CVM Grand Rounds January 14, 2026

Transcript

• 05:55Okay. Good afternoon, everybody.
• 05:59Just going through upcoming schedule,
• 06:02some faculty research,
• 06:04meetings coming up. And then,
• 06:05as briefly alluded to, last
• 06:07week, doctor Berkhof is coming
• 06:09in early February, and that'll
• 06:10be the Forrester Lee, CBM
• 06:13Giants lecture.
• 06:14And then doctor Shen will
• 06:16be doing a great structural
• 06:17case conference later in the
• 06:19month.
• 06:23So it's my great pleasure
• 06:24today to introduce doctor Rob
• 06:26Adderan.
• 06:27He is a associate professor
• 06:28of medicine in cardiovascular
• 06:30medicine here at Yale.
• 06:31He is director of the
• 06:32endovascular and interventional cardiology fellowships,
• 06:36and he's a member of
• 06:37the Vascular Disease Council and
• 06:38Publications and Guidelines Committee of
• 06:41the Society of Cardiovascular
• 06:42Angiography and Interventions.
• 06:45Doctor Adiran is chair and
• 06:46lead author of the chronic
• 06:48venous disease guidelines and the
• 06:50Society for cardiac angiography and
• 06:52interventions.
• 06:53He has chaired the early
• 06:54career committee and the of
• 06:56the American Venus Forum from
• 06:58twenty twenty four to the
• 06:59present.
• 07:00He is on the board
• 07:01of the American Board of
• 07:02Venus and Lymphatic Medicine.
• 07:04His research interests include the
• 07:06physiology of venous insufficiency
• 07:09and deep vein obstruction.
• 07:10Please join me in a
• 07:11well in a warm welcome
• 07:13of doctor Adderan.
• 07:21Thank you very much, doctor
• 07:22Clark, and I'm really,
• 07:24really delighted,
• 07:26to be invited to speak
• 07:27here today.
• 07:30I have no disclosures.
• 07:33So
• 07:35as a brief summary, what
• 07:36we hope to do is
• 07:37to introduce chronic venous disease
• 07:39in particular in particular of
• 07:41the of the legs. We'll
• 07:42look a little bit at
• 07:43the pathophysiology.
• 07:45We'll look at some treatment
• 07:46options that are out there
• 07:47now.
• 07:48Look at some of the
• 07:48guidelines and some interesting cases
• 07:50along the way.
• 07:52So as it turns out,
• 07:54venous disease and varicosities
• 07:56are not a new phenomenon.
• 07:58As you can see from
• 08:00this bust at the foot
• 08:01of the Acropolis and actually
• 08:03Egyptian papyrus dating back
• 08:06over three thousand years ago
• 08:08describes
• 08:09serpentine windings in the legs.
• 08:11So it's not new. It's
• 08:13been part of the human
• 08:14condition for a long time.
• 08:16And people have tried to
• 08:18treat it for a long
• 08:19time. I look at these
• 08:20kind of rock star ancient
• 08:22physicians, Hippocrates,
• 08:23Celsus, and Galen, and they
• 08:25all
• 08:27treated venous disease.
• 08:28Actually, they noted an association
• 08:31between varicose veins and ulcers
• 08:33for as far back as
• 08:34then, and they actually
• 08:36applied compression.
• 08:38And in fact,
• 08:39Galen was particularly stylish. He
• 08:41would do stripping of the
• 08:43veins and then pour some
• 08:45wine over it afterwards.
• 08:47So, a good use of,
• 08:48Merlot maybe.
• 08:50And then famously,
• 08:52the a very tough man,
• 08:53Roman general and statesman,
• 08:55Gaius Marius, underwent varicose veins
• 08:58surgery
• 09:00during
• 09:01that point in time. And,
• 09:02of course, no anesthesia, no
• 09:04local back then. And he
• 09:06refused surgery to the other
• 09:07leg saying,
• 09:09I see the cure is
• 09:10not worth the pain.
• 09:13Over the years,
• 09:15we have very slowly
• 09:17gained more knowledge. But for
• 09:18a very long time because
• 09:19of the so called humor
• 09:20theory, the thought was that
• 09:22ulcers are allowing
• 09:23evil humors to leave the
• 09:26body. So we did not
• 09:27even think about treating ulcers
• 09:28for many many many centuries.
• 09:30Then by the seventeenth century,
• 09:33the concept of valvular incompetence
• 09:35was noted. The the term
• 09:37varicose ulcer came about. Later
• 09:40on, we appreciated
• 09:41the mechanical theory of venous
• 09:44insufficiency better.
• 09:46We understood the post thrombotic
• 09:48syndrome better, and the term
• 09:49venous ulcer came about. And
• 09:52now in modern times,
• 09:55over twenty five million Americans
• 09:57in fact,
• 09:58in terms of amount of
• 10:00disease, if you include all
• 10:02forms of it is commoner
• 10:03than PAD, very common as
• 10:05we age. Most of us
• 10:06will have some form of
• 10:08varicose veins, etcetera.
• 10:10And the risk factors
• 10:11are many, but certainly family
• 10:13histories there, multiple pregnancies, obesity,
• 10:15etcetera.
• 10:16And in fact, probably the
• 10:18leading cause of leg ulcers
• 10:19overall is
• 10:20venous hypertension.
• 10:23Interestingly, many of our endovascular
• 10:25fellows, when they finish the
• 10:27fellowship year and they start
• 10:28their practice, they email back,
• 10:30send help. I
• 10:32underestimated how much venous disease
• 10:33I'll see in my career.
• 10:35So so, what should I
• 10:36do?
• 10:39So very common
• 10:41indeed. If we're to broadly
• 10:43divide up advanced
• 10:45arterial or critical lymph friendly
• 10:47ischemia with venous disease, the
• 10:49ischemia takes a different form.
• 10:51The ulceration's a little different.
• 10:53As you might expect with
• 10:56arterial disease, the ischemia
• 10:58affects the very, very extremities,
• 11:01and there is necrosis.
• 11:03Venous ulcers,
• 11:05for some reason, seem to
• 11:07concentrate around the ankle
• 11:09and the lower two thirds
• 11:10of the leg area.
• 11:13And the C app classification,
• 11:15this is just the c
• 11:16that I'm showing you, try
• 11:18to put together the gamut
• 11:19of
• 11:21the manifestations that you might
• 11:22see clinically of
• 11:24venous disease. And you can
• 11:25see things such as spider
• 11:26veins, reticular veins that hardly
• 11:28ever bother anybody, flaricose veins
• 11:30that may,
• 11:31and on and on to
• 11:33lipodermatosclerosis
• 11:34with the so called
• 11:36upside down champagne bottle sign
• 11:37and and, ulceration.
• 11:40And one way to describe
• 11:42what may happen in venous
• 11:44insufficiency is is to broadly
• 11:47say that as we stand,
• 11:50our vein pressures start to
• 11:51rise a little faster. And
• 11:53if we have venous insufficiency
• 11:55or ambitative venous hypertension,
• 11:57the walking does help lower
• 11:58the vein pressure. But in
• 12:00those with venous insufficiency, it
• 12:01doesn't drop as much as
• 12:03it should.
• 12:04What we did was put
• 12:05together this graphic in a
• 12:07recent review
• 12:09to describe that really with
• 12:10venous insufficiency, there's not only
• 12:12obstruction in some cases, but
• 12:14reflux and sometimes, frankly, both.
• 12:16And the sum total of
• 12:18that can lead to venous
• 12:19hypertension, and we also added
• 12:21obesity to the mix because
• 12:22that can contribute
• 12:24common problem.
• 12:25And the net effect of
• 12:27that is
• 12:28associated with inflammation, thrombosis, and
• 12:31any treatments that have been
• 12:33attempted
• 12:35are designed to
• 12:36block or mitigate
• 12:38any one of these things
• 12:40that are contributing
• 12:41to the end result of
• 12:42pain, edema, ulcers, etcetera.
• 12:46So very simply, on the
• 12:48left, I'm just showing you
• 12:49some deep veins and some
• 12:50superficial veins. The superficial
• 12:52veins on the right could
• 12:54be, for example, the great
• 12:55saphenous that we'll talk about
• 12:56today. They communicate with perforators
• 12:59and with normal
• 13:00vein valve function. The flow
• 13:02should be integrate
• 13:03and with the deep veins
• 13:05helped by
• 13:06the cath soleus pump.
• 13:08If there
• 13:10is theinous insufficiency,
• 13:13as you can imagine,
• 13:17there is not that integrate
• 13:18or upward flow that we
• 13:19might expect, and we get
• 13:21that
• 13:22hypertension.
• 13:24There are also a couple
• 13:25of examples here of compression.
• 13:28One classic one that you
• 13:29would have heard about is
• 13:30the the so called non
• 13:31thrombotic lesions or the May
• 13:33Thirner syndrome. And you can
• 13:34see on the
• 13:38you can see my arrow
• 13:39right here,
• 13:41the iliac artery can compress
• 13:42the iliac vein, but compression
• 13:44can happen elsewhere.
• 13:45And the case below, which
• 13:46I won't talk about, but
• 13:47just so you can see,
• 13:48there are many examples of
• 13:49this in our bodies.
• 13:51Spare thought for a man
• 13:52who might have hematuria or
• 13:54flank pain, groin pain, for
• 13:56a woman who gets pain
• 13:57after sexual intercourse
• 13:59and is found to have
• 14:00an engorged left ovarian vein.
• 14:02And in this case, it
• 14:03is because
• 14:05her left ovarian vein, which
• 14:08drains into
• 14:09the left renal vein here,
• 14:10has to pass into the
• 14:12IVC
• 14:13behind the SMA,
• 14:14which in some cases,
• 14:16presses
• 14:17and pinches
• 14:18between the SMA and the
• 14:19aorta. And this is the
• 14:21so called nutcracker syndrome.
• 14:23So there are many ways
• 14:24in which the veins which
• 14:25have lower pressure compared to
• 14:27the arteries
• 14:28can be compressed.
• 14:30And spare a thought for
• 14:31someone who's had a DBT
• 14:33in the past, many of
• 14:34you will have sent patients
• 14:35who had a DBT a
• 14:36year ago for an ultrasound
• 14:37and the report comes back
• 14:38and says chronic thrombus. Well,
• 14:40it's really not thrombus anymore.
• 14:42What they're usually seeing is
• 14:44this, which is very tough
• 14:46leathery
• 14:47type three collagen, which can,
• 14:49of course, cause valve damage
• 14:50and, frankly, obstruction.
• 14:54So we know based on
• 14:56both animal and human studies
• 14:59that
• 15:00with venous hypertension in the
• 15:01limbs, we get
• 15:03inflammation, leukocyte infiltration,
• 15:05matrix metalloproteinase
• 15:07endothelins
• 15:08are over expressed, and MMPs
• 15:10as,
• 15:11the basic science
• 15:14of us,
• 15:15folk among us know degrade
• 15:16collagen and elastin.
• 15:18And they're associated with
• 15:20inflammation.
• 15:22They stimulate fibrosis. So all
• 15:24these have a multiple
• 15:26or a multiplying effect that
• 15:27leads to weakening of the
• 15:28veins and inflammation.
• 15:30And we do know that,
• 15:32actually, if you look at
• 15:32varicose veins histologically,
• 15:34they have lower levels of
• 15:36elastin,
• 15:37laminin, and collagen. So they're
• 15:39less elastic to begin with.
• 15:41And with the increased endothelial
• 15:44permeability,
• 15:45the red cells extravasate,
• 15:47and you get the classic
• 15:48hemosiderin
• 15:49deposition that you see in
• 15:50this image here.
• 15:54And in fact, blood that's
• 15:55collected from from human varicose
• 15:57veins contains more
• 15:59inflammatory markers and lower white
• 16:02blood cells
• 16:03suggesting that they're getting trapped.
• 16:06Clinically,
• 16:07the symptoms are many, but
• 16:09here are some of the
• 16:10classic ones. The aching of
• 16:11the heaviness
• 16:12with PAD will get claudication
• 16:14potentially or night cramps with
• 16:16venous disease. You can certainly
• 16:18get night cramps, but the
• 16:19aching, the heaviness, the itching
• 16:20is very common. Restless legs
• 16:22at night. And, of course,
• 16:24ultimately,
• 16:25ulceration can occur.
• 16:27So
• 16:29interestingly,
• 16:30even though venous disease has
• 16:31been around for a long
• 16:32time,
• 16:34practicing and the study of
• 16:35venous disease is in a
• 16:36way like studying cardiology
• 16:39back in the sixties. There's
• 16:40still yet to be determined.
• 16:42The research
• 16:44devoted to it has lagged
• 16:46behind, I think, even PAD.
• 16:49So that's an interesting opportunity.
• 16:51And in fact,
• 16:52as a group, cardiologists
• 16:54are probably only second nationally
• 16:57to vascular surgeons and the
• 16:59number
• 17:00of vascular procedures, vein ablations,
• 17:02etcetera that are done. And
• 17:04there's a lot of variability
• 17:05or simply lack of knowledge.
• 17:06So
• 17:07a few years ago, we
• 17:09decided to get together with
• 17:10a group through Sky, our
• 17:12society,
• 17:13but it was a
• 17:15document with a lot of
• 17:16help to put together guidelines
• 17:18to assist,
• 17:20clinicians in the care of
• 17:22venous disease. The people who
• 17:24help with this, some were
• 17:25vascular medicine specialists, some were
• 17:27surgeons,
• 17:28some were cardiologists and methodologists.
• 17:30And, of course, to create
• 17:31guidelines, we needed to do
• 17:33a systematic review
• 17:34and a technical review, which
• 17:36we did. It took about
• 17:37two to three years, and
• 17:38it was published,
• 17:39not that long ago. And
• 17:41I just wanna show you
• 17:42some of the guidelines and
• 17:43the basis behind them.
• 17:46So one is
• 17:47and this is the first
• 17:48thing in the guidelines
• 17:49is
• 17:50and you remember Hippocrates and
• 17:52those guys
• 17:53years ago were using compression
• 17:55for patients with symptomatic varicose
• 17:57veins
• 17:58and or chronic venous insufficiency.
• 18:01The panel recommends or suggests
• 18:03in this case, compression therapy
• 18:05rather than no compression alone.
• 18:06You've all heard about no
• 18:07compression
• 18:08versus compression
• 18:10and how patients feel about
• 18:11it.
• 18:13Conrad Jobbs, you've heard of
• 18:14Jobbs Stockings, noted that patients
• 18:17with venous insufficiency, when they're
• 18:19submerged
• 18:20in water,
• 18:22say that their legs actually
• 18:24feel better.
• 18:25And the thought was that
• 18:27as you are deeper in,
• 18:29there's greater pressure and that's
• 18:30creating a gradient upwards to
• 18:33perhaps aid with flow.
• 18:35And he thought, and now
• 18:36we are assuming it's related
• 18:38to Laplace and Pascal's laws,
• 18:40that
• 18:41with compression stockings,
• 18:44the radius of the ankle
• 18:45is less than at the
• 18:47calf level. And so you
• 18:48have a greater pressure effect
• 18:50of the ankle than at
• 18:51the calf level, so you
• 18:52get that graduated
• 18:53compression effect. That's the name.
• 18:55So he was really the
• 18:56first person to
• 18:59suggest compression stockings, understanding that
• 19:01they were emulating
• 19:03immersion in water.
• 19:05Now compression stockings do not
• 19:07reduce venous hypertension. If you
• 19:09stand, your vein pressures will
• 19:10rise, but
• 19:12they do reduce interstitial pooling
• 19:14and that is related to
• 19:16better outcomes. So to this
• 19:18day, even all these years
• 19:19later, to this very day,
• 19:21it is still a cornerstone
• 19:22treatment.
• 19:24And it does certainly reduce
• 19:26the rates of ulcer healing
• 19:27and recurrence if you continue
• 19:29to use it. But, of
• 19:30course, the challenges with it,
• 19:32as you would have all
• 19:32seen, are with the elderly,
• 19:34with the obese
• 19:36being able to don or
• 19:38remove these
• 19:39stockings. So
• 19:41some solutions,
• 19:42you can
• 19:43ask your patient to go
• 19:44on Amazon and for about
• 19:45forty dollars,
• 19:46get one of these gadgets,
• 19:47the Donner devices to help
• 19:49put the stockings on,
• 19:51or the little donut device
• 19:53to help unroll it. And
• 19:55it helps
• 19:56to some degree.
• 19:57We can get them the
• 19:59zipper kind, which they like
• 20:01if it fits well. Some
• 20:02of these obviously
• 20:04lose their,
• 20:06ability over time. Velcro is
• 20:08very popular, though expensive.
• 20:10And then on the right,
• 20:12two that you can see
• 20:14here, these are really more
• 20:15reserved
• 20:16for lymphedema patients, but
• 20:19particularly this device here is
• 20:22quite inexpensive. It's really a
• 20:23Velcro
• 20:25device that's put on and
• 20:26then you can
• 20:27press the
• 20:28you can crank up the
• 20:29pressure, there are air pockets,
• 20:31and then it has a
• 20:32pop up valve. So you
• 20:33cannot mess it up. And,
• 20:35it's very easy to apply.
• 20:37And I think the coolest
• 20:38of all is this device.
• 20:39You've heard of home
• 20:40air pumps, but this is
• 20:42it uses electrical energy
• 20:44that applies to memory metal
• 20:46that heats and the memory
• 20:48metal or the the metal,
• 20:50which is sort of a
• 20:51nitinol alloy, will
• 20:53contract and create a a
• 20:54peristaltic
• 20:55wave that kind
• 20:57of massages the leg. It's
• 20:58like a lymphoidema pump, but
• 20:59you can actually walk around
• 21:01with it. So pretty cool
• 21:02ideas, and they're easy to
• 21:03apply, and they're often available
• 21:05through
• 21:06insurance.
• 21:08Before I continue, any questions
• 21:10or comments about
• 21:12these devices or compression in
• 21:14general?
• 21:18Alright. Wanna show you a
• 21:19couple of interesting articles that
• 21:21have been published about compression.
• 21:22And this one interestingly,
• 21:24really is not about venous
• 21:25patients. This was a single
• 21:27center small study, still made
• 21:28it to the New England
• 21:29Journal.
• 21:30And they took patients who
• 21:31had chronic edema,
• 21:33and they were getting recurrent
• 21:35cellulitis.
• 21:36Most of the edema was
• 21:37due to obesity,
• 21:39not lymphedema, and only a
• 21:40minority had venous hypertension.
• 21:43But the group that received
• 21:46compression therapy
• 21:48had showed a drastic reduction
• 21:50in rates of recurrent cellulitis.
• 21:54So this is, I think,
• 21:55very
• 21:56practical and something that we
• 21:57can apply to a lot
• 21:58of our patients.
• 22:01We also noted,
• 22:02that
• 22:04a lot of practitioners
• 22:05who take care of
• 22:07venous ulcer disease or advanced
• 22:09disease were too afraid to
• 22:11apply
• 22:12compression stockings
• 22:14to their patients because of
• 22:15the theoretical fear that it
• 22:16might cause a cardiac decompensation.
• 22:19This was never borne out
• 22:20by anything. Now we did
• 22:22a study. You could not
• 22:23do a randomized control trial
• 22:25because you would be taking
• 22:26an ulcer patient saying, hey.
• 22:28I'm gonna randomize you to
• 22:29not get the the treatment
• 22:31that you need. But we
• 22:32at least looked at the
• 22:33retrospective data. We looked at
• 22:34the Yale data,
• 22:36and, you can see doctor
• 22:37Ahmad help us with the
• 22:39study.
• 22:40And we looked at the
• 22:41Yale database of patients with
• 22:43heart failure
• 22:45and diastolic dysfunction, low EF,
• 22:48who were getting compression therapy.
• 22:50And we compared the data
• 22:51to historic controls with the
• 22:53CHAMP registry.
• 22:54And in summary,
• 22:56the rates of exacerbation
• 22:58with CHF
• 23:00with compression were very low
• 23:02and, in fact, lower than
• 23:03in the CHAMP registry. So
• 23:05there was no signal to
• 23:06suggest that
• 23:07patients would decompensate
• 23:09if you treated them with
• 23:11compression stockings.
• 23:15Our second guideline is that
• 23:17for patients who have symptomatic
• 23:20saphenous vein reflux,
• 23:22that they would benefit from
• 23:23ablation therapy over conservative.
• 23:25And I'll just take a
• 23:26second to describe to you
• 23:28what we're talking about because
• 23:29this is very common.
• 23:31On the
• 23:33left here,
• 23:34you can see some of
• 23:35the deep veins.
• 23:36The great saphenous vein runs
• 23:38medially, the small saphenous in
• 23:40the back.
• 23:41Oftentimes,
• 23:43incompetent valves in the great
• 23:44saphenous vein lead to symptoms.
• 23:46So if you see someone,
• 23:47and I'm sure you've all
• 23:48seen people who have veins
• 23:50that are like this,
• 23:51these varicosities,
• 23:53this is not the you're
• 23:54not looking at the great
• 23:55saphenous vein. The great saphenous
• 23:57vein is underneath. And if
• 23:58you suddenly see a vein
• 24:00protruding out like this, chances
• 24:02are that there's an incompetent
• 24:03saphenous vein immediately underneath that.
• 24:06And that is effectively feeding
• 24:08or dumping into what you
• 24:10see here and leading to
• 24:11the symptoms.
• 24:14To demonstrate that someone has
• 24:16saphenous reflux, a common test
• 24:18is to do a doppler
• 24:20study.
• 24:21And to demonstrate that on
• 24:23the left,
• 24:25we have, if you'll imagine,
• 24:28it's saphenous vein that is
• 24:29incompetent.
• 24:30And we can compress
• 24:33below with either a cuff
• 24:35or by hand
• 24:36to force the blood to
• 24:37move integrate and then suddenly
• 24:39let go.
• 24:41An incompetent valve by definition
• 24:43should snapshot very quickly within
• 24:44half a second. But if
• 24:46it doesn't, there's just a
• 24:47certain period of time when
• 24:48that reflux occurs and it
• 24:50fills that reservoir that's lower
• 24:52down. And the PW that
• 24:54you see here shows an
• 24:56example of reflux. The PW
• 24:58cursor is put on the
• 25:00great saphenous vein or any
• 25:01other vein that you want,
• 25:02and you can compress below
• 25:04the vein and let go.
• 25:06You can see this reverse
• 25:07flow, in this case, lasts
• 25:09over four seconds.
• 25:12So this is an is
• 25:13an incompetent vein, presumably because
• 25:15the vein is dilated.
• 25:17But is a vein that's
• 25:19refluxing for, say, three seconds
• 25:21any healthier than a vein
• 25:23that's
• 25:24refluxing for, I don't know,
• 25:25ten.
• 25:28The idea of insufficiency
• 25:30to all of you who
• 25:31do echo is very different
• 25:32because the heart's pulsatile.
• 25:34You're looking generally at one
• 25:35cycle. With veins, it's a
• 25:37whole different thing.
• 25:39Essentially, the valve is incompetent
• 25:41and it stops leaking when
• 25:42that reservoir has been filled.
• 25:44But there was still this
• 25:46common misconception
• 25:47that the duration of reflux
• 25:49time mattered.
• 25:50And, led by Damianos
• 25:52Kokanidis, who was a fellow
• 25:53here, is now faculty with
• 25:55us, we looked at
• 25:57the correlation between reflux time
• 25:59and venous symptom scores. And
• 26:00in summary, there's no correlation.
• 26:02They're not related. It is
• 26:04not a factor.
• 26:08What we do know is
• 26:09that if you have someone
• 26:10who's symptomatic with the saphenous
• 26:12vein that is incompetent,
• 26:14eliminating
• 26:16that incompetent vein will help
• 26:18the patient
• 26:19feel better
• 26:20or it would help to
• 26:22heal the ulcer.
• 26:23This has been known for
• 26:24quite some time just that
• 26:26it's been done in some
• 26:27surgical way with some very
• 26:29invasive and morbid procedures.
• 26:31Nowadays, and to some of
• 26:33you who've spent time in
• 26:34the in the clinics with
• 26:35us, we can
• 26:36close down an incompetent vein
• 26:38with a catheter procedure under
• 26:40local. It can either be
• 26:42heat energy with radio frequency
• 26:43or laser
• 26:44or in the middle with
• 26:48what you see the bottom
• 26:49here, this is super glue
• 26:50or cyanoacrylate,
• 26:52or this technology actually invented
• 26:54by,
• 26:55Michael Tall, a former IR
• 26:57professor here at Yale,
• 26:59where the device will spin
• 27:03rapidly inside the vein, scraping
• 27:05the endothelium while the scleroscent
• 27:06is injected slowly,
• 27:08and that will close the
• 27:09vein. Or you can use
• 27:10a sclerosing agent like the
• 27:12bottom right to close the
• 27:13vein down. But the bottom
• 27:15line is that what we've
• 27:16noticed is that if you
• 27:17close down an incompetent saphenous
• 27:19vein and allow effectively for
• 27:21the deep veins to, so
• 27:23to speak, take over, people
• 27:25feel better.
• 27:26And lasers have been around
• 27:28in medicine for a long
• 27:29time in Venus work for
• 27:31over twenty five years and
• 27:32similar with radio frequency ablation.
• 27:34And they have over ninety
• 27:36percent success rate in shutting
• 27:38the vein down. Here's an
• 27:39animal
• 27:40installed I think this is
• 27:41from a goat model where
• 27:42they took a great saphenous
• 27:43vein that you see on
• 27:45the left and they performed
• 27:46radiofrequency
• 27:47ablation. The first thing you
• 27:48notice is
• 27:50that it's venoconstricted,
• 27:51this thrombus, and the endothelium
• 27:53does get denuded.
• 27:55And then
• 27:56over a matter of time,
• 27:58the complete lumen is fibrosed
• 28:00and gone.
• 28:03And one, I think, key
• 28:05trial to show in
• 28:07great saphenous vein or saphenous
• 28:09ablation is the IVRA trial
• 28:11that was published a few
• 28:12years ago. And these are
• 28:13patients with a saphenous reflux
• 28:16and an ulcer,
• 28:18and they were randomized to
• 28:19either compression
• 28:20first or ablation.
• 28:23The lower line that you
• 28:24see is actually the compression
• 28:25group, and this is a
• 28:26follow-up
• 28:27out to a year.
• 28:28And you notice that actually
• 28:30even with compression,
• 28:31people do heal
• 28:33pretty well.
• 28:35The thing that this does
• 28:36not show you is that
• 28:36recurrence rates are higher if
• 28:38you just treat with compression
• 28:40therapy. But if you instead
• 28:41just ablated
• 28:43plus compression, if if you
• 28:44ablated the incompetent saphenous vein,
• 28:46then
• 28:47it heals quicker and the
• 28:48recurrence rates are much lower.
• 28:50And I'll show you some
• 28:51work that's not, we've not
• 28:53shown before
• 28:54that,
• 28:56we're writing up currently. We
• 28:57actually noninvasively
• 28:59measured
• 29:00lower grade saphenous pain pressure
• 29:01in people with incompetence
• 29:03who were undergoing ablation. So
• 29:05we did it beforehand. On
• 29:07the left, you can see
• 29:07their symptoms scores pre and
• 29:09post.
• 29:10And the post was about
• 29:11two months later. You can
• 29:13see that their symptoms scores
• 29:14after an ablation, as you
• 29:15would expect, as we know,
• 29:16get better. But something that's
• 29:18not been known up to
• 29:19now, and we're still collecting
• 29:20this data. I just wanted
• 29:21to show you what we've
• 29:23got is that their saphenous
• 29:24pain pressure after an ablation
• 29:27does
• 29:28fall,
• 29:29there is a trend to
• 29:30a lower GSP pressure, and
• 29:31that's never been,
• 29:33elucidated before.
• 29:36Something else that we noticed,
• 29:38and this has become less
• 29:39of a problem recently, is
• 29:40that
• 29:41when you as you would
• 29:43have seen when you book
• 29:44a procedure, sometimes it gets
• 29:45denied by insurance. And we,
• 29:47for many years,
• 29:49would get a denial for
• 29:50an ablation in a perfectly
• 29:51symptomatic patient,
• 29:53and the insurances would cite
• 29:55that the great saphenous vein
• 29:57was too small. Therefore, we're
• 29:58not gonna cover this procedure.
• 30:00So we actually did this,
• 30:02study looking at,
• 30:04patients undergoing ablation
• 30:06prospectively
• 30:07and found that whether their
• 30:09saphenous vein diameter is small
• 30:11or less than five point
• 30:12five or plus five point
• 30:13five,
• 30:15their improvement and their outcomes
• 30:18are the same. And, actually,
• 30:20these days, there is much
• 30:21less of this problem with
• 30:23insurance companies.
• 30:25Some special cases that come
• 30:27up.
• 30:28There are times when,
• 30:30I would not suggest we
• 30:32destroy a great saphenous vein.
• 30:35A diabetic patient with coronary
• 30:36disease who may need that
• 30:38for a conduit or a
• 30:39PAD patient with advanced arterial
• 30:42disease. Unless, of course, the
• 30:43vein is so dilated, it
• 30:44probably wouldn't be acceptable for
• 30:46a conduit either. And the
• 30:48other is
• 30:49if they
• 30:50have deep vein obstruction and
• 30:52reflux, what do you treat
• 30:53first? This is an area
• 30:55that's open to discussion.
• 30:57Something the patients often ask
• 30:59and practitioners is, well, fine.
• 31:01You treat these veins, but
• 31:02don't they all just come
• 31:03back anyway? And there is
• 31:05a grain of truth to
• 31:06that because it's a chronic
• 31:07condition. But specifically
• 31:09for
• 31:10varicose vein recurrence after ablation,
• 31:12some years later, it can
• 31:13recur, but it's only rarely
• 31:15because that saphenous vein opened.
• 31:17That can happen, but it's
• 31:18rare. It could be because
• 31:20you have other veins that
• 31:21are
• 31:22incompetent,
• 31:23have become confident, and you've
• 31:25missed them.
• 31:27So I just wanna show
• 31:28you some cases that you
• 31:29may see,
• 31:31and you may decide to
• 31:32treat them or not, but
• 31:33I just wanted you to
• 31:33see that.
• 31:35And I think
• 31:36I've certainly seen a few
• 31:37of these, and I think
• 31:38you have too. So twenty
• 31:40four year old,
• 31:42active young person, not overweight,
• 31:44and they say, you know,
• 31:45every time they go running
• 31:46or they go skiing, their
• 31:48calf on one side swells
• 31:50up.
• 31:52What do you say to
• 31:53this purse? What are you
• 31:53gonna do for that?
• 31:59So, of course, for me,
• 32:00I may do a reflux
• 32:01study. I may ask them
• 32:03if they've had history of
• 32:04DVT, have they had injuries,
• 32:05all the usual questions.
• 32:07And all of those are
• 32:08negative.
• 32:10Yet
• 32:11and I'll just show you
• 32:12a venogram.
• 32:13Some individuals
• 32:15on the left, you can
• 32:16see
• 32:17flow
• 32:18through the popliteal vein.
• 32:21Look looks open.
• 32:23When you ask them to
• 32:24plantarflex
• 32:25their foot,
• 32:27you will notice
• 32:30that
• 32:31the popliteal vein has become
• 32:32very stenosed. So any clues,
• 32:34fellows, as to what could
• 32:35be going on?
• 32:41So when they let go,
• 32:42when they relax their leg,
• 32:43the vein is good. When
• 32:44they flex, there it is.
• 32:47And it's on the same
• 32:48side where they're getting the
• 32:49swelling when they run or
• 32:50when they ski.
• 32:52And this is a case
• 32:53of palpitio
• 32:54compression syndrome,
• 32:55and
• 32:56it is usually
• 32:58compression from the lateral head
• 33:00of the gastroc muscle.
• 33:02Now treatment here is
• 33:04controversial. Are you gonna resect
• 33:06the gastroc muscle?
• 33:09Very I think it's
• 33:10very aggressive and unnecessary unless
• 33:12they're having DVTs.
• 33:14Something else that's been tried
• 33:15is to inject Botox into
• 33:17the gastroc head to see
• 33:18if they feel any better.
• 33:20But this is something that
• 33:20you may see, but you
• 33:21may not necessarily want to
• 33:23treat.
• 33:24You just have awareness of
• 33:25it.
• 33:26So moving on, guideline number
• 33:28four is if patients have
• 33:29varicose veins without
• 33:31reflux in their saphenous veins
• 33:33and the varicose veins are
• 33:34hurting or causing a problem,
• 33:37do consider sclerotherapy.
• 33:38And very simply, that is
• 33:40just injection
• 33:42injection of a
• 33:44foam or an agent directly
• 33:45into the vein
• 33:47to shut down the vein.
• 33:49And there is
• 33:50some data to support this,
• 33:51and it is a very
• 33:53common procedure.
• 33:56Now moving on to the
• 33:58deep veins for a second,
• 33:59the guideline panel suggests, and
• 34:01we use the word suggest,
• 34:02not recommend because the data
• 34:03is limited, but stenting the
• 34:05ileal cable segments for symptomatic
• 34:08compression.
• 34:09And, of course, you've heard
• 34:10of the so called May
• 34:11Thurnau syndrome, and I think
• 34:12this shows you very nicely
• 34:14what we're talking about. So
• 34:16in the front, you see
• 34:17the aorta
• 34:18and the iliac
• 34:20arteries, and down we go.
• 34:22And behind it
• 34:23is the IVC
• 34:25and the venous cyst. Now
• 34:28as you classically know, and
• 34:29it's a classic board question,
• 34:31that the right common iliac
• 34:32artery compresses the left common
• 34:34iliac vein because
• 34:37because they're typically offset. So
• 34:37this is the classic site
• 34:38for what you may know
• 34:40as a May Thurner, but
• 34:41actually, the compression can happen
• 34:43anywhere. It can happen between
• 34:45these arteries, the internal external
• 34:46iliac
• 34:47here, and even in other
• 34:49locations.
• 34:51Venograms in these patients don't
• 34:53always look this obvious. Here,
• 34:55you can clearly see
• 34:57flattening of this vein and
• 34:59lots of collaterals,
• 35:01but doesn't always look like
• 35:02that. It can look pristine.
• 35:03It is only the IVUS
• 35:05that can show you. You.
• 35:06And you can see on
• 35:07the right
• 35:08here, the vein, the IVUS
• 35:10catheter is inside the common
• 35:11iliac vein, and the artery
• 35:13is compressing just a little,
• 35:14but the compression is a
• 35:15lot more dramatic up here.
• 35:17So if this patient had
• 35:19significant symptoms, aching, swelling, past
• 35:21DVT,
• 35:22you may be within your
• 35:23right to want to stent
• 35:25that.
• 35:25And here's a case we
• 35:27did actually.
• 35:28Here is a
• 35:29an iliac vein that is
• 35:31compressed between the internal and
• 35:33the external arteries. And after
• 35:34it's stented, you can see
• 35:36that it is wide open
• 35:37because the stent can overcome
• 35:38the external
• 35:39forces.
• 35:41Now there are some interesting
• 35:42nuances that you just will
• 35:43not get in arterial disease.
• 35:46What you see here
• 35:47is
• 35:50an IVUS catheter parked in
• 35:52the common iliac vein, and
• 35:53we've just asked the patient
• 35:54to
• 35:55breathe.
• 35:57And you can clearly see,
• 35:58and this happens in many
• 35:59patients, that the caliber of
• 36:01the vein changes. So if
• 36:02we were to do a
• 36:03pullback
• 36:04by IVUS like we do
• 36:05in arterial disease,
• 36:07we may not fully appreciate
• 36:09if there's stenosis here or
• 36:10not. So this is a
• 36:11common phenomenon,
• 36:12and it's an interesting nuance
• 36:14in venous disease that not
• 36:15all patients have, but they
• 36:17can have.
• 36:18The other very interesting nuance
• 36:20is hydration status.
• 36:24NPO after midnight is something
• 36:26we tell a lot of
• 36:27our patients or we even
• 36:29cancel procedures for it. It's
• 36:30been burnt into our brain
• 36:32stem,
• 36:33But it's based on tradition
• 36:36dating back to before most
• 36:38of us were born.
• 36:39So
• 36:40if you do a Venus
• 36:43study, a deep vein study
• 36:44on someone who's been NPO,
• 36:47their veins may actually be
• 36:48smaller in caliber. So when
• 36:49it's time to IBIS and
• 36:51measure and decide if you
• 36:51need to treat it or
• 36:52not,
• 36:53you may not actually know
• 36:54what you're getting.
• 36:56My colleague, doctor Char here
• 36:58at Yale,
• 36:59looked at
• 37:00the stents that we put
• 37:01in at Yale
• 37:03retrospectively.
• 37:04And he divided the stents.
• 37:06These are May thirteenth patients.
• 37:07He'd included
• 37:09patients who had been stented
• 37:10before eleven AM.
• 37:12These are NPO patients not
• 37:14hydrated.
• 37:15And he looked at patients
• 37:16who got a stent after
• 37:18eleven AM. And interestingly,
• 37:21the group that were stented
• 37:22later received
• 37:23seems smaller stents, presumably because
• 37:26they were less well hydrated.
• 37:28So this is interesting
• 37:30retrospective, but kind of an
• 37:31interesting finding.
• 37:33So nowadays, it's common practice
• 37:35for a lot of us
• 37:35to hydrate these patients.
• 37:38This is a young man
• 37:39I first met when he
• 37:40was eighteen years old, and
• 37:42he had some leg swelling.
• 37:43He had a CT scan
• 37:44that suggested a left sided
• 37:45May thirner. Didn't bother much,
• 37:47left him alone. But by
• 37:48by age twenty two, he
• 37:50was starting to have a
• 37:51lot of discomfort, so we
• 37:52took him back. And you
• 37:53can see I just want
• 37:54you to appreciate that you
• 37:56don't see an obvious stenosis,
• 37:57but you kinda get flattening
• 37:59effect
• 38:00in the common iliac. And
• 38:02by IBIS, we confirmed the
• 38:03May Thurner.
• 38:04We
• 38:05stented, and here are the
• 38:07we actually did
• 38:09a double stent, like a
• 38:10double barrel to ensure both
• 38:11sides were good. So this
• 38:13is someone it's a non
• 38:14thrombotic
• 38:15matron or case.
• 38:17Sometimes it's a lot worse
• 38:18than that. This is a
• 38:19lady with a learning disability.
• 38:21She had a history of
• 38:22a DVT
• 38:24filter that was placed at
• 38:25the time, and she had
• 38:26this horrible, painful ulcer that
• 38:28was almost going all the
• 38:29way around her leg,
• 38:31and she tried wound care.
• 38:34Leaving IVC filters in, as
• 38:36you would have seen more
• 38:37recently,
• 38:39is really
• 38:40a very problematic thing for
• 38:42us. So we
• 38:44decided to first remove the
• 38:46filter.
• 38:46So on the left, you
• 38:48can see
• 38:49that we have snared the
• 38:50filter.
• 38:51And with old filters, with
• 38:53all the fibrosis that is
• 38:54in the veins, they become
• 38:56really stuck. So we use
• 38:57laser similar to EP lead
• 38:59extractions. So we use laser
• 39:00and we took the filter
• 39:01out.
• 39:02And what you can see
• 39:03is
• 39:04that the filter does not
• 39:06have thrombus on it. Otherwise,
• 39:08we would not have touched
• 39:09it, but it has all
• 39:09this
• 39:10fibrotic
• 39:11material
• 39:12that can really impede flow.
• 39:14This is a lady, and
• 39:14we said at the beginning,
• 39:16obstruction and reflux are behind
• 39:18venous hypertension. In this case,
• 39:20she has
• 39:23she has significant outflow obstruction.
• 39:25But we did not stop
• 39:26there because she had had
• 39:27a DVT, and we went
• 39:29on to do the middle
• 39:30image, a venogram of her
• 39:32left
• 39:33iliac vein
• 39:35that you see here.
• 39:37We confirmed it by IVUS,
• 39:38but the left side was
• 39:39severely post thrombotically
• 39:41stenosed.
• 39:42And just there, you can
• 39:43see this vein going up
• 39:45there acting as a collateral.
• 39:46Do you know what that
• 39:47is?
• 39:48That's her left ovarian vein.
• 39:50So she not only has
• 39:51collaterals through her pelvis,
• 39:53she's actually draining up into
• 39:55her ovarian vein into the
• 39:56renal vein because of this
• 39:57tremendous obstruction.
• 39:59So we used IVUS and
• 40:00stented it,
• 40:01and,
• 40:03she had significant improvement in
• 40:04her symptoms after that
• 40:06because we used a mechanical
• 40:08procedure
• 40:09to supplement compression to reduce
• 40:11venous hypertension.
• 40:13Sometimes,
• 40:15the problem is caused by
• 40:17us.
• 40:18Here's a lady
• 40:20we treated
• 40:21about ten years ago for
• 40:23PAD. Turned out she had
• 40:24bilateral common iliac artery stenosis.
• 40:26So we just put in
• 40:27chasing stents. And she was
• 40:29very happy. Thank you very
• 40:30much. My collodication is better.
• 40:32But since you've done the
• 40:33procedure, my left calf kinda
• 40:36swells up after I stand
• 40:37for a while.
• 40:38So as it turned out,
• 40:41when we
• 40:43her veins, the part of
• 40:44her left iliac vein that
• 40:46passed under
• 40:48the right
• 40:50thrombophilic artery stent was getting
• 40:52compressed because we had pushed
• 40:53the plaque and the artery
• 40:55out further. So we actually
• 40:56had to put in a
• 40:57venous stent there,
• 40:59which you can see just
• 41:00about here. There it is
• 41:02in the in the vein
• 41:03to stop the vein from
• 41:04imploding
• 41:05and her leg pain improved.
• 41:09Venous stents are not benign.
• 41:11Fellows, you all know the
• 41:12direction of blood flow in
• 41:13the veins. This is a
• 41:14case that happily did not
• 41:15happen to us, but she
• 41:17came to us later for
• 41:18a subsequent issue.
• 41:20This is a young woman,
• 41:21twenty nine years old,
• 41:23gravitated to,
• 41:25worked in a bar standing
• 41:26job, and she had varicose
• 41:28veins in her left calf.
• 41:30The physician who saw her
• 41:31was a vascular surgeon somewhere
• 41:33in Connecticut,
• 41:34said, well, let me just
• 41:35check. Let me do
• 41:37an MRI. And turns out
• 41:38she did have a May
• 41:39thirsen syndrome.
• 41:41Now
• 41:42I don't think that
• 41:44proceeding with stenting the iliac
• 41:46vein was what she needed,
• 41:48but she got it anyway.
• 41:50After she got her iliac
• 41:51vein stent, she was sent
• 41:52home, and a couple of
• 41:53days later, she started to
• 41:54get palpitations
• 41:55and chest pain. So she
• 41:57comes to the ER,
• 42:00and on the left,
• 42:02you can perhaps appreciate something
• 42:03that looks a little odd
• 42:04in the
• 42:05interatrial septum carrier. Everybody see
• 42:07that? And then if you
• 42:09look
• 42:09here, you start to appreciate
• 42:11something that shouldn't be there.
• 42:14I think the subsequent images
• 42:16show it better.
• 42:18Her she had two stents,
• 42:20the embolized, they were undersized
• 42:22and,
• 42:23possibly
• 42:24hydration thing, possibly poor IVUS
• 42:26use, but they embolized and
• 42:28they could not snare them.
• 42:29So she actually had twenty
• 42:30two year old woman had
• 42:32to have a median sternotomy
• 42:34to extract two venous stents
• 42:36done for a for an
• 42:37unclear reason. So
• 42:39when it goes wrong, it
• 42:40can really go wrong. And
• 42:41actually, here's, by the way,
• 42:42an echo
• 42:44of her stent. And you
• 42:45can actually see not only
• 42:47is the stent where it
• 42:47should not be up in
• 42:49the atrium, but it's forming
• 42:51thrombus within it as well.
• 42:53So thankfully,
• 42:56this disastrous complication seems to
• 42:58occur very, very seldom,
• 43:00but it seems to affect
• 43:01mostly short stents, which are
• 43:02not well anchored or small.
• 43:06One of the things we
• 43:07also did is to look
• 43:08at the medical therapy and
• 43:09and patency rates or the
• 43:11data at Yale,
• 43:13and we looked retrospectively
• 43:15at stents that were put
• 43:16in for post thrombotic patients,
• 43:18Maytherna,
• 43:20DVT.
• 43:21And
• 43:22we found that as we
• 43:23would expect, the patients with
• 43:25history of DVT had higher
• 43:26rates of reocclusion.
• 43:27We wanted to see if
• 43:28there was any
• 43:30signal to suggest if the
• 43:31mode of anticoagulation
• 43:34mattered
• 43:36in terms of patency.
• 43:37And as it happened, it
• 43:38didn't. The only thing that
• 43:39we noticed
• 43:41is that the stents that
• 43:42tended to preclude were a
• 43:43little smaller,
• 43:44and that was statistically significant.
• 43:49So back to the guidelines,
• 43:50what we did in addition
• 43:51to just putting together the
• 43:52guidelines, we thought would make
• 43:54them practical as we took
• 43:56the data that we had
• 43:58and our recommendations and tried
• 43:59to break them down clinically
• 44:01for
• 44:03physicians. So if somebody had
• 44:05c two to c four
• 44:06disease varicose veins and, yes,
• 44:08they were symptomatic
• 44:10because we're just trying to
• 44:11treat symptoms here, if they
• 44:13happen to have certain types
• 44:14of reflux, we made recommendations
• 44:17on
• 44:18what they can do. And
• 44:19for more advanced forms, if
• 44:21they did not improve,
• 44:22then and only then could
• 44:23they start to deal with
• 44:25deep vein disease. With venous
• 44:27ulcer disease, we're a lot
• 44:28more aggressive, obviously, and we
• 44:30recommended a course of action
• 44:31that included eliminating superficial superficial
• 44:33reflux first before we get
• 44:35to
• 44:36the deep veins.
• 44:37And this is on the
• 44:38Sky point of care app.
• 44:40So you may see patients
• 44:42like this in clinic, and
• 44:43I just wanted to show
• 44:44you these because there are
• 44:45these so called masquerader conditions
• 44:47that can look like venous
• 44:49disease, but
• 44:51are not necessarily.
• 44:53Someone comes in, they're getting
• 44:54these pigmented
• 44:55areas on their skin of
• 44:57their legs. You've probably seen
• 44:58this. Right?
• 44:59And
• 45:00on further questioning, they also
• 45:02get this sometimes on their
• 45:03back or on their abdomen.
• 45:05So it doesn't really make
• 45:07sense. You can even do
• 45:08a venous study. It's perfectly
• 45:09normal.
• 45:10This is a benign condition
• 45:11called Schamberg disease. It's not
• 45:13really well known. It's a
• 45:14purpuric dermatosis. It's not really
• 45:16well understood, but it's benign.
• 45:18Some dermatologists treat it with
• 45:20with low dose steroids, but
• 45:21it goes away by itself.
• 45:23Although there are certain meds
• 45:24including aspirin that are associated
• 45:26with it.
• 45:27Here's an ulcer that happened
• 45:29in a patient
• 45:30include the patient's been on
• 45:31hydroxyurea.
• 45:34And this is not entirely
• 45:36unusual,
• 45:37but it is not related
• 45:38to vascular disease at all,
• 45:40but rather
• 45:41hydroxyurea as well as other
• 45:42drugs affect cell the cell
• 45:44cycle, in this case, the
• 45:45synthesis phase
• 45:47of cell division and the
• 45:48ulcer can form,
• 45:50but mimic venous disease. And
• 45:52there are other drugs that
• 45:53can do it as well.
• 45:55And here's one, those of
• 45:56you who, are
• 45:58our ONC colleagues here, this
• 46:00is a tyrosine kinase inhibitor
• 46:02ulcer that occurred in a
• 46:04patient
• 46:05that received,
• 46:06I think this was sunitinib,
• 46:08and it looks like
• 46:10punched out or blown out
• 46:12ulcers in the legs, but
• 46:13this is not venous insufficiency.
• 46:14But, unfortunately,
• 46:16because of the anti angiogenic,
• 46:18effects of these drugs, these
• 46:20can occur. And it seems
• 46:21that the best way to
• 46:21deal with them is to
• 46:22reduce the dose or eliminate
• 46:24it.
• 46:26So I think to bring
• 46:27things,
• 46:28nearly to a close,
• 46:30obesity is a real problem
• 46:32in the leg space as
• 46:34well. I showed you the
• 46:34beginning that
• 46:36obesity is associated with higher
• 46:38vein pressures.
• 46:39And we actually looked at
• 46:40obesity in our patients who
• 46:42already were being treated for
• 46:44reflux.
• 46:45So as they came up
• 46:47for the re ablation, we
• 46:48checked, measured their sapless vein
• 46:50pressure before the re ablation,
• 46:52and we found that
• 46:54there's actually a correlation between
• 46:57your saphenous vein pressure and
• 46:59body mass index.
• 47:00The patients had their
• 47:03ablation,
• 47:04and this is we're gonna
• 47:05present this, so this hasn't
• 47:06been presented before. But actually
• 47:09post ablation on follow-up,
• 47:11there still was a pretty
• 47:12strong correlation, even a stronger
• 47:14correlation than this between
• 47:16saphenous vein pressure and BMI.
• 47:19So obesity remains a problem.
• 47:22And then lastly, some thoughts
• 47:23about the future.
• 47:24We've talked a little bit
• 47:25about deep vein reflux, which
• 47:27can occur primarily or post
• 47:29thrombotic, but we really don't
• 47:30have an answer for it
• 47:31right now. Some very accomplished
• 47:33surgeons can cut into the
• 47:35endothelium
• 47:36and create
• 47:37these neovalves, but they're very,
• 47:39very hard to do. Any
• 47:40attempts up to net to
• 47:41create a stent valve in
• 47:43the veins of the legs
• 47:44has been not very successful,
• 47:46high rates of thrombosis, and
• 47:48the FDA recently
• 47:49actually denied,
• 47:51approving this particular device. So
• 47:53back to the drawing board.
• 47:55And I think lastly,
• 47:58DVT
• 47:59and the post thrombotic syndrome,
• 48:01there has been a significant
• 48:02rise in catheter procedures over
• 48:04the past ten or so
• 48:06years to reduce hopefully the
• 48:07rate of post thrombotic syndrome.
• 48:09Yet,
• 48:10with the best study attract
• 48:12around half these patients, even
• 48:14after
• 48:16early mechanical thrombectomy, still go
• 48:17on to develop post thrombotic
• 48:19syndrome.
• 48:20So why is
• 48:22that? One of the,
• 48:23subgroup analysis that Rabinovich did,
• 48:27found that and this this
• 48:29was done prospectively.
• 48:30Patients
• 48:31post DVT who had higher
• 48:33levels of these inflammatory markers
• 48:35actually went on to develop
• 48:37post thrombotic syndrome.
• 48:39So certainly a a correlation
• 48:40there. What do we do
• 48:42about it?
• 48:43Well,
• 48:44medical therapy right now is
• 48:46very limited, but
• 48:47the dexterity
• 48:48trial just stopped recruiting. And
• 48:51the idea with this was
• 48:52to use this very kind
• 48:53of cute looking device
• 48:55called the bullfrog,
• 48:56and it's advanced into a
• 48:58vein where a DVT has
• 49:00occurred.
• 49:01The balloon is inflated. A
• 49:03small needle is used to
• 49:05pierce the vein wall, and
• 49:06then steroids are injected in
• 49:08various location. So I know
• 49:10it's very crude,
• 49:11but it's a start. And,
• 49:13of course, we don't know
• 49:13if it works yet. They
• 49:14haven't they've not shown the
• 49:15long term follow-up data on
• 49:17this yet.
• 49:19So veins,
• 49:20carry blood, but unlike,
• 49:23that is about where the
• 49:25similarity ends between veins and
• 49:27arteries.
• 49:28And as you've seen, it
• 49:29is a
• 49:31venous hypertension condition associated with
• 49:33reflux and obstruction, maybe both.
• 49:36There's growing data on management,
• 49:39but we're really entering at
• 49:41the ground level. There's much
• 49:42to be discerned. In particular,
• 49:43I think, repairing the valves
• 49:45and medical therapy, which is
• 49:47very
• 49:48compared to what we have
• 49:49for coronary disease, it's very,
• 49:50very
• 49:51rudimentary indeed.
• 49:53If you have any patients
• 49:54with leg swelling, aching, and
• 49:56so on,
• 49:57I would ask you to
• 49:58get older order an ultrasound
• 50:00reflux study, not a DBT
• 50:01rule out. They will still
• 50:03rule out a DBT for
• 50:04you, but with a reflux
• 50:05study, they can see how,
• 50:08the valves are functioning.
• 50:09And, of course, we're happy
• 50:10to see them. And I
• 50:12wanted to acknowledge all my
• 50:13colleagues who've been gracious enough
• 50:15to,
• 50:16send those patients and doctor
• 50:17Young and Lansky who have
• 50:18been wonderful mentors. Thank you
• 50:20for your attention.
• 50:30There's some questions. Maybe I'll
• 50:32start you off and then
• 50:33hand off the mic. So
• 50:34I have, three very, maybe,
• 50:36simple,
• 50:37questions. One is you didn't
• 50:39mention, you showed us the
• 50:40the the hemodynamic effects of,
• 50:42different positions and walking. But
• 50:44I'd be curious to know,
• 50:46what your recommendation is with
• 50:47patients with chronic pain and
• 50:48sinusitis
• 50:49regarding exercise
• 50:50therapy and and,
• 50:52and is it something that,
• 50:54is there any evidence that
• 50:55supports or improves
• 50:57pain?
• 50:59That's one. Second is I'm
• 51:00very interested to know if
• 51:01there's any work on,
• 51:03GLP ones,
• 51:04in particular subsets, and and
• 51:06if you can comment on
• 51:07that. And the third is
• 51:08maybe your just general thoughts
• 51:09on on,
• 51:11what kind of,
• 51:12patients you'd like to see
• 51:14your faculty, colleagues, and fellows
• 51:16refer to you. So Thank
• 51:18you. Thank you. So
• 51:20the the first question,
• 51:21exercise and weight loss certainly
• 51:23helps patients feel better. A
• 51:25lot of patients with Venus
• 51:26suspiciously tell you that if
• 51:28they just stand still like
• 51:29I'm doing now, the leg
• 51:30starts to throb and bother
• 51:32them. As soon as they
• 51:32start to walk, they feel
• 51:34better.
• 51:35The one exception is someone
• 51:36with post thrombotic deep vein
• 51:38occlusion.
• 51:39They seem to get venous
• 51:41claudication.
• 51:42So that's interesting.
• 51:44And that might be because
• 51:45with reflux, you start to
• 51:47recruit the calf pumps.
• 51:48You feel better as you
• 51:50exercise. Whereas with deep obstructive
• 51:52veins, you're trying to,
• 51:54if you will, force the
• 51:55flow and they actually feel
• 51:57worse.
• 51:59With regards to GLP
• 52:01ones, I think that we
• 52:03know that
• 52:04the patients who are the
• 52:05obese respond the worst to
• 52:07vein treatments.
• 52:08The patients who
• 52:10have
• 52:11some method of
• 52:12losing weight will improve their
• 52:14leg edema better than others.
• 52:15There's data already to support
• 52:17that.
• 52:17The
• 52:18the summit trial with GLP
• 52:20one showed in diastolic dysfunction
• 52:22patients that they you can
• 52:23reduce fluid volume. There's data
• 52:24on platelets, and we've actually
• 52:24stay posted with
• 52:26There's
• 52:26data on platelets, and we've
• 52:28actually stay posted. We've we
• 52:30have pitched, a proposal to
• 52:32industry
• 52:33for a large
• 52:34study, a prospective study to
• 52:35look at the obese with
• 52:36venous insufficiency
• 52:38with the GLP one.
• 52:40So we'll
• 52:41that's something that I think
• 52:42has merit to look at.
• 52:44And I think any,
• 52:47glad to see any patients
• 52:48with
• 52:49with achy legs that have
• 52:52obvious or not so obvious
• 52:53manifestations
• 52:54of venous insufficiency.
• 52:57That's a really wonderful presentation.
• 52:59Thank you.
• 53:00Both veins and lymphatics are
• 53:02involved in fluid return.
• 53:04And so I was wondering
• 53:05whether there's any relationship between
• 53:08venous dysfunction and lymphatic dysfunction.
• 53:10Yeah. Great question. And there
• 53:12there seems to be the
• 53:14in fact, there's a term
• 53:15that's been coined phlebolymphhedema.
• 53:18So patients with advanced venous
• 53:19disease
• 53:20start to develop lymphedema as
• 53:22well. And actually
• 53:23and you could you know,
• 53:24we can check their deep
• 53:25veins. We can check for
• 53:27reflux, and they may not
• 53:28have any of that. But
• 53:29we treat them with pump
• 53:31therapy and try to help
• 53:32them to lose weight, and
• 53:34it does improve their symptoms.
• 53:36But, yes, there's certainly a
• 53:37a connection.
• 53:39So I had a question.
• 53:41So we've started to do,
• 53:43red blood cell imaging
• 53:45of the lower extremities during
• 53:46cuff occlusion and looking at
• 53:48reflow
• 53:49in in assessment of arterial
• 53:51disease and collateral formation. I
• 53:53was wondering
• 53:54whether there might be any
• 53:55role for this in the
• 53:57setting of venous disease and
• 53:58whether this is really just
• 54:00blood in the vessels, or
• 54:02is it more in the
• 54:03tissues as well that gets
• 54:05retained?
• 54:07Yeah. Great question. I think,
• 54:09we do know that interstitial
• 54:11pooling
• 54:12does cause
• 54:14it is associated with inflammation
• 54:16and the inflammatory
• 54:18markers. And reducing that
• 54:20pooling can
• 54:24can resolve can re result
• 54:26which is associated with lower
• 54:27levels of inflammatory markers,
• 54:30ulcer healing, etcetera.
• 54:32I think what would be
• 54:33nice to see is if
• 54:34you're able to show
• 54:36if this will be in
• 54:37an upright like in a
• 54:38human,
• 54:39if we could see the
• 54:40direction of flow in patients
• 54:42with
• 54:43deep and or superficial reflux
• 54:45and what happens when they're
• 54:46static versus when they're walking.
• 54:48I think that would be
• 54:49very helpful.
• 54:51So,
• 54:52Rob, great talk.
• 54:54If you remember, we had
• 54:55a discussion about the genetics.
• 54:57As you mentioned, this is
• 54:58a familial disorder.
• 55:00And, there was a GWAS
• 55:01that I talked to you
• 55:02about that is done already.
• 55:04And one of the strongest
• 55:05signal was Piezo one, which
• 55:07is a mechanosensing,
• 55:10protein in the cell surface.
• 55:11I wonder actually using this
• 55:13data for polymorphism of this
• 55:15can actually guide you in
• 55:16the treatment because if it
• 55:17is mechanosensing, maybe those are
• 55:19the one that already better
• 55:20respond
• 55:21to all these kind of
• 55:22devices that you showed
• 55:24and kinda kinda guide the
• 55:25health the the treatment that
• 55:27you have. What are your
• 55:28thoughts on that?
• 55:30I suppose you could. I
• 55:31mean, you need to have
• 55:32a good size,
• 55:34study. The studies up to
• 55:35now in genetics have been
• 55:36pretty small. The,
• 55:40the probably one of the
• 55:41best quoted studies was done
• 55:43out of France where they
• 55:44took people young enough for
• 55:45their parents to both be
• 55:47alive, and they examined them
• 55:48and both their
• 55:50parents. And,
• 55:51for people who
• 55:55in those whose both parents
• 55:57had visible varicose veins, there
• 55:59was an eighty percent chance
• 56:00that they had varicose veins
• 56:02as well. So with the
• 56:03genetic aspect of it
• 56:05is is huge.
• 56:06In terms of response to
• 56:08treatment,
• 56:09that would obviously take a
• 56:10larger study. Is that what
• 56:11you're thinking of, Aria, in
• 56:12terms of
• 56:13depending on genes and how
• 56:15they would respond? Mhmm.
• 56:17Yeah. I mean, we could
• 56:18we could think about doing
• 56:19designing a study.
• 56:24If there are no more
• 56:25questions, really, thank you, Rob.
• 56:26That was fantastic and very
• 56:28educational. Thanks.