patients have a chronic occlusion and then they close off their collateral this is a superior epigastric branch look how extensive these collateral are draining up into the thorax her left side this is her right side she's on her belly was patent up to here and then the bursanus filter can be seen right here the spokes of the bursanus filter and this is we did her in a stage fashion we recanalize one side and you can see here these are this hyper-echoic scar within the cava and this is after the stent this side had not been treated yet and then we brought her back and we treated her right side and you can see blood coming in from the prior treatment and new blood so we've studied we've done more cases but this is data up to 2015 almost 70 patients who've had acute or chronic DVT involving the iliofemoral system IVC most of these patients had some form of hypercoagulable state or had anatomic variations specifically metherner or heart syndrome and some very few patients had anatomic obstruction this was after liver transplantation most of the patients were female average age was 46 years of age IVC filters were present in a lot of these patients and as you guys know from data looking at IVC filter placement for DVT to prevent PE it does reduce PE and it does increase the risk of recurrent DVT and presentations were various patients presented with swelling, PE, pelvic congestion syndrome, we had a couple patients that presented with acute renal failure who had filters that had been placed and thrombose below the renal veins and we used a large number of motalities that have been some of them come and gone over the years the most common device used is the angiojet which is basically a vacuum cleaner that you pass through the vein or artery and it aspirates clot it also has a mode that allows you to squirt thrombolytic agent into the clot you let it dwell there for about 20 minutes and then you can go back in there and aspirate the thrombus thrombolytic is another form of catheter to aspirate clot after you agitate TPA in the clot catheter directed thrombolysis which most of you guys are familiar with which involves inserting a coaxial catheter in the vein that has multiple side holes and you basically just spray thrombolytic there over 10, 12 hours, 16 hours a couple of days sometimes in patients with DVTs angiovac is a surgical device that is inserted larger than 20 French cannula in the groin of the neck and it's used for large cable thrombus you have to do it with a with a veno-veno bypass and a centrifugal pump because you remove so much blood you have to reinsert in the patients pursuing the OR and then angioplasty and stenting was very common stents placed in over 60% of patients and bilateral stenting in almost 20% of patients technical success rate was high in over 90% of patients this includes acutes and chronics the success rate with chronic DVT is lower partial success in 8.6% of patients unsuccessful in one patient average hospital stay was 4 days mostly for anticoagulant therapy hematoma formation these are patients that are getting illytics 8% transfusion in one, infection in one symptomatic PE was not seen in this case series we have a follow up of almost 40 months and we've had to re-intervene on about 10 patients this is several operators at the hospital not just be Dr. Crazier Dr. Strickman also perform these procedures and several of the vascular surgeons are now involved in doing these at our hospital too death in one patient not related to the procedure improves symptomatically in over 80% of patients so if we look at just to conclude here treatment algorithm of how to think to treat these patients the patient shows up to your office and you believe they have signs of venous insufficiency they're C1 or C2's or mild C2's in other words they have some varicose veins that they don't bother them or they have telangiectages you can manage those medically they probably have venous reflux but you don't necessarily have to ablate their saphenous vein they can be treated with sclerotherapy by a lot of the cosmetic guys do this and stalking therapy patients with more advanced disease C2 to C6 these would be symptomatic varicose veins to active ulcers Doppler ultrasound should be performed to diagnose the extent of reflux in location if they've got superficial venous reflux stalking therapy for three months if they fail then consider ablative techniques or whatever form of therapy the vascular surgeon performs if they've got superficial and deep reflux or perforated reflux the saphenous vein can still be ablated and you can follow the patients and see if they need perforated treatment in patients that have just deep reflux then we start thinking why do they have deep reflux well if they had a DVT then you have a reason for the deep reflux because the veins are damaged by the DVT but if they don't then you should consider whether the patient has a Nibbles lesion right an Iliac vein lesion and those patients can be referred to venography and as we talked about now consideration for referral for intravascular ultrasound other diagnostic techniques that you may consider on your own when you see these patients they go look you know it's patients left leg is swollen I suspect they may have maytherner I'm going to get a CT vena gram or an MR vena gram in this patient see what they have so learning points patients with acute or chronic DVT can be revascularized successfully with potential improvement in quality of life consider Nibbles or maytherner in all patients with DVT involving the left common Iliac vein correction of anatomic obstruction with scents can reduce the risk of recurrent DVT and reduce post thrombotic syndrome Nibbles are a target for therapy in patients with chronic venous disease that means saphenous vein reflux who don't respond to saphenous vein ablation they still are symptomatic maybe something else is going on intravascular ultrasound is a valuable tool for evaluation of these patients that you suspect that may have Nibbles IVC filter stenting is feasible generally safe we get a lot of concerns and they're legitimate concerns that once you stent the filter then what's protecting this patient so generally we if we do this it's someone who's going to remain on thrombotic therapy maybe their filter was put in when they couldn't get anticoagulated or patients who really had a DVT in the setting of an acute event and really got the filter put in it thrombose but they don't have a long term chronic thrombophilia that's predisposing to DVT in general you can stent the filters and with that I conclude