As part of the virtual medical education webinar series, Matt Selmon, MD, FACC, discusses the epidemiology and prevalence of venous disease, along with various treatment options.
Good morning. Hope you can hear me. Uh, welcome to the vein Center where we're broadcasting from this morning. Andi, thank you for getting up and sharing your morning with us. Um, we thought this was an opportune time to go over the disease management. As we're celebrating our 10th anniversary of the start bein center, we did our first cases in July 2010 on DSO were enjoying new space and an anniversary of sorts. And so we thought this would be a great time Thio over same disease management and update. We'll also talk a little bit about deep venous management as well. So the things we'd like to touch on this morning are venous insufficiency, which is what we managed here in the vein center, along with DBT and May Thorner. We'll talk about a little bit. The diagnosis indication, the rationale for treatment and a little bit about the procedures and the devices that we use some of the new devices. Then we'll talk a little bit about guidelines in cases. So just to get in, uh, and to get started venous insufficiency. Our bread and butter here at the vein center is managing venous insufficiency use thermal ablation, uh, for most of the patients. But we also do start therapy and micro flip ectomy, which is part of the management of superficial Venus insufficiency. So what is Venus insufficiency? Uh, a lot of you know. Well, what venous insufficiency is there's a lot of misconceptions about it. This is what your patients see when they go to the website. This is actually pretty good. It comes from WebMD. There's a lot of information out there, but basically venous insufficiency is problem with the blood flow in the things of the legs coming back to the heart. It's called chronic venous insufficiency or Stasis, because there's very little flow in the skin. Things have valves to keep the blood moving in one direction. When they don't work creates pooling in the legs leads to varicose veins and other problems. So this is what your patients see, and they may be asking you questions about it. We're proud to have made this poster, which is available to, if you'd like a copy of it either digitally are real copy. It shows the anatomy both the superficial and the deep, along with a little bit about May 3rd er syndrome, which we're going to talk about some of the basic path of physiology of the Venus valves and how the Venus hypertension, high pressure in the veins creates problems with skin and with varicose fans. So Venus disease is incredibly prevalent. Some estimates have it in half of the population in the United States. At the most conservative estimates, there's probably at least 25 million symptomatic people in the United States with Venus disease, and only a fraction of those actually seek treatment for it. So that's a huge, unmet clinical lead that we face. So why do we have such high prevalence of chronic venous insufficiency? I think partly because we all get older at some time. Half of us are women. Uh, there's hormonally mediated damage to vows, especially during pregnancy, so we get older. The smooth muscles and the veins don't work well. Collagen and especially the elastin in the valves, starts to deteriorate with age. Lot of people have clots in the veins that the inflammation pretty much destroys the valves. So anybody with DVT gets a post traumatic syndrome, which destroys the valves as we get older than the calf muscle pump, which we rely on on the blood flow back up, becomes less active. And then there's more chronic proximal in compression. Uh, that we see contributing to chronic venous insufficiency. That's classically made Turner syndrome, and we'll talk about that. So heredity these air Two of my patients. This is a grandmother and a daughter who have literally the same vein. They both tell me that the mother, uh, in between them has the exact same vein army, but I didn't have a chance to get a picture of that. But this is kind of what we're dealing with with varicose veins from chronic venous insufficiency. So morality plays a huge portion of the causes of their capacities and chronic venous insufficiency. 70% of our patients will relate to us that their parents had venous insufficiency of their siblings. You see it more frightened frequently and females than we do in males, especially women who have been pregnant. The metallic oh protein ian aces that circulate during pregnancy, along with the increased vascular volume pretty much destroyed the valves, and a lot of women describe being sufficiency beginning during their pregnancies and never really totally recovering from it. and then everybody stands or sits one of the two during the occupation, and most people relais the onset of their symptoms. Thio standing for prolonged periods or standing for prolonged periods during their job. So what do we see with chronic venous insufficiency? It's clearly a spectrum beginning, with some swelling or discomfort in the legs lower and the legs we go, the higher the pressure and the more the symptoms so usually down low in the legs that we get most of the symptoms people describe. And the Cavs, especially a cramping and a throbbing sensation. Heaviness or generalized discomfort. Um, ultimately, uh, itching, burning from Stasis. Dermatitis from for Venus, circulation in the skin. And then ultimately, as the skin becomes more and more involved, get discoloration, read that then turns into brown and purple swatches and discoloration of lipo, dramatic sclerosis and varicose veins and ultimately, uh, lesions that don't heal that turn into chronic ulceration Stasis ulcers. So it is a progressive disease that usually happens over years with increasing pain. Discomfort and production and quality of life begins is the valves become competent, which creates high pressure. On the legs are Venus hypertension, which stretches, the veins and the veins get stretched, the valves become even less competent and the symptoms become worse. It ends up creating varicose veins. Swelling in the legs ultimately changes in the skin from Stasis dermatitis on then, ultimately, Venus ulcers. I just want to make a distinction between the deep system and the superficial system. This is well described in this poster that we've made. The deep system is inside the muscle and fashion superficial system is outside the Muslim fashion. In the vein center, we deal with the superficial system. That's what we can treat. There's not as much that we could do with the deep system until there's a plot, and then we can remove that. We're gonna talk about it. I also wanted to go over a little bit, Uh, the the role that ultrasound plays in, uh, managing venous disease. It's really become the gold standard. It's cheap. It's easy to do it. Z. As the years have gone by, the quality of imaging with ultrasound has gotten better and better. We use ultrasound from the very beginning to follow up in the process of managing Venus disease, from screening patients to diagnosing it to mapping the system. We use it during the procedure, uh, both during the thermal ablation procedure, as well as stressing and flew back to me, become a quite good looking during flow back to me to make sure that we've gotten all the arch fans out. We always do that at the end of the procedure, and then we do it and follow up afterwards to see how it's changed over time. So it's really uninterested, part off management of beings disease. This is what it looks like. This is up with the saffron ephemeral junction, where the great sadness vein connection to the common femoral vein. And you can see I think I have a little marker here. Um, maybe you can't see that on the left panel. You can see a valve that's just flopping back and forth, and that's the problem that we have with reflects or venous insufficiency. You can see the red and the blue, the blood flow going back and forth through that foul. That should be a one way valve. But is the veins enlarge? The valves become incompetent. We see blood flow going backwards in the veins, which creates the Venus hypertension. By definition, anything over a half of second of reflux backwards is considered to be abnormal, so we can actually grade the amount of reflux. And that's helpful. Uh, in terms of clinically following these patients, grade one is anywhere. Blow half second toe one second, and that goes up to grade for over four seconds. Um, actually, insurance companies require this, uh, to approve procedures on. It's helpful for the clinicians to get a nice idea of how much reflects there's in some of these patients. Thio use it with a clinical, um, to assess how severe the diseases. So what do we do about it? This goes way back, uh, not only decades and centuries but millennia. So there's actually very well documented treatment for this. Going back to more than 2000 years ago, people have been trying to treat Venus disease. Probably quite unsuccessfully, is my guests for many, many years on. It's usually because of the pain and discomfort of the that's for many decades, especially in the 20th century, at least, standard treatment was tripping, and we should we use the term stripping mostly the describe removal of the great sadness vein this was done by surgeons in the operating room. It involves lighting the savviness vein up at the top right where it goes into the seven of Federal Junction and then removing it from below, usually putting up, uh, tool or rod and on grabbing it and literally pulling it out. Uh, this was the treatment for decades and decades for severe venous insufficiency and had on actually a pretty good rate of success. The problem. Waas ah, high recurrence rate of symptoms. And that's almost certainly because of progressive worsening. Uh uh, tributaries and accessory sappiness, veins that were not treated with stripping, which over time, get worse. This is kind of what it looks like, this incision of the top, where it's located and then uh on, then you literally pull it out. The problem with this is it really destroys a lot of the the surrounding tissue, and there's a lot of morbidity in the Chief where it comes out, and that's the surrounding Baines. So everybody back in the nineties started looking for a better way and with new technology, both with radio frequency and with laser on with the desire to take it out of the operating room and go into the office to treat it. Uh, people started looking for better ways to do it. And that's where, uh, initially Venus, which is the first company to develop radio frequency ablation, which is just heat, essentially, which actually got FDA a clearance in 1999. Laser didn't get a clearance until 2002, but the technique really wasn't widely accepted until probably 5. 10 years later. This is what the radio frequency first device looked like. UH, you put the catheter in just below the knee and the federal gain in the savannas vein, advance it up to the seventh Terminal junction, and then segments of seven centimeters would have liked the vein. Going down. The vessel laser is pretty much the same, uh, technique, except you have to put the laser in to the same spot and then slowly pull it back after turning it on. This requires numbing with light cane before it's done. Uh, but there's always been a competition between laser and radio frequency. We usually use radio frequency I. My personal preference is that I think it's a little more elegant. We see a little less bruising. I'm less damage to the tissue around it because it has to touch the vein wall toe, actually deliver the energy and heat on. I think it's a little bit more elegant, so if you look at surgical them stripping versus in the Venus inflation, this has done many years ago. But around 10 years ago, there was a tremendous amount of information and analysis of the literature. Another analysis came to the conclusion that, um, they're essentially the same in terms off success, with a little bit of edge given toward for Catania's treatment and certainly cheaper and easier, um, than surgical approach. And so pretty much everybody has now adopted, uh, in the Venus technique for a bleeding, the great and small sadness faints and any tributaries or accessories after the saints done so who gets this? This is the definition of the indication that Medicare and insurance companies used. They say that in the Venus Laser, our radio frequency therapy is indicated for the treatment of chronic venous insufficiency, varicose veins associated with reflux of the great and small sapling planes in the lower extremities. So most insurance companies require certain size the veins and a certain amount of reflux and a certain clinical presentation. Thio approve the, uh, the procedure. The contraindications obviously would be acute DVT severe purple disease, which should be treated first. Uh, and then we proceed with the Venus treatment. Obviously, pregnancy contraindications. For most things, this is what the procedure looks like. We usually go in just below the knee. We put the laser the radio frequency device up to the near the staff of the thermal junction. So we pull it back and it simply heats the vein damages and ethereum clots off the vein and oblates it so that there's no flow in it. The goal is toe reduce. The Venus hypertension allow the smaller, healthier veins. Thio prove circulation through the skin. After the procedure. We have the patients where graduated compression stocking thigh high stocking for 48 hours without taking it off. We would like for them to wear it for two weeks just during the day. Uh, there is always a little bit of bruising and some type. Feeling for a day or two afterwards usually doesn't require anything more than a nonsteroidal anti inflammatories or Tylenol on its really we don't need a ivy for this, and it's, uh, rare. Thio Use ivy sedatives. But there is that option for some patients, so were the complications. The only real complication we worry about is DVT. Fortunately, that's very rare. Uh, pulmonary emboli, ex extremely rare. What we do see more frequently is superficial thermal phlebitis, and that could be upto 5% of the cases that usually presents as, ah, it's a small area of tenderness on it's usually from some tributary that has clotted off and become a inflamed, and that typically will go away within days to weeks. We do see occasionally. Some hyperpigmentation, and especially in young women way do worry about that. But it's unusual. The other thing that we do see is what's called in geothermal heat induced Ramasar hit. It's graded from 1 to 4. That's when a toe end of the ablation close to the seven ephemeral junction we will sometimes clot, propagate back toward the deep system of the common ephemeral. If it reaches the deep system that does not encroach it, we call that he had won. That virtually always recedes, goes away without any treatment. Uh, he hit, too. Is if it's less than 50% encroaching in the common for moral, and we don't treat that either. That virtually always goes away. Repeat the duplex ultrasound in a couple of weeks to make sure he had three is when it's been more than 50% but non inclusive. And we will treat that for between 1 to 2 weeks without regulation and repeat the ultrasound and hit four is PVT that we've induced, and that's rare. So what are the results? This is old studies from almost 20 years ago at the very beginning on this is held up and is there some of the original studies that were done looking at the results? And this is what we quote now because it's held up. What we see is about 95 to 97% inclusion in two years of the veins that we treat. We do occasionally see some of these veins recapitalize. The veins generally want to be open and not closed, and some of them that are very large that we get an inadequate A position will reopen, but it's less than 5% of the time. Typically, we'll just go back and do those so some patients require more than in the Venus ablation. That's what we call axial treatment of the Venus disease. And we always do that first and foremost, and we get the biggest bang for the buck with ablation of the staff nurse vein. But it doesn't completely treat the patients, so we do have objective care. Most of these patients get compression stockings and try to tell them that they were not going to necessarily get them out of compression stockings. Attn least when they travel or they're gonna be sitting or standing for long times. But we do know ambulatory or stabbed for back to me, and we will take out the box varicose veins and we do square therapy, which is injecting sclerosis and fans. We use ultrasound guidance for some of them, and some of it is visual. We also do what's called tears or terminal interruption of the reflux source. This is for the more secure patients with Venus ulcer disease. We will commonly see the large reflecting veins deep underneath the skin surrounding a venous Stasis. Also, those could be injected on a bladed, and it significantly improves the Venus flow. Um, uh, it's significantly improves the Venus flow on the ultra bed and doesn't make the ulcer hell. But it allows it to go through a healing process over usually several weeks to months and usually keeps it from coming back. So it's actually a untangle part of treating Venus ulcer disease that we fact so scare therapy. Um, what do we use these air? The sclerosis that have been tried? I can simplify this and tell you that the very early treatment was with hyper topic saline. The advantage is that it's cheap. It's easily available. UH, it typically does not create damage if it x Travis states outside the vein. The problem is, it's extremely painful to the patients, and when you have a lot of injections to do, it's poorly tolerated. What we, uh, almost everybody now uses either such a deck call are probably broken. All, uh, the advantage of so true that call is that it's cheap. It, um, it is painless, but it can be, uh, uh, damaging to the tissue around the vein. If it gets X, Travis stated, and it very commonly gets X, Travis stated what we use and what most people use. Now. Probably Duncan all probably broken all comes in. Uh huh, right. A preparation that we can foam, um, in the office. Or it comes a zvehr Athena, which it comes in a can that's already phoned. Uh, the advantage to it is that it's painless. It's very effective, and it doesn't create damage to the surrounding tissue if it extracted states outside. The thing Problem is, it's more defensive, but it works very well. The potential complications. Fortunately, they're also very unusual. We worry about DVT, but we rarely ever see it. We also worry about post square therapy hyperpigmentation, especially in young women that we also rarely see occasionally. And it's probably from the inflammation caused by clotting. Off the vein, we just see superficial throne will flight us almost always goes away. One of the chronic problems that we can see afterwards is what we call matting. Uh, this occurs frequently when we when, uh, sclerosis has been given before, uh, ablation of this afternoon. Spain has been a done, so it's a process. It looks like a rash, but it's tiny, tiny little clams checked Asia that are very difficult to get rid off once it's there. So before doing square, Uh, sclerosis therapy will virtually always like this After this thing. Let me talk. Just a minute about flew back to me. Uh, back to me is where we take the veins out. Um, we do it in the office. It's very effective for removing large our coast veins. It could be, uh, life changing for a lot of patients who have lived with these huge veins for a long time. Is one of our early famous patients, uh, was a coach would never wear anything but long pants and literally was life changing for him. He started wearing shorts. After this procedure on, we'll continue to follow him. Let me go just a little bit. I want toe talk just a little bit about DVT. And from a phlebitis verticals triad. You may recognize this hyper quiet gullibility Stasis in the vascular injury, which sets up, uh, clotting and the Venus system. Uh, Elio Ephemeral DVT versus formal papa till versus left versus calf DVT are completely different. The more proximal, the more severe and the more likely the patients are to get long term, uh, post the robotic syndrome. So we treat those much more aggressively our goals of treatment, obviously to prevent propagation and pulmonary emboli, but most importantly, to prevent post traumatic syndrome, which could be devastating to the patients. This is what post robotic syndrome looks like. Um, not only skin changes in swelling, but a lot of pain involved, like a dramatic sclerosis, which is the discoloration of the skin and scarring underneath. And then ultimately, be the Stasis ulcers. This is from 10 years ago. View of the literature Onda Surgical Society decided that looking at all of this data that acute, really, a film or TV T should be offered a strategy of promise removal. So, really, for the last 10 years, everybody has been looking for the best way to remove plot in the acute setting. Andi, this is what we've had over the last 10 years. Craig McNamara Catheter is correct. Catheter directed from a license, which for older plot doesn't work as well, had a trellis device which was removed from the market about a year ago, and you just been around for a long time, but also not very good for chronic DVT. We do use the ecos ultrasound facilitated catheter directed Trumbull Isis, but again for old plot it's not very good. The best thing that we have is a new device called a clock. Trevor. This is what it looks like, and it's designed for treating DVT. That's, Ah, large night in all cage with a core ing element and a retrieving sheet that usually goes into the papa till, and it's fairly effective at removing a large amount of clot with a reasonable amount of time. Andi, it has good results. This is the cloud Registry, which looked at the It was just presented in 19 in 2019. Viva I was too is 50 patients followed out for 30 days, and this was a combination about a third acute third sub, acute up to six weeks and then chronic DVT patients. 75% effectiveness in removing almost all of the clock, low major adverse event rate. And at 30 days, these values remained Peyton almost 90% of the time, with very low complication rate. This is what this device looks like. Uh, this is the night cage and the inferior vena cava, and this is the Korean element, and it's brought down. It literally shears the clock off of the wall and it comes down to the papa till where this retrieving element. And she then pulled up the clock out of the body and into this hub. It's a very large sheets. So, um, it's not a totally benign procedure to do, but you got a lot of caught out. This is what, uh, this is a federal vein that's included. This is after removing a large amount of plot. This is what the ultrasound looks like and clot removing. And this is, uh, iliac vein in the federal vein after some, uh, some cases. So what we do now is treat aggressively the l E ephemeral disease with interventional therapy below the calf below the need in the caf de Baynes, we treat Advantica regulation. The ephemeral pop appeal is really a case by case. So young, active patients that are very symptomatic. We will try to remove the plots. Just a moment about May 13 syndrome. This is, uh, a proximal occlusion, usually of the common iliac vein on the left, by the right common iliac artery. Uh, it goes now by non from Bolic iliac in compression because we see it classically on the left. But now we see it on, uh, literally, anywhere in the right or the left leg. This is a classic patient. You could see the aorta coming down and the right calcification in the right iliac artery. Compressing the left common iliac banks sort of classic X ray. This is what the intravascular ultrasound looks like right here. You can see this is the iliac being compressed? This is what it should look like beyond the compressed area. And this is where it's compressed. This is a three D image and really shows how not only the common iliac on the left, but the right leg is, well, more distillate on either side because of tortuous city because of aneurysms and various anatomy can compress either the right or the left. So eso way now look with CTV anagrams and m r V s to look for a proximal compression on are more severe patients. This is one of our early patients with classic made Turner syndrome, left leg enlarged high grade compression and the left common iliac vein. After stent in six months or leg was back to normal. Let me present one case and we'll be done. This is a fairly recent. About a month ago, 44 year old patient came with left leg DVT turned out on CTV diagram. Also toe have left iliac vein occlusion from external compression. And this is what the pace. This is what the federal bank looked like on the left plot filling the proximal part of the thermal vein. This is the iliac vein completely occluded. This is the clock tree for coming up from the, uh, from the, uh, left papa teal. And this is pulling the clock down into the sheath and removing it. This is a picture after removing the clot and before the iliac bain stent down to the bottom right is after the iliac vein stent has been opened. This was a thinner, which then created DBT. And this is the femoral vein on the next to last. This is the clock that was received. You can see on the far left, the night and all cage. Um, that was full of clock that was removed. I mean, thank you. Number one and show you a short video that'll show you pictures of our new vein center that we're so proud off. Uh, a patient in a hospital E. On entering. You did not happen. A blanket. A experienced interventional cardiologist. A very common A. If you have symptoms such as pain and find bones, very husbands like heaviness or 9 15. Ask your doctor patient if treatment is necessary. A messenger e. Okay, thanks, Sarah, look into the issue. Isn't always e Oh, thank you that so I think we had a question. What percentage of patients require follow up treatment are routine is to see the patients. One week later, we re image to make sure they don't have DVT, and at that point, we'll do scare therapy. If there's a large tributaries are distal a large disintegrate savviness are any sort of tears around the system eso that we complete the ablation procedure, and I would say that's probably somewhere around 20% of the patients that require additional treatment afterwards. Most of the patients in the 5 to 10 year range if they had significant venous insufficiency to begin with, will get either a large accessory. Savviness are large tributary that can usually be injected, so we'll see a lot of patients that air out 10 or 20 years that need follow up treatment, and that's pretty common. I'd say. More than half of the patients