This is a webinar led by three women with a multi-specialty approach to the diagnosis of venous disease. The format will include didactic sessions and a “How would you work this patient up?” panel discussion. The topics will range from how each faculty member got to where that are now, where their patients come from, CEAP classification, VCSS scoring and patient work-up.
tonight I have the pleasure of introducing dr Kathleen Gibson. She's a vascular surgeon from Washington vascular surgeons and Bellevue Washington erin Murphy from. She's also a vascular surgeon and she is the director of venus and lymphatic Institute from Sang Her Heart and vascular You Tree um Health in charlotte north Carolina, an e book Spencer who's an interventional radiologist from minimally invasive procedure specialists in South Denver colorado. Welcome. And I'm going to hand it off to you ladies. Thank you. Great, thank you Nicole. Um and I think that I'm leading this off and I want to thank Philips for putting this together. And I can tell you when they invited me to be on this panel, I was so excited because dr Murphy and dr Spencer, or two ladies I've known for a long time and I have great respect for so I'm delighted to be included on a panel with them. And so we're gonna get right into it after this slide. And this is the disclosure. You'll see disclosure for each of us. So uh you can we can go back to that at some point if you want to. But so why is venus disease important? And I can tell you when I started in vascular surgery, it was not because of love of venus disease. I thought that arteries were exciting. I thought that aneurysms were exciting. I thought that it was very dramatic. Um and then once you get out and practice and really care for people, you realize how very important venus diseases to all of us. And if we look at the prevalence of arterial disease in the United States. So this includes Both people that are very symptomatic and people that have plaque in arteries. It's estimated that 10 of the United States population at any given time, about 10 million people have um actually should be 20 million people, I believe if it's 10 or more have some form of arterial disease, but this is dwarfed by the number of people that have some sort of venus disease. So venus disease runs the gamut all the way from having spider veins on the leg, to having varicose veins to having what we call chronic venous insufficiency to blood clots. So venus disease is one of the most common disorders that you see in humans. So then we'll get into a little bit about death. We'll go to the next slide. So again, uh, aneurysm disease. We cannot stop talking about annual disease, aneurysm disease and vascular conferences. That is the big thing everyone talks about That causes about 15,000 deaths in the United States every year. This number is dwarfed by the number of people that die from pulmonary embolism in the United States every year. And also when we think about it, none of these 15,000 deaths of aneurysm disease should be discounted. But this 100,000 deaths of pulmonary embolism include one of the leading causes of death of women around the time of childbirth. So we are talking about deaths in patients that are young, productive, healthy. So we know, and in this space we know as we've been doing this longer and longer, how very important the treatment of venus disease is. We'll also talk about disability from venus disease. So there are about 600,000 roughly and you look at various studies and they quote different amounts. But some of the more studies in the last 10 to 15 years show that there's about 600,000 venous leg ulcers in the United States being treated nearly we know that this is an underestimate of the true burden of this disease because a lot of people, particularly in underserved communities, don't get care. We know that medical treatment plus time off work for caring for these ulcers is an enormous impact on our economy about a billion dollars a year. And to treat a venus leg also for Medicare, To heal an ulcer and treat a patient to healing is about $16,000 per ulcer for a patient. So, the disability in these patients, some of this is preventable. And that's some of the things that we're going to be talking about in these series of lectures that we're going to have can go, yep, so that's an intro to vein disease. How did I get here? Well, I started out as a chemical engineer and we do a lot of things with flowing pipes. And I had no idea when I was studying flow in pipes as a chemical engineer. that that would be actually helpful when I became a vascular surgeon and learning about flow inhuman pipes. So initially I wanted to be a general surgeon. I thought that sounded exciting. But when I was in vascular surgery training, I had a really excellent mentor during residency that got me interested in pursuing a vascular fellowship. So that was in 1999. And believe it or not, I was the first woman to finish the vascular surgery fellowship at the University of Washington. We've come a long way since then. They've had a lot of women fellows since then. And this is kind of really how I got into a really strong mentorship and my love of venus disease actually came after I was in practice and learned some of the things that I just was talking to you about, about how important it is to treat venus disease. And I've been in private practice in the Seattle area ever since then. Um I do do a lot of talks and research and that's how I got to know these other two ladies that you're gonna hear from and I think that they are next up to tell you about how they got here. Yeah. Thanks Cathy I think I'm up next and so we're all going to talk about kind of how we got here as Kathy said and mine, I was always medically inclined from as little as I could be. I wanted to do something medical, but it was usually veterinarian. Um I doubted my choice for a while, but at some point I switched to physician and I'm glad now um in medical school I went to Georgetown University, I went in saying anything but surgery and I came out applying to surgery. Um I think uh you never really know into you engrossed in things and residency. Again, general surgery like Kathy went to Ut Southwest, I did some research at stanford during that time and you know, you kind of, I kind of narrowed things to my skill set and then similarly I think it was guided by mentors, so in residency and research years it was frank cargo chris Darren's tom Fogerty um in fellowship, once the University of pennsylvania for vascular surgery um worked with Ron Fireman, Ed Woo. Again, great leaders in their fields. Um and so because of all this mentorship, I did have this goal of life or limb drama and arterial uh surgery that I think, you know gets us all in there. Um but I and I didn't know much of venus disease to start with, which is an interesting um things still in our fields, I don't think there's a lot of training in it. Uh And as I came out I had a lot of intrigue. What about this area? What about this field? Why don't we paying attention here? And what I've learned is there's always a new challenge. This is a field where we're still defining um and we don't we don't even know what we don't know until we delve into it. So the ability to make such a huge impact for patients and also the entire field has been very motivating and it has kind of drawn me in and Brooke spencer I think is going to talk about her her route here. Yeah. Thanks erin and Kathy, I love to reiterate that. I think that vascular surgery and interventional radiology are two sub specialties in medicine, with very few women in them. So it's been super fun for me to meet both of you guys and um just be part of the whole female community. I mean we have wonderful guys who work with us to, but um there's something special about that. So I've followed along with your careers as well as mine and there's been a lot of parallels, which I think is really cool. So I think that venus diseases, something treated by multiple specialties now, and there are people who are really excellent and multiple different specialties. And then there are people who are dabbling in multiple specialties. And so it's really important to understand the difference. So um for me, how I got here, um I think I'm one of the rare, I've always been a little bit of an outlier, so I guess I'm a little bit of a rare breed. So I decided to become a doctor at eight, which is pretty similar and I knew I liked to do things with my hands. So in med school I did rotations and Gi and E. R. And lots of surgical rotations. And I ended up going to Cato's peru to do cleft lip and palate surgery for a month. With a A mission trip. That was really inspiring. And at that point I had already applied to radiology residency to do interventional radiology. And after that experience I came back and I applied for general surgery. So I was a categorical general surgery resident first and then part way through due to a lot of interesting stories that I could write a book about. This was over 25 years ago Um in a southern institution with 20 other male interns. Um I decided to go into radiology again and do interventional radiology. So I found my way back to interventional radiology And then in terms of the venus disease I there was a specific patient for me it was a physician assistant who was 45 years old. He worked for one of the neurosurgeons in my hospital and he was diagnosed with pancreatic cancer. He they thought they were going in to do a curative whipple. It was a surprising diagnosis for he and his family and when they came out they realized he was under aceptar Ble and they had done ruined wife had to go JJ Nozomi which is a big abdominal surgery. He had healed from his abdominal incision he was eating but they had put an I. V. C. Filter in him because of a blood clot which goes along with pancreatic cancer. He'd been on Heparin for five days and the blood clot was propagating and getting really close to his heart. Nobody wanted to operate it. Nobody wanted to give him throw politics. They basically told him he was probably going to die in the ICU and he had two teenage Children and a wife and that none of them had processed any of this. He had no metastatic disease at the time. So we had the opportunity to live for, you know, eight months or a year on average at least. And um, he begged me to give him an opportunity. I had partners at the time. He said I was committing malpractice and there was a new device out that I hadn't used before that could maybe help him in a protected manner. And I, we made an agreement and I used the device and within three days he was completely asymptomatic and discharged home. So he spent about 10 months with his family before he eventually passed away. But he had time to process things with them and be with his kids and do what he did, and he came back and he just said, you know, whatever you do, don't stop innovating, don't stop pushing the envelope and um, you know, stay engaged in venus disease. So that's what got me involved with industry and developing products and in the venus world. And it just kind of took off from there, awesome story, we had a question to you guys. Just elaborate a little bit more about. I know Dr Gibson touched on it a little bit, but about the gender disparities that we typically see in venus disease and how it's different, you know, with women and men and maybe maybe why women might not seek out treatment or, you know, those kinds of things that you guys see in your practice, know, somebody seeking out treatment or was it a disparity in who goes into these fields? What was the no in in treatment, dr. Dobson? Oh, okay. So treatment um, it's the opposite of what we see in terms of representation in medicine. It's a medicine, there's fewer women that I mean, I guess not medicine, but in our specialties, but women seek medical attention more than men do in terms of who comes into the doctor's office. Women also come for treatment at a young at a earlier stage and younger age than men do. And that is not just for venus disease, it's for disease in general, women are better about getting immunized for shingles and flu shots and all of that, so that I don't think I can answer the question of. Um, but, you know, part of that I think is a definite societal thing is that men don't seek care as much and and so this transcends venus disease. Uh so again, men tend to present at higher clinical classes than women do, and so it's not just vanity that women are coming in because they think their legs ugly early. Um It's I think that there's there's so much layering to that. So do you guys agree with that? So I do agree that men tend to wait until they have more advanced symptoms to present, particularly with the varicose veins. Um So they're always they're always in here with, you know, 30 year disease and and uh you know, massive flab ectomy patient. Um but I would say that women to have a few more risk factors um being, you know, having babies um and the pressure that puts on the venus system causing pelvic reflux, um causing varicose veins from the nine months of um you know, carrying the baby and having the higher venus pressures. I think it contributes. I get a lot of women that say oh I had these varicose veins have popped up when I had when I was pregnant and they haven't gone away. Um And I think the lumbar large doses contributes in women and the tilt of the pelvis contributes a little bit more to some of the non probiotic iliac vein lesions. So there is some I think um anatomy to it as well. But I do treat a lot of men. So I do think it is in in both when I think also the other thing is how you address that is education of patients and also primary care doctors. Because some of what I see is people don't sometimes come to see you for a vein problem until it's quite advanced because a primary care doctor told them veins are cosmetic. So I think that people get dissuaded from coming. And um I think if there was education that yes, they can be cosmetic, that they also can cause impact on quality of life that we would have patients come at earlier stages. And I think also I think also that a lot of women, um not so much with the leg varicose veins, which we're talking about today, but we will be doing a future webinar on the female pelvic green and female pelvic congestion. I think a lot of those patients have been made to feel like they're crazy because they've gone to a lot of doctors and they've talked about what their symptoms are and the doctors don't understand that there's a venus ideology to those symptoms. And when doctors don't understand what's wrong with men, I think they tend to say, we don't know what's going on, we can't figure it out. And when they don't know what's wrong with women, they tend to say you're crazy. So maybe there's a little bit of a trend towards that, so I'm not saying it's 100 across the board. I try not to tell anyone they're crazy, but you know, I think there's a little bit of that somewhere in there, but we'll talk about the female pelvic stuff at a future webinar to Alright Cathy, I think you're up for where do my patients come from? Where did my patients come from? Okay. So my patients come from a variety of places, so they can be self referred primary care in O. B G Y N are the main things. And then also I didn't put on there, but a lot of orthopedists we'll send them, particularly for if it's a robotic event. So for obstruction we do have an active DVT clinic that our practice has. So in any one area you'll sometimes get ownership of DVT is a disease state. So maybe hematology group, a medicine group and in the area that we live in east of Seattle, it's our DVT practice I think. Okay I guess I talked enough on that. It's good to to someone else to go. Um So uh the er census patients and you know, I do get some patients regionally and those come by word of mouth and presentations like this. People see me talk and say oh she must know how to do this and that and they send patients to me. So that's kind of the referral sources I get I get a lot from Alaska and Idaho and kind of the Washington state area. I think that next we can go to dr Murphy. Yeah my answer is everywhere I get. It depends a little bit on which category of disease that we're talking about. Um But there are a lot of these patients in the er in patients who have been told there's nothing they can do that keep going in with a history of DVT and like swelling and their legs were swollen. And is it a new DVT is an old DVT. What about my wound? A lot of people are managed with compression. Um And I don't know there's other things that can be done. Um Gynecology, medicine, family practice those fields um You know are are getting used to referring the varicose veins patients or um certainly ulcers um in conjunction with wound care however there's still a lot of knowledge gap there that these patients with old D. V. T. S. With SvC filters with 20 year olds you know swollen legs from a from a blood clot ages ago that they can actually be treated now. And so I I do get a lot of referrals as we are educating those practices like oh yeah I can think of a couple of patients right off the bat that can use your health. Um pediatrics, hematology, hematology. We've been winning over a little bit. They've been following a lot of their patients like this without referring. Um So I've got a good referral pattern going with them now after some education. Um Lymphedema centers wound care centers. Um I get a lot of direct referrals once you get into this. If you're doing it a lot you'll get referrals from colleagues. So cardiology IR vascular surgeons who aren't that adept at the more advanced cases or who have complications. Um We'll send patients as well. The industry reps will call and say you know we've got a complex case here. Can you talk to the doctor? Would you be willing to see them if they came down that sort of thing? In dutch Spencer? Yeah. So similarly I see people from all over the country and outside the U. S. I think I do a lot a lot a lot of chronic DvT recapitalization reconstruction. I would say they're only 25 or 30 people in the country that I know that do a lot of this. And so as a result we all know each other. We kind of regionally refer to each other. The reps refer to us um locally a lot of primary care hematology, Ortho and podiatry. And I know part of this discussion was supposed to be for those of you who are looking to maybe start a new vein practice or learn about these things and kind of ease into it. I think a lot of it is like Kathy and Aaron both said it's it's education of the community, it's helping your primary care Doctors know that when someone has density, most cirrhosis or skin changes, you know, there's a vein problem underlying there potentially um that we could really help with. And so one of the things that we've done is to try to do in some of our education and marketing efforts is having the ability for them to just send us yucky legs. Like they're embarrassed to say, we don't know what's wrong with the leg. Is that arterial, is that venus? And we found that a lot of podiatrists don't even understand what's an arterial wound or a venus wound. So if they just send a wound patient over, you know, we've been really accepting of doing a screening with our nurse practitioners to talk to the patients. Where is your wound? What does it look like? What is the weeping? What is whatever even with telemedicine now in the days of covid to pre screen. So we're ordering the right studies for the patients to come in and be evaluated for whether it's arterial or venous more likely or one or another. So I agree with all the sources that you guys have talked about. And the one thing I would say if you're starting off a practices to start small, learn really well what you're doing. But you have to learn a little bit even if you don't treat it about the deep and the superficial system so that you make sure that you can differentiate if it's something that you don't do you understand who does do it. So you may become really, really advanced in one thing over time and you may just do a really great job at basic stuff and have referral sources. So I have a lot of of superficial vein clinics and and and yeah, other interventional vascular surgeons who refer to me as well. I think it's a collegial community and um I think a big part of doing it well is knowing what you don't know. So I'm going to talk to you a little bit about the breath of venus disease in clinical practice and this is something I never would have imagined when I was in training of all the things you can do in vain. So we kind of to put it in different buckets, there's obstruction and reflux and under this for obstruction. And you guys can tell me if I'm missing something so acute thrombosis removal, dealing with people with acute uh robotic events, whether it's DVT or pulmonary embolism and the vascular open reconstruction of chronic inclusive disease. And I can tell you the number of open reconstructions that I've done In my 20 years of practice is minimal and diminishing because it's not fun. Um there uh really difficult surgeries and as we get better and better tools and I've become better and better at endo. I do primarily in the vascular reconstruction of chronic venous occlusion, pageant Schroeder syndrome, that's first rib compression with clot. Uh and then managing of the post traumatic syndrome medically is something that often is done besides the interventions that we can do in terms of reflux. Uh there's all kinds of ablation techniques now for superficial reflux, There's lasers, radio frequency, there's the non thermal technologies ambulatory fly back to me, foam spider vein treatment and then treatment of pelvic venous reflux. And again we're going to get into pelvic venous reflux in another webinar. So here's a promo for that. Um Please come to that because there's a lot of um crossover between public venus disease with reflux and obstruction that they can be interrelated. We'll talk more about those another time and then uh the additional things that I have is you do one more click for me um A v malformations and wound care. So all of this is kind of encompassing venus disease and uh what I don't have on there like I just noticed is dvT care medically. So medical management of deep venous thrombosis with anticoagulants is another area that some of us practicing. Am I missing anything guys use twice? Have you ever missed anything? Yeah, it's a pretty big and exciting list. Uh And the other thing again, we to emphasize is the range of patients you treat in terms of where they are in their life, um gender and age and all that is so broad that this can be very gratifying to have venus disease is a big part of your practice. You really help a lot of people. Okay. We're gonna move on a little bit to Dr Spencer is now going to talk to you Brooke is going to talk to you about clinical grading Zoe. We've got a polling question. What is the common most common venus pathology you treat in your practice? Acute G. T. E. Chronic venous obstruction, varicose veins, advanced venus insufficiency including wounds or pelvic venous reflux? Ah chronic venous obstruction. All right. So maybe I was advertising to the wrong group when I said learn but you all want to learn about pelvic venous reflux. So you'll all have to come to the next webinar or the one after that. I guess it's a couple of way. Yeah but dr Spencer is going to talk to us about some grading systems. Yeah. Which is funny because Yeah. Okay good. So we have clinical grading system. So my friends all make fun of me because in my electronic medical record on every single patient I collect all of these which takes a lot of extra time. But I feel like some of the studies talk about one or the other or this or that. So if you want to compare yourself to how you're doing in the world of all this or if you want to publish your data eventually it's helpful to collect them all. But if you don't want to collect them all you don't need to. But it's nice to have at least an objective system that you work with That kind of fits your patient population and helps to keep track of how you're doing. So one of them is the CPE classification, the venus clinical severity score, the Villalta score VV. Some um scales quality of life and there's a V. V. Sim quick score and then there's the venus quality of life surveys that we all tend to use. So I think you know people talk about all these different surveys but we're going to move on to talk a little bit about the CPE classification which was kind of I think one of the most ubiquitous and first used classifications next. Okay, so what seeps stands for is clinical radiologic anatomy and path of physiology. So the reality of the world of clinical medicine for most people is we use the clinical scores. Most people talk about the clinical scores so we can talk a little bit about getting into the details of the ideology, anatomy and path of physiology of what's causing the disease. But when most people just throw around the terminology of seat, they're talking about the clinical. So do you have no visible signs of venus disease? Thailand's lactase is our particular veins is c. one. You can read the screen here. So it's a scale that goes from no venus disease all the way up to act as active venous ulcers. And there's even a symptomatic or asymptomatic C. Six. So I think we're going to move into Kathy's gonna talk to us a little bit about C. One too because she is Maybe the master of the universe in uh in square therapy and things and I'm sure I can learn a few things. Uh and then I think Dr Murphy is going to talk to us about the c 44 seats. Uh Our and then I'll talk about 56 after that. So this is just kind of a little bit of a deeper dive into what the ap means. And if you want to get that deep a lot of the M. R. S. Will let you do it. But if you don't at least using the clinical score can help you talk to other venus physicians and follow something objective on your patients. Okay? So uh this is c. one and c. two and see one is to landlocked asia and C. Two is varicose veins without edema or other complications. And this could be symptomatic or asymptomatic. And we're gonna then show I'm going to show you my algorithm. We're not going to talk a lot about spider veins. Um But this is kind of the algorithm I use. So if the patient dislikes the appearance, if the answer is no then you reassure them. So I actually had a patient like this today. Older lady with red ankles. You know a few little purple veins too whose primary care doctor said you really should get that looked at. So I looked at it and I'm like do they hurt if they ever blood? No. No. And I'm like do you think they're ugly? She says I don't care and I say don't worry about it, I can reassure you. These are okay. So some patients will come to you with that if they want treatment. If the veins are so small that I cannot see them with reading glasses or just differentiate them I will refer them to a dermatologist for topical laser. But if I can actually see that the veins are there with my reading glasses then I will treat them. And if they're little spider veins, I usually treat them with liquid Poland O. Connell usually half percent, sometimes quarter percent. If there are particular veins a little bit more purple or maybe feeding a big kind of star burst of veins, then I will use a stronger Poland O connell. I tend not to use sodium tetra tech will sulfate for veins like this because you have to dilute it so much and I think that you're a little bit more likely to get ulceration. It's just that I'm more comfortable using pull it open all. Um if I have a patient that's failed, pull it open all, then I might move up to two sodium tetra nickel sulphate. The other thing with STS is you do need to be prepared for the occasional allergy and have anaphylaxis meds available to you. If you're using STS anaphylaxis with pull the dough can all um has been reported in the literature, but I haven't seen it in years of using buckets of the stuff. So not very common to have that reaction. But if you're using sts make sure you do have some drugs available to you. Um For big particular veins or small varicose veins. That's when I tend to use foam and I don't use room air primarily because of the black box warning. Not necessarily because I think room here is terrible. Um But I tend to use a mix of physiological to and CO. Two that come in a little cartridge and that's that's just my protocol for dealing with kind of the more cosmetic. See one veins And we're gonna move on to c. two. So some clinical tips for Oh, polling question. Yeah. Okay. Before we get in to see to what is your go to technology? If you do treat superficial venous disease for sadness and confidence and the venus laser radio frequency one of the non thermal techniques or a mix depending on patient factors or I guess it does have that option that you don't treat staff innocent confidence. I feel like we should have some sort of music going on. Right? I agree. Very kristen if you want to show us the responses, please a mix there wouldn't have been that a few years ago. So I think that's that's pretty cool. All right. So some of Kathleen Gibson's tips. I'm gonna close the pole um for C. two. So you should examine your patients standing and that's what I always tell our our VTS to um is you know, we do a lot of standing exams but look at your patient first, see where these veins coming from. Uh look for the pattern. And in a few other slides I'm going to talk about pelvic source varicose veins. I can't remember where that's coming really soon or towards the end of the talk. Look for a Dema. Um if that is there then that would make the patient a clinical class three. If they've got a Dema look for unusual patterns, I certainly have had patients with KTS. Klippel Trenaunay syndrome come bill just as varicose veins and it's a malformation. So knowing those sort of patterns are a good thing to do and then ask the patient what's bothering them just because you think something looks bad or ugly with the C. Two doesn't mean that that's what is bothering them. So you really want to hone in on what is bothering them is your focus. So this is my very complex algorithm for c. two. So if the patient does not have symptoms I reassure them. Do I have to have something done? No. If they're asymptomatic they don't need treatment. If they do have symptoms they get a deep and superficial duplex scan. And if they have a pelvic source of their varicose veins, I have a different algorithm. I use uh pathologic perforate er veins. There's really no such thing as a pathologic perforating vein with c. two. Because Pathologic perforating veins occur near damaged skin. Um so one of my pet peeves is you go to a meeting in here that somebody closed 10 perforating veins in AC. To patient. And it's just a misunderstanding of anatomy and what a reentry perforating vein is rather than a pathologic perforating vein. If there's deep venous reflux, when I say don't treat, there's what I really mean is we don't have an intervention specifically. Now that is good for deep venous reflux on its own other than compression. If they've got trunkful reflux, uh, and it's recurrent and tortuous, then I tend to use foam, either proprietary, uh, political and the venus microphone or physician compounded. If it's their first treatment for tropical reflux, the patient's cash paying, I give them the choice of everything that's out there and give them pluses and minuses otherwise. Uh, and then how much each one of those costs. If they have insurance, then we talk about whether or not their insurance plan covers. Um, we often get preauthorization. So some insurance plans don't cover non thermals. Others do you really need to know in your region who covers? What? Uh, if they got small branches, I phoned them and if they have large branches, I do micro flow back to me. However, I do a lot of staging and I didn't used to do this 10 years ago, 10 years ago. I just threw everything at them. I did an ablation. I took out all the branches And we did a number of clinical trials where we weren't allowed to treat the branches because we wanted to hone in on the effect of the treatment. And we found that a good portion of the time the branches regress, particularly with C2 disease. If you close the trunk or you downstage them essentially that you don't have to do as much flow back to me as you thought or don't need to use as much foam. So I do a lot of staging and we're moving next. Okay, How how far apart do you stage them? Because there's insurance issues with that too. In some places we staged them three months. Um, and the reason we do three months is when we were doing clinical trials. Apart from insurance, we were seeing patients at a month and at three months. And there was a big difference between a month and three months in terms of branch regression. We do have, I think a couple plants, plants that want you to wait three months. Um So you know, you hear that if you uh you know, a lot of the centers will do the the ablation is but they won't complete the full effect amis And so then the patients think their treatments done, the veins get better, but then they start coming back or kind of refilling from either perpetrators or reopened segment. Um And then they come. But after six months the insurance companies here won't pay for anything back to me. Uh We don't have that in our area. But that that does highlight know your region. And also when you hear people like me or Aaron or Brooke talk, we're probably giving you our viewpoint of what our region allows and we don't know the rules of where you live. So you need to know the rules where you live because they vary a lot for varicose veins and they vary a lot actually for venus inclusive disease to in the pelvis and coil embolization. So the next one's my pelvic venous disease algorithm. And the part that's great out is great out because we're going to talk about pelvic disease at other talks. So um if the patient has symptoms of pelvic pain, that's a whole different pathway that I run them through. If they've got pelvic source varicose veins on their ultrasound, including in the vulva. And they tell me my pelvis does not hurt at all. And I give them the whole survey. Um I, you know, sometimes I look with duplex for fun, but I'm not going to intervene on an ovarian vein or anything like that if they've got C to disease in their leg and I can treat them with ultrasound guided foam square of therapy. So I reserve pelvic treatment for leg veins for people who either have pelvic vein pain also, or who have failed my book from below treatment. Now, this is controversial. There's other people who say if you've got ovarian vein reflux and you've got these pelvic and leg varicose veins from that, you should do treatment of that vein. And that's not been my approach. And we did a study of like 72 patients and evolve our veins without pelvic vein symptoms. Um, and we found that over a period of several years, we only needed to do pelvic intervention with coil embolization in two of those women. So this is another one of those things where I think you really listen to what your patient tells you and don't get too excited about your an atomic findings and how much fun it would be to do other things is hone in on what they want and so I've had pretty good luck with that approach. I know others don't always agree with that. And the fact is we don't have data about which approach is best. It's everyone's opinion in terms of pelvic thanks. Um but we'll get into that more I think with our pelvic vein webinar that we're going to do um later. Okay and I think that we're we now getting into Aaron you're talking about C3 C4. Oh it's still me. Oh boy. Okay so I'm not going to spend too much time on this slide. This is kind of old news at this point. We have a bunch of choices for treating treating sadness veins between thermal and non thermal. My recommendation is get good at one thermal technique and make sure that you have at least one non thermal technique in your quiver and that would be how to start. If you if you can do everything that's great. But those to start out, make sure you have both of those and I think I have one more slide and then we're to Aaron about kind of which one of these treatments is dust. Can we put that up? Okay, one more click. So this is a little table. I think if you've got a re flexing G. S. V. Uh from knee to Sappho femoral junction dealer's choice unless they're gigantic veins, you can do any of these and they all have good data if it's really tortuous. I use physician compounded foam or homemade foam if it's below the knee and I really feel that that segment needs to be treated. I prefer the non thermals for the small staff anus, I prefer non thermals and um I don't usually use physician or pem uh foam on that because there's a higher rate of dvt into the pop, a little vain if you use that technique and if it's a big vein, I either use thermal or I use glue, but with the glue you need to increase your alec watts and volume of glue or you're not going to have success. So, I have heard people say you can't use glue on big veins, That's untrue. You just have to alter your technique. Okay, so then any comments from the panel or from bricker ERin on C to disease? No, I just think it's funny. I think we have super different approaches to everything and I think you're really, really, really good at all the foam square piece stuff and everything else. But I think I probably do more full back to me than you do me. As I get a better cosmetic results and I have unhappy patients when they get staining. I do think that you're very talented at the foam stuff and I do think it takes it takes some skill and ability and talent. So maybe if you're just starting out and the veins are bigger, flow back to me is not a terrible option at first because you might have some unhappy patients, if you get a lot of trapped blood, you don't know what you're doing. But as you get better and more technical, you can treat more and more veins that are larger with foam. So there are lots of techniques and I think that, you know, I agree with everything you said, I use laser for almost everything. I do a small staff penis with laser. I don't use non thermal ablation, I use glue. Sometimes we've had a lot of reactions to glue that have been really tricky for us to handle. So it's just funny. I think I've had a really different experience, but then a lot of people I've talked to, but I agree that the bottom line for all of it is that if you're thoughtful about what you do and you get good at a technique and you're having few complications and good outcomes, you know, you're probably in a good place. No, I think you're absolutely right. And um, you know, I I do like put back to me, I don't want to tell you I don't And which surgeon doesn't like a scalpel, but I think that you're right is that people think that foam is easy. And the technique itself, you can put a needle in something and inject it, but it takes a lot of judgment and positioning. And how much do you do with each injection? So it's it's a it's a fake out like when vera athena came out, I'm like, okay, I know some people said, all right, this is gonna be great because people who aren't very experienced can use it. And I'm like, that's the people you don't want. Yeah. No, it's um you know, it's it's unleashing a genie from a bottle. So you have to you have to know what you're doing with it. And some of the best people in the world that using foam are in France and they've been using it for 40 years. And yeah, it's an art form for them. For sure. So I think your points are excellent. Yeah and I guess I would I would agree with that. I do mostly fly back to me instead of the foam for similar reasons because patients get unexpected pain and cosmetically the pigmentation has been an issue. Um But I think to mentioning like you know the need to do micro expressions if you do larger veins and to bring your patients back if you're doing the foaming of the varicose veins to see if they need any adjustments or expressions. Um And in that case you can evacuate from those trapped blood and mitigate some of the um pigmentation. But you know that also depends on clinic staff and availability to bring them back for those appointments. Yeah. And I also a lot of times can combine flow back to me and foam and I find that foam can be an adjunct to cause the vein to go into spasm. And then you have less uh less bleeding as you're doing it. So often times with patients I'll say I'm going to do what I think in that particular vein we need on that day. And you know I try to preauthorize for full back to me whether I'm going to do it or not. Um So I try to preauthorize for everything that I think I'm going to possibly do. And then if you you say I ended up not doing this then I think the insurance companies are perfectly happy with you not doing something. But if you do it without asking first you're going to get into trouble because you won't get it paid for. Yeah, that's a great point agreed. All right. Uh We'll move on the two C. Three and beyond. Now. I'm gonna talk mostly about C. Three and four. Um If you can advance that one. Um The C three patients are you know your patients with primarily oedema uh See before gets into the skin changes that you see here and then um expenses. Gonna talk about the ulcer patients moving on. So the really important thing with CP three um the evaluation of the Dema patients is that uh this can be non venus. Um And that is the biggest issue when dealing with these patients. Um And it's not understood necessarily but everyone's sending these patients to you. The number one cause of bilateral equal lower extremity edema is by far and large. It's medical oedema. It's patients who have venus hypertension from obesity, COPD sleep apnea, heart failure, calcium, channel blockers, no frantic syndrome. Um So what's really hard to convey is that just because the patient has been a stasis they have swollen legs. They have skin changes. Some of them have ulcers. Yes they have been as hypertension and yes they have been a synthesis but doesn't necessarily mean they have a vein problem. So you have to look at their overall picture and their medical problems in order to sort through that. Um And then if it is a venus lymphatic problem, well there's multi multiple facets to that. Um So is it a calf pump issue? Do they have you know they don't have did they lose movement of their their joints there? Paraplegic patients, Sherko joint patients who have no calf pump. Those patients are very swollen. Um And it's not necessarily a vein procedure that will fix that patients have valve problems both superficial and deep that we need to look at. Patients have venous hypertension from proximal obstruction. Um Whether they've had prior D. V. T. S. Or non from biotic issues. Um patients who have included I. V. C. Filters, patients with lymphedema often have underlying vein problems or venus obstruction in addition to having a primary or a secondary lymphedema. So there are certainly things that can cause it from a venous lymphatic standpoint. But this isn't in isolation of the rest of the patient. So how how you kind of sort through this is basically a very thorough history and physical you can move right on. Um And I just want to prove to how hard this is to train people. My clinic. I'm three years in and I'm finally starting to get the community a little trained up. But I sent out these massive educational things to the clinics here that refer a lot into all of my sanger cardiac. And I get this email because I said please, you know we're getting inundated with medical Oedema. This is what we're looking for these patients. Look for this. And I got this email on behalf of my patient. Please see this guy sooner. He has heart failure. He has diastolic heart failure is restrictive cardiomyopathy. I finally got his societies and pulmonary hypertension controlled. I got his weight down from 362 to 74 with ivy. Lasix, £100 weight loss from Lasix. His lower extremity swelling is much better with £100 weight loss. But his he's in renal failure. So because of that, we put in a Porta Cath so we can alternate his um fluids and his Lasix once his weight gets back up above 2 90 this is a goal. Thank you. Unfortunately, I can't tolerate compression and the sentence that I keep meaning to put back on here that was left off when I made the slide was I believe he meets all criteria for urgent evaluation in the vein click. And he had a already done Venus studies and he had a reflux ng GSB on one side that reflux at the knee and was three. So not every swollen patient with skin changes is a is a vein patient. Uh Next so again, complete history and physical, really suspect your venus patients and your venus diseases. The problem if the swelling is out of proportion to the medical problems and that the medical problems are not prohibitive. So what I mean by that, you know, I have been I don't know about you guys. I know Cathy really doesn't have to deal with it. The BMS we've talked about before a little lower in Seattle compared to where I've been but um I have been my restrictions in here when I made you know this slide 45. I've really brought that down closer to 40 for most patients if they have bilateral edema because that weight just causes the swelling and so does the medical problems that come with it. Um if you do flow vasectomies on those patients they have a higher bleeding risk. If you do um stenting their higher risk for complications it's very difficult tomorrow those stents with ultrasound because you can't see um and then they have compliance issues. They often do not improve. So unless the patient has an acute DVT and I have no way around it. I really don't offer those patients elective stent so I really don't look for that problem unless they understand it's just a diagnostic study only. Um The ideal patient that you're looking for in these categories with CP three disease and summoned to C. Four's. You're otherwise healthy patient released reasonable medical issues who's not super obese whose ambulatory when the elevation improves their swelling. Um When one leg is worse than the other. Either that because it's a it's a vein problem obstruction wise unless it's cable one leg should usually be worse than the other. A history of DVT or pE history of filters. Um And certainly any presentation of lymphedema lymphedema can mask a undiagnosed venus obstruction. So those patients deserve at least a one time view of what their cave and Elliot banes look like. Um So what is the work up I do when somebody comes in with C. Three and C. Four um for venus evaluation I kind of have to look at the whole picture to weigh. What am I going to offer. What am I going to do? Um Is this a vein problem? And so I look at the lower extremity from an ultrasound standpoint. We do um ultrasound and DVt and reflex testing um determine you know what what they have as far as val val function in both their deep and superficial system. Um I do duplex ultrasound looking for including in the iliac veins looking for obstruction. So um external compression typically arterial with your maternal patients. Any non probiotic compressions um any post robotic changes in the vein. So discreet narrowing but also diffuse lee. Um Small veins thickened veins um thickened wall vein walls thicken valves webbing with inside the vein. Um I look at the inflow. So if a patient has an occlusion you find an iliac conclusion. One of the things I'm always looking at an ultrasound is are they even a candidate for stenting you need either a good per fund a good ephemeral or both. So my text I'm always asked him how is the profound to show me the Brenda? How big is the propaganda? Um You need to make sure you really have a good inflow source or anything you do is not worth it. Um I do often in patients that I'm considering for the R. A. C. T. As well. I think it gives a more definitive picture. My last institution. I did MRV. It may depend on your institution which study is better for you. Um We just don't get really good M. R. V. S. Here. Um But that helps me a lot of my operative planning and it's it kind of confirms or um negate some of the very proximal ultrasound. And patients who are harder to ultrasound next. So my treatment algorithm based on these patients is basically weighing and we'll go through a couple couple cases to illustrate this. But based on the ultrasound the patient's medical conditions the C. T. Um reflux testing where I start. Am I going to recommend this patient has you know if they're deep reflux or their medical problems primarily or they're they have reflux but it's nowhere near er of any significance to cause this massively swollen legs. I'm not going to offer them the treatment. I see a lot of patients that have these huge swollen legs and went to a local vein clinic quote unquote. Um and then got these tiny little G. SVS treated or 88 venus procedures on their superficial veins that never would have caused massive legs going to start with. So why why offer those treatments for that problem? Um As Kathy said listen to your patients. What's bothering them and then think about whether there fixing that anatomy finding you found is actually going to make a difference. Um In patients who have a occlusion of the iliac vein and an exam that makes sense. Then you know offering them stenting and treatment of their obstruction first. And patients who have um you know ankle swelling with a local problem and a big Gsp. You're going to go after your superficial Disease 1st. Um so it's all you can go to the next next click. Um it's just really judgment as to where you start with those people. But it is a big endeavor to start sorting through them to find these patients. Because if you open that door you're going to get all of these people sent to you and it's a bit to we to go through them. Yeah so I I got C. 56 and you know I think our next webinar that we're going to do together is on chronic venous obstruction and on venus obstructions. So I'm not gonna go into great detail about exactly how we treat these. But I'm going to talk briefly about my philosophy of uh healed and non healed ulcers and wounds. So I think some of this is a little bit controversial but but I don't think it should be. I think that in order to get an ulcer you have to have elevated pressures in your entire venus system. It is very hard to have enough superficial vein reflux without elevated deep venous pressures to also write your skin. Now, Aaron just went over in a beautiful discussion all the reasons that are non venus for elevated deep venous pressures, right heart failure, obesity, all that stuff. So that in my mind counts as an obstruction and it's not necessarily an obstruction but it counts as a cause of elevated depressors. So if you've ruled those out, then you need to assume there's a venus cause of your elevated deep venous pressures. And I just work from the heart back. So we do a lot of sleep apnea evaluation. I never thought as an interventional radiologist, the miners practitioners would be ordering sleep apnea valves on 20 of our patients. But they are and a lot of them are significant and it can lead to heart failure and all sorts of other things. So I think it is important to manage those patients that way. And then we look from imaging studies using M. R. C. T. V. About whether they have retro peritoneal fibrosis. Did they have radiation that they have chemo? Do they have surgical problems? Do they have chronic DVT or what's going on in there? Deep system? And we follow through from there to try to decide if they have a deep venous obstruction before we just go on to looking at superficial reflux. Next slide. Okay, so this was sent to me by a friend of mine who is also a big venus reconstruction person in the country. This was a tweet. So this is publicly available out on twitter. But I was horrified when I read this. This is a is a young man who said my legs would continue opening new wounds Which wouldn't heal after battling 14 years. He started when he was in his early 20's or teens, you know, without any healing in sight. After wearing compression bandages and teaching nurses and wound care that he'd had enough. It took him two years begging surgeons to amputate his leg. No one would do it finally escalated to the VP of vascular surgery. You wouldn't do it right away. He said, you have a year to do whatever you want to me to try to get this to heal. And if you haven't healed in in a year, you have to agree to cut my leg off. So after a year they hadn't healed it and they cut the guy's leg off, and with another year they cut his other leg off. So now you have a 40 year old bilateral venus amputee. This should never happen to anyone in this country. There are specialists in this country who can fix these deep venous obstructions to the point where the patients that can at least till they're wound, the number of times that this should happen should be you should be able to count them on one of the three of ours hands in the world. So I guess part of this webinar was to talk about people who are interested in getting into venus practices and learning and starting these things and enhancing their own venus practices. And the one thing that I would implore you, if you remember nothing from this entire thing is that that that these problems. Any wound that's above the ankle is venus almost always. It may have an arterial component, but anything above the ankle is almost always venus and they should all be something that can be healed. Next slide. This is an example of a nurse working 12 hour shifts for 17 years with this venus wound 17 years venus wound, innumerable physicians and the left hand pictures or pelvis where we can see massive perry uterine collaterals, trans sacral collaterals, a sending lumbar veins, even collateral venous, strange Luca nadal veins, which is really rare to see even with a complete inferior vena cava and iliac vein obstruction. This is one of the hardest cases I've ever done, but I was able to completely reconstruct her inferior vena cava and iliac veins and she healed that wound in a month and a half. So 17 year wound healed in a month and a half. So um I think with C. 56 is it's really important to understand that ruling out a deep venous obstruction is absolutely critical and that if you don't have the skill set or the ability to fix it, there's no shame in that it takes a lot of time and brain damage to learn how to do this stuff. And but there are people out there that who are willing or crazy enough to do it and try. I like that, it takes time and brain damage. Right. Well, I mean, a lot of people ask me, how did you get into this and why do you do it? And you know, it must be very lucrative. And the answer is it's not lucrative at all, which is why only those of us willing to undergo brain damage actually do these cases, because they're really challenging. But you know, if you're a bleeding heart, These are these cases are the ones that, like, make your career right? These people, this woman's been suffering for 17 years, she's a nurse, she gives her time, her care and her energy to other people and she's really suffering and you know, yes, maybe it takes 678 hours sometimes to fix something this challenging. Um but if you do it and you're successful, it's really worth it in the end, and it's not something to dabble in. These things are something that you go to an expert for. But there are a lot of things that we'll be talking about in our next webinar. There are things that people who are skilled and no vascular people could definitely learn to do well and easily without having to take that on next slide please. So I guess just the message I would give here is that with with superficial venous reflux and deep venous obstruction. If you have advanced skin changes the deep venous stuff trump's is superficial all the time with C. I mean C. Foreign below you may be treating the superficial veins first but you have to be very careful if someone truly has a significantly obstructed deep venous system, especially in the fem pop and you treat the superficial veins you can make it worse instead of better. So if they're deep systems open and the fem pop and they're superficial reflection. You can certainly proceed to treating that first, see if you can heal the wound and how they do. But if they have a significant central obstruction, it usually takes fixing that for them to get better forever. Or it usually comes back within five, six years next slide. So we're gonna briefly just talk about. Not really go spend time on talking about but make people aware that there are other there are other scaling systems the Venus clinical severity score. This is a score of 0-3. And you can see the categories here paying varicose veins, edema, pigment, inflammation and duration. Number of ulcers, duration of ulcers, size of ulcers and whether they wear compression and you get a number. And it's an objective measure. You can follow next slide. Villa Alta score has two components to it. It's the subjective which comes from the patient and the objective which comes from the provider. It's a scale of 0-3 again and it involves pain cramps, heaviness, Paris, seizures and itching for patients next slide. And the objective for the providers is pre tibial edema, skin and duration, hyperpigmentation, redness, venus, act asia pain with calf compression and venus ulceration being present or absent. A maximum score would be 48 per leg. And so you get a number and as you do stuff you can follow and see if your numbers dropping. So it gives you a nice objective measure as to whether you're achieving your goals. So now we're moving on to some case studies and I think Kathy is going to start with a nice example of what she was talking about before, which would be these viruses probably coming from the pelvis. Yeah, that's right. So this is a really good case study of listening to your patient and pattern recognition. So I have seen a number of patients like this case that have had the same ultrasound that this lady you're gonna see has uh that um were treated completely different way than how I treated them. And a lot of times you would see a pattern like this. Someone not recognizing it from the pelvis and avoiding their great staff into spain and leaving that chain of varicose veins alone. So this is a 42 year old colleague pediatrician that had two babies venus and medial thigh viruses. They developed in her second pregnancy. And even though this leg vein does bother her, her main complaint is and these veins go up into her vulva is that she has itching in her vulva. It's worse with Menzies. She has no pelvic pain, she has no edema, no activity limitations. She's had multiple topical anti itch medications and anti yeast medications given by her O. B. G. Y. N. That have not helped her. And next next slide please. So this was the duplex. This is just a worksheet from our lab. Yellows, no reflux pincus reflux. So there's a chain of eric Aussie's, they're coming from her p point, the peroneal vein uh perforating through the pelvis. The veins there are about point uh five. And you can see that her GSB has segmental Reflex as this, her small sadness, pain. She has absolutely no visible varicose veins in the small sadness territory and her great sadness vein is not huge. Um and she doesn't have much pain in her leg, below these viruses in her thigh. And then we also did a have a worksheet from her pelvic exam, which I did do on her. I told you earlier I don't always do a pelvic exam on patients without pelvic pain. But here I'm showing myself to you never say always or never because I didn't examine her. Can we see that? So this is just a worksheet drawing and she's got the gamut, she's got compression of both iliac veins. She's got some pelvic collaterals. What I don't have listed on there as velocity ratios. But when we do duplex we always look at velocity ratio in areas of compression and she has elevated velocity ratio. She has some um you see this dent up on her left renal vein, it's a modest compression of her left renal vein and she's got an 11 millimeter re flexing ovarian vein. So there's a lot of different things you could do on this patient from fixing everything in the pelvis to a bleeding. The G. S. V. Two bleeding the ssv if you just based your decision making on looking at the imaging work shoots and not talking to the patient, think of the next slide. So again she has no patient, no pelvic symptoms. No oedema. Um in my mind embolization and stinting are not needed and her stint because she doesn't have a lot of pelvic symptoms. She doesn't have any swelling in her legs. And although there's segmental GSB incompetence that Shane of viruses is not coming from the GSB even though it hooks in later. And I treated her with ultrasound guided phone. Now you could make an argument to useful back to me. I think that that would have worked too or a combo. We go to the next slide. So this was done in the office. I don't use sedation When I go up into the pelvis I usually have them wear compression stockings and Spanx for two weeks. She went back to work the same day with a single dose of ibuprofen. She's currently for years post procedure without recurrence. And I think the next slide is her picture of her results. So a slight amount of hyperpigmentation in the medial thigh, but not, not too bad. Um, and then I think we have a polling question or nope, we're up to the next case, but just an idea of patient centered care. So, um, I'll go through some of these cases, but uh, they're more theoretical situations based on uh, you know what, what kind of patients I wind up seeing in clinics so feel free to hop in on the discussion guys. Um, I think we should skip this polling question that just popped up because it was already for the last case. Oh yeah. So for for first example, 65 year old male who comes in, he's got to be in my 35. So you know, obese but not over threshold. He's got some diastolic heart failure. He's got some obstructive sleep apnea. Um He presents complaining of bilateral leg swelling, diffuse skin changes. He's got hyperpigmentation, say lower third of his legs or from french lee on both sides. Um Pretty equal. He has, you know, bad joints. So he uh maybe one worse than the other. Um He's got reflux in his deep veins. Um and he's got on his cross sectional imaging um large iliac veins, so no obstruction, but rather they're bigger than normal and he appears rather full. Um So you know, with with that patient and you know, we should probably have a polling question here. But um if you could do a couple of clicks, you'll get kind of my categories of treatment. So, you know, do you offer this guy, do you look for superficial stuff on this guy? And he didn't really have anything. Do you offer this kind of guy stenting? He doesn't really have anything. Um And then the last option, uh, you know, is conservative care and click again. So for this patient in my clinic, he's going to get conservative care. He's gonna get expectation management. He's going to get talks about his weight and managing his medical problems and compression stockings. Um And his, you know, primary care is going to get a, you know, Yes. He has some, you know, deep valve disease. Um, but there's really not much from a vein, surgical standpoint that we can offer him. Sometimes you can still use pumps and other conservative things, but that's really it in this kind of patient. Um Did you guys have anything else to add to that one? No, but I do think if you really start a big venus practice, I totally agree with you. And I think that the use of the lymphedema pumps and patients who have no other option can be really helpful to them because this kind of person getting back and forth with the shark oh, joint, like to a lymphedema, physical therapist or getting in triple wraps is something that's incredibly cumbersome. But if they qualify from an insurance standpoint to have a pump at home, sometimes they will stick the pump on, use it on a daily basis and get some control of their Dema. So I totally agree with that. Yeah, and I don't know if you have any experience, but I've tried now in a in a little handful of patients with good results who have um paralysis or polio or something like that where they don't have their calf pump due to a mechanical issue. Um And I've used calf um stimulators um and I've had some improvement in the swelling from that, so that's another, you know, you can't do that and everybody and really it's a small group that benefits from it, but it's really from patients with muscular, you know, issues or paralysis. Um You can go to the next one. So this case uh 65 year old male with a B. M. I. Of 35 again a beast does selling heart failure, They all seem to have it. And then bilateral swelling, knees down again, a few skin changes. But this guy um he has pretty, his pump is within normal limits. He's not super active as you can see from his weight, but he's gets around, he's active enough. Um, we checked his reflux. He's got minimal deep valve reflux. Um, and he's got a two millimeter GsB that's reflux ng all the way down, including the junction and then he's got this vocal, You know, left May three owner. This is probably, we should have our poll, what, what are you gonna do with this guy? Um and then, you know, if you guys want to comment first or I can just go through, but if you want to do a couple of clicks, I think the options come up. Yeah, I mean, the only thing I would say is that when you say it's a two millimeter GSP. To me that would be that's different from like a five millimeter or six millimeter GsB, which still isn't huge, but sometimes in these big people with shitty hearts and a lot of swelling, like you don't see as much reflux as you might anticipate, I think because they're so tight distantly, you know, it's hard to reflux because they've got the deep pressure, right? And in some of those people I think of blaming them, you can help by just decreasing the recirculating volume. But in somebody with a two millimeter G. S. V. I don't think you're going to gain a lot. No. Yeah, so, so that's that's kind of what I was going for because yeah, I agree with you. I mean if he had like a one centimeter re flexing GSB, you're gonna say, yeah, that's going to take some edge off. If you have a 56 millimeter, then yeah, you might see something, you're not going to have knees down improvement, but it might take off the edge off some of the pain or a little bit of the skin changes, right? Um But the two millimeter I put on purpose to point out that you really shouldn't be treating these patients. But I see him treated all the time, like you can barely get a catheter in that, you know, we're a three millimeter and it's certainly going to do nothing for massive swelling. Um And then I don't know, but I'm pretty sure you guys would agree. Like a focal left may 3rd owner this 50% in veins. You really, I really look for longer lesions. Like even if it's an obstruction or a non from biotic, I look for something where it's compressing an entire segment and that it's a very high grade obstruction. Not not a focal 50 like this, that wouldn't really, certainly wouldn't cause bilateral swelling. But I see these kind of patients treated all the time, which is why why I put it in here. Um So one other thing I would say is that I have seen, I did have a seven year old Parkinson's patient who obviously the pump doesn't work correctly, had multiple recurrent cellulitis episodes in the left leg, right equivalent, not very impressive superficial vein reflux in both legs, but a significantly more swollen left leg with recurrent cellulitis. And I was actually really surprised in that person. He had 3, 10 and 50 still knows he's on the left side and he needed a deep brain stimulator and they weren't going to do it because he kept getting embedded with cellulitis, silent. So I talked to him. I did well and I stated that patient and he had a remarkable recovery, right, which is a different scenario, But I agree with you completely. That was a totally asymmetric scenario. And it was three tandem lesions. I don't usually treat 50 stenosis in anybody unless they have advanced wounds and you're at your wit's end. Yeah. And I think in veins there's still some things we don't understand. So for every time you say not to treat them, if you had, you may get somebody who improves, right? And I agree 3, 10 lesions is different than one lesion, right? Because yeah, so I do think that that one is more legitimate. But um, you know, in my I have seen uh Leaving out context, I have seen patients treated with 50 or less with focal things and um every once in a while one of them improves. You know, I think patient's physiology and venus diseases very complex, but I wouldn't generally recommend it for this kind of patient where things are better explained otherwise and certainly not for bilateral swelling, But yeah, your patient, I can see that. It's a lot of judgment with these cases. Can you quick forward? Yeah. Next one. So uh I'm laughing because yesterday I had B. M. I. 65 on here by accident and uh I got caught um 32 year old male being my 25 with no past medical history. Um This guy presents with a large uh large left thigh and calf varicose veins, left ankle swelling. Um Some focal medium al your skin changes, but it's not circumferential, it's not going up the leg, it's kind of you know, focal um His pump is normal. He's an active guy on his reflex. Can he doesn't have any deep disease. Um He's got left GsB very large, 1.2 centimeters below the junction. Um eight millimeters mid thigh, six millimeters in the upper calf. The GsB feeds directly into his varicose veins. Um He doesn't really have any findings on his right leg clinically or reflux. Um So you know do you need a C. T. Or any iliac um evaluation on this patient? Or or is that you know enough to explain those findings? Do you stop there? I wouldn't do a C. T. I. You know in our clinic they would probably get an iliac just as a matter of protocol. If they have a Dema they usually get protocol to get it. But uh I think that the chance that in this scenario I'm going to find something on ultrasound that I'm going to be tweeting in the pelvis is low compared to the you know impressive size of the 12 millimeter G. S. V. I think another thing that can help is that he's really young. So if he told me this was a 50 year old I'd say I'd never look in the pelvis right too and he's got a 1.2 centimeters Gsp. So I think that's where I would say. Okay. Have you had knee injuries? Have you had any surgery? Have you had ankle injuries? Did you sprain your ankle playing baseball 27 times? Like usually there's some reason that it's that asymmetric that you could say okay fine and then you just treat the cevennes. Um I probably would treat the cevennes and not look at the pelvis first. Um But I would tell the patient that there is given his young age and the significant asymmetry and the massive size of one size while the other is normal. That there's a reasonable chance that if he has persistent leg swelling and symptoms that will look at the pelvis and we'll make sure there's not a problem and if there is, we'll fix it at that point. Yeah, just expectations. Maybe rather than advancing to the examine, spending the money up front, at least just setting the expectations. So there's not disappointment from the patient when they get some relief, but they're still having a problem. They understand that that was a reasonable expectation to begin with. For sure. Absolutely agree. You want to click through these. Um, I generally, in a patient like this, if the I'll start with the reflux DVT if it's localized swelling like this, but you're right, Kathy, sometimes they already have the iliac scan before they get to me. But if I see this kind of a patient and it seems like the sad if it was a four millimeter saffron is it's probably not going to cause swelling. So I might look at the iliac just to get an idea before I treated to help set expectations. Um But if it's a really big Safina's vein, um enough to explain some ankle swelling because that's really all the staff anus can do right, It's not going to cause calf swelling, it's gonna cause ankle swelling at maximum. Then I'll usually go that direction first and tell them we'll look elsewhere if we need to. Um But yeah, so so I agree with all of that and then um kind of keep clicking forward. So for this patient, I said to start, you know, there, but um you know, certainly looking as kind of a judgment call, which is why, you know, I left it kind of open. Um And then I think there's one more um this patient, 45 year old female B. M. I. 30 prior extensive left DVT history presents with swelling left much more than right. Skin changes, circumferential around the lower leg. As a normal kind of average pump fairly active but you know, slow says she slowed down by her by her leg. Um She has axial deep vein reflux on the right. She has superficial veins that were prior a bladed on the right, on the left. She is a gsb reflux. It's a reasonable size, 45 millimeter G. S. V. Um And on the ct scan or ultrasound you're you're both whatever your study of choice, she has left iliac vein occlusion. She does have an open per fonda and she has kind of non inclusive but you know scarred uh ephemeral vein. So where do you start with this kind of patient? They've got multiple things going on. Um And her complaint is primarily swelling. But she's already at the point of skin changes. Or we could even give her an ulcer um where you guys starting the outflow inclusion is the, probably the main thing you need to address when you look at the size of the gsp is not that impressive compared to what you found. So I think it's primarily determining whether or not the she's got adequate inflow. It sounds like she does or profound is okay that you could probably help her by opening up that inclusion. So that's probably where I disagree the most with all of my other venus experts in the world. I think fem pop dvt is significantly more symptomatic than we're giving it credit for. So, I personally would do all of these with a venogram from the poster tibial vein. If they're collateralize ng through the saffron is primarily, they don't have enough deep venous flow to keep their cafe symptomatic, in my experience. So I'll go do in a prolonged balloon angioplasty if their primary flows through the deep system even through the for fonda and ephemeral then you know you can go and treat the deep the pelvic venous system first. But in young patients like this I find that each of these things contributes to elevated deep venous pressures. And I just treat them all at once and the deep vein first and then I treat the superficial fame later if necessary. That's my approach. But I know it's different. I think I have about 3000 patients now and I need to publish it, which I haven't done yet and I'm planning on doing soon. But I think it's still controversial whether you have to fix the fem pop stuff before you fix the pelvis. But I will say that if you do thousands of Vienna grams from a poster tibial vein, you will be shocked at the level to which it doesn't match the ultrasound. So I um I kind of approached this patient kind of I guess it's similar and different. We all have our subtle differences. But I think I tend to look at them like anything that interferes with their or elevates their venous pressure, anything you can do to whittle that down. So um I think probably in this patient, the biggest contributor like Kathy said is you know, the deep venous obstruction. But I generally when they've gotten enough obvious stuff also in the superficial, I'll usually make a plan to treat both. So in the case of an occlusion with um with reflux in Gsp, I usually achieve the inclusion first. Um And I do generally balloon the federal. But in a lot of these patients have a you know like an enlarged for fonda and they're getting pretty good flow and their symptoms dramatically improved with the really extent, as long as you've got good inflow. Um When the patients I see with the bad fem pop is where they're pop. Little secluded and then they tend to have some pretty persistent symptoms. Um So I agree with you there. Um The but yeah, so in this one I probably would approach the iliac. First I tried to just kind of write it as having good inflow. Um Almost good inflow and then treat the GSB afterwards while they're still in their blood thinner because you can still get pretty good results. Um Occasionally if the patient had a non inclusive iliac vein and needed lumpectomies, I'll often do either do the flu Vietnamese and GSB first if I don't think they're at risk of including their iliac. Um and then the stent. So I don't have to pull them off their blood thinner. But they get both treatments early or I'll do their stent and then stage the superficial about six months later when I can pull them off their blood thinner. They do try to treat kind of everything that seems substantial in those kind of patients to kind of whittle away at it, Especially in somebody that age. Right. I mean, 45, listen, coming for me, it's extremely young. Mhm. Yeah, it makes me feel a little better. Yeah, 45 is very young and I mean it could be half a lifetime again. Right. So I think one thing we don't have enough date on and we really don't understand in general Is what is the time frame? These symptoms are going to come back? What is the time frame things are going to get worse, who's going to get worse? Who would be okay for the next 20 years? Who's not going to be okay? And I've been doing this for over 20 years now and I've had a clinic for 18 years, but I've never stayed in one place more. I'm in 11 years now, Kind of in the same place. So, you know, I've never had more than 10 years follow up on any of my specific patients. And but I do see people who have been treated 20 years ago and now they're coming back and everything's blown out, right. Or I see people where we didn't treat the central stuff and they weren't symptomatic then, but now it's a mess, right? So I just we have so much to learn about all this, but I love what you're saying, which is that you can take a staged approach, but I agree with you if the staff bonuses abnormal now and you open the deep system, if you don't want that deep system to get even more abnormal over time, which we don't have a treatment for. You know, then I would treat the superficial system also and I think you can make an argument for treating it first and doing the flow back to me and then treating the iliac, you can make an argument for treating the iliac first. You can make an argument for doing a vein ablation at the same time as treating the iliac and then waiting to see if you need to do the flow back to me. Like Kathy had talked about right if you don't need to do the flow back to me later, if you get rid of the deep pressure and oblate the superficial. I think, I think as long as you're being thoughtful as you do these cases and you're following your patients and making sure you're not hurting people I think there's still some areas that are gray for us. Mhm. I think that was my last case. Do we have more after this? Like, nope. That was your last case. I want to thank you all for joining us tonight and thank dr Gibson dr Murphy and dr spencer for For presenting and educating us. Um as they all mentioned, our next one is um Wednesday November 11 and we're gonna be talking about the post robotic patients. So again thank you again everybody have a good evening stay safe. Thank you. Thank you. Thanks guys. Thanks mm mm.