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New Treatment Methods in Phlebology The Official Journal of Center for Vein Restoration Understanding Post Thrombotic Syndrome ........................................................Page 2 Vol. 6, Issue 2 Q&As .............................................................................................................Page 4 CME Courses & Events ....................................................................................Page 5 inside this issue Community Outreach:Free Workshops in our LegsWork Program..........................Page 5 Meet Drs. Nguyen, Hong & Ahuja .....................................................................Page 6 CME Conferences ...........................................................................................Page 6 New Treatment Methods in Phlebology By Robert C. Kiser, DO, MSPH Phlebology is a rapidly advancing branch Newer phlebology treatments focus of medicine. It has been just over 10 on providing highly effective treatment years that thermal closure techniques methods (>90% success over multiple such as radiofrequency and laser years) with less bodily invasion, less time ablation were invented, and now they and fewer or equal risks.1 are the standard of care for ablation of Supergluing Veins: Sapheon superficial venous insufficiency. Thermal closure is extremely effective and safe. It Cyanoacrylate has been used in is far less time consuming and has much medicine for many years, primarily to less down time and associated expense close skin wounds. It also has been used compared with ligation and stripping. to close arterio-venous malformations, Thermal closure incompetent has much more ovarian veins reproducible and duodenal 2 results and is varicose veins. also much more Cyanoacrylate consistently for saphenous effective in the vein closure Editorial Staff long term as is not yet compared to available in the Editor-in-Chief, President & CEO, sclerotherapy United States, Center for Vein Restoration alone. However, although phase Sanjiv Lakhanpal, MD, FACS endovenous thermal closure does have 3 trials are underway in the US and Editor its own requirements, such as disposable the UK. The technique is as follows: a Robert C. Kiser, DO, MSPH catheters, laser fibers, and because it uses long glue-installation catheter is placed Associate Editor, Director of Research heat within the vein it requires the use of within the vein, much as one would place & Director of Vascular Labs tumescent anesthesia around the vein to a thermal catheter. Glue is injected under Shekeeb Suian, MD, FACS act as a heat-sink. For the phlebologist, ultrasound-guidance, starting at 5cm Associate Editor, Director, Research & requirements add expense and time to from the saphenofemoral junction. The Medical Education the procedure. For the patient, the more ultrasound probe compresses the glued Nicos Labropoulos, PhD, RVT that the body is penetrated with needles, vein for 3 minutes. The remaining length Managing Editor infused with fluids, or otherwise invaded, of incompetent vein is then glued in a Kathleen A. Hart the less comfortable the procedure. proximal to distal fashion. The effect is a ISSN 2159-4767 (Print), ISSN 2159-4775 (Online) Continued on Page 3 Copyright © 2013 Center for Vein Restoration. All rights reserved. 1 Understanding Post Thrombotic Syndrome By Gautam Shrikhande, MD In patients with deep venous thrombosis (DVT), the most In addition, from the American College of Chest Physician significant immediate concern is that of pulmonary embolus. Evidence-Based Clinical Practice Guidelines in 2012, there is Over the next several months to years, however, development evidence to suggest that catheter directed thrombolysis (CDT) of post thrombotic syndrome (PTS) presents a much more in the setting of acute DVT may reduce PTS and improve quality prevalent chronic morbidity. PTS refers to the signs and of life without being associated with an unacceptable increase symptoms that occur as long term consequences of DVT. in bleeding. The patients who experience the best results PTS can affect up to 23-60% of patients in the two years are those who have ileofemoral DVT for less than 14 days.5 following DVT, and up to 10% of these patients may go on to CDT involves taking the patient to an angiography suite and have ulceration.1 The most significant long term sequelae of infusing thrombolytic therapy, typically tissue plasminogen PTS are a significant loss of quality of life and limitations in activator (TPA), directly into the thrombus. The dissolution the abilities to perform daily activities.2 Signs and symptoms of thrombus can prevent the subsequent inflammation of in the leg include swelling, heaviness, aching, cramping, obstruction which occurs secondary to the thrombus and can varicose veins, skin discoloration, and ulceration. The preserve long term deep venous function. inflammatory response secondary to the thrombus as well as Lastly, in patients with established PTS, some have shown the physical pressure from the thrombus is thought to lead to that venous balloon dilation and stent therapy can be 3 venous valvular disruption and incompetence. This valvular effective treatments for chronic ileofemoral thrombosis.6 With incompetence, combined with persistent venous obstruction this minimally invasive approach which can be safely and from the thrombus, easily accomplished increases the in an angiography pressure in the suite, patients veins and leads to with PTS can get a state of venous quick symptomatic hypertension. Risk relief with minimal factors for the morbidity and good development of PTS patency of the include proximal venous system after DVT, recurrent stenting. We have ipsilateral DVT, had several patients persistent DVT with ulcerations in symptoms one the setting of PTS month after DVT who have gone onto diagnosis, obesity, complete resolution Venographic image (pre-treatment) Venographic image (post-treatment) and inadequate of this pathology. anticoagulation representing a right external iliac vein representing a stent placed in the right narrowing due to chronic DVT which has external iliac vein to relieve the venous In summary, PTS during the first resulted in venous ouflow obstruction and outflow obstruction and decompress the 3 months of DVT post-thrombotic syndrome (PTS). post-thrombotic syndrome (PTS) can be a significant treatment. Images courtesy of Center for Vascular Medicine source of morbidity in patient with DVT, however with the proper evaluation and The most important initial step in the evaluation of PTS after treatment selection by a venous specialist, PTS can be either obtaining a history of DVT is obtaining a venous duplex prevented or treated to provide patients with an excellent ultrasound. The key features of this evaluation include quality of life. the degree of recanalization of the deep venous system, the location of the obstruction (proximal or distal), and the Footnotes: presence of both deep and superficial venous insufficiency. 1.Ashrani AA, Heit JA. Incidence and cost burden of post-thrombotic syndrome. J Thromb Thrombolysis 2009; 28: 465- 76. Initial, conservative treatment options for PTS include 2.Kahn SR, Shbaklo H, Lamping DL, Holcroft CA, Shrier I, Miron MJ, et al. Determinants of health-related quality of life appropriate anticoagulation for DVT, leg elevation, during the 2 years following deep vein thrombosis. J Thromb Haemost. 2008;6:1105-12. 3. Roumen-Klappe EM, Janssen MC, Van Rossum J, Holewijn S, Van Bokhoven MM, Kaasjager K, et al. Inflammation in deep vein thrombosis and the development of post-thrombotic syndrome: a prospective study. J Thromb Haemost weight loss in overweight patients, and the use of elastic 2009;7:582-7. 4 compression stockings for up to 2 years post DVT. In patients 4. Brandjes DP, Buller HR, Heijboer H, Huisman MV, de Rijk M, Jagt H, et al. Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis. Lancet 1997;349:759-62. with ulceration development, appropriate wound care and 5. Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, et al. Antithrombotic Therapy for VTE Disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians compression bandages are indicated. Also, in some patients, Evidence-Based Clinical Practice Guidelines. venous ablation in patients with significant superficial venous Chest. 2012; 141(2_suppl):e419S-e494S. doi:10.1378/chest.11-2301 6. Sarici IS, Yanar F, Agcaoglu O, Ucar A, Poyanli A, Cakir S, et al. Our early experience with iliofemoral vein stenting in reflux may provide symptomatic relief. patients with post-thrombotic syndrome. Phlebology. 2013 Mar 19. [Epub ahead of print] 855-835-VEIN (855-835-8346) www.centerforvein.com 2 New Treatment Methods in Phlebology Continued from Page 1 sort of “spot welding” of the vein. The cyanoacrylate causes an even long-term closure. However, the percentage of veins that reopen acute inflammatory reaction, at the endothelium, that results in some years after sclerotherapy is estimated to be as high as 40% in fibrotic closure of the vein. some studies.4 This is likely due to varying techniques, which can lead I had the good fortune to speak with Tristan Lane, surgeon and to inadequate destruction of endothelium and subsequent, inadequate clinical research fellow at the Imperial College, London. Mr. Lane fibrotic closure. Clarivein uses both chemical sclerosant (generally has had the experience of performing more than 100 of these sodium tetradecyl sulfate in the United States) and
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