Case Studies - 3-15-13

November 10, 2012 - Ronald Bush, MD, FACS Thermal Ablation of the Saphenous Vein With Co-Existing Femoral Vein Occlusion

Thermal Ablation of the Saphenous Vein With Co-Existing Femoral Vein Occlusion Copyright 2012 by www.veinexperts.org

Red Arrow – Popliteal artery Blue Arrow – Femoral Vein Green Arrow – Ablated saphenous vein 37-year old male with a history of previous knee trauma with resultant DVT. Superficial femoral vein is occluded. Popliteal to proximal vein occlusion just distal to the common femoral vein. Has only partially recanalized portions of the vein.

Now 2-years post injury, marked swelling of the left lower extremity with saphenous insufficiency from groin to ankle.

Underwent successful endovenous ablation 2 months ago. Has had good relief from swelling/edema. Also states that leg does not feel as heavy.

Iliac system is free of any disease. Attempts to lyse the popliteal and femoral thrombis in the past was unsuccessful. This case demonstrates that even with occlusion of the femoral vein, this is not a contraindication to addressing areas of reflux.

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A refluxing vein provides very little collateral flow. In actuality, symptoms can be greatly alleviated by doing thermal ablation of refluxing saphenous vein trunks. (GSV, SSV, AAGSV), in the face of outflow obstruction distal to the femoral vein

11/13/12

Were you able to visualize and confirm patency of the profunda femoris vein prior to the ablation? If so did that impact your decision to move forward with ablation? Also, were you able to ascertain the likelihood of symptomatic improvement of treating the saphenous vein prior to the procedure?

Leanna L. Beaumont MSN, APNP The Wisconsin Vein Center Manitowoc Wisconsin P-920-686-7900 F-920-686-7985

11/13/12 – Dr. Bush responds This patient was treated at another facility and I saw the patient for consultation about another issue.

However, a truly refluxing vein is nonfunctional and should be ablated. I agree it is nice to see the profundus vein in these situations. Sometimes the profunda will be very dialated superficial to the femoral vein thrombus.

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11/13/12 – Dr. Tyrrell responds

Red arrow: femoral artery Pink: Thrombus in femoral vein Green arrow: profundal vein Profunda vein can typically be found entering laterally to the common femoral vein. It can become more prominent as a decompressing vein to the leg with deep venous thrombosis as in this case.

Rob Tyrrell, MD Midwest Vein & Laser Center 8101 Miller Farm Lane, Centerville, OH 45459 Google Maps / Directions 937-281-0200 Visit Website

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12/10/12 AAGSV Aneurysm - Learn How to Resect this Aneurysm With Minimal Amounts of Tumescent Solution The following movie reveals a large AAGSV aneurysm that occurred 3-years post endovenous ablation of the GSV at another center. The green arrow in Figure 1 points to a previously ablated GSV.

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As you can see in Figure 2, the arrow points to a large AAGSV aneurysmal neck. You can see from the video, a very large AAGSV trunk.

A 5-Fr catheter was placed in the trunk percutaneously then the skin was infiltrated with tumescent solution in the inguinal crease for approximately 34 inch length.

What we are showing in this video is that the tumescent is delivered under

US guidance around the aneurysm. This can be done anytime a high 5

ligation is needed be it an aneurysm or not.

By doing US guided tumescent, you use substantially less fluid. After the skin incision is made, the AAGSV trunk is identified and divided. Approximately 10-20 cc of tumescent solution is injected with a syringe (no needle), posterior to the AAGSV branch superiorly. 40cc to 50cc is usually all the tumescent that is required.

Proximal dissection of the AAGSV branch and the aneurysm that it enters is carried out. After circumferential dissection, the point of entry into the femoral vein is identified in this case. Sometimes the point of entry will be the saphenous vein itself.

I place a right angle hemoclip at the junction and then suture superiorly with 4-0 prolene just proximal to the clip. The aneurysm is then excised.

The operative site is irrigated with a dilute betadine solution and closed in layers.

After this, endovenous ablation of the distal AAGSV trunk is done.

Phlebectomies if needed, are also performed at the same setting.

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12/11/12 Avoiding Sural Nerve Injuries

This is a rare US image in that the sural nerve is easily identified in close proximity to the SSV. The sural nerve was traced laterally and inferiorly, as well as superiorly to midcalf level.

This US is in the region of approximately 5 inches above the lateral malleous.

It is rare to see the sural nerve this clearly. This also points to the fact that in the lower calf, if you are not careful with generous tumescent, this nerve can be injured due to the close proximity of the SSV.

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Figure 2 is a video loop tracing the sural nerve and SSV superiorly. Notice at midcalf in this patient, the sural nerve becomes quite lateral.

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Figure 3 shows the tumescent being placed around the SSV to separate the sural nerve from the SSV. If you stimulate the sural nerve, during thermal ablation, the patient will feel an electric shock in the lateral aspect of the ankle. If this should happen, stop and inject more tumescent in the location of the laser fiber.

Pull back your filament 1-2 cm and start the ablation once again.

Sural nerve injury should be a rare occurrence when thermal ablations are properly performed.

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Vein Experts members Avoid injury to this nerve. See the Case Presentation

2/16/13 10

Spontaneous Thrombosus during Attempted EVLT – Dr. Mueller shares a case

woman in her 40's 20 yr history of symptomatic right leg varicosities, medial calf 7 yrs symptomatic medial calf left leg varicosities symptoms progressive bilaterally, left worse than right pan, edema, aching, heaviness, burning, heat, restless legs, cramps, numbness, erythema bilateral ankle distal calf no relief 6-7 months compression and several months of daflon venotonic agent large varicosities right and left posterior medial calves and left medial ankle, bilateral calf and nakle reticular veins, left medial ankle dense erythematous blush of telangiectasias, bilateral mild ankle edema doppler revealed extensive reflux of the right gsv, right ssv, left gsv, and 2 left gsv accessory veins 3.0+ sec reflux duration, high velocity reflux, gsv diameter 8 mm at right sfj, 11 mm at left sfj, 6 mm at left proximal thigh left gsv evlt started with uneventful mid calf first attempt access in 6 mm vein and 4 french one step sheath wire passed easily to the junction followed by the dilator/sheath essentially instantaneous formation of a large thrombus at the tip of the sheath was noted on real time imaging. proximal edge of head of thrombus slightly mobile and 2 cm distal to SFJ, head of thrombus adherent to posterior gsv wall, distal end of head of thrombus 3 cm distal to SFJ. with a thin, short mobile extension into the common femoral vein and also had long tail of thrombus in 2 segments extending into the distal thigh gsv. wire and dilator removed rapidly, attempted routine aspiration of sidearm of sheath prior to flush failed gentle flushing without resistance readily achieved. catheter wiggled gently proximal and distal in attempt to gentle try to aspirate clot into the sheath to remove it; unsuccessful. pulled sheath back 2-3 cm distally and then finally able to aspirate blood into sheath side arm normally and sheath by then detached from thrombus (see images). lovenox 80 mg sq given, situation discussed with patient and husband and elected to abort evlt

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sheath gently removed frequent re imaging revealed resolution of the CFV 'head' ? favorable 'remodelling' and compaction of the thrombus vs. embolization plan was d/c home and rescan in 24 hours. pt stable until she was dismissed. when she got up, she became nauseated, diaphoretic, ashen, retched, presyncopal, dyspneic. sbp dropped to 55. Sa02 remained 99% throughout. differential diagnosis was massive PE vs. vasovagal reaction, more likely the latter given normal oxygenation, normal hr and ecg. responded slowly to atropine 0.4 mg IM. transported to local ER. chest CT negative for PE, venous doppler unchanged SVT in GSV. local respected surgical opinion advised a/c over ligation. minimal reduction in size of thrombus at 24 hours. 30-40% reduction in size of head of thrombus in proximal GSV at day 5, with complete resolution of long tail throughout the thigh gsv. hypercoagulability workup is pending. plan is proceed with vein treatments under full anticoagulation if/when thrombus resolves. difficulty is if gsv thrombus doesn't resolve. if doesnt, i invite opinions and would favor evlt from mid thigh distally after course of anticoagulation (45 days per calisto study for svt, or 3 months if one considers this a 'dvt' which it was for approx. 20 minutes), or ligation + evlt of the left gsv. she prefers to avoid ligation / surgery, even under local.

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Copyright  2013 by Courtesy of Cosmetic Vein Solutions- Sutton Place Laser

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5-days post procedure – Copyright  2013 by Courtesy of Cosmetic Vein SolutionsSutton Place Laser

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Spontaneous Thrombosus during Attempted EVLT â&#x20AC;&#x201C; Dr. Mueller shares a case - Update with image < back

Last Updated: 2/20/2013

Responses thrombophilia w/u returned today pt heterozygous for factor V leiden f/u u/s today on 2 weeks full dose lovenox shows 90% svt resolution

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Submitted by Rich Mueller - 2/19/2013

2/15/13 woman in her 40's 20 yr history of symptomatic right leg varicosities, medial calf 7 yrs symptomatic medial calf left leg varicosities symptoms progressive bilaterally, left worse than right pan, edema, aching, heaviness, burning, heat, restless legs, cramps, numbness, erythema bilateral ankle distal calf no relief 6-7 months compression and several months of daflon venotonic agent large varicosities right and left posterior medial calves and left medial ankle, bilateral calf and nakle reticular veins, left medial ankle dense erythematous blush of telangiectasias, bilateral mild ankle edema doppler revealed extensive reflux of the right gsv, right ssv, left gsv, and 2 left gsv accessory veins 3.0+ sec reflux duration, high velocity reflux, gsv diameter 8 mm at right sfj, 11 mm at left sfj, 6 mm at left proximal thigh left gsv evlt started with uneventful mid calf first attempt access in 6 mm vein and 4 french one step sheath wire passed easily to the junction followed by the dilator/sheath essentially instantaneous formation of a large thrombus at the tip of the sheath was noted on real time imaging. proximal edge of head of thrombus slightly mobile and 2 cm distal to SFJ, head of thrombus adherent to posterior gsv wall, distal end of head of thrombus 3 cm distal to SFJ. with a thin, short mobile extension into the common femoral vein and also had long tail of thrombus in 2 segments extending into the distal thigh gsv. wire and dilator removed rapidly, attempted routine aspiration of sidearm of sheath prior to flush failed gentle flushing without resistance readily achieved. catheter wiggled gently proximal and distal in attempt to gentle try to aspirate clot into the sheath to remove it; unsuccessful. pulled sheath back 2-3 cm distally and then finally able to aspirate blood into sheath side arm normally and sheath by then detached from thrombus (see images). lovenox 80 mg sq given, situation discussed with patient and husband 16

and elected to abort evlt sheath gently removed frequent re imaging revealed resolution of the CFV 'head' ? favorable 'remodelling' and compaction of the thrombus vs. embolization plan was d/c home and rescan in 24 hours. pt stable until she was dismissed. when she got up, she became nauseated, diaphoretic, ashen, retched, presyncopal, dyspneic. sbp dropped to 55. Sa02 remained 99% throughout. differential diagnosis was massive PE vs. vasovagal reaction, more likely the latter given normal oxygenation, normal hr and ecg. responded slowly to atropine 0.4 mg IM. transported to local ER. chest CT negative for PE, venous doppler unchanged SVT in GSV. local respected surgical opinion advised a/c over ligation. minimal reduction in size of thrombus at 24 hours. 30-40% reduction in size of head of thrombus in proximal GSV at day 5, with complete resolution of long tail throughout the thigh gsv. hypercoagulability workup is pending. plan is proceed with vein treatments under full anticoagulation if/when thrombus resolves. difficulty is if gsv thrombus doesn't resolve. if doesnt, i invite opinions and would favor evlt from mid thigh distally after course of anticoagulation (45 days per calisto study for svt, or 3 months if one considers this a 'dvt' which it was for approx. 20 minutes), or ligation + evlt of the left gsv. she prefers to avoid ligation / surgery, even under local.

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Copyright 2013 by Courtesy of Cosmetic Vein Solutions- Sutton Place Laser

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5-days post procedure – Copyright 2013 by Courtesy of Cosmetic Vein SolutionsSutton Place Laser

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Richard L. Mueller, MD, FACC, FACP, FAHA Cosmetic Vein Solutions; Sutton Place Laser Vein + Hair Removal 401 East 55th Street, New York, NY 10022 Google Maps / Directions 212.832.7575 & 212.593.9800 Visit Website

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SPONTANEOUS FATAL HĂ&#x2020;MORRHAGE CAUSED BY 20

VARICOSE VEINS - Case Study shared by a doctor < back

Last Updated: 3/11/2013 3/11/13

The following case is extremely unusual, previously reported complication of varicose veins. It is important to recognize the potential tragic results that can occur with venous disease In this case there is a skin ulceraton in direct continuity with the varice. This is a 35-year-old male with a history of 2 previous bleeds from the area as demonstrated in the image. He had been seen in an emergency room and referred to a very experienced venous treatment center.

The patient had an US, which revealed a large perforator in the lower thigh with resultant large varicosities and inferior GSV insufficiency. The patient had elected to get insurance approval before doing any type of treatment.

3-weeks later, the patient was engaged in physical activity doing yard work, developed a spontaneous bleed and instead of lying down & elevating his leg the patient re-entered his house, climbed steps to the second floor and collapsed and died from what appears to be exsanguination.

Autopsy revealed no other pathology, pulmonary or cardiac.

When you see this pattern, if possible, you should do immediate

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foam sclerotherapy injection of the varice underlying the area of the spontaneous bleed.

Shared by a doctor

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