VEIN PHYSICIAN EDUCATION

BUSH VENOUS LECTURES MEDICAL BLOG

Find below information concerning some of the case studies that have been discussed on our Blog at bushvenouslectures.com:

AAGSV Reflux

Jean-Claude Schwartz, MD, FACS- 10/10/11
I have an older lady who underwent a GSV stripping many years ago. She now comes to me with some skin changes and pain. Her reflux study shows deep system reflux in addition to what appears to be an AAGSV (almost 1 cm) that comes off the CFV and immediately becomes extremely tortuous. This has reflux throughout from groin to ankle and I believe is only being fed by the CFV. Because of the tortuousity, EVLT is not possible. I understand that ultrasound guided sclerotherapy is a good option.

1.) Would using 2-4 cc of 1-2% sotradecol foam ~ 4 cm from the CFV junction be reasonable?

2.) Should I elevate the leg after injection? Do I need any perivenous tumescence after injection? Should I compress the AAGSV-CFV junction while injecting?

3.) What should I do with the rest of the vein? Parts of it are superficial enough for phlebectomy but parts of it are a little deep. Phlebectomize the accessible parts? Any indication for additional foam in this vein distally in the leg?
http://www.bushvenouslectures.com/blog/content.asp?id=1706

AAGSV Thrombus

Ronald Bush, MD – 5/17/11
56-year-old female presents with painful thrombosis of thigh veins from AAGSV branch. US completed which show many superficial clots and a large thrombus at the junction of the AAGSV and saphenous vein. Who would anti-coagulate this patient?
http://www.bushvenouslectures.com/blog/content.asp?id=1143

Abdominal Wall Varicosities

Douglas Stafford, MD, FACS – 2/17/11
28 y/o female with painful abdominal wall varicosities. 3 years ago she had a DVT in her Left common femoral vein that was felt secondary to birth control pills. She was treated with coumadin for 6 months then ultrasound show no residual clot and it was stopped. Shortly after she started to notice bulging veins on her abdominal wall that have increased over the past 3 years. Ultrasound showed there was no deep vein obstruction from the IVC to femoral veins. Old chronic thrombus in the left common femoral with no obstruction. The left inferior epigastric is incompetent, measures 1.3 cm and fed the complex. The drainage is through the right inferior epigastric vein with is incompetent and measured 1.1 cm. Any thoughts on a treatment plan.
http://www.bushvenouslectures.com/blog/content.asp?id=820

Angiogenesis

Ronald Bush, MD, FACS-  9/14/11
49-year old female with previous phlebectomy to the right medial leg and thigh has developed this pattern of angiogenesis. The occurrence of multiple small spider veins in a close approximation is common, after treatment of superficial veins, without addressing the deeper source of reflux. This pattern can occur both after injections or phlebectomy and can be related to multiple venous sources.

The primary treatment is correction of reflux and then treatment of spider veins with different modalities.
http://www.bushvenouslectures.com/blog/content.asp?id=1616

Arm Veins

Doug Stafford, MD – 2/17/11
24-year-old female presents with large arm veins. These are asymptomatic but patient is embarrassed of them and wishes to have them removed. She did have a tendon repair in her left wrist years ago and no significant medical history. Does any one have any thoughts or experience with this type of problem?
http://www.bushvenouslectures.com/blog/content.asp?id=821

Arterialization of Previously Ablated Vein

Richard Mueller MD – 2/14/12
I have a patient who has had gsv evlt twice (12 mm vein that didn''t close the first try) Now has a 2-3 cm long partially open mid thigh segment (closed proximally and distally) with a strongly arterialized signal in the lumen, which is traceable to a common femoral artery branch, likely a pudendal or circumflex iliac artery So it looks like what is rarely reported, an AV fistula post ablation Would you advise surgery ? observation ? compression?
http://www.bushvenouslectures.com/blog/content.asp?id=2312

EVLT

Leanna L. Beaumont MSN, APNP – 1/30/12
I have a 50 year old patient on Pradaxa due to a.fib because she is allergic to warfarin and aspirin. Prior to the Pradaxa she was using daily Lovenox. She is in need of bilateral GSV ablations. Her cardiologist has instructed her not to stop anticoagulation for this. Do you have any experience with performing ablations while on Pradaxa or is there any information available on this topic?
http://www.bushvenouslectures.com/blog/content.asp?id=2244

Gastrocneimus Perforator

Richard Mueller, MD – 11/10/10
 I have a pt. whose varicosities and symptoms have cleared 90% after evlt of gsv and one round of a.p. however, one large calf varix remained and he wants it out. On doppler it comes off a perforator (entirely subfascial in course) leading to a deep vein tributary that dumps into a very large gastroc venous sinusoid. About 2.5 cm of superficial varix under the skin before dives into the perforator. Can’t ablate perforator with sclero or laser as its all subfascial. My concern is the theoretical risk of avulsing a deep gastroc. but since ap of perforators is an accepted treatment there is always a theoretic risk of tearing a deep vein. However, this perf is all subfascial. Several surgeons have advised u.s guided a.p. with a proximal ligation with one loop of 3-0 silk. as a non surgeon, are dr. bush and fellow phlebologists comfortable with my doing this. dont want to stray from scope of practice but tying one suture proximal to a hemostat after exteriorizing the vein seems simple enough and pt prefers i do it rather than a vasc. Surgeon. i even have one of my trusted dermatologists nice enough to come to the procedure and watch me do it and bless the knot ! Would appreciate everyones thoughts
http://www.bushvenouslectures.com/blog/content.asp?id=343

Goltz Syndrome

William Salerno, MD, – 4/16/12
27-year-old woman that presented with Goltz Syndrome that I think was a wrong diagnosis (she has no other stigmata). There are essentially areas of thin or missing SQ and thin dermis but I believe the veins are normal with visible reticulars and livideo reticularis all over and mostly on the legs but also some on trunk. Are there other variants or is this something else?
http://www.bushvenouslectures.com/blog/content.asp?id=2552

Hand Veins

Deborah Gumina, MD – 3/22/11
Have a middle age candymaker with a varicose vein of her palm that has developed below her thumb. Ther are no other varicosities of the forearm. It doesn’t bother her unless she is making candy, which requires pressure placed on her palm. Would you SAP this? I didn’t think that sclero would be sappropriate. Difficult place to ultrasound as well. Any thoughts would be appreciated.
http://www.bushvenouslectures.com/blog/content.asp?id=938

Klippel Trenaunay Syndrome

George Lionel Zumbro, Jr MD – 3/7/11
28 yo man seen today with history of RF Closure and multi phlebectomy 5 yrs ago on rt leg. Recurrent VV past few yrs with swelling and pain. On PE(see pics). DUS shows 15cm prox GSV with old thrombus. Mid thigh GSV open with large thigh perf feeding GSV which is open dilated and refluxing with numerous VV tributaries to foot. Numerous large refuxing perf to ant and post tibial veins. Rt SSV 10mm with large refluxing perfs to gastroc veins . Note foot and leg skin color has been this way since childhood.
http://www.bushvenouslectures.com/blog/content.asp?id=877

Lymphedema

Lionel Zumbro, MD – 2/15/11
This 60 y/o female with long HX of pain and swelling both legs. Right leg pain. Rt leg 1.5 sec reflux reverse Trendelenberg. Can''t stand long enough for US. Has never been able to wear stockings. Never any compressionRX. See pics. Thoughts please!
http://www.bushvenouslectures.com/blog/content.asp?id=808

Mass

Painful Mass Posterior Thigh - Ronald Bush, MD, FACS – 12/26/11
Patient presents with a few scattered reticular veins. In the posterior upper aspect of the thigh she has point tenderness to palpation. Only a small area on the posterior thigh has on palpation an area of slight induration. US over this area reveals a larger mass that is present and measures approximately 4 cm in diameter. Patient denies any history of trauma but has continuous pain over this region.

Initial impression is fatty necrosis. Re-evaluation at 3 months reveals no change in mass but continuation of pain so a biopsy was performed

Biopsy reveals spindle cell lipoma–benign. This is often the result of trauma.

This is a good example of why careful evaluation by US may reveal important information not related to the venous system.
http://www.bushvenouslectures.com/blog/content.asp?id=2128

Microphlebectomy

Richard Kimmel, MD – 3/7/12
Any thoughts on this case: 50 y/o male with hx of IVC/right iliac thrombotic occlusion for many years, has large painful bulging AAGSV that is tortuous with >6sec reflux and dilitation, and extends to antero-lateral thigh and lateral leg causing significant pain/swelling. Pt considering disability due to pain and interference with doing his job in a resturant. Partial/incomplete CFV thrombosis, no dilitation or reflux in GSV, patent deep femoral vein and enlarged pelvic veins. My plan is to do a ligation of AAGSV at junction and extensive microphlebectomy of bulging veins. On warfarin for IVC/iliac occlusion.
http://www.bushvenouslectures.com/blog/content.asp?id=2385

May-Thurner Syndrome

Deborah Gumina, MD – 3/22/11
I have a 19 yo pt with MT syndrome who had a Left iliac stent placed at Stanford at age 14. He was followed for several yrs with ultrasound and no problems. He now has large varicosities that are getting worse. US shows an incompetent GSV. I did a CT angio with venous phase that shows no significant residual stenosis and stent patent. Is a CT venogram and pressure measurements necessary or can I go ahead and do an ELVT with SAP.
http://www.bushvenouslectures.com/blog/content.asp?id=937

Neovascularity

Richard Mueller, MD, – 7/19/11
Patient with a large thigh varicose veins, GSV and accessory GSV both reflux but only accessory feeds the VV. also neovascularization type varicose veins and channels around SFJ/IEV with no prior venous procedure (MRV advised as he also reports failed venous access twice for AF ablations....) I would like to laser the accessory thigh GSV and then do AP, but there is a fair amount of tortuosity. Would you do segmental accessory evlt as best you can, then ap, for best chance of closure or do UGS of accessory, or just do AP / CHIVA. Accessory 4-5 mm diameter. Plus to make things interesting he is on Pradaxa? for a fib and had 2 episodes thrombophlebitis, one treated with oral anticoagulation in Spain, both after orthopedic surgery. He has had 7 right leg ortho surgeries dating to childhood. Have you ever seen neovasc. from non vascular leg surgeries?
http://www.bushvenouslectures.com/blog/content.asp?id=1396

Ronald Bush, MD – 9/8/10
52-year old male, 25 years post GSV stripping, developed varicosities right lower leg, US shows thigh perforator and resultant lower saphenous sheath neovascularity, treated with US guided 1% Sotradecol ® foam (2cc)
http://www.bushvenouslectures.com/blog/content.asp?id=168

Pelvic Congestion Syndrome

G. Lionel Zumbro, MD – 10/4/10
35-year-old female physicians wife had right GSV laser ablation, right SFJ reflux by duplex ultrasound in a nearby city one year ago. Symptoms were right upper thigh and groin discomfort. No relief. She transferred to our city and was seen by interventional radiology. Pelvic venography and CT reportedly showed bilateral ovarian vein reflux. Both had coil embolization by the radiologist. Patient recently seen by me for right thigh and groin pain, occurring around menstrual period. Duplex US shows partial recanalization of the right thigh GSV. Vein light examination shows a plethora of reticular veins from thigh to groin and labia. Pain and tenderness localized to the high thigh, groin, and labial area. Any thoughts?
http://www.bushvenouslectures.com/blog/content.asp?id=224

Penile Cavernous Hemangioma

Paul Espinoza, MD – 2/22/11
I have a 14 y.o. male who presented to my office from a urologist''s office because of varicose veins on his glans.
History reveals that he has had this abnormality since birth and mom was told it was a cavernous hemangioma and was advised to watch and see what happens over time. Patient is active in sports and reports occasional pain and swelling at times...3 out of 10 on pain scale.

 He also is embarrassed about how it looks cosmetically. Physical exam: 6''1'''' Tanner stage 4 male with cauliflower-like appearing blebs only on his glans, they have a bluish/grey discoloration, soft, and easily compressible.

Has anyone come across something like this? Would you consider sclerotherapy? Expectant management until he is fully-grown? Any advise or recommendations would be greatly appreciated.
http://www.bushvenouslectures.com/blog/content.asp?id=839

Perforators

Ronald Bush, MD, FACS, – 4/24/12
63-year-old female presents with a lateral knee perforator as shown in Fig. 2. These are usually treated by percutaneous injection using Sotradecol® 1% foam. As you can see, the butterfly needle is positioned into the superficial varice in direct continuity with the perforator. (Fig3). Fig 4 shows the foam in the perforator with marked spasm. Phlebectomy is then done as usual using the subdermal tumescent technique. Markings show where the phlebectomy will be done.
http://www.bushvenouslectures.com/blog/content.asp?id=2583

Ronald Bush, MD – 12/5/11
35 – year old female with large incompetent refluxing branch in direct continuity with a mid-thigh perforator. Through a 2 mm incision the superficial vein was elevated and cannulated with a guide wire. Figure 1 shows the guide wire into the perforator. The wire was exchanged for a 5 FR micro-introducer. Through the introducer, a 400- micron filament was inserted into the perforator. Next tumescent was injected, laser activated for 10-second pulses at the fascial level x2. The laser filament was withdrawn at 2mm increments with 15 joules delivered per firing.
http://www.bushvenouslectures.com/blog/content.asp?id=2038

Sonny Wong, MD – 11/16/11
Patient is in his early 60's and had both his GSV ablated about five years ago he now has bilateral recurrence. Both GSV are sclerotic in the upper thigh and mid thigh. On the right he has an AASV that is incompetent and lower down he has incompetent low thigh and calf perforators. On the left he has incompetent calf perforators. Additionally, we scanned both his deep systems femoral and popliteal veins bilaterally and he has significant deep vein reflux bilaterally. No history or evidence of DVT. What can we offer him? I think it would be simple enough to do USG sclero of the perforators but with the significant deep veins reflux would I be helping this guy? He has chronic venous stasis changes bilaterally.
http://www.bushvenouslectures.com/blog/content.asp?id=1885

Ronald Bush, MD – 4/6/11
55-year-old female presents with varicosites and tenderness lower anterior calf. On examination the patient has saphenous insufficin of the GSV, however, as you can see by the US, this has nothing to do with her symptomotology of varicosites. These varicosites originate from a perforator in the anterior tibial compartment from the anterior tibial vein.

The patient has considerable retrograde flow on foot compression. This is an uncommon clinical presentation from perforator pathology. In my experience, I have seen 3 similar cases in the last 5 years. Unusual site for perforator pathology.
http://www.bushvenouslectures.com/blog/content.asp?id=978

Peri-Orbital Veins

Carl Powell, DO – 3/16/11
I have attached pictures of another patient who has veins around his right eye that he wants removed. My plan was to make a small needle stick incision and hook the vein and tease it out. I feel it is too dangerous to do sclerotherapy so close to the eye. I have attached pictures of the vein(s) for Ron to review. I''m wondering if the VeinGogh or VeinGogh and Phlebectomy combined would be the best way to approach this young man''s veins. I have a 940 nm laser however, my experience with the laser is that it leaves a trough either as an indention or a sclerotic track. I would very much appreciate Ron''s advice on how to approach this case.
http://www.bushvenouslectures.com/blog/content.asp?id=915

Recurrent Varicose Veins

Ronald Bush, MD, FACS- 10/5/11
This is an example of recurrent veins after thermal ablation caused by AAGSV insufficiency. In recurrent vein studies, completed by 7 centers by the Vein Affiliates members, 24% of all recurrent veins were secondary to new AAGSV insufficiency. We will discuss this more later, on why this happens. The abstract has been submitted to AVF.

In this patient, the arrow represents the AAGSV. The dots are the varicosities coming from the AAGSV. The straight line is a branch coursing inferiorly to a 14 mm superficial branch incompetent to below the knee.

The (H branch) of the saphenous was treated with endovenous ablation, a phlebectomy was done for the superficial varicosities on the anterior thigh.
The AAGSV was treated with US guided foam injection as shown in Figure 3. 
http://www.bushvenouslectures.com/blog/content.asp?id=1686

Ronald Bush, MD – 1/20/11
 65-year-old female presents with recurrent varices in the anterior thigh. 15 years ago, she had a high ligation and phlebectomy. Seven years ago she had a thermal ablation of the GSV.  Figure 1 shows neovascularity with resulting branches emptying into AAGSV. (Figure 2) Figure 3 shows the previously ablated GSV.
http://www.bushvenouslectures.com/blog/content.asp?id=701

Retroperitoneal fibrosis

Sendhil Subramanian, MD – 6/2/11
I recently saw a patient who has a history of retroperitoneal fibrosis. I reveiwed the CT which showed encasing of IVC above bifurcation was well as extension around both iliacs, which was worse on the right. He has had previous DVT on the right in 2006. His symptoms currently are swelling billaterally, however worse on right, with more hyperpigmentation on the right. He states he has had weeping of the calf on the right 3-4
http://www.bushvenouslectures.com/blog/content.asp?id=1228

Seroma After EVLT

William Salerno, MD - 4/18/11
One month ago I did about 25 phlebectomies in the lower thigh, knee and calf area on a 55-year-old female that had severe varicose vein disease. She had previously been treated by another doctor in my area with a standalone ELVT of the left GSV (he left everything else) one-year prior. Things went well but one week post phlebectomy she developed a lump at her instep of her left foot. I felt it was a seroma, aspirated it and got out 1.5 ml of serous fluid. Unfortunately it has returned every week and I have now treated it weekly for the past 4 weeks. No real change; 1 to 1.5 ml of serous fluid is drained each time. I keep draining it because the skin becomes quite tense causing an erythema. The remaining calf portion of the GSV (3 mm dia.) was still refluxing so today I injected it with STS 0.5% (foam) hoping may decrease any hydrostatic pressure exacerbating the seroma.
http://www.bushvenouslectures.com/blog/content.asp?id=1031

Small Saphenous Vein Reflux

Angel Rodriguez, MD – 4/15/11
I have an 44yr old female who has presented with short saphenous vein reflux of greater than 4 seconds. The short saphenous measures 6.2mm at the popliteal junction and is 3.7cm in length before returning to a normal diameter of 1.2mm in the proximal calf. There is a posterior thigh extensor present that communicates with the short saphenous with reflux noted. The vessel measures 3.0mm at the knee and 2.2mm at the junction of the great saphenous vein at the mid thigh. The vessel does not reflux proximally, but does give off several large varicosities at the knee with reflux present. Would you recommend using ultrasound guided sclerotherapy on the short saphenous and posterior thigh extensor or endovenous laser ablation? Or would a combination of approach work better?
http://www.bushvenouslectures.com/blog/content.asp?id=1018

Spontaneous Bleed

Ron Bush, MD, FACS, 2/22/12
60-year old female presents with spontaneous hemorrhage. The patient has GSV insufficiency, multiple varicosities, and chronic stasis changes. 0.5% Sotradecol foam injected into veins surrounding hemorrhage site with good penetration. US shows good foam distribution under area of hemorrhage. Primary therapy for spontaneous bleed is injection of foam and not placement of suture.
http://www.bushvenouslectures.com/blog/content.asp?id=2341

Ronald Bush, MD, FACS -  9/20/11
52- year old female presents to the clinic 2-weeks post spontaneous bleed. The arrow points to the hemorrhage site. I injected the small spider veins around the area of the bleed with Sotradecol ®0.3%.

Interesting finding is that this patient has a very large left lateral calf perforator. As you can see in Figure 2, this perforator is very large and most of the flow is antegrade. This perforator is located exactly inferior to this complex.

The multiple large varicose veins associated with the perforator course up the calf and anterior lateral thigh. There is no termination point superiorly that can be identified by US. Probably empties into the gluteal vein complex.
http://www.bushvenouslectures.com/blog/content.asp?id=1632

SSV Aneurysm

Richard Mueller, MD - 1/24/11
I saw a patient today with an 18 mm focal proximal SSV aneurysm, approx. 5 mm distal to the fascial curve and several cm from the SPJ. There is reflux through the SSV. Symptoms are nil in the SSV territory. http://www.bushvenouslectures.com/blog/content.asp?id=2221

Ronald Bush, MD – 10/10/11
29-year old male presents with calf swelling, varicosities starting at mid-calf inferiorly with a refluxing SSV at mid-calf to ankle. Patient also has a huge SSV aneurysm. (35 mm when standing) No reflux could be demonstrated. No reflux in popliteal vein, but good flow. Very sluggish flow, the SSV remains very dilated to mid-calf and at this point becomes superficial and refluxes. http://www.bushvenouslectures.com/blog/content.asp?id=1705

SSV

Ronald Bush, MD – 11/10/10
38- year old male with a history of previous stripping of the GSV. He developed recurrent veins and edema of the lower extremities. US findings included large thigh perforator with multiple varicosities and primary SSV insufficiency (18 mm vein). SSV treated with thermal ablation. Averaged 80 joules/cm. At 4 months has developed re-cannalization of the SSV. This is not uncommon in this very large vessel as a large amount of clot leads to neo-vascularity and new http://www.bushvenouslectures.com/blog/content.asp?id=374

Thrombophilia

R. Sudheendra, MD – 12/27/10
I have a 49 yr old pt with history of established throbohilia and is on coumadin. I understand it is a relative contraindication for thermal ablation. I plan to do laser ablation of the GSV one at a time. Any special precautions to be taken? I will continue his coumadin and not plan on any phlebectomies. He has symptomatic venous reflux with skin changes but no ulcerations.
http://www.bushvenouslectures.com/blog/content.asp?id=578

Richard Mueller, MD – 11/12/10
I thought I would share a recent instructive case and find out your thoughts on hypercoagulable / anticoagulated patients. pt had old occult svt on baseline doppler, declined one dose lovenox for her evlt (just because of the old svt), then during guidewire manipulation to reposition sheath near sfj developed a large proximal gsv thrombus near the sfj. i elected to quickly ablate with best position possible to close the vein and try to also lase the thrombus itself. good result, put her on lovenox immediately, did hypercoag w/u and she is protein c deficient ! plan is for 3-6 months warfarin then stop. she wants other axial veins lasered and is aware of the risk. have done evlt on patients on warfarin without clot or recanalization. plan is 2 mo. warfarin now, then evlt on warfarin then d/c it after 10 days if no new clot. what is your approach for pts who shouldnt stop warfarin and need evlt, sclero, veingogh, or phlebectomy? or for those who are hypercoagulable, family hx dvt/pe, or those with prior dvt or svt?
http://www.bushvenouslectures.com/blog/content.asp?id=350

Thrombosis

Richard Mueller, MD – 4/6/11
I have a new pt with giant (20+ mm) GSV, high velocity reflux and very large v.v. has what appears to be acute to subacute partially occlusive svt within the varicose vein network. No involvement of deep veins or gsv proper. Traditionally we wait 2+ months after any acute thrombotic event to perform evlt but is this really evidence based? I would suspect not, just out of fear of higher risk thrombotic complications. Also, should the 2-month rule be limited to those with dvt rather than svt (esp. svt confined to the varicose veins)? How long would you wait? While clinically there is no rush, is it reasonable to treat with lovenox for a few days and proceed now? Also, where do you advise being the best journal to publish a venous case report?
http://www.bushvenouslectures.com/blog/content.asp?id=976

Dr. Nicos Labropoulos/ Antonios Gasparis, MD – 2/8/11
A 24-year-old female presented to the emergency room with a 2 day history of left lower extremity swelling to the level of the mid-thigh. She had pain and difficulty walking. Her past medical history was negative. Her medications only included OCP. A venous duplex ultrasound was obtained of the lower extremities, which revealed extensive of deep vein thrombosis (DVT) involving the iliofemoral and popliteal veins (Figure 1). She was started on IV Heparin and additional diagnostic evaluation was obtained with CT venography of the abdomen and pelvis to evaluate any venous outflow pathology and extent of thrombus. We routinely obtain CTV (especially with unprovoked DVT) looking for IVC aplasia or hypoplasia, iliac vein compression, thrombus extension into the IVC, or pelvic/intra-abdominal neoplastic process. Such pathology may be found in around 30% of patients and is helpful to know prior to any intervention.
http://www.bushvenouslectures.com/blog/content.asp?id=766

Thrombus

Paul Espinoza, MD – 3/24/11
I have 75 y.o.WF patient who was seen in the Emergency Room for back pain with associated radiating pain going down her right leg after working in her yard. She reports she was working in a bent over position for two hours straight cutting limbs etc. Anyways, she got a full workup in the ED to include CT of chest,abd, and pelvis venous duplex scan,EKG, labs, etc.Duplex occlusive deep venous thrombosis in Right posterior tibial and peroneal veins with evidence of gastrocnemius and soleal vein occlusion on the right. Left side showed a partially occlusive superficial femoral vein.Discharged with diagnosis of low back pain and DVT with lovenox and coumadin therapy.Patient reports to me for follow up
and states that she had no other complaints such as swelling, etc.except for the acute onset of back pain that prompted her visit to the ED.Physical exam essentially unchanged from last visit with me 6 months ago with scattered venulectasias. I feel that the vein occlusions were incidental findings and that she may not need to be on coumadin given she has a questionable history of hemorrhagic stroke.What are your thoughts?
http://www.bushvenouslectures.com/blog/content.asp?id=942

Deborah Manjoney, MD – 1/11/11
I would appreciate input on a difficult case.  I recently saw a 52-year-old man who has a history of left lower extremity chronic edema with bilateral varicose veins for over 5 years.  He complains of aching, fatigue, itching of the skin, swelling, and skin discoloration on the left. He is a PE teacher, and is always very active.  He had played high level handball for years, with multiple blows to his legs, and he had written- off any history of pain or swelling to injuries from his sport. He denies any history suggesting DVT or superficial phlebitis.  He wears 30-40mm knee-high compression hose daily, prescribed by his PCP because of leg swelling that was never evaluated further.
On exam, he has a markedly enlarged left calf and ankle when compared to the right.  Multiple 6-10mm varicosities are present on each leg, limited on the right, but extensive varicosities on the medial and posterior thigh and calf on the left.  There is 2+ left ankle edema.  Left ankle is 0.5 inches larger than the right, and calf is 1.5 inches larger. Skin discoloration is present on the posteromedial left calf. 
http://www.bushvenouslectures.com/blog/content.asp?id=644

Richard Mueller, MD – 1/27/11
Just saw a patient with symptomatic posterior calf varices and recurrent dvt/svt. post. tibial dvt and thrombosed varices 3 yrs ago treated elsewhere with 6 mo. warfarin. then 1 week ago found on outside doppler to have new ''saphenous vein'' thrombus by radiologist (vein not specified). on initial consult with us yesterday, found to have duplicated pair of gastroc veins, all 4 thrombosed and dilated (i.e. acute appearing), small chronic appearing focal bilateral ssv thrombi, refluxing gsv but the varicosities do not come off the gsv but instead off post tibial & soleal perforators. the varices are extensively thrombosed. i put him on lovenox/warfarin and advised lifelong a/c, and sent him for hypercoag workup. if varices remain symptomatic, is there ever a role for phlebectomy and peforator sclero, while on warfarin (with suturing of incisions), or would you never touch thrombosed varices for fear of extruding the clot into unseen perforators? the other issue is would you then laser ablate the refluxing gsv as the patient also has venous eczema and edema. i guess one could apply chiva and see if those resolved with treatment of the end varices first.
http://www.bushvenouslectures.com/blog/content.asp?id=724

Ronald Bush, - 9/30/10
77-year-old female symptomatic GSV insufficiency. Had multiple incompetent venous channels (neovascularity) in saphenous sheath at mid-thigh. Treated with endovenous ablation, 65 joules per cm and 2cc 1 % sotradecol  foam sclerotherapy  to multiple incompetent venous channels.  These venous channels were in connection to the saphenous vein at different levels and also gave rise to independent varicosities.

TIA

Lionel Zumbro, MD – 10/19/11
38yo healthy female(has migraines) neighbor who underwent RF closure Rt and Lt GSV with Tumescent only. No sedation. Also STS CO2 reticular V sclero at same time. DUS 3 days PO both GSV closed. No DVT. POD 4 transient hemiparesis that resolved. MRI small frontal cortex infarct. TEE shows PFO. Local vascular surge said she should have had sedation and not had back to back closures.he made no comment about sclero. Have you seen late nuero problems from sclero or closure?
http://www.bushvenouslectures.com/blog/content.asp?id=1742

George Lionel Zumbro, MD, FACS- 10/19/11
38yo healthy female(has migraines) neighbor who underwent RF closure Rt and Lt GSV with Tumescent only. No sedation. Also STS CO2 reticular V sclero at same time. DUS 3 days PO both GSV closed. No DVT. POD 4 transient hemiparesis that resolved. MRI small frontal cortex infarct. TEE shows PFO. Local vascular surge said she should have had sedation and not had back to back closures.he made no comment about sclero. Have you seen late nuero problems from sclero or closure?
http://www.bushvenouslectures.com/blog/content.asp?id=1742

Varicosities

Doug Stafford, MD – 2/17/11
28 yo female with painful abdominal wall varicosities. 3 years ago she had a DVT in her Left common femoral vein that was felt secondary to birth control pills. She was treated with coumadin for 6 months then ultrasound show no residual clot and it was stopped. Shortly after she started to notice bulging veins on her abdominal wall that have increased over the past 3 years. Ultrasound showed there was no deep vein obstruction from the IVC to femoral veins. Old chronic thrombus in the left common femoral with no obstruction. The left inferior epigastric is incompetent, measures 1.3 cm and fed the complex. The drainage is through the right inferior epigastric vein with is incompetent and measured 1.1 cm. Any thoughts on a treatment plan.
http://www.bushvenouslectures.com/blog/content.asp?id=820

George Lionel Zumbro, MD – 2/15/11
75 yo female three RF closures Left leg done at local vein clinic. I did CABG on her husband years ago so she thought I could help. US severe left BK GSV reflux and L SSV reflux. Very pitting edema. Very compliant with compression. Please comment on both pts.
http://www.bushvenouslectures.com/blog/content.asp?id=809

Varicose Veins

Ronald Bush, MD, - 9/9/11
Patient presents with symptomatic varicosities, lateral aspect of the thigh and leg. She has a not unusual finding, of an incompetent lateral reticular perforator. This perforator connects the femoral vein to the dilated veins of the lateral system. It is extremely important to treat not only the varicosities, but also the perforator. If you do not treat this perforator, there is a high likelihood of recurrent varices. Our method of treatment is 1% foam with US guidance and this is usually effective in one treatment.
http://www.bushvenouslectures.com/blog/content.asp?id=1599

Ricardo Barboza, MD – 12/10/10
 have a young woman patient with vulvar and left lower extremity varices and dyspareunia. MRI shows congested pelvic veins. I tried to do a gonadal vein venogram but the vein is small and apparently competent. Would you be willing to see this lady in consultation?
http://www.bushvenouslectures.com/blog/content.asp?id=550

Ronald Bush, MD, FACS -  8/1/3/10
37-year-old female presents with symptomatic vulvar varices. She has had a previous venogram and placement of coils in the ovarian vein. Symptoms persist especially at time of menses.  There has been no reduction in size of varices.
What is your next step?
http://www.bushvenouslectures.com/blog/content.asp?id=143

Venous Aneurysm

John Chuback, MD, - 8/9/11
I have a patient with a venous aneurysm within a couple of centimeters of the SFJ. The terminal GSV then narrows quite a bit and measures .85cm at the SFJ. I would not ligate an SFJ of that diameter normally, but having that aneurysm so close is a bit worrisome visually on ultrasound. Obviously I’m concerned about thrombus propagation into the deep system. Would you suggest ending the ablation just proximal to the venous aneurysm? By the way, there does not appear to be any significant venous tributary distal to the aneurysm, which would help maintain flow through the junction. I look forward to hearing your thoughts.
http://www.bushvenouslectures.com/blog/content.asp?id=1500

Ronald Bush, MD, FACS -  3/29/12
60-year old female presents with spontaneous bleed from the lower leg as shown in Fig. 1. The spontaneous bleed is treated at the time of presentation with 0.5% Sotradecol? foam as shown in Fig. 2. This patient has long standing venous HTN with a venous aneurysm just distal to the SFJ and also in the lower thigh. This is a Type III aneurysm.
http://www.bushvenouslectures.com/blog/content.asp?id=2493

Venous Malformation

Venous Malformation of Knees - Case Study - 17-year old girl
This is a 17-year old girl post femoral fx at age 5. Developed a venous malformation. She was treated at a University hospital with one session of sclerotherapy. I have done foam sclerotherapy with good reduction in size of this mass. As you can see from the US, there is not much flow present. However, the patient still has pain in this area and is very conscious of it cosmetically. Patient will need to be referred to a plastic surgeon.
http://www.bushvenouslectures.com/blog/content.asp?id=2131

Patient – 5/19/11
Please forgive my directness, I read a journal article on your TIRS technique and I thought that you may be able to help. I am on a medical leave of absence from my job because of a venous ulcer due to complications of an AVM and venous hypertension. Over the past two years I have had ten procedures done by an interventional radiologist to correct many of the underlying high-flow AV connections in my right foot. Unfortunately while some of my symptoms have improved I still have a small, painful ulcer in between my 3rd and fourth digits of my right foot that have failed treatment of compression therapy, and multiple kinds of wound treatments including silver impregnated alginate dressings.
http://www.bushvenouslectures.com/blog/content.asp?id=1136

Richard Mueller, MD – 3/14/11
Saw a young gentleman today with possible venous malformation on feet, toes, though not well demarcated. differential includes erythromelalgia and other skin conditions. any reliable way other than mri to confirm that an erythematous patch is a venous malformation rather than something else? can high resolution ultrasound superficially show a lake-like structure? or is it always a clinical dx? any preference on rx, sclero vs. laser? any technical pearls/parameters?
http://www.bushvenouslectures.com/blog/content.asp?id=909

Richard Mueller, MD – 1/17/11
I have a young man with calf varicosities stemming from both the gsv, which had significant reflux and which I laser ablated last week, and also from the ssv, which is small and has segmental reflux in the mid to distal segment, but distal to the varicosities and therefore unrelated. My plan was for phlebectomy in 4 weeks if gsv evlt alone did not eliminate the symptomatic varices, but will recurrence be high if i do not also ablate the proximal ssv? if the ssv should be ablated, would you do ugs or laser?
http://www.bushvenouslectures.com/blog/content.asp?id=680

Venous Thrombosis

Paul Espinoza, MD, – 5/24/11
68 y/o average sized WM presents from a referring primary MD for increasing prominence of his left basilic vein. He reports he has noticed it there for about SIX months but it has been worsening this past month especially when he is out doing yard work. He also states that this past month his left shoulder and chest wall veins have also become more prominent. Denies any arm or shoulder pain. No trauma. Has lost about 10 lbs. over the past 2 months. Never smoked. He had a negative chest X-ray. I ordered a CT of the chest w/ and w/o contrast. CT showed findings suggestive of a partial thrombosis of the left subclavian vein with chest wall collaterals...clot burden is minimal. Also, a 6 mm well-circumscribed nodule within the anterior segment of the right upper lobe was noted. I will set him up for a diagnostic venography. I suspect a spontaneous thrombosis vs. effort thrombosis.
http://www.bushvenouslectures.com/blog/content.asp?id=1201

Venous Ulcer

Ron Bush, MD, FACS – 1/18/12
68-year old female with long standing saphenous insufficiency and dilated varicosities in the lower leg. Over the years, patient developed severe stasis changes and recurrent ulcerations.
http://www.bushvenouslectures.com/blog/content.asp?id=2207

Ricardo Barboza, MD – 12/10/10
 have a young woman patient with vulvar and left lower extremity varices and dyspareunia. MRI shows congested pelvic veins. I tried to do a gonadal vein venogram but the vein is small and apparently competent. Would you be willing to see this lady in consultation?
http://www.bushvenouslectures.com/blog/content.asp?id=550

Sendhil Subramanian, MD – 11/7/11
I have a patient that has deep vein insufficiency bilaterally and has evidence for chronic venous stasis below the knees. He has a medial ulcer with isolated GSV below the knee reflux on the right which I am going to ablate. Do you think that there is more proximal obstruction in the iliac veins? I am considering accessing both common femorals and injected contrast.
http://www.bushvenouslectures.com/blog/content.asp?id=1839

Von Willebrand’s Disease

Leanna L. Beaumont MSN, APNP- 11/3/11
49 y/o female with history of Type 1 Von Willebrand’s disease. Has a symptomatic VV across the popliteal fossa of her left leg. No axial reflux identified and does not want long term conservative therapy as this would require a thigh high stocking. This appears amenable to sclerotherapy, but I have no experience with Sclero and a concurrent diagnosis of Type 1 VonWillebrand’s disease. Does anyone have any experience with this or thoughts regarding this situation?
http://www.bushvenouslectures.com/blog/content.asp?id=1822

WHIM Syndrome

Patient- 2/1/12
I am 23 years old and I suffer from warts on my hands, knee, and feet. I have seen my pediatrician a few years back and they froze them off, many went away, but most came right back. After a couple painful treatments, I gave up. The one dermatologist I saw treated them with squaric acid, which did nothing. He gave me the option of treating with a laser, which he explained they would scar my hands and they could come right back. He said the other option was to live with them.
http://www.bushvenouslectures.com/blog/content.asp?id=2256