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SCORE School Vascular - Venous
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SCORE School Vascular - Venous
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Segment:0 .
AMIT JOSHI: Hi, everyone. It's Amit Joshi from SCORE, and welcome to this week's edition of SCORE School. The topic of the week is vascular-venous. I'm delighted to introduce our lecturer today, doctor-- Hi, everyone. It's Amit Joshi from SCORE School. Welcome to this week's edition, where we will be covering vascular-venous.
AMIT JOSHI: I'm delighted to introduce our lecturer today, Dr. Misaki Kiguchi. She is a vascular surgeon at MedStar Heart and Vascular Institute at Georgetown in Washington, DC. She's an assistant professor there and associate program director of the vascular residency. She's a graduate of both undergraduate and Med school of Yale and then did a vascular residency at the University of Pittsburgh along which at the time also obtaining an MBA.
AMIT JOSHI: Dr. Kiguchi will be covering four modules today: evaluation of the swollen leg, venous insufficiency, varicose veins, and venous stasis. So it's a real pleasure to introduce you, Dr. Kiguchi. Thank you so much for your expertise, and take it away.
MISAKI KIGUCHI: Thank you so much for this privilege. This is one of my favorite topics to discuss with trainees, and so I'm really excited to give these talks here. So one of the main topics here that I wanted to discuss is when you see a swollen leg, how do you evaluate it? How do you order the correct tests? And as well, what treatment options are available? The disclosures I have is that I do speak for Medtronic on their venous technologies.
MISAKI KIGUCHI: I wanted to start off with a case presentation, something I'm sure all of us have probably seen. Similar to this is a 72-year-old female admitted to the medical service for CHF exacerbation two days ago. Had a history of recurrent alterations of both medial ankles, wears TED hose intermittently when she can get them on. Her ulcers are currently open for two months.
MISAKI KIGUCHI: They wax and wane in their severity. And vascular surgery is called for a consult. Here's a picture of this wound when it's at its worst. On physical exam, she's really a non-apparent distressed. She's a little bit short of breath, but as she's lying there, it's not too bad. Her white count is 8.3. And again, she's got this sort of fibrinous left medial ankle ulcer.
MISAKI KIGUCHI: Her one on the right is a little bit smaller. There's no purulence. And the question really is, what do we do now with a swollen leg with an ulcer? So keep this in mind, sort of as we go through the evaluation of a swollen leg. I think we really need to start off by reminding ourselves that there are three sort of main components to venous anatomy.
MISAKI KIGUCHI: There's a superficial system. On the left there, you'll see the sort of drainage of the foot. And you could see that it is really affiliated with a lot of the nerves in that system, but as you can see, most of it is superficial. And then, on the right, you'll be able to see sort of the deep veins and where it connects to this superficial vein.
MISAKI KIGUCHI: Remember, the superficial system really consists mostly of the great saphenous vein and the small saphenous vein, or some people call the lesser saphenous vein on the posterior side of the leg. And, of course, the deep system like the femoral vein, the popliteal veins, and of course, the tibial veins down in the calf. And some sort of ignore the perforator veins, but they're very important, especially when evaluating ulcer inside a swollen leg.
MISAKI KIGUCHI: The perforator veins actually connect the superficial to the deep. So if you think of sort of the superficial system really taking the brunt of collecting the blood flow that come from the arteries back up to the heart. The superficial vein really takes the blood from the superficial areas through the perforators connections to the deep and the deep sort of the highway back up to the iliac veins and the vena cava.
MISAKI KIGUCHI: I wanted to sort of specify the sort of focus to the superficial things because we will talk about this later and how we actually get rid of superficial reflux, and we'll also discuss reflux as well. But the great saphenous vein anatomy, it really drains the blood from dorsum of the foot. It runs along the medial aspect of the thigh. It's really underneath the fascia there, and it's very close to the saphenous nerve below the knee, which is really important to keep in mind when we talk about treatments.
MISAKI KIGUCHI: And as you can see from this diagram here, it really runs along the entire leg from the groin all the way to the ankle on the median side of the leg. I also drew in the anterior accessory vein. This is something that's really forgotten, but when patients have problems that are sort of on the lateral side, we can't really forget that there's also the lateral anterior accessory saphenous vein.
MISAKI KIGUCHI: It's also a superficial vein as well. The small saphenous vein or the lesser saphenous vein runs along the posterior lateral aspect of the leg. It's very close to sural nerve, and it terminates actually in a variety of ways. Most of them actually terminate into the popliteal fossa. 20% actually go into the femoral vein, and then 5% actually terminate at the below the popliteal fossa.
MISAKI KIGUCHI: So the physiology of veins. Veins are different from arteries because of the fact that they have capacities to allow for blood pooling. And so, the calf pump is what I always tell patients is their sort of heart. We all know that the heart pumps blood to our extremities, and we have gravity actually to help us out as well, but there's nothing really to pump it right back up against gravity.
MISAKI KIGUCHI: So I always say that the cap is really the heart that brings back the blood within our veins. And inside our veins are these little valves one way that actually allow that every time you do a calf pump, the blood sort of shoots up. And the reason it doesn't really reflux back down is because these valves shut when the calf relaxes. So these one-way valves really prevent reflux. So every step that you take brings blood flow into one direction all the way back to our sort of central system.
MISAKI KIGUCHI: And really, it's the principle force that returns the blood to the heart by sort of displacing the blood from the extremities back up into the central system. So when we see a swollen leg, I always tell trainees that you can get so much information from the history and physical exam. We really have to take a detailed history.
MISAKI KIGUCHI: What are their comorbidities? Do they have acute renal failure, kidney failure, chemotherapy recently, history of DVT? Do they have CHF like our case presentation show? Are they on hormone therapy? Are they obese? Have they had a diagnosis of lymphedema? Are they pregnant? Do they have pericarditis?
MISAKI KIGUCHI: Do they have pulmonary hypertension? All of these things definitely get missed when we're evaluating patients for swollen lymph. Within that history, you really can differentiate the causes of leg swelling based on the time of onset, duration, sort of the unilateral or bilateral involvement, how it started, and whether the swelling has been stable over time or progressive.
MISAKI KIGUCHI: When you think of acute onset of leg swelling, you really need to think about is there a trauma that happens? Is there an infectious process? Is there DVT? With really chronic leg swelling, you think more of venous insufficiency or lymphedema. When you think of duration, if it's short, you think more of DVT, trauma, infection. If you think it's been chronic or a long-standing, likely venous insufficiency, lymphedema, or more central causes like CHF.
MISAKI KIGUCHI: And that brings us to unilateral or bilateral involvement. Oftentimes, if you have bilateral involvement, it's really something more central that's going on, such as acute renal failure, congestive heart failure, things like that. And really, how stable it is and how progressive it is really will also give you sort of an idea of what possible etiologies can be from presentation of leg swelling.
MISAKI KIGUCHI: So I always tell patients that right-- I'm sorry, not patients, trainees that right after their history, they really need to do a thorough physical exam. Not only do you have to get your stethoscope out to listen to their heart, look for bruits in the carotid, look for jugular distention, all of those things. The most important is to really take your hand and do a tactile and visual exam of the lower extremities.
MISAKI KIGUCHI: Do you see varicosities? Is the swelling pitting? Do you see swelling in the foot? Is there skin discoloration? Assess the distribution of what you see, whether it's varicosities or the skin discoloration. And that really allows you to pinpoint the site of venous dysfunction. For instance, you can really tell a lot about how long it's been going on if you look at a person's leg.
MISAKI KIGUCHI: They don't have hair. They have sort of that brawny discoloration. That did not happen overnight, and so just by looking at the leg and my feeling the texture of the leg that's sort of woody feeling of the leg, you can really tell that this has been going on for quite some time, and it's unlikely to be acute. So looking at sort of the physical exam, I wanted to give a little bit of an anatomy and what you might see when valves dysfunction, especially in the superficial system.
MISAKI KIGUCHI: When you have medial calf and thigh varicosities, just like this picture, it's likely due to the great saphenous vein and branch reflux. If you have paired varicosities over the lateral and medial thigh, likely due to anterior vein problem. If you see bulging varicosities in the calf or ulcerations at the lateral malleolus, it's usually due to small saphenous vein reflux or disease. And then, of course, if you see bulging varicosities or ulcers at the ankle without any other visible disease, you'll always have to think about those pesky perforators.
MISAKI KIGUCHI: Again, those perforators are what connects the deep system to the superficial system. One of the main things about how you can describe a patient's venous disease, if that is the cause of their swelling, is really to CEAP classification. And the CEAP classification is actually getting revised this year. But what's really important about the CEAP classification is that it's spelled C-E-A-P. The C part is the sort of clinical classification, and that's what I think as sort of general surgeons that this is the most important part.
MISAKI KIGUCHI: We'll go over that, but the E part of the CEAP is the etiologic classification, whether it was congenital primary, secondary, things like that. The A is the anatomic classification. There's the superficial veins. Do you think it's the perforating veins? Do you think it's the deep vein? And then, P is the pathophysiology classification. Is there reflux?
MISAKI KIGUCHI: Is there obstruction? Are there both or no venous pathophysiology? So as I said, that's very, very specific, but the most important is probably just the clinical class and presentation. CEAP class zero is that you have no visible or palpable signs of venous disease. They're beautiful legs. The CEAP 1 is telenjectation, where you see spider veins or this flare that you see on that side.
MISAKI KIGUCHI: CEAP 2 is varicosities, varicose veins. You can see in this patient that they have pretty large varicose veins going down the medial posterior side of the leg. What's interesting is that a more severe clinical class and presentation of CEAP 3, edema. This is what we're talking about without skin changes. I think this is a really important point that we really need to stop and look at is that patients, even with varicose veins, as we said, is in a lower class of clinical class and presentation of venous insufficiency than it is a person who looks like this.
MISAKI KIGUCHI: Swelling--
AMIT JOSHI: The giveaway there is the sock-line?
MISAKI KIGUCHI: Yes, exactly right, and we'll talk about how that differs in lymphedema as well, but you can really see that the sock, even though it's probably not a compression sock, is definitely indent, has an indent inside the patient's leg. And so, the leg is really trying to swell. And you don't see much skin changes, but this is a CEAP 3 leg here. And then, of course, the CEAP 4, you can see here a skin changes.
MISAKI KIGUCHI: You can see that lipodermatosclerosis that hyperpigmentation on the lower side of the leg, that is a chronic issue that did not happen overnight. The constant swelling has really affected the skin integrity and causes sort of this pigmentation and the venous eczema. Many of your patients will say, oh, and these my legs really, really itch.
MISAKI KIGUCHI: And that you can tell it's been going on for some time. Now, even patients without venous problems will tell you that the swelling itself will cause hyperpigmentation that lipodermatosclerosis, and that discoloration. And CEAP 5 is a healed ulceration, and CEAP 6 is active ulceration. Now, this can happen in any patient with venous insufficiency and any patient with just regular old swelling as well.
MISAKI KIGUCHI: So you can really tell a lot about saying this patient has a CEAP 6 class score. That just means that they have ulceration that's likely due to their swelling and their venous insufficiency. And again, this is another CEAP 6 classified ulcer. So we sort of touched on this about how you can tell from a swollen leg whether they have bad veins or lymphedema.
MISAKI KIGUCHI: Based on their physical exam, you can really get a good idea whether this is a vein problem or a lymphatics problem by actually looking at the dorsum of their foot. There's actually the foot is often spared, especially the toes in venous insufficiency. And we sort of go back to how the veins actually work in the dorsum of the foot superficial reflux in that area, not much of deep veins in that area.
MISAKI KIGUCHI: So lymphedema actually affects the entire foot as well. Also, the shape of the extremity and the pattern of edema here, you can really see it's really diffuse that lymphedema there. The woody induration, of course, the lipodermatosclerosis pigmentation changes, but of course, this can happen in both patients who have lymphedema and venous insufficiency. What's also key is the effect of limb elevation.
MISAKI KIGUCHI: Veins, like I said before, have the ability to have sort of capacitance. Limp is a little bit slower, so it's great when you do a physical examination is if you lift up their leg, if the swelling, the discoloration actually gets better. It's more of a telltale sign that it's probably venous insufficiency, not so much lymphedema. So when you see a swollen leg, the imaging of choice is always a Doppler ultrasound.
MISAKI KIGUCHI: Why? What's important is to really eliminate the most acute problem. Now, again, most of this you can really eliminate just by the history and physical exam. But if it is acute in onset, you should get a Doppler ultrasound. Why? It delineates anatomy.
MISAKI KIGUCHI: You can map sort of the structural veins, assess the function by looking at reflux. How do each of the valves close? Do they close properly, so you still have that one-way direction? And of course, what you're looking for is assessing for DVT is your scarring that shows that you had a previous DVT. Are there webs that definitely obstruct venous outflow?
MISAKI KIGUCHI: Assess for perforating veins, and you can also visualize nerves and surrounding structures. What surrounding structures? Well, a lot of patients who come in with acute leg swelling also have a Baker's cyst that they didn't know about. And then, they're also diagnosed with some sort of orthopedic meniscal tear or whatnot. These all can be actually found by a Doppler ultrasound. So again, it's the imaging of choice to delineate anything structural, functional, and of course, anything else like perhaps a cyst, like a Baker's cyst, or anything else that might be causing their swelling.
MISAKI KIGUCHI: And the functional portion actually has to be performed standing. I think that's something that people don't know. The structural portions, of course, can be performed sitting. So again, the ultrasound tests that you will order should either be a reflux study and a DVT study or just a DVC study. The reflux study again includes a DVT study.
MISAKI KIGUCHI: So sometimes it's really good to order both because it can measure the diameter of your veins, the function or the reflux time, its relation to the varicosities. And, of course, really map out the anterior accessory, the small saphenous, whether they have a duplicated saphenous, and of course, the deep vein. Are they functioning properly? Do we have concern that there's something obstructive going on, like a DVT in the legs or more proximally?
MISAKI KIGUCHI: All of that can be shown by ultrasound testing. Of course, mapping those pesky perforators. And what I wrote here is you should think of something physiologically sort of contributing to swelling if you have dilated veins greater than 3.5 millimeters in CEAP four to six patients really, we should focus a lot on perforators as well. So as we sort of discussed before, this patient, by history, they had CHF.
MISAKI KIGUCHI: We optimize them. They were in decompensated heart failure at the time that we saw them. When we ordered their reflux studies, we actually showed that even though historically they did not say that they had any deep vein thrombosis, they were never on anticoagulation. It showed that there was a lot of scarring that caused chronic DVT, caused webbing that really impeded their ability to push the blood out of their leg, causing swelling.
MISAKI KIGUCHI: So they did not have an acute DVT, but structurally, they had a lot of problems because they could not mobilize the fluid out of their leg, no matter how much they walked. Now, you probably can't see it here, but the patient also did not walk too much because they had an arthritic knee. And so, as we recall before, these patients really have to rely on compression therapy to squeeze that fluid out and bring the valves closer together if they cannot walk.
MISAKI KIGUCHI: If they cannot walk, they cannot get that calf pump to work, and so they will always have a swollen leg without any external force, so compression therapy is what we use in these patients. And within a few weeks, actually the wound got much, much better, and the patient was able to heal the wounds. So the real key point here is that you have to do a thorough history and physical exam.
MISAKI KIGUCHI: By doing so, you can really understand whether the acute process is going on or chronic process, and that can direct your diagnostic imaging. Again, you have to think about all the etiologies as my case presentation brought forth. These patients have multiple etiologies of leg swelling, whether it's their CHF, their kidney failure, bad valve due to DVT, the inability to use their calf pump, and each one of those things really have to be addressed to optimize getting rid of their leg swelling.
MISAKI KIGUCHI: And again, that was talking about the management. There's systemic reasons, and that there's focused reasons. And so, hopefully, this gave you a little bit of understanding on how to manage a swollen leg and what diagnostic test to work.
AMIT JOSHI: Yeah, that was great. I love the emphasis on physical exam. I've never heard that pearl of sparing of the foot with venous disease but not with lymphatic disease, but it certainly makes a lot of sense and really nice, organized way to take us through that. So thank you so much for that.
MISAKI KIGUCHI: Absolutely. I think too some of our trainees, you know, wherever they practice, they may not be able to get an ultrasound in the middle of the night, or you have to call people in to do that and really by taking a thorough history and physical exam, oftentimes you can really elucidate whether this has been going on for quite some time or not. And really can just help the patients out by not ordering sort of irrelevant tests.
AMIT JOSHI: I'll ask you one more question. So with chronic venous disease, or I should say, with chronic venous stasis, do the actual valves themselves start to become damaged? Do they become more leaky?
MISAKI KIGUCHI: Absolutely. So we'll sort of touch on this. It's a good segue about how to fix superficial reflux, but absolutely. You know, genetics is really a major point in having faulty valves, but the second thing is the history of DVT. Just having structural obstruction can really damage those valves directly. But in addition, having a obstruction like a DVT makes those valves have to work harder, have to push against it, have to really hold tight so that there's no backflow, and that sort of pressure functionally can make them weaker and work less efficiently.
MISAKI KIGUCHI:
AMIT JOSHI: OK, on the next model. Thank you.
MISAKI KIGUCHI: No problem. So here's your QR code to log your attendance that will generate a receipt to your email. So one of the things I do is direct our MedStar Health Vein Center, and we primarily focus on relieving venous hypertension so that we can heal a lot of these venous ulcers. I'm really going to touch on venous insufficiency of superficial veins in this because I think this is a really emerging technique that really is become minimally invasive things that we could do in the office.
MISAKI KIGUCHI: Now, I do have to mention that venous insufficiency can really-- it's really a gamut of disease, as we sort of learned from the CEAP classification. It could be asymptomatic all the way to venous ulcers. And when we talk about this, let's not forget that it's really the venous hypertension that causes all of the symptoms. So there's a structural component, and there's a functional component.
MISAKI KIGUCHI: I'm really going to base my talk on the functional component, but don't forget that the deep veins, if they have DVTs or May-Thurners or retroperitoneal fibrosis, all of that can cause sort of a structural obstruction that need to be addressed so that the venous hypertension can be relieved. So that will be for another module, but don't forget that just because you get rid of the superficial hypertension doesn't mean that you can ignore the deep vein obstruction that could cause the venous hypertension as well.
MISAKI KIGUCHI: So the key points, I think, when you talk to patients about this, is that chronic venous insufficiency is indeed chronic. So what does that mean? There's no curative treatment once the valves in your leg are damaged. There's no way to put them back together, so it's progressive, and the treatment rationale is for symptomatic relief and prevention of clinical symptoms.
MISAKI KIGUCHI: I'm sorry, clinical progression. So as we talked earlier in the first talk in the first module about evaluating like swelling, the presentation of venous insufficiency can run the gamut of asymptomatic to ulcers, and there's a whole lot in between. And so, the patient has terrible valve, but they don't feel anything. There's no reason to actually treat them.
MISAKI KIGUCHI: Now, patients will say that their legs feel swollen and you have no visible varicosities. That is actually a symptom that you might have varicosities inside your leg that you just don't visibly see that might need to be treated. So really, chronic venous insufficiency the treatment rationale is really driven by curing patients or relieving patients of their symptoms and preventing them to get to a higher CEAP classification.
MISAKI KIGUCHI: So the indications to intervene on superficial reflux. Again, reflux means that you have venous hypertension due to the valves that are supposed to keep the blood from going back down, creating reflux that they don't work. So basically, you have leaky valves. The blood is supposed to go back up with every calf pump from your tippy toes all the way back up to your central system.
MISAKI KIGUCHI: And when those one-directional valve leak, the blood actually goes back down to your ankles, causing swelling, causing varicosities, causing heaviness, causing achiness, all of those things that a lot of patients actually complain about. So really, what we want to do is to get rid of that faulty vein. Once we get rid of it, we close it. There are many ways to do that, and we'll go over it. And once we do that, the blood actually will reroute into the deep vein where the valves are often competent.
MISAKI KIGUCHI: And so then, the body will know to go into the deep veins once you close those pesky reflecting superficial veins. So there are multiple ways to get rid of it. One is the endovenous ablation or stripping. So before, probably 20 years ago and before then, we used to strip the veins by taking them out. We made an incision in the groin, and then we basically took a stripper and just took it out of the body.
MISAKI KIGUCHI: Nowadays, we do things a little bit less invasive, and it's really the principle is just to close down that vein, whether you do it by sclerosis, whether you do it by glue, whether you do it by heat, it doesn't matter. The principle is to close down that vein so that the blood can't get stuck in there and cause those patients those symptoms. So either way, endovenous ablation or stripping is used to eliminate symptomatic venous reflux.
MISAKI KIGUCHI: Patients have had to have tried compression. Why? Compression is always going to be the mainstay. The key point is vein disease is chronic. So just because you get your veins stripped or veins treated does not mean that you don't have to wear compression anymore because remember, the compression is also good for your deep veins. I tell this to all of my patients who probably grumble and don't want to wear compression.
MISAKI KIGUCHI: I say, listen, you've got to wear your compression even after you feel great. It's a maintenance program here. So dilatation to the veins greater than five millimeters. Why is that? Well, if you think that the capacitance of your vein, you can hold a lot, but once it gets to five millimeters, those valves that are on the inside of the veins will separate, causing more reflux, causing more dilatation, causing more reflux.
MISAKI KIGUCHI: So really, it is sort of a domino effect. More dilatation causes separation of the valves that are supposed to keep the blood going back up, and so causing more reflux. The reflux will harbor more blood or more capacitance of the blood dilating the veins. So the FDA guidelines say that the dilatation of greater than five millimeters is definitely pathologic. Reflux time.
MISAKI KIGUCHI: How fast the valves close. If it's greater than 0.5 seconds, that's pathologic. So again, we want to look at the great saphenous vein, the anterior accessory vein, the small saphenous vein, and of course, the perforators on our ultrasound. Thermal ablation. Thermal ablation really revolutionize venous treatment. It's performed in the office under just local anesthesia. What's interesting about that is that you pass a catheter inside the vein.
MISAKI KIGUCHI: You start really right at the knee. Using an ultrasound, you put a micropuncture needle right directly inside the vein. You put then a fiber all the way up to the groin to the sapheno femoral junction, or if you're treating the lesser saphenous vein to the saphenopopliteal junction. What's interesting about this is, as we sort of read about in the anatomy, you use heat to close down the vein.
MISAKI KIGUCHI: The heat can come in the form of laser that emits a single wavelengths of light to damage the endothelial lightning to close the vein, or radiofrequency that creates resistive heating that can track the vein collagen occludes the vein. But remember that the nerves are very close to the vein full in the calf. So you really have to be careful about where you treat. That's why most people stay right at the knee because below that, the great saphenous vein and the saphenous nerve are very close to each other.
MISAKI KIGUCHI: Especially also in the small saphenous vein, if you treat the small saphenous vein close to sural nerve, you really will get some paresthesia and the damaging from the heat that's emitted. What's also interesting is that in these patients, the heat, especially for radio frequency, it goes to 120 degrees Celsius. So if you didn't have anesthesia around your vein, it's going to be a major issue. The tumescence is really made up of bicarb, saline, and lidocaine.
MISAKI KIGUCHI: And you actually infiltrate that all along the leg around the vein and separating it from the nerve. That is actually the most painful part of any sort of thermal ablation. It's really the tumescence. They've done a lot of extensive studies on this, and that's really what's the problematic. Both are really effective greater than 90% closure rates, both with about a 1% to 5% DVT and EHIT rate.
MISAKI KIGUCHI: We'll go over what EHIT is later in this lecture. I personally do a lot of these, and my DVT rate is less than 1%. So I think it really depends on the volume that you do and sort of your familiarity with these devices. I wanted to go over the sort of procedure itself here, and hopefully, this will work. There we go.
MISAKI KIGUCHI: Turn the volume off here. Really this just goes through the closure fast procedure, and you can really see this one-way valve that are not closing and bringing the reflux back. This is my micropuncture needle that I go through the vein with, and then I put the 7 French catheter inside. Through the sheath, excuse me, it's seven French sheath, the catheter goes all the way up. This is a great saphenous vein, and of course, the access is right at the knee.
MISAKI KIGUCHI: And you can see it gets very close to the sapheno femoral junction. This is the tumescence. Here's the catheter right here, and then the tumescence is being infiltrated all around the bull's eye. The bull's eye is the catheter itself, and it really constricts. It pushes the vein closer to the catheter so that the catheter actually can emit the heat and the radio frequency so that it will contract.
MISAKI KIGUCHI: You always position it two centimeters away from the sapheno femoral junction or the epigastric vein that you see right up there. You put a little compression on the outside, it heats, and then you pull back another seven centimeters. For the small saphenous vein, you actually use a 3-centimeter heating segment just because it is shorter. And that's what they're talking about in the small saphenous right there.
MISAKI KIGUCHI: Again, it heats it. There's about 20 seconds that they do for each segment, then you pull it back, and you keep treating that segment. With laser is very similar, it's just a laser emission and you have a continuous pull back, but really the principle is still the same. You really try to just heat and burn the vein so that it collapses the vein so that you don't have any sort of reflux inside and blood can't get inside there.
MISAKI KIGUCHI: So a non-thermal way is actually become pretty popular in the outpatient vein centers, and I'll sort of give you my take on these. I think it's good. What you do is you actually can use pre-made sclerosis or or you can make your own. Now, that's a little bit off-label, but physician compounded has a little bit of irregularities and things like that.
MISAKI KIGUCHI: But of course, it's a little bit cheaper. What you can use is a chemical or a detergent called polidocanol or SDS, the sodium dodecyl sulfate. And what you do is you actually mix it with air or CO2. And what's great about this is it can really get into the sort of hard-to-reach places. So instead of the heat closing down the vein, the foam or the sclerosis will actually agitate the size of the veins and really chemically agitate it to a point where you disrupt the endothelium, and it closes.
MISAKI KIGUCHI: Now, the foam has a lower vein closure rate than thermal ablation and so sometimes requires repeated treatments. But what's advantageous about this is that it's able to treat torturous or partially occluded veins. There is absolutely no tumescence anesthesia required. In addition, you can treat the entire length of the vein. Remember that the great saphenous and the small saphenous go all the way down to the ankles.
MISAKI KIGUCHI: And before, with a thermal ablation, you can't treat all of it. You got to be able to be careful of the nerve. So oftentimes, the great saphenous goes at the knee or the proximal catheter, the small saphenous or thermal ablation. With this, you could start all the way down at the ankle, and it just takes one needle poke. So you need no lidocaine, and you need no tumescence.
MISAKI KIGUCHI: You're able to treat these torturous or partially occluded veins because you don't have to put a catheter through there. However, as I said before, the closure rate is much lower, and as well the foam can travel despite you putting pressure at the sapheno femoral junction, saphenopopliteal junction. You can't put pressure there forever. And if it's some of that sclerosis goes systemically, it's been reported you can get migraines, visual disturbances, people faint.
MISAKI KIGUCHI: There's always a risk of DVT, and God forbid, you give patients a stroke. That's a big deal. It doesn't happen a lot. It happens obviously in more patients who have a PFO. But once you have a patient who has a migraine or a visual disturbance, it really makes you sort of think twice about doing these chemical ablation or non-thermal endovenous closures.
MISAKI KIGUCHI: So one of the main devices out there is called ClariVein, and for sure it's a MOCA, Mechanicochemical Endovenous Ablation, or non-thermal, non-tumescent, really highlighting their advantages, non-thermal, non-tumescent. So non-thermal, they're trying to tell you that you don't have any risk of nerve injury. So at the tip of the ClariVein here, you can see a sort of a wire tip.
MISAKI KIGUCHI: It rotates so that it agitates the proximal portion of the vein so that it collapses or really sort of retracts. And so, it doesn't go systemically, and I'll show you that in a second. And then, the injection portion of this has sclerosis inside, and you pull back while injecting. So here, you can see the wire tip about five centimeters away from the sapheno femoral junction. And that wire tip will sort of rotate to agitate and really close down this vein, as you can see here.
MISAKI KIGUCHI: And as you pull back that catheter, you inject the sclerosis. And by putting pressure, and by doing the mechanical portion, where you really agitate that vein to the point where it's spasms down, the sclerosis can really act on the endothelium of that vein pretty locally to a point where it closes. So the new hot sort of method of closing veins now is cyanoacrylate.
MISAKI KIGUCHI: So it's sort of a glue or an adhesive. They don't like to actually tell if it's glue, its adhesive in anionic substance such as plasma or blood causes polymerization of the adhesive upon contact, and really is just a fancy word for a hot glue gun that puts the side of the vein together to occlude it and not allow blood to go through. It triggers this acute inflammatory reaction in the endothelial wall in the surrounding tissues, and that damage really induces an inflammatory and immunological response to the point where the vein just fibrosis and basically closes and scars away.
MISAKI KIGUCHI: So this is a VenaSeal made by Medtronic. It's an interesting adhesive. It's a cyanoacrylate adhesive, and what it really does is, if I can-- we don't need any of that. This is really the glue. You sort of draw it up in these syringes, and you get access to the veins, just like you would with thermal, but you don't need any tumescence.
MISAKI KIGUCHI: You place the delivery catheter approximately 5 centimeters away from the sapheno femoral junction. You then start putting pressure right up here at the sapheno femoral junction, and you just release the glue stepwise every three centimeters. The first one, you do centimeter, and then you wait to allow it to polymerize. And then, the basically, the ends of the glue will sort of collapse the walls of the actual veins, not allowing any blood to get in there, and thus no blood will be fluxing through it.
MISAKI KIGUCHI: It happens pretty quickly, so at the end of the case, you can actually see that there's no blood going through the vein itself, and you just pull back the entire portion length of the vein. I think that this is a great product. However, I would tell you that there is good things and bad things about each technique. One of the bad things I would say about this technique I will tell you is that if you're allergic to glue, and of course, not everybody knows whether you're allergic to glue, you can have a severe reaction.
MISAKI KIGUCHI: And people don't necessarily know whether they're allergic to glue or not. If the patient has any sort of rheumatological conditions like lupus or HIV or anything like that, that's sort of detrimental to their immunological system. I personally don't use that. Now, that's not on the IFU, but that's just from a personal experience that I hesitate because the glue is really elicit an inflammatory response.
MISAKI KIGUCHI: So the results of this glue is pretty good. The sustain closure rate at one year is 95%. So it really is up there with the thermal techniques enclosure. And the advantages again is that there's no nerve injury and there's no skin injury, and this study, there was no DVTs. Again, you can treat the entire length of the vein. I think this is really important to remember because when you treat the entire length of the vein, you're not leaving any disease behind.
MISAKI KIGUCHI: You're not leaving any potential for some venous hypertension to recur. And this is particularly important for patients who have advanced CEAP diseases. You really have to get rid of all of them to optimize the patient symptomatic improvement. Obviously, with thermal ablation, you cannot do that. And again, I would like to reiterate that although the closure rate is great for this and you can treat the entire vein, the glue is considered an implant.
MISAKI KIGUCHI: And some people will sort of object to that and say I don't want an implant inside of me, even though it does dissolve over the years, the thermal techniques. There is no implant. It's really just your sort of attaching itself there that we treat it with. So again, there's a pivotal trial, the VeClose trial. There was really high closure rates of the saphenous vein.
MISAKI KIGUCHI: At six months, there's really no outcome and the closure rates or patient pain versus the ClosureFast. The ClosureFast is actually the RFA or the radiofrequency. And then, of course, the multicenter of European trials actually have showed that the occlusion rate is also good at one month. The VCSS score, which is the venous clinical severity score significantly reduced with the VenaSeal or the cyanoacrylate glue.
MISAKI KIGUCHI: What's important to note here is that the nerve injury rate was zero. I think that's really the main point in addition to being able to treat the entire length of the vein as well as the fact that they didn't have any DVT or PE, but again, those are clinical DVTs or PEs. If you had no suspicion for DVT or PE, they didn't check. So again, there could be some sort of subclinical diagnosis that were sort of missed in that case.
MISAKI KIGUCHI: So I also wanted to mention that before, we talked a lot about stripping, which is really the mainstay, probably 20 years ago, we rarely, rarely perform stripping. In reality, we can use the combination of these endothermal techniques and use sort of pin stripper and pull out the vein. And there's no need to stop anticoagulation. We do them all in the office. We can even do sort of small incisions by doing a high ligation in these patients.
MISAKI KIGUCHI: And really, the sort of microstab phlebectomy technique has really taken over instead of the high ligation and stripping that we used to do in the era where patients would have to stay overnight. And I wanted to show you sort of a case presentation where there is a patient here preoperatively had all these varicose veins. So, as you remember, this would be a CEAP 2 patient. Had minimal swelling, but of course, had a ulcer, and really the ulcer was what brought the patient in had veins for quite some time.
MISAKI KIGUCHI: So again, this puts the patient at a CEAP 6 category. Three weeks post-op to not only the endovenous ablation and micro phlebectomies, you can really see that the wound has healed dramatically. That's just three weeks post-op. Again, these patients wear compression, but the discoloration up here has also really improved, and you can really see that the visibility of the varicosities that really harbor a lot of the venous hypertension has been eliminated.
MISAKI KIGUCHI: And I took a closer shot of these incisions because people always ask me, well, how big are these little stab incisions? Again, this is three weeks after. They'll heal to a point where you probably can't really see them, and you can tell that this person's leg is quite flat, and there's none of that bulgy varicosity that comes out. So I've really gone over a lot of options.
MISAKI KIGUCHI: The VenaSeal or the glue is really new, and there's not really a lot of randomized studies of comparing the VenaSeal or the adhesive to other modalities. But looking at the thermal modalities compared to foam, non-thermal, non-tumescent endovenous closure, you can really see that the EVLA or the laser and the RFA have a much higher immediate occlusion rate comparable to stripping. The recanalization, what brings patients back, is quite high for foam.
MISAKI KIGUCHI: And, of course, new veins that occur is actually pretty comparable to all of them. And so, although the foam is really good and that it is non-tumescent, meaning that it's really patient-centered so that they really don't feel all that lidocaine that goes up and down their leg, and can treat torturous varicosities or tortuous saphenous vein refluxing sort of hypertensive veins, it really has a high failure rate and a high recanalization rate.
MISAKI KIGUCHI: So really, use that only in certain instances. As well, there was no difference in the quality of life or the VCSS score between all of these modalities. So post-procedure, I always tell patients compression, compression, compression. It's a way of life and that you have other veins, even if we treated a lot of them, you have the deep veins that you really have to take care of.
MISAKI KIGUCHI: And, of course, the compression really puts external force to bring the valves closer together to minimize reflux. I always ask patients after each procedure to ambulate in the office for at least 30 minutes to 60 minutes after the procedure. These patients come in, get a procedure for about 10 to 15 minutes. We wrap their legs up in compressive bandages, and then they can get out of here.
MISAKI KIGUCHI: They can walk. There's no reason that they need anybody to take them anywhere. So I always ask them it's a quick and easy procedure, but the longest part of your stay in the office is going to be that I'm going to make you walk for 30 to 60 minutes after the procedure. Resuming normal activities. This is definitely something that is new with the endovenous techniques that we do in the office.
MISAKI KIGUCHI: You could not have done this when you did the high ligation stripping that happened about 20 years ago. I only prescribe NSAIDs for discomfort, Ibuprofen, Advil. That's really about it, no narcotics for these patients. And of course, the most important is that you really need an ultrasound within seven days not only to assess for good closure but, of course, one of the dreaded complications is a DVT and an endovenous heat-induced thrombosis.
MISAKI KIGUCHI: Now, we talked about heat. There's also glue-induced thrombosis as well that we'll talk about. So some of the complications from these endovenous superficial vein surgeries. Ecchymosis, phlebitis. This is a good picture of phlebitis. It is quite painful, but of course, we're getting rid of the outflow to a lot of these varicosities.
MISAKI KIGUCHI: If you don't have good compression to get the blood out in time for the sort of the closure of the vein, if the blood gets stuck in there, you might get a little bit of superficial phlebitis. So I always tell patients you've got to wear the compression to really minimize the blood that's inside these varicosities. We're closing off their outflow, so it's really, really important to try to get as much blood out as possible to minimize their phlebitis.
MISAKI KIGUCHI: If they get it, it's not a big deal. You'll just get a bunch of phone calls and saying that they have a blood clot. But you can assure them they don't and that it's just superficial. Nerve injury. As infrequent as nerve injury is, the patients that do get nerve injuries from thermal ablation will basically torture you for the rest of your life because they really complain about it.
MISAKI KIGUCHI: They can't feel the medial side of their leg or the lateral side of their life depending on whether you do the great staff or the small staff. And at two years, the majority of them resolve. They've done studies on this. However, during that time, patients really, really complain about it. Skin burns happen more with laser than it does with radiofrequency.
MISAKI KIGUCHI: Cellulitis sometimes happens as well. I always tell these patients to keep their sterile dressings on for 48 hours, but sometimes things happen, and people get cellulitis. And, of course, DVT. We always check to make sure that these patients don't get DVTs after we are inside their veins and intervening on them. And the EHIT, the endovenous heat-induced thrombosis.
MISAKI KIGUCHI: There's a cabinet classification for this, and of course, we're treating their veins and creating heat or glue so that we close it down. Sometimes the veins overreact and creating much more thrombus. And so, if it encroaches on the deep veins, there are definitely sort of classifications of this controlled sort of thrombus that we're creating. If it goes past the epigastric vein, there's a class one.
MISAKI KIGUCHI: If it encroaches into the deep vein, that's class two. Class 3 is really more than half of it, and class 4 is really the entire lumen of the deep vein. And obviously, you can see here the recommendations of how to treat it. I personally am a little bit more aggressive. If I'm in sort of a class one, people say that you can definitely do the follow-up ultrasound five to seven days and ask for an optional.
MISAKI KIGUCHI: I actually put them as sort of a NOAC for seven days if they can tolerate it, and I still get the ultrasound follow up in seven days. Oftentimes, because of that superficial epigastric vein and that outflow plus the anticoagulation, it really does recede, and it just makes me feel better that these patients will not propagate. So you can really see here. This is an EHIT class two ultrasound, where you can see that thrombus and sometimes that glue that can really propagate up.
MISAKI KIGUCHI: You see that superficial epigastric right there that should be an anatomical marker that you shouldn't go past it. But even if you treat with a good distance, of course, two centimeters for the thermal ablation and five centimeters for the non-thermal sclerosis or the glue, it happens where the body's inflammatory response and sort of reaction will propagate either the glue or the thrombus all the way up, and you really don't want to see it.
MISAKI KIGUCHI: But if you do, you want to catch it, and of course, treat the patient appropriately. So the key points here is that superficial reflux causing superficial-- I'm sorry, causing venous hypertension and chronic venous insufficiency. There are minimally invasive, safe, and effective options that we can do it in the office. But remember and set expectations to your patients, the chronic venous deficiency is not curable, and although we can halt the progress of sort of symptoms and sort of the physiology that goes on, compression is still the mainstay, and that really will progress eventually.
MISAKI KIGUCHI: And here, I just wanted to show that with the glue, we found many sort of good results with this cosmetically and systematically. Before the VenaSeal procedure, you can see this great saphenous vein sort of being a problem right at the anterior thigh, and of course, that the medial knee. And three months after the VenaSeal procedure, where we closed down the great saphenous vein, this patient did not need a phlebectomy or anything.
MISAKI KIGUCHI: That's just happened on itself, where the varicosity is coming off the reflux, and great saphenous vein just shut down and really got reabsorbed in the body. But I'll tell you this patient religiously wore compression every day for three months. And so, it cannot be understated to patients that we treat that compression is definitely still going to be the mainstay.
AMIT JOSHI: What a nice comprehensive review of all the procedures, and actually, I just reviewed the SCORE module on this, and it sounds, you know, the advances over the last couple of years have been pretty profound. So this must be a pretty fulfilling practice. I mean, these patients come in. My suspicion is at least most of them are healthy, and they must be very, very grateful and satisfied after what is hopefully a low morbidity procedure.
MISAKI KIGUCHI: I totally agree. I think one of the reasons I came to Georgetown is that the volume that we see sort of in our room center is quite high, and it seems that most of the attention was really turned to the arterial practice, which I think is great. But because this is a low morbidity and sort of chronic. The chronic venous ulcers and venous hypertension and the hyperpigmentation, all of those things really were put sort of on the back burner.
MISAKI KIGUCHI: And for patients, it really does affect their quality of life. Even if they have a venous ulcer that'll never get infected, it really does take them off time from work. Really they're just not satisfied with the fact that they have these open source, and we can easily treat them and really bring them back to a higher quality of life with these minimal invasive procedures. So I've definitely found a lot of great satisfaction in being able to provide these patients who've had ulcers for quite some time, especially patients with palpable pedopulses, to really get them back to sort of being able to swim or go into the ocean and doing all those things by closing their wounds.
AMIT JOSHI: Well, great. Dr. Kiguchi, thank you so much for this great review, and we'll see everyone next week on SCORE School.
Segment:0 .
AMIT JOSHI: Hi, everyone. It's Amit Joshi from SCORE, and welcome to this week's edition of SCORE School. The topic of the week is vascular-venous. I'm delighted to introduce our lecturer today, doctor-- Hi, everyone. It's Amit Joshi from SCORE School. Welcome to this week's edition, where we will be covering vascular-venous.
AMIT JOSHI: I'm delighted to introduce our lecturer today, Dr. Misaki Kiguchi. She is a vascular surgeon at MedStar Heart and Vascular Institute at Georgetown in Washington, DC. She's an assistant professor there and associate program director of the vascular residency. She's a graduate of both undergraduate and Med school of Yale and then did a vascular residency at the University of Pittsburgh along which at the time also obtaining an MBA.
AMIT JOSHI: Dr. Kiguchi will be covering four modules today: evaluation of the swollen leg, venous insufficiency, varicose veins, and venous stasis. So it's a real pleasure to introduce you, Dr. Kiguchi. Thank you so much for your expertise, and take it away.
MISAKI KIGUCHI: Thank you so much for this privilege. This is one of my favorite topics to discuss with trainees, and so I'm really excited to give these talks here. So one of the main topics here that I wanted to discuss is when you see a swollen leg, how do you evaluate it? How do you order the correct tests? And as well, what treatment options are available? The disclosures I have is that I do speak for Medtronic on their venous technologies.
MISAKI KIGUCHI: I wanted to start off with a case presentation, something I'm sure all of us have probably seen. Similar to this is a 72-year-old female admitted to the medical service for CHF exacerbation two days ago. Had a history of recurrent alterations of both medial ankles, wears TED hose intermittently when she can get them on. Her ulcers are currently open for two months.
MISAKI KIGUCHI: They wax and wane in their severity. And vascular surgery is called for a consult. Here's a picture of this wound when it's at its worst. On physical exam, she's really a non-apparent distressed. She's a little bit short of breath, but as she's lying there, it's not too bad. Her white count is 8.3. And again, she's got this sort of fibrinous left medial ankle ulcer.
MISAKI KIGUCHI: Her one on the right is a little bit smaller. There's no purulence. And the question really is, what do we do now with a swollen leg with an ulcer? So keep this in mind, sort of as we go through the evaluation of a swollen leg. I think we really need to start off by reminding ourselves that there are three sort of main components to venous anatomy.
MISAKI KIGUCHI: There's a superficial system. On the left there, you'll see the sort of drainage of the foot. And you could see that it is really affiliated with a lot of the nerves in that system, but as you can see, most of it is superficial. And then, on the right, you'll be able to see sort of the deep veins and where it connects to this superficial vein.
MISAKI KIGUCHI: Remember, the superficial system really consists mostly of the great saphenous vein and the small saphenous vein, or some people call the lesser saphenous vein on the posterior side of the leg. And, of course, the deep system like the femoral vein, the popliteal veins, and of course, the tibial veins down in the calf. And some sort of ignore the perforator veins, but they're very important, especially when evaluating ulcer inside a swollen leg.
MISAKI KIGUCHI: The perforator veins actually connect the superficial to the deep. So if you think of sort of the superficial system really taking the brunt of collecting the blood flow that come from the arteries back up to the heart. The superficial vein really takes the blood from the superficial areas through the perforators connections to the deep and the deep sort of the highway back up to the iliac veins and the vena cava.
MISAKI KIGUCHI: I wanted to sort of specify the sort of focus to the superficial things because we will talk about this later and how we actually get rid of superficial reflux, and we'll also discuss reflux as well. But the great saphenous vein anatomy, it really drains the blood from dorsum of the foot. It runs along the medial aspect of the thigh. It's really underneath the fascia there, and it's very close to the saphenous nerve below the knee, which is really important to keep in mind when we talk about treatments.
MISAKI KIGUCHI: And as you can see from this diagram here, it really runs along the entire leg from the groin all the way to the ankle on the median side of the leg. I also drew in the anterior accessory vein. This is something that's really forgotten, but when patients have problems that are sort of on the lateral side, we can't really forget that there's also the lateral anterior accessory saphenous vein.
MISAKI KIGUCHI: It's also a superficial vein as well. The small saphenous vein or the lesser saphenous vein runs along the posterior lateral aspect of the leg. It's very close to sural nerve, and it terminates actually in a variety of ways. Most of them actually terminate into the popliteal fossa. 20% actually go into the femoral vein, and then 5% actually terminate at the below the popliteal fossa.
MISAKI KIGUCHI: So the physiology of veins. Veins are different from arteries because of the fact that they have capacities to allow for blood pooling. And so, the calf pump is what I always tell patients is their sort of heart. We all know that the heart pumps blood to our extremities, and we have gravity actually to help us out as well, but there's nothing really to pump it right back up against gravity.
MISAKI KIGUCHI: So I always say that the cap is really the heart that brings back the blood within our veins. And inside our veins are these little valves one way that actually allow that every time you do a calf pump, the blood sort of shoots up. And the reason it doesn't really reflux back down is because these valves shut when the calf relaxes. So these one-way valves really prevent reflux. So every step that you take brings blood flow into one direction all the way back to our sort of central system.
MISAKI KIGUCHI: And really, it's the principle force that returns the blood to the heart by sort of displacing the blood from the extremities back up into the central system. So when we see a swollen leg, I always tell trainees that you can get so much information from the history and physical exam. We really have to take a detailed history.
MISAKI KIGUCHI: What are their comorbidities? Do they have acute renal failure, kidney failure, chemotherapy recently, history of DVT? Do they have CHF like our case presentation show? Are they on hormone therapy? Are they obese? Have they had a diagnosis of lymphedema? Are they pregnant? Do they have pericarditis?
MISAKI KIGUCHI: Do they have pulmonary hypertension? All of these things definitely get missed when we're evaluating patients for swollen lymph. Within that history, you really can differentiate the causes of leg swelling based on the time of onset, duration, sort of the unilateral or bilateral involvement, how it started, and whether the swelling has been stable over time or progressive.
MISAKI KIGUCHI: When you think of acute onset of leg swelling, you really need to think about is there a trauma that happens? Is there an infectious process? Is there DVT? With really chronic leg swelling, you think more of venous insufficiency or lymphedema. When you think of duration, if it's short, you think more of DVT, trauma, infection. If you think it's been chronic or a long-standing, likely venous insufficiency, lymphedema, or more central causes like CHF.
MISAKI KIGUCHI: And that brings us to unilateral or bilateral involvement. Oftentimes, if you have bilateral involvement, it's really something more central that's going on, such as acute renal failure, congestive heart failure, things like that. And really, how stable it is and how progressive it is really will also give you sort of an idea of what possible etiologies can be from presentation of leg swelling.
MISAKI KIGUCHI: So I always tell patients that right-- I'm sorry, not patients, trainees that right after their history, they really need to do a thorough physical exam. Not only do you have to get your stethoscope out to listen to their heart, look for bruits in the carotid, look for jugular distention, all of those things. The most important is to really take your hand and do a tactile and visual exam of the lower extremities.
MISAKI KIGUCHI: Do you see varicosities? Is the swelling pitting? Do you see swelling in the foot? Is there skin discoloration? Assess the distribution of what you see, whether it's varicosities or the skin discoloration. And that really allows you to pinpoint the site of venous dysfunction. For instance, you can really tell a lot about how long it's been going on if you look at a person's leg.
MISAKI KIGUCHI: They don't have hair. They have sort of that brawny discoloration. That did not happen overnight, and so just by looking at the leg and my feeling the texture of the leg that's sort of woody feeling of the leg, you can really tell that this has been going on for quite some time, and it's unlikely to be acute. So looking at sort of the physical exam, I wanted to give a little bit of an anatomy and what you might see when valves dysfunction, especially in the superficial system.
MISAKI KIGUCHI: When you have medial calf and thigh varicosities, just like this picture, it's likely due to the great saphenous vein and branch reflux. If you have paired varicosities over the lateral and medial thigh, likely due to anterior vein problem. If you see bulging varicosities in the calf or ulcerations at the lateral malleolus, it's usually due to small saphenous vein reflux or disease. And then, of course, if you see bulging varicosities or ulcers at the ankle without any other visible disease, you'll always have to think about those pesky perforators.
MISAKI KIGUCHI: Again, those perforators are what connects the deep system to the superficial system. One of the main things about how you can describe a patient's venous disease, if that is the cause of their swelling, is really to CEAP classification. And the CEAP classification is actually getting revised this year. But what's really important about the CEAP classification is that it's spelled C-E-A-P. The C part is the sort of clinical classification, and that's what I think as sort of general surgeons that this is the most important part.
MISAKI KIGUCHI: We'll go over that, but the E part of the CEAP is the etiologic classification, whether it was congenital primary, secondary, things like that. The A is the anatomic classification. There's the superficial veins. Do you think it's the perforating veins? Do you think it's the deep vein? And then, P is the pathophysiology classification. Is there reflux?
MISAKI KIGUCHI: Is there obstruction? Are there both or no venous pathophysiology? So as I said, that's very, very specific, but the most important is probably just the clinical class and presentation. CEAP class zero is that you have no visible or palpable signs of venous disease. They're beautiful legs. The CEAP 1 is telenjectation, where you see spider veins or this flare that you see on that side.
MISAKI KIGUCHI: CEAP 2 is varicosities, varicose veins. You can see in this patient that they have pretty large varicose veins going down the medial posterior side of the leg. What's interesting is that a more severe clinical class and presentation of CEAP 3, edema. This is what we're talking about without skin changes. I think this is a really important point that we really need to stop and look at is that patients, even with varicose veins, as we said, is in a lower class of clinical class and presentation of venous insufficiency than it is a person who looks like this.
MISAKI KIGUCHI: Swelling--
AMIT JOSHI: The giveaway there is the sock-line?
MISAKI KIGUCHI: Yes, exactly right, and we'll talk about how that differs in lymphedema as well, but you can really see that the sock, even though it's probably not a compression sock, is definitely indent, has an indent inside the patient's leg. And so, the leg is really trying to swell. And you don't see much skin changes, but this is a CEAP 3 leg here. And then, of course, the CEAP 4, you can see here a skin changes.
MISAKI KIGUCHI: You can see that lipodermatosclerosis that hyperpigmentation on the lower side of the leg, that is a chronic issue that did not happen overnight. The constant swelling has really affected the skin integrity and causes sort of this pigmentation and the venous eczema. Many of your patients will say, oh, and these my legs really, really itch.
MISAKI KIGUCHI: And that you can tell it's been going on for some time. Now, even patients without venous problems will tell you that the swelling itself will cause hyperpigmentation that lipodermatosclerosis, and that discoloration. And CEAP 5 is a healed ulceration, and CEAP 6 is active ulceration. Now, this can happen in any patient with venous insufficiency and any patient with just regular old swelling as well.
MISAKI KIGUCHI: So you can really tell a lot about saying this patient has a CEAP 6 class score. That just means that they have ulceration that's likely due to their swelling and their venous insufficiency. And again, this is another CEAP 6 classified ulcer. So we sort of touched on this about how you can tell from a swollen leg whether they have bad veins or lymphedema.
MISAKI KIGUCHI: Based on their physical exam, you can really get a good idea whether this is a vein problem or a lymphatics problem by actually looking at the dorsum of their foot. There's actually the foot is often spared, especially the toes in venous insufficiency. And we sort of go back to how the veins actually work in the dorsum of the foot superficial reflux in that area, not much of deep veins in that area.
MISAKI KIGUCHI: So lymphedema actually affects the entire foot as well. Also, the shape of the extremity and the pattern of edema here, you can really see it's really diffuse that lymphedema there. The woody induration, of course, the lipodermatosclerosis pigmentation changes, but of course, this can happen in both patients who have lymphedema and venous insufficiency. What's also key is the effect of limb elevation.
MISAKI KIGUCHI: Veins, like I said before, have the ability to have sort of capacitance. Limp is a little bit slower, so it's great when you do a physical examination is if you lift up their leg, if the swelling, the discoloration actually gets better. It's more of a telltale sign that it's probably venous insufficiency, not so much lymphedema. So when you see a swollen leg, the imaging of choice is always a Doppler ultrasound.
MISAKI KIGUCHI: Why? What's important is to really eliminate the most acute problem. Now, again, most of this you can really eliminate just by the history and physical exam. But if it is acute in onset, you should get a Doppler ultrasound. Why? It delineates anatomy.
MISAKI KIGUCHI: You can map sort of the structural veins, assess the function by looking at reflux. How do each of the valves close? Do they close properly, so you still have that one-way direction? And of course, what you're looking for is assessing for DVT is your scarring that shows that you had a previous DVT. Are there webs that definitely obstruct venous outflow?
MISAKI KIGUCHI: Assess for perforating veins, and you can also visualize nerves and surrounding structures. What surrounding structures? Well, a lot of patients who come in with acute leg swelling also have a Baker's cyst that they didn't know about. And then, they're also diagnosed with some sort of orthopedic meniscal tear or whatnot. These all can be actually found by a Doppler ultrasound. So again, it's the imaging of choice to delineate anything structural, functional, and of course, anything else like perhaps a cyst, like a Baker's cyst, or anything else that might be causing their swelling.
MISAKI KIGUCHI: And the functional portion actually has to be performed standing. I think that's something that people don't know. The structural portions, of course, can be performed sitting. So again, the ultrasound tests that you will order should either be a reflux study and a DVT study or just a DVC study. The reflux study again includes a DVT study.
MISAKI KIGUCHI: So sometimes it's really good to order both because it can measure the diameter of your veins, the function or the reflux time, its relation to the varicosities. And, of course, really map out the anterior accessory, the small saphenous, whether they have a duplicated saphenous, and of course, the deep vein. Are they functioning properly? Do we have concern that there's something obstructive going on, like a DVT in the legs or more proximally?
MISAKI KIGUCHI: All of that can be shown by ultrasound testing. Of course, mapping those pesky perforators. And what I wrote here is you should think of something physiologically sort of contributing to swelling if you have dilated veins greater than 3.5 millimeters in CEAP four to six patients really, we should focus a lot on perforators as well. So as we sort of discussed before, this patient, by history, they had CHF.
MISAKI KIGUCHI: We optimize them. They were in decompensated heart failure at the time that we saw them. When we ordered their reflux studies, we actually showed that even though historically they did not say that they had any deep vein thrombosis, they were never on anticoagulation. It showed that there was a lot of scarring that caused chronic DVT, caused webbing that really impeded their ability to push the blood out of their leg, causing swelling.
MISAKI KIGUCHI: So they did not have an acute DVT, but structurally, they had a lot of problems because they could not mobilize the fluid out of their leg, no matter how much they walked. Now, you probably can't see it here, but the patient also did not walk too much because they had an arthritic knee. And so, as we recall before, these patients really have to rely on compression therapy to squeeze that fluid out and bring the valves closer together if they cannot walk.
MISAKI KIGUCHI: If they cannot walk, they cannot get that calf pump to work, and so they will always have a swollen leg without any external force, so compression therapy is what we use in these patients. And within a few weeks, actually the wound got much, much better, and the patient was able to heal the wounds. So the real key point here is that you have to do a thorough history and physical exam.
MISAKI KIGUCHI: By doing so, you can really understand whether the acute process is going on or chronic process, and that can direct your diagnostic imaging. Again, you have to think about all the etiologies as my case presentation brought forth. These patients have multiple etiologies of leg swelling, whether it's their CHF, their kidney failure, bad valve due to DVT, the inability to use their calf pump, and each one of those things really have to be addressed to optimize getting rid of their leg swelling.
MISAKI KIGUCHI: And again, that was talking about the management. There's systemic reasons, and that there's focused reasons. And so, hopefully, this gave you a little bit of understanding on how to manage a swollen leg and what diagnostic test to work.
AMIT JOSHI: Yeah, that was great. I love the emphasis on physical exam. I've never heard that pearl of sparing of the foot with venous disease but not with lymphatic disease, but it certainly makes a lot of sense and really nice, organized way to take us through that. So thank you so much for that.
MISAKI KIGUCHI: Absolutely. I think too some of our trainees, you know, wherever they practice, they may not be able to get an ultrasound in the middle of the night, or you have to call people in to do that and really by taking a thorough history and physical exam, oftentimes you can really elucidate whether this has been going on for quite some time or not. And really can just help the patients out by not ordering sort of irrelevant tests.
AMIT JOSHI: I'll ask you one more question. So with chronic venous disease, or I should say, with chronic venous stasis, do the actual valves themselves start to become damaged? Do they become more leaky?
MISAKI KIGUCHI: Absolutely. So we'll sort of touch on this. It's a good segue about how to fix superficial reflux, but absolutely. You know, genetics is really a major point in having faulty valves, but the second thing is the history of DVT. Just having structural obstruction can really damage those valves directly. But in addition, having a obstruction like a DVT makes those valves have to work harder, have to push against it, have to really hold tight so that there's no backflow, and that sort of pressure functionally can make them weaker and work less efficiently.
MISAKI KIGUCHI:
AMIT JOSHI: OK, on the next model. Thank you.
MISAKI KIGUCHI: No problem. So here's your QR code to log your attendance that will generate a receipt to your email. So one of the things I do is direct our MedStar Health Vein Center, and we primarily focus on relieving venous hypertension so that we can heal a lot of these venous ulcers. I'm really going to touch on venous insufficiency of superficial veins in this because I think this is a really emerging technique that really is become minimally invasive things that we could do in the office.
MISAKI KIGUCHI: Now, I do have to mention that venous insufficiency can really-- it's really a gamut of disease, as we sort of learned from the CEAP classification. It could be asymptomatic all the way to venous ulcers. And when we talk about this, let's not forget that it's really the venous hypertension that causes all of the symptoms. So there's a structural component, and there's a functional component.
MISAKI KIGUCHI: I'm really going to base my talk on the functional component, but don't forget that the deep veins, if they have DVTs or May-Thurners or retroperitoneal fibrosis, all of that can cause sort of a structural obstruction that need to be addressed so that the venous hypertension can be relieved. So that will be for another module, but don't forget that just because you get rid of the superficial hypertension doesn't mean that you can ignore the deep vein obstruction that could cause the venous hypertension as well.
MISAKI KIGUCHI: So the key points, I think, when you talk to patients about this, is that chronic venous insufficiency is indeed chronic. So what does that mean? There's no curative treatment once the valves in your leg are damaged. There's no way to put them back together, so it's progressive, and the treatment rationale is for symptomatic relief and prevention of clinical symptoms.
MISAKI KIGUCHI: I'm sorry, clinical progression. So as we talked earlier in the first talk in the first module about evaluating like swelling, the presentation of venous insufficiency can run the gamut of asymptomatic to ulcers, and there's a whole lot in between. And so, the patient has terrible valve, but they don't feel anything. There's no reason to actually treat them.
MISAKI KIGUCHI: Now, patients will say that their legs feel swollen and you have no visible varicosities. That is actually a symptom that you might have varicosities inside your leg that you just don't visibly see that might need to be treated. So really, chronic venous insufficiency the treatment rationale is really driven by curing patients or relieving patients of their symptoms and preventing them to get to a higher CEAP classification.
MISAKI KIGUCHI: So the indications to intervene on superficial reflux. Again, reflux means that you have venous hypertension due to the valves that are supposed to keep the blood from going back down, creating reflux that they don't work. So basically, you have leaky valves. The blood is supposed to go back up with every calf pump from your tippy toes all the way back up to your central system.
MISAKI KIGUCHI: And when those one-directional valve leak, the blood actually goes back down to your ankles, causing swelling, causing varicosities, causing heaviness, causing achiness, all of those things that a lot of patients actually complain about. So really, what we want to do is to get rid of that faulty vein. Once we get rid of it, we close it. There are many ways to do that, and we'll go over it. And once we do that, the blood actually will reroute into the deep vein where the valves are often competent.
MISAKI KIGUCHI: And so then, the body will know to go into the deep veins once you close those pesky reflecting superficial veins. So there are multiple ways to get rid of it. One is the endovenous ablation or stripping. So before, probably 20 years ago and before then, we used to strip the veins by taking them out. We made an incision in the groin, and then we basically took a stripper and just took it out of the body.
MISAKI KIGUCHI: Nowadays, we do things a little bit less invasive, and it's really the principle is just to close down that vein, whether you do it by sclerosis, whether you do it by glue, whether you do it by heat, it doesn't matter. The principle is to close down that vein so that the blood can't get stuck in there and cause those patients those symptoms. So either way, endovenous ablation or stripping is used to eliminate symptomatic venous reflux.
MISAKI KIGUCHI: Patients have had to have tried compression. Why? Compression is always going to be the mainstay. The key point is vein disease is chronic. So just because you get your veins stripped or veins treated does not mean that you don't have to wear compression anymore because remember, the compression is also good for your deep veins. I tell this to all of my patients who probably grumble and don't want to wear compression.
MISAKI KIGUCHI: I say, listen, you've got to wear your compression even after you feel great. It's a maintenance program here. So dilatation to the veins greater than five millimeters. Why is that? Well, if you think that the capacitance of your vein, you can hold a lot, but once it gets to five millimeters, those valves that are on the inside of the veins will separate, causing more reflux, causing more dilatation, causing more reflux.
MISAKI KIGUCHI: So really, it is sort of a domino effect. More dilatation causes separation of the valves that are supposed to keep the blood going back up, and so causing more reflux. The reflux will harbor more blood or more capacitance of the blood dilating the veins. So the FDA guidelines say that the dilatation of greater than five millimeters is definitely pathologic. Reflux time.
MISAKI KIGUCHI: How fast the valves close. If it's greater than 0.5 seconds, that's pathologic. So again, we want to look at the great saphenous vein, the anterior accessory vein, the small saphenous vein, and of course, the perforators on our ultrasound. Thermal ablation. Thermal ablation really revolutionize venous treatment. It's performed in the office under just local anesthesia. What's interesting about that is that you pass a catheter inside the vein.
MISAKI KIGUCHI: You start really right at the knee. Using an ultrasound, you put a micropuncture needle right directly inside the vein. You put then a fiber all the way up to the groin to the sapheno femoral junction, or if you're treating the lesser saphenous vein to the saphenopopliteal junction. What's interesting about this is, as we sort of read about in the anatomy, you use heat to close down the vein.
MISAKI KIGUCHI: The heat can come in the form of laser that emits a single wavelengths of light to damage the endothelial lightning to close the vein, or radiofrequency that creates resistive heating that can track the vein collagen occludes the vein. But remember that the nerves are very close to the vein full in the calf. So you really have to be careful about where you treat. That's why most people stay right at the knee because below that, the great saphenous vein and the saphenous nerve are very close to each other.
MISAKI KIGUCHI: Especially also in the small saphenous vein, if you treat the small saphenous vein close to sural nerve, you really will get some paresthesia and the damaging from the heat that's emitted. What's also interesting is that in these patients, the heat, especially for radio frequency, it goes to 120 degrees Celsius. So if you didn't have anesthesia around your vein, it's going to be a major issue. The tumescence is really made up of bicarb, saline, and lidocaine.
MISAKI KIGUCHI: And you actually infiltrate that all along the leg around the vein and separating it from the nerve. That is actually the most painful part of any sort of thermal ablation. It's really the tumescence. They've done a lot of extensive studies on this, and that's really what's the problematic. Both are really effective greater than 90% closure rates, both with about a 1% to 5% DVT and EHIT rate.
MISAKI KIGUCHI: We'll go over what EHIT is later in this lecture. I personally do a lot of these, and my DVT rate is less than 1%. So I think it really depends on the volume that you do and sort of your familiarity with these devices. I wanted to go over the sort of procedure itself here, and hopefully, this will work. There we go.
MISAKI KIGUCHI: Turn the volume off here. Really this just goes through the closure fast procedure, and you can really see this one-way valve that are not closing and bringing the reflux back. This is my micropuncture needle that I go through the vein with, and then I put the 7 French catheter inside. Through the sheath, excuse me, it's seven French sheath, the catheter goes all the way up. This is a great saphenous vein, and of course, the access is right at the knee.
MISAKI KIGUCHI: And you can see it gets very close to the sapheno femoral junction. This is the tumescence. Here's the catheter right here, and then the tumescence is being infiltrated all around the bull's eye. The bull's eye is the catheter itself, and it really constricts. It pushes the vein closer to the catheter so that the catheter actually can emit the heat and the radio frequency so that it will contract.
MISAKI KIGUCHI: You always position it two centimeters away from the sapheno femoral junction or the epigastric vein that you see right up there. You put a little compression on the outside, it heats, and then you pull back another seven centimeters. For the small saphenous vein, you actually use a 3-centimeter heating segment just because it is shorter. And that's what they're talking about in the small saphenous right there.
MISAKI KIGUCHI: Again, it heats it. There's about 20 seconds that they do for each segment, then you pull it back, and you keep treating that segment. With laser is very similar, it's just a laser emission and you have a continuous pull back, but really the principle is still the same. You really try to just heat and burn the vein so that it collapses the vein so that you don't have any sort of reflux inside and blood can't get inside there.
MISAKI KIGUCHI: So a non-thermal way is actually become pretty popular in the outpatient vein centers, and I'll sort of give you my take on these. I think it's good. What you do is you actually can use pre-made sclerosis or or you can make your own. Now, that's a little bit off-label, but physician compounded has a little bit of irregularities and things like that.
MISAKI KIGUCHI: But of course, it's a little bit cheaper. What you can use is a chemical or a detergent called polidocanol or SDS, the sodium dodecyl sulfate. And what you do is you actually mix it with air or CO2. And what's great about this is it can really get into the sort of hard-to-reach places. So instead of the heat closing down the vein, the foam or the sclerosis will actually agitate the size of the veins and really chemically agitate it to a point where you disrupt the endothelium, and it closes.
MISAKI KIGUCHI: Now, the foam has a lower vein closure rate than thermal ablation and so sometimes requires repeated treatments. But what's advantageous about this is that it's able to treat torturous or partially occluded veins. There is absolutely no tumescence anesthesia required. In addition, you can treat the entire length of the vein. Remember that the great saphenous and the small saphenous go all the way down to the ankles.
MISAKI KIGUCHI: And before, with a thermal ablation, you can't treat all of it. You got to be able to be careful of the nerve. So oftentimes, the great saphenous goes at the knee or the proximal catheter, the small saphenous or thermal ablation. With this, you could start all the way down at the ankle, and it just takes one needle poke. So you need no lidocaine, and you need no tumescence.
MISAKI KIGUCHI: You're able to treat these torturous or partially occluded veins because you don't have to put a catheter through there. However, as I said before, the closure rate is much lower, and as well the foam can travel despite you putting pressure at the sapheno femoral junction, saphenopopliteal junction. You can't put pressure there forever. And if it's some of that sclerosis goes systemically, it's been reported you can get migraines, visual disturbances, people faint.
MISAKI KIGUCHI: There's always a risk of DVT, and God forbid, you give patients a stroke. That's a big deal. It doesn't happen a lot. It happens obviously in more patients who have a PFO. But once you have a patient who has a migraine or a visual disturbance, it really makes you sort of think twice about doing these chemical ablation or non-thermal endovenous closures.
MISAKI KIGUCHI: So one of the main devices out there is called ClariVein, and for sure it's a MOCA, Mechanicochemical Endovenous Ablation, or non-thermal, non-tumescent, really highlighting their advantages, non-thermal, non-tumescent. So non-thermal, they're trying to tell you that you don't have any risk of nerve injury. So at the tip of the ClariVein here, you can see a sort of a wire tip.
MISAKI KIGUCHI: It rotates so that it agitates the proximal portion of the vein so that it collapses or really sort of retracts. And so, it doesn't go systemically, and I'll show you that in a second. And then, the injection portion of this has sclerosis inside, and you pull back while injecting. So here, you can see the wire tip about five centimeters away from the sapheno femoral junction. And that wire tip will sort of rotate to agitate and really close down this vein, as you can see here.
MISAKI KIGUCHI: And as you pull back that catheter, you inject the sclerosis. And by putting pressure, and by doing the mechanical portion, where you really agitate that vein to the point where it's spasms down, the sclerosis can really act on the endothelium of that vein pretty locally to a point where it closes. So the new hot sort of method of closing veins now is cyanoacrylate.
MISAKI KIGUCHI: So it's sort of a glue or an adhesive. They don't like to actually tell if it's glue, its adhesive in anionic substance such as plasma or blood causes polymerization of the adhesive upon contact, and really is just a fancy word for a hot glue gun that puts the side of the vein together to occlude it and not allow blood to go through. It triggers this acute inflammatory reaction in the endothelial wall in the surrounding tissues, and that damage really induces an inflammatory and immunological response to the point where the vein just fibrosis and basically closes and scars away.
MISAKI KIGUCHI: So this is a VenaSeal made by Medtronic. It's an interesting adhesive. It's a cyanoacrylate adhesive, and what it really does is, if I can-- we don't need any of that. This is really the glue. You sort of draw it up in these syringes, and you get access to the veins, just like you would with thermal, but you don't need any tumescence.
MISAKI KIGUCHI: You place the delivery catheter approximately 5 centimeters away from the sapheno femoral junction. You then start putting pressure right up here at the sapheno femoral junction, and you just release the glue stepwise every three centimeters. The first one, you do centimeter, and then you wait to allow it to polymerize. And then, the basically, the ends of the glue will sort of collapse the walls of the actual veins, not allowing any blood to get in there, and thus no blood will be fluxing through it.
MISAKI KIGUCHI: It happens pretty quickly, so at the end of the case, you can actually see that there's no blood going through the vein itself, and you just pull back the entire portion length of the vein. I think that this is a great product. However, I would tell you that there is good things and bad things about each technique. One of the bad things I would say about this technique I will tell you is that if you're allergic to glue, and of course, not everybody knows whether you're allergic to glue, you can have a severe reaction.
MISAKI KIGUCHI: And people don't necessarily know whether they're allergic to glue or not. If the patient has any sort of rheumatological conditions like lupus or HIV or anything like that, that's sort of detrimental to their immunological system. I personally don't use that. Now, that's not on the IFU, but that's just from a personal experience that I hesitate because the glue is really elicit an inflammatory response.
MISAKI KIGUCHI: So the results of this glue is pretty good. The sustain closure rate at one year is 95%. So it really is up there with the thermal techniques enclosure. And the advantages again is that there's no nerve injury and there's no skin injury, and this study, there was no DVTs. Again, you can treat the entire length of the vein. I think this is really important to remember because when you treat the entire length of the vein, you're not leaving any disease behind.
MISAKI KIGUCHI: You're not leaving any potential for some venous hypertension to recur. And this is particularly important for patients who have advanced CEAP diseases. You really have to get rid of all of them to optimize the patient symptomatic improvement. Obviously, with thermal ablation, you cannot do that. And again, I would like to reiterate that although the closure rate is great for this and you can treat the entire vein, the glue is considered an implant.
MISAKI KIGUCHI: And some people will sort of object to that and say I don't want an implant inside of me, even though it does dissolve over the years, the thermal techniques. There is no implant. It's really just your sort of attaching itself there that we treat it with. So again, there's a pivotal trial, the VeClose trial. There was really high closure rates of the saphenous vein.
MISAKI KIGUCHI: At six months, there's really no outcome and the closure rates or patient pain versus the ClosureFast. The ClosureFast is actually the RFA or the radiofrequency. And then, of course, the multicenter of European trials actually have showed that the occlusion rate is also good at one month. The VCSS score, which is the venous clinical severity score significantly reduced with the VenaSeal or the cyanoacrylate glue.
MISAKI KIGUCHI: What's important to note here is that the nerve injury rate was zero. I think that's really the main point in addition to being able to treat the entire length of the vein as well as the fact that they didn't have any DVT or PE, but again, those are clinical DVTs or PEs. If you had no suspicion for DVT or PE, they didn't check. So again, there could be some sort of subclinical diagnosis that were sort of missed in that case.
MISAKI KIGUCHI: So I also wanted to mention that before, we talked a lot about stripping, which is really the mainstay, probably 20 years ago, we rarely, rarely perform stripping. In reality, we can use the combination of these endothermal techniques and use sort of pin stripper and pull out the vein. And there's no need to stop anticoagulation. We do them all in the office. We can even do sort of small incisions by doing a high ligation in these patients.
MISAKI KIGUCHI: And really, the sort of microstab phlebectomy technique has really taken over instead of the high ligation and stripping that we used to do in the era where patients would have to stay overnight. And I wanted to show you sort of a case presentation where there is a patient here preoperatively had all these varicose veins. So, as you remember, this would be a CEAP 2 patient. Had minimal swelling, but of course, had a ulcer, and really the ulcer was what brought the patient in had veins for quite some time.
MISAKI KIGUCHI: So again, this puts the patient at a CEAP 6 category. Three weeks post-op to not only the endovenous ablation and micro phlebectomies, you can really see that the wound has healed dramatically. That's just three weeks post-op. Again, these patients wear compression, but the discoloration up here has also really improved, and you can really see that the visibility of the varicosities that really harbor a lot of the venous hypertension has been eliminated.
MISAKI KIGUCHI: And I took a closer shot of these incisions because people always ask me, well, how big are these little stab incisions? Again, this is three weeks after. They'll heal to a point where you probably can't really see them, and you can tell that this person's leg is quite flat, and there's none of that bulgy varicosity that comes out. So I've really gone over a lot of options.
MISAKI KIGUCHI: The VenaSeal or the glue is really new, and there's not really a lot of randomized studies of comparing the VenaSeal or the adhesive to other modalities. But looking at the thermal modalities compared to foam, non-thermal, non-tumescent endovenous closure, you can really see that the EVLA or the laser and the RFA have a much higher immediate occlusion rate comparable to stripping. The recanalization, what brings patients back, is quite high for foam.
MISAKI KIGUCHI: And, of course, new veins that occur is actually pretty comparable to all of them. And so, although the foam is really good and that it is non-tumescent, meaning that it's really patient-centered so that they really don't feel all that lidocaine that goes up and down their leg, and can treat torturous varicosities or tortuous saphenous vein refluxing sort of hypertensive veins, it really has a high failure rate and a high recanalization rate.
MISAKI KIGUCHI: So really, use that only in certain instances. As well, there was no difference in the quality of life or the VCSS score between all of these modalities. So post-procedure, I always tell patients compression, compression, compression. It's a way of life and that you have other veins, even if we treated a lot of them, you have the deep veins that you really have to take care of.
MISAKI KIGUCHI: And, of course, the compression really puts external force to bring the valves closer together to minimize reflux. I always ask patients after each procedure to ambulate in the office for at least 30 minutes to 60 minutes after the procedure. These patients come in, get a procedure for about 10 to 15 minutes. We wrap their legs up in compressive bandages, and then they can get out of here.
MISAKI KIGUCHI: They can walk. There's no reason that they need anybody to take them anywhere. So I always ask them it's a quick and easy procedure, but the longest part of your stay in the office is going to be that I'm going to make you walk for 30 to 60 minutes after the procedure. Resuming normal activities. This is definitely something that is new with the endovenous techniques that we do in the office.
MISAKI KIGUCHI: You could not have done this when you did the high ligation stripping that happened about 20 years ago. I only prescribe NSAIDs for discomfort, Ibuprofen, Advil. That's really about it, no narcotics for these patients. And of course, the most important is that you really need an ultrasound within seven days not only to assess for good closure but, of course, one of the dreaded complications is a DVT and an endovenous heat-induced thrombosis.
MISAKI KIGUCHI: Now, we talked about heat. There's also glue-induced thrombosis as well that we'll talk about. So some of the complications from these endovenous superficial vein surgeries. Ecchymosis, phlebitis. This is a good picture of phlebitis. It is quite painful, but of course, we're getting rid of the outflow to a lot of these varicosities.
MISAKI KIGUCHI: If you don't have good compression to get the blood out in time for the sort of the closure of the vein, if the blood gets stuck in there, you might get a little bit of superficial phlebitis. So I always tell patients you've got to wear the compression to really minimize the blood that's inside these varicosities. We're closing off their outflow, so it's really, really important to try to get as much blood out as possible to minimize their phlebitis.
MISAKI KIGUCHI: If they get it, it's not a big deal. You'll just get a bunch of phone calls and saying that they have a blood clot. But you can assure them they don't and that it's just superficial. Nerve injury. As infrequent as nerve injury is, the patients that do get nerve injuries from thermal ablation will basically torture you for the rest of your life because they really complain about it.
MISAKI KIGUCHI: They can't feel the medial side of their leg or the lateral side of their life depending on whether you do the great staff or the small staff. And at two years, the majority of them resolve. They've done studies on this. However, during that time, patients really, really complain about it. Skin burns happen more with laser than it does with radiofrequency.
MISAKI KIGUCHI: Cellulitis sometimes happens as well. I always tell these patients to keep their sterile dressings on for 48 hours, but sometimes things happen, and people get cellulitis. And, of course, DVT. We always check to make sure that these patients don't get DVTs after we are inside their veins and intervening on them. And the EHIT, the endovenous heat-induced thrombosis.
MISAKI KIGUCHI: There's a cabinet classification for this, and of course, we're treating their veins and creating heat or glue so that we close it down. Sometimes the veins overreact and creating much more thrombus. And so, if it encroaches on the deep veins, there are definitely sort of classifications of this controlled sort of thrombus that we're creating. If it goes past the epigastric vein, there's a class one.
MISAKI KIGUCHI: If it encroaches into the deep vein, that's class two. Class 3 is really more than half of it, and class 4 is really the entire lumen of the deep vein. And obviously, you can see here the recommendations of how to treat it. I personally am a little bit more aggressive. If I'm in sort of a class one, people say that you can definitely do the follow-up ultrasound five to seven days and ask for an optional.
MISAKI KIGUCHI: I actually put them as sort of a NOAC for seven days if they can tolerate it, and I still get the ultrasound follow up in seven days. Oftentimes, because of that superficial epigastric vein and that outflow plus the anticoagulation, it really does recede, and it just makes me feel better that these patients will not propagate. So you can really see here. This is an EHIT class two ultrasound, where you can see that thrombus and sometimes that glue that can really propagate up.
MISAKI KIGUCHI: You see that superficial epigastric right there that should be an anatomical marker that you shouldn't go past it. But even if you treat with a good distance, of course, two centimeters for the thermal ablation and five centimeters for the non-thermal sclerosis or the glue, it happens where the body's inflammatory response and sort of reaction will propagate either the glue or the thrombus all the way up, and you really don't want to see it.
MISAKI KIGUCHI: But if you do, you want to catch it, and of course, treat the patient appropriately. So the key points here is that superficial reflux causing superficial-- I'm sorry, causing venous hypertension and chronic venous insufficiency. There are minimally invasive, safe, and effective options that we can do it in the office. But remember and set expectations to your patients, the chronic venous deficiency is not curable, and although we can halt the progress of sort of symptoms and sort of the physiology that goes on, compression is still the mainstay, and that really will progress eventually.
MISAKI KIGUCHI: And here, I just wanted to show that with the glue, we found many sort of good results with this cosmetically and systematically. Before the VenaSeal procedure, you can see this great saphenous vein sort of being a problem right at the anterior thigh, and of course, that the medial knee. And three months after the VenaSeal procedure, where we closed down the great saphenous vein, this patient did not need a phlebectomy or anything.
MISAKI KIGUCHI: That's just happened on itself, where the varicosity is coming off the reflux, and great saphenous vein just shut down and really got reabsorbed in the body. But I'll tell you this patient religiously wore compression every day for three months. And so, it cannot be understated to patients that we treat that compression is definitely still going to be the mainstay.
AMIT JOSHI: What a nice comprehensive review of all the procedures, and actually, I just reviewed the SCORE module on this, and it sounds, you know, the advances over the last couple of years have been pretty profound. So this must be a pretty fulfilling practice. I mean, these patients come in. My suspicion is at least most of them are healthy, and they must be very, very grateful and satisfied after what is hopefully a low morbidity procedure.
MISAKI KIGUCHI: I totally agree. I think one of the reasons I came to Georgetown is that the volume that we see sort of in our room center is quite high, and it seems that most of the attention was really turned to the arterial practice, which I think is great. But because this is a low morbidity and sort of chronic. The chronic venous ulcers and venous hypertension and the hyperpigmentation, all of those things really were put sort of on the back burner.
MISAKI KIGUCHI: And for patients, it really does affect their quality of life. Even if they have a venous ulcer that'll never get infected, it really does take them off time from work. Really they're just not satisfied with the fact that they have these open source, and we can easily treat them and really bring them back to a higher quality of life with these minimal invasive procedures. So I've definitely found a lot of great satisfaction in being able to provide these patients who've had ulcers for quite some time, especially patients with palpable pedopulses, to really get them back to sort of being able to swim or go into the ocean and doing all those things by closing their wounds.
AMIT JOSHI: Well, great. Dr. Kiguchi, thank you so much for this great review, and we'll see everyone next week on SCORE School.
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