Please use the form below to submit questions to our Advisory Board. These can relate to any aspect of phlebology and the treatment of related conditions. Previous questions are shown below as they may be helpful to you, but if you do not wish your question to be shared below, you can request this through our contact form.
Q1 A) We have found a few times AV fistulas connecting to truncal or accessory truncal veins. We immediately took out of consideration foam sclerotherapy or clarivein for such veins. I have successfully performed EVLA on one such vein (SSV), without embolic problems. 1) do you have any safety concern (Thrombus passing into the artery side of the fistula) with EVLA of such veins? - Richard Mueller FCPhleb (New York, USA)
Q2 B) We have found a few times AV fistulas connecting to truncal or accessory truncal veins. 2) is it ever safe to use sclerosants in the same leg? Extreme example: one of my patients refuses closure of his AVF from ext pudendal artery to his SFJ. Is it safe to foam the dilated tributaries under his ankle ulcer? Following the path of injected foam with ultrasound reminds me every time of the amazing interconnectivity of all levels of leg veins. Might sclerosant get into the pudendal artery? - Richard Mueller FCPhleb (New York, USA)
Q3 C) We have found a few times AV fistulas connecting to truncal or accessory truncal veins. 3) Can sclerosant surmount the AV pressure gradient in such a case? Many say it cannot. If not, then why the cases of tissue loss with sclerosant ‘crossing the AV border’ in small vein injections. - Richard Mueller FCPhleb (New York, USA)
Q4 What level of liver dysfunction / cirrhosis (childs class I? II? III?) contraindicates using lidocaine in tumescent fluid? - Richard Mueller FCPhleb (New York, USA)
Q5 What is your cutoff of reduced ABI in PAD for themoablation? Other than possible intolerance of post procedure compression, is there any solid rationale for excluding pad patients from thermoablation. Ideally fix arteries first, yes, but patients often decline pad procedures, have renal insufficiency, etc. - Richard Mueller FCPhleb (New York, USA)
In terms of principles, firstly why has the patient presented? Clearly if they have severe PAD it is unlikely that they have turned up for their varicose veins to be treated. It is much more likely that they are complaining of claudication, rest pain or arterial ulceration all which need to be fixed before any venous surgery. In the few patients we have had who have venous eczema and very mild claudication, I would not use ABI as a cut-off as it can be artificially raised with atherosclerotic arteries. I do keep a record of ABI for medicolegal reasons and prefer to use the “Pole test” – i.e. at what height the leg can be elevated before the toes turned white.
In leg ulceration, it is often impossible to measure an ABI and so the clinical questions of whether the pain occurs when the leg is elevated or dependent coupled with the results of an arterial and venous duplex usually pointed to the correct treatment.
Finally, as a general principle, anyone who is having venous thermoablation with severe PAD is having it for non-cosmetic reasons. As such, the lesions that are being treated such as leg ulcers, LDS or leg ulceration are being caused by venous reflux from one of the truncal veins or perforators. One of the delights of using adequate thermoablation is that the relevant veins can be treated either by truncal ablation or TRLOP of the perforators with instant ablation and no requirement for any compression. Therefore the PAD is irrelevant to such antireflux treatment.
Q6 When aiming for a LEED of approx. 80 J/cm for a larger truncal vein per the GSV EVLA educational video, what size would be considered a larger vein? 7-10 mm diameter? larger? - Richard Mueller FCPhleb (New York, USA)
As such, until we have better techniques to evaluate this, one has to look at the ultrasound image and consider if the vein is large with a thick wall, is small with a thin wall, or looks small but due to contraction and therefore actually with a thick wall. What is clear is that if the vein is ever measured over 7 to 10 mm diameter, it is clearly a large vein and may even be larger but be contracting at the time of measurement. Once again, although many “experts” talk about what LEED to use with what diameter, this will only be an estimation into we can have a proper measurement of the mass of cells to be destroyed in the vein wall.
Q7 When performing the very rare truncal vein access via cutdown, does one have to ligate the distal segment after venotomy? Or do you just lift the vein and cannulate with needle without venotomy? Is it OK to hook and cutdown the SSV near the sural nerve at mid calf? I realize I may never have to do this. If ligating the distal vein, use 3-0 or 4-0 silk? - Richard Mueller FCPhleb (New York, USA)
Q8 Beyond the marking function of duplex guided phlebectomy, do you ever use ultrasound in real time to help hook the vein if they don’t hook easily blindly? - Richard Mueller FCPhleb (New York, USA)
Q9 Your vein depth approximate cutoff of 5 and 10 mm for safe thermoablation of varying size veins is very helpful practically. What size veins are safe to thermoablate between 5-10 mm from the skin? - Richard Mueller FCPhleb (New York, USA)
Q10 If a pigmented cord occurs after thermoablation, do you try to aspirate blood as a treatment? If so, at what time frame? Do you ever try hydroquinone cream in case there is a post inflammatory hyper pigmentation (I.e. melanin) component in addition to a hemosiderin component? - Richard Mueller FCPhleb (New York, USA)
The most common is an inadequate treatment which has allowed thrombus to accumulate in the lumen that has not been successfully ablated. The best treatment for this is to do the ablation properly in the first instance and then this will not occur. If blood can be aspirated, this is a sign that the ablation was unsuccessful and the operator’s technique needs to be looked at. In such a case, the blood liquefies after four weeks and can be aspirated, but the ablation will have to be re-performed several months later. If at that stage the lumen is very small and the vein scarred, and endovenous device might not be able to be passed up the vein and foam sclerotherapy might be needed instead.
The second reason is that the vein treated with thermoablation was too superficial, and the inflammatory process of the vein ablation is causing a reddish or brownish line. Once again the best way around this is to get it in the first place and to make sure that thermoablation is not performed on veins that are too superficial. If it does occur, the primary problem is an inflammatory one and hence any anti-inflammatory drugs such as aspirin will help settle down.
To date we have never had to try hydroquinone cream and I would wait to see studies before commenting on this use. It will clearly depend on what the cause of the pigmentation is as to whether we would expect this treatment to be successful.
Q11 For duplex guided phlebectomy of superficial truncal segments, are all segments safe to treat? Should mid to distal calf segments be avoided due to proximity of saphenous and sural nerves? And what about proximity of Gastroc veins and the SSV? - Richard Mueller FCPhleb (New York, USA)
On the rare occasions that the patient is slim enough to see such truncal veins, it is very uncommon to need to treat the distal Great Saphenous Vein (GSV) as the reflux within it is passive only (see the book “Understanding Venous Reflux – the cause of Varicose Veins and Venous Leg Ulcers“). As such, when the proximal vein has been successfully ablated, it is very uncommon that the distal Great Saphenous Vein (GSV) needs to be removed by phlebectomy. Unless there is an incompetent perforator continuing reflux within it during the active phase, the vein will often reduce in size with time and can be treated successfully with ultrasound guided foam sclerotherapy as it shrivels away.
Q12 If one wanted to foam a distal truncal vein after EVLA ablation, after removing the fiber near the access site, can one use the same sheath and have the foam track retrograde from the sheath tip into the distal vein as it is blocked proximally (and helped with manual milking at skin level)? have you tried this? - Richard Mueller FCPhleb (New York, USA)
Very rarely I have treated a distal GSV with foam sclerotherapy, months after performing ablation of the proximal section and having successfully treated the perforators, but still having some skin changes that are not improving. In these rare cases, duplex ultrasound usually shows a profusion of small veins under the damaged skin which are not suitable for anything that foam sclerotherapy. Injection of the remnant of the truncal vein under ultrasound control usually ablates both this remnant and also this network of veins, giving a satisfactory result.
As such, I cannot conceive of a situation where I would ablate a truncal vein and then immediately perform sclerotherapy of the distal section of the same vein. However I am always open to seeing new techniques if there is a good indication that I have missed.
Q13 If performing EVLA and foam sclerotherapy in the same session in the same truncal vein, is there any fear of tissue necrosis from sclerosant extravasation from laser vein wall perforations or if performing phlebectomy at the same sitting? - Richard Mueller FCPhleb (New York, USA)
Q15 For superficial truncal segments that are 3 mm in diameter, I presume another option is to thermoablate deep segments then use the same catheter to foam the superficial segments? - Richard Mueller FCPhleb (New York, USA)
Q16 If ablating an ulcer patient to the ankle, why not access at the ankle? - Richard Mueller FCPhleb (New York, USA)
Q17 Is there any advantage to a 2nd access below knee for a retrograde ablation segment? - Richard Mueller FCPhleb (New York, USA)
Q18 Is your LEED target 60-70 j/cm for SSV? - Richard Mueller FCPhleb (New York, USA)
Q19 If one wants to stage phlebectomy of branch varicosities or hidden tributaries (or superficial segments of truncal veins), how long on average does one have, in days, before varicose branches/tribs might clot off and become phlebitic, preventing ultrasound guided phlebectomy? - Richard Mueller FCPhleb (New York, USA)
Q20 Would thermoblation of 3-5 mm truncal veins be likely to cause a painful cord if 3-4 mm under the skin? - Richard Mueller FCPhleb (New York, USA)
Q21 For truncal laser ablation, do you use a uniform LEED at proximal/mid/distal segments? Or only when vein diameter varies? An older Min article I trained with advised 140/70/45 j/cm, quite a large gradient, but I have always used higher LEED proximally, with great results for years with a bare fiber and 810 nm - Richard Mueller FCPhleb (New York, USA)
Q22 I take it that you still aim for a LEED of 60-90 j/cm even with 1470nm laser + radial fiber, and 10W, rather than 5-6W and 30-50 j/cm? - Richard Mueller FCPhleb (New York, USA)
This is discussed in more detail in our next book that is shortly to be released as the second book in The College of Phlebology’s series.
Q23 Is there any rationale for superiority of applying tumescent from proximal to distal rather than starting at the level of the sheath? - Richard Mueller FCPhleb (New York, USA)
The rationale for starting tumescence from proximally is that this is the first area of vein that gets heated when the thermoablation starts, and so if the tumescence is also started here, the local anaesthetic has the longest possible time to work before thermoablation commences.
I do not feel very strongly that there is an awful lot of difference where the tumescence is started, provided it is positioned correctly and enough is given, but it seems illogical to start at the sheath and finish at the groin, when the heating starts at the groin and finishes at the sheath.Answer by Mark Whiteley MS FRCS (Gen) FCPhleb on 10th May 2012
Q24 What energy dosing/pullback do you use specifically for TRLOP with a radial fiber/1470 nm laser of perforators? - Richard Mueller FCPhleb (New York, USA)
Q25 For superficial truncal veins and accessory truncal veins, what depth from skin is your cutoff for avoiding laser for fear of producing a hard pigmented cord? Some have advised 4 mm to me - sometimes the vein is only focally closer than 4 mm to the skin and I feel I can still laser but just do a faster pullback at the focally more superficial location. And for such veins, other than the foaming or stripping option, do you advise ultrasound guided phlebectomy? Is that ok for accessory veins and even superficial GSV or SSV, or do you reserve phlebectomy only to branch varicosities? - Richard Mueller FCPhleb (New York, USA)
Therefore in our practice, we would ablate the sections of the truncal vein deeper than 1 cm, and perform duplex guided phlebectomy for sections getting closer to the skin. We may well have two or three entry points for one truncal vein in such cases.
The same as above applies to the anterior accessory saphenous vein. I would use thermoablation for the trunk that is subfascial, starting at the point where the trunk perforate through the superficial fascia. I then perform phlebectomies for the subcutaneous part of this vein if varicose, or foam sclerotherapy if less than 3 mm, refluxing and feeding into thread veins.