Episode 33

Building a Comprehensive Vein Practice

with Dr. Brooke Spencer and Dr. Isabel Newton

Dr. Brooke Spencer gets into the pearls and pitfalls of building a comprehensive vein practice, including a detailed discussion on the treatment of May-Thurner and Pelvic Congestion syndrome.

Cite this podcast: BackTable, LLC (Producer). (2018, October 9). Ep 33 – Building a Comprehensive Vein Practice [Audio podcast]. Retrieved from https://www.backtable.com/podcasts

Full Transcript Below

In this Episode

Podcast Participants

Dr. Brooke Spencer is an interventional radiologist at the Minimally Invasive Procedure Specialists (MIPS) group in Denver, CO. View Dr. Brooke Spencer's full profile here.

Dr. Isabel Newton is a practicing interventional radiologist at UC San Diego Health in San Diego, CA. View Dr. Isabel Newton's full profile here.

Disclaimer: The Materials available on the BackTable Podcast are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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Full Transcript

Building a Comprehensive Vein Practice

[Isabel Newton]
Hello, and welcome to the BackTable podcast. BackTable is your resource to connect with your IR colleagues and learn tips, techniques, and the ins and outs of devices in your cabinets. This is Isabel Newton as your guest host coming to you straight from the Exhibitors Hall at the Western Angiographic and Interventional Society in Maui, 2018.

I'm here with Brooke Spencer, the "vein lady". Brooke is well known for her advanced interventions in treating patients with chronic venous occlusion and all things vein, so it's a pleasure today to speak with her about how she has built a very unique and successful vein practice.

Hi, Brooke.

[Brooke Spencer]
Hi Isabel. Thanks for having me.

[Isabel Newton]
It's my pleasure. So as we're moving towards being more IR clinicians, you have kind of led the way in the vein world. Can you give us some tips on how to create a successful longitudinal vein practice?

[Brooke Spencer]
That's a very broad question, Isabel, but I can definitely do that for you.

So I think there's a couple of different components to that, right? One is that you have to have the skill and ability to technically do the cases, right? So I think most interventional radiologists are really well trained, and if not, can become trained fairly easily in ultrasound-guided techniques, interventions, venography, and all the rest of that. So that's a basic inherent strength that interventional radiologists have that set them up to be the best vein doctors in the country.

I think that another advantage that interventional radiologists have over other physicians is being able to understand both the deep and superficial venous system and treat both. Not treat them as if they're disconnected or disjointed or not part of the same system because we talk about them as if they're totally separate, and they're clearly very interconnected.

So, as interventional radiologists, if you're trying to start a new vein practice, I think it's really important to market and make aware your ability to treat all portions of the venous system and to understand all portions of the venous system. So that's from a procedural standpoint where interventional radiologists are really well-seated to do this.

The place that not all interventional radiologists are as comfortable with yet, sometimes, is the clinical management of these patients. I think that my personal belief is that the inherent key to all of this is that interventional radiologists need to start seeing themselves of clinicians in the sense that they own the patient, which means it's their job to take care of every portion of the patient's venous care from the start to the finish.

So that means knowing, learning, and understanding anticoagulation regimens. It means knowing, learning, and understanding compression therapy, lymphedema physical therapists, what all the options are for treatment even if it's not an intervention, and that's something I think most interventionalists are less comfortable with, but if you want to establish yourself as a true venous expert, you need to not only learn about these things, but you need to own them and manage your patients preoperatively, intraoperatively, and postoperatively in all of these areas.

So if you're not comfortable with one of those areas, and you want to start a vein practice, then I think going and training or getting that information or advice or learning over time is really helpful.

[Isabel Newton]
What would be a really good place to start for someone who's just trying to build this practice? Would it be varicose veins or maybe interacting with referring physicians or setting up the infrastructure? Where's a good starting point?

[Brooke Spencer]
Starting a superficial vein practice is definitely the easiest place to start because you're not going to have trouble accomplishing treatment of those patients in a successful and low complication way. If you start to treat superficial venous patients, you're going to realize that a lot of these patients have deep venous problems, pelvic venous problems, and things you can treat as well. It will help you expand your practice from there going forward if you start in that location.

This may sound the opposite of what most of the advice is out there today, but there are journals like Endovascular Today and other journals that have techniques in vascular interventional radiology, seminars in interventional radiology. They're not as level A clinical medicine oriented, but they are practice oriented, and they tell you, "Here's how you set up a practice. Here's how you treat these patients from the start to the finish. Here's all the things that you should consider in doing this."

You still need to practice evidence-based medicine, but hopefully you're trained in that. What you're not trained is the nuances or the details of how you do this.

I think the other thing is that starting a vein practice is an excellent way for a young interventional radiologist to be able to develop a clinical practice. So there are a lot of impediments to doing that, right? But then you can also see your uterine fibroid patients there. You can also see your cancer patients there. You can slowly build and grow.

And then going and visiting someone who has an established clinic or a practice, even if you think it's obvious that you know kind of how to do a clinic, is always a good option. I think there's a lot of partners in industry who will help support that and who know who's out there doing that and willing to train and help.

[Isabel Newton]
Who were your key allies when you were beginning your practice, in terms of referring physicians or people within IR, even on the business side?

[Brooke Spencer]
Yeah, so I think that that's really important question to answer for yourself, and I think it's different in everyone's different local environment.

For me, I felt that early on, and it was very frustrating for me. I had some really, really talented interventional radiology partners who really helped me with the technical side, but my group was always very resistant initially to having a clinical side of the practice. Karen Garby, who's an interventional radiologist in Arizona started the vein practice with me, we kind of did it together and learned together.

And you definitely have to advocate for yourself when you do that, but I think that the hospital administration and the referring physicians are going to advocate for you as well in the sense that if you provide really good clinical care, and you communicate well, and you help them take care of these challenging patients, they're going to keep sending up patients.

One critical thing you need to do if you're going to set this up is make sure you understand the coding and the billing for all the procedures that you're going to do, and make sure you understand appropriate revenue capture. So you should never be seeing a patient in a broom closet in a hospital that you don't bill for. In order to bill for it, you need documentation. So you have to, if it's paper charts or an electronic medical record, you have to have a way to create that documentation. I think it's really interesting, and I think it's a point that people are missing right now.

If you round on patients in the hospital, and you do see patients in your clinic, you can generate up to a third to 40 to 50% of your salary generation can come from seeing those patients. So if you're in a practice where your RVUs are being monitored and you're being watched and you're being told to go read a chest X-ray, you can actually get paid several hundred dollars an hour to go see a patient on the floor and do an excellent H&P and establish yourself as a clinician in the environment, in the community.

And you can have to read a lot of chest X-rays and other studies to generate the same revenue now. If you just sit down and you just read and read and read you're going to generate more money per hour, but the discrepancy in the RVU and financial revenue generation is going to be much smaller if you actually start billing for the things that you're doing. So you need to do these clinical things, but you have to find a way within your practice to bill for them. I mean, I think that's a really critically important piece.

[Isabel Newton]
So that’s one pitfall that some people fall into is they don't know how to accurately capture the effort that they're putting in. A lot of people think that they're becoming vein specialists, or they think they're launching their vein practice. What do you see as being the biggest pitfalls or the biggest fallacies as they do this where perhaps they're not doing it as effectively, clinically or maybe on the financial side?

[Brooke Spencer]
Yeah, so one of the clinical things I would say is that it's one thing to go to a course and learn about saphenous reflux, varicose veins, and perforators. It's another thing to truly understand where the venous flow is coming from and going to and the physiology of the venous system, and I think there are very few people that truly understand that.

People say things all the time that make no sense to me after treating thousands and thousands of patients, right? So I mean, a couple of pearls on that, I would say anyone with a vascular wound has elevated deep venous pressures. I look at that as a central venous obstruction or any form of deep venous obstruction. What I mean by that is, you have to say elevated deep venous pressures instead of truly obstruction because pulmonary hypertension, right heart failure, morbid obesity with massive pressure in the IVC are all forms of a central venous obstruction. It's some form obstruction to flow back to the heart or impediment to flow back to the heart.

I think it's very difficult, in the absence of elevated deep venous pressures, for the superficial system to be able to overwhelm the deep venous system to the point that you get an ulcer. So if you're seeing ulcer patients, and you're treating the superficial veins first, and you're seeing perforators under the wound, and you're going after the perforators, you're missing the point.

So I think that's one place where I've had a lot of success that other people haven't in prolonged wound care. The problem is you'll ablate the saphenous vein or the perforator, you'll get the wound to heal in the short-term, and then a year or two later, the patient has a wound again because it's just like treating an AVM incorrectly, right? You can't coil the inflow. It's going to recruit more flow, and then it's going to still be there and become abnormal. You may give a short-term improvement, but you're not going to end up giving a long-term improvement in the patient's care and truly treat the underlying problems.

I think more and more, people are starting to learn that May-Thurner defects and pelvic obstructions are really important in this process, but I have people ask me all the time, "Well, who do you treat the superficial system in first? And who do you look in the deep system in?" And I would say we don't have strong enough data to say yet we should start going after all of these May-Thurners and all of these non-thrombotic deep venous obstructions before we treat the superficial system, I would say, except in the presence of CEAP four through six patients.

If you have advanced skin changes or ulceration, I really think you need to learn to look at the deep system. So even if you have a superficial practice, you have to be thinking about that in every patient. Now do you have to an intervention in every patient? No. You could do an MRI CT venogram. You could see a moderate May-Thurner on that and say, "Okay, I know this patient may be more significant if I looked with intravascular ultrasound, but they're elderly, they're not running marathons. I'm going to treat the superficial system first."

But you still have to always have in your head the algorithm of, what's the deep system doing, and what's the superficial system doing? And a perforator is not a perforator. Right? So some perforators are a re-entry pathway to superficial reflux, in which case, they're not the problem. They're part of the solution. Some perforators are coming from elevated deep venous pressures out into varices. Those are a problem and not part of the solution.

So you can't just learn the physical anatomy, and part of that is also training your sonographer. So if you're going to start a vein practice, you have to be hands-on, and you have to personally train your ultrasound technologist to understand how you think.

So an example from just this week in clinic. I have a new partner that didn't do a lot of superficial vein stuff. He's been working with me on these patients to learn that part of it. I have an excellent sonographer. We had a deep venous system that's re-cannulized. The patient was never intervened on. He had a massive pulmonary embolism. We had done a thrombolysis on his pulmonary arteries. He was coming back in for follow up. He has a re-cannulized channel of flow in his femoral and popliteal vein, but he's not having pain in his leg or massive swelling or something that would require going through the process of putting him on Lovenox, doing a re-cannulization of his deep veins, bringing him back, following him, and doing all that because he was doing well except he has a large patch of venous eczema on the posterolateral aspect of his calf.

And so I looked at my partner, and I said, "Okay, he has a large perforator underneath leading to a varix that's then going to be emptying back into the small saph or back into the distal gastroc at the end of the venous eczema patch."

And he looked at me like I was possibly smoking crack, right? And then I grabbed my handheld ultrasound, stuck it on his leg, there's a big perforator, and there's a varix running under his venous eczema patch and emptying back into his small saphenous vein which was not incompetent beyond that point.

My sonographer missed that, so if you're counting on the results of an ultrasound technologist or someone else to understand and know what's happening in your patient, and they have all these problems, and they're not getting better, you really need to understand where the problems are probably coming from, and you need to make the diagnosis, which sometimes mean picking up an ultrasound probe and looking yourself. And I think that it does make a difference between the person who's just the average vein clinic and the one who's not.

[Isabel Newton]
Let's talk a little bit about some of your favorite tools. You do cases that would take a normal human either forever 'cause they would never get through it or 12 hours, and you do them in a record time. I've watched you do it, we've filmed you. What are some of your go-to tools and how you use them in a unique way to get through those difficult obstructions?

[Brooke Spencer]
Yeah, so I think the chronic DVT re-cannulization work can be some of the most satisfying work that I do as an interventional radiologist because these people are truly suffering, and they've been told for years sometimes that there's nothing that can be done. So in a matter of a couple of hours, you can change their life. It's really worth learning these techniques and doing this work because it's incredibly satisfying.

The first thing I would say is that I personally believe, and I know this is very controversial, and I take a lot of slack for it, but the posterior tibial access is absolutely critical. So first of all, you have got to open the tibial peroneal trunk and the popliteal vein if you want to fix these people's problems from chronic DVTs. If they have disease in the popliteal vein, you have to start from below. So that's the first thing that I think is critical.

The second thing is that I talk to people all the time, and I say, "Okay, what is your algorithm of catheters that you use?" And they're like, "Well, I use a Berenstein first, and then I use this, and then I use this." And I'm like, "So just never use a Berenstein. You need to skip all regular diagnostic catheters. If you have a chronic occlusion, you go straight to a braided taper-tip catheter."

There are a lot on the market. Some of them are significantly more expensive than others, and I'm going to leave my biased discussion of specific companies' products out of this conversation. You can look it up for yourself, but there are innumerable crossing catheters. I will tell you that some of them are $50 to $80 a catheter or more, and when you do five or ten a week, it starts to add up. So if you want to be fiscally responsible, find out what the cheap ones are 'cause they work just as well as the expensive ones.

And then it's a technique where you want your wire in a chronic venous occlusion only to be an inch or two ahead of your catheter, and you don't want to buckle the wire. So you can do that, if you have an acute DVT, you can roll the wire over and push it up. You don't hurt the valves, it goes through easily, you know you're not poking holes in things or selecting branches, and you don't want to do that in a chronic DVT. You want to keep your guidewire's tip straight. Otherwise, you will dissect, and then you've gotta pull down below the dissection to get back up through.

And then you want your hands on top of the catheter. So I see people with them under or around. It's the same thing when you're - I was a surgery resident before IR - and they put a clamp in your hand, and they try to teach you how to barely put your fingers in so you can move it, you can twist it so you can do things. It takes a while to figure out how to do that, right? And everyone's clumsy at first, but you want both of your hands on top of the catheter, and then it's a clockwise motion and then a counterclockwise motion, and you're spinning the catheter forward and backward like a drill across the wire.

And then the amount of tension that you want to push to get through the lesion is often less than you would think. So you want to keep the wire system straight and have a little bit of back tension without losing your wire in the patient.

So the skills that it takes to get through these are definitely acquired skills, and it takes more skill than you would think than just cramming something through an obstruction. Once you're through, the next tip that I would give is that sometimes the catheter can get three quarters of the way up through the obstruction, and you just cannot advance it anymore, and it's because the entire length of the catheter is being held on by a very tight obstruction. So at that point, you can go in with a four millimeter balloon and start angioplasting from behind to create a little bit of space around your catheter. You don't want to lose your pushability, so you want to keep that balloon small, and you want to keep your tract fairly small and tight until you can get up. Eventually, over time, you learn to get through anything.

[Isabel Newton]
Can you describe the access points that you prep so that you have many different options? I thought that was pretty interesting.

[Brooke Spencer]
Well, I would say that 90-plus percent of my patients with chronic venous occlusions, I prep their IJs and their ankles. I use the jugular vein so that I can use intravascular ultrasound in the pelvis. If I have someone with a chronic fem-pop DVT that's been really symptomatic or has a wound and we're going to go in and re-cannulize that, I check every single one with intravascular ultrasound.

The more CTs and MRs that I do, the more inaccurate I'm realizing those studies are, in terms of determining whether there's significant flow. What I mean by that is that they're only very small studies, right? The video trial, which was industry sponsored, was 100 patients looking at multiplanar venography versus intravascular ultrasound for a diagnosis of a greater than 50% lesion, and all those patients were CEAP four through six, so these were advanced patients. These aren't just your non-thrombotic May-Thurners, right?

What they found is that the cross-sectional area narrowing is the most accurate in predicting clinical improvement, quality of life, and ulcer and wound healing. So you want to be able to measure the area of the vessel distal to the obstruction and then the area of the vessel in the obstruction and see what percent stenosis you have.

Now, if it's a 50% stenosis in an non-thrombotic 19-year-old who just has a chronic fem-pop DVT, you're probably not going to put a stent in that patient, right? But if you have a 90% stenosis in that patient, and you have filling through collaterals in the spine, para-lumbars, epidurals and parametrium, and they have pelvic pain, heavy periods, and back pain, you're not doing them any favors by not stenting that. The vessel's 90% occluded, and I really believe that those patients benefit from that.

We still have a lot of data that needs to be gleaned from all of this. The other thing is that if you don't know how to place a May-Thurner stent correctly, it seems like a simple thing to do, but I will tell you, I think placing a stent in a non-thrombotic iliac vein is one of the hardest things I do in interventional radiology.

[Isabel Newton]
So tell us about that. How do you size it, and what is your positioning?

[Brooke Spencer]
Well, I'll tell you, every day I struggle with this. Just this week alone I had three patients I struggled with this because I think you get a pre-stenotic dilation, and so I'll geek a little bit. I'm the vein geek, so we'll talk about Murray's Law. If you don't know about Murray's Law, you need to know about Murray's Law in order to do venous stenting.

The cube root of the parent vessel should equal the cube root of the radius of the daughter vessels, right? So what the heck does that mean? Nobody has any idea what that means. Raj, you probably showed that at 20 meetings before I ever had any idea what it meant. So I finally went, found a calculator on the Internet for cube roots to figure out what the heck that means, right?

If your inferior vena cava is 17.8 millimeters, then your iliac veins should be 14 millimeters, okay? So a lot of women have a cross-sectional area of an average diameter of 18 millimeters in the IVC, so their iliacs should be 14. There are some six-foot-six guys whose inferior vena cava is truly 24 centimeters, in which case, their iliacs maybe 20 or 22 millimeters in diameter.

So you need to throw out this concept that every common iliac vein is 16 millimeters in diameter. It's complete nonsense. And people say, "Well, do you look at the contralateral side?" Maybe. You can, as additional information to help you, right? But you have a pre-stenotic dilation, so the question is, if you look at the size of the IVC, that should tell you kind of on average what size your iliacs should be.

Now what do you do with a person who has an 18 millimeter common iliac and a 90% obstruction, but their external iliac is 10 or 12 millimeters, and that looks like their normal size, right? These are really challenging, challenging cases to fix. What I would say is that a lot of people are doing all these May-Thurners from the groin, and I've done that, but if you have a large vein, and you need to deploy a wall stent, I will tell you that you're going to do a better job if you have a jugular approach.

And the reason is that if you have to put an 18 millimeter wall stent in, and you know it is not going to open to 18 millimeters at the level of the obstruction, but maybe in order to get just a wall apposition, you have to do that. You want to be deploying the wall stent from above so that you can force the wall stent out to have wall apposition before you've deployed the portion of the stent in the stenosis.

If you deploy the portion of the stent in the stenosis first, the distal part of the stent will often not open, and then you'll have what looks to you like a floating stent. It can be really scary because now you don't know what to do, and now you've got this huge stent, it's floating in the vein. Do you overlap a second huge stent that now goes into a very small area of the vein, and the patients having an enormous amount of pain?

It can be really challenging, but if you do a larger stent like that from above, and you leave the point of no return exactly where you think that stent needs to land, it's very rare that you extend all the way into the inferior vena cava across the wall of the vein after dilating. It's also very rare that it pulls all the way back out of the stenosis. So if it does pull all the way back out of the stenosis, you have to put another stent in.

And so that's the other thing I would say is that, if you're young, and you're doing this early on, you're going to misplace the stent several times in the process of doing these. Just put another one in.

And use how short your current one is, put the same size stent in, and put it another centimeter or two centimeters or whatever it is. If you put in an eight, don't put a four in to overlap at the top because you don't have a great way of measuring exactly where that's going to land. Just put another eight in, and if it was two centimeters too short, leave it two centimeters further in and overlap it.

These are just some of the tricks that I've learned over time, but I do think that non-thrombotic May-Thurner stents can be some of the most challenging cases. The last thing that I'll say is that if you have incomplete wall apposition, as long as you have a couple centimeters of wall apposition proximally or distally in the common iliac vein before the obstruction, and as long as the stent is open but being held by the obstruction, I've seen all of those patients remodel around the stent. I haven't seen any migration from those stents, and I know migration is a big concern for people.

[Isabel Newton]
That's great. Let's talk a little bit about pelvic congestion syndrome, which as you know, was the topic of Without a Scalpel, episode three, “Hysterical”, and it has garnered a lot of attention because it's probably a whole lot more prevalent than it is recognized. You're doing some work now or starting to do some work in seeing kind of more of the ramifications of what this is, and it may be responsible for a larger swath of problems than we know. Can you speak to that?

[Brooke Spencer]
Yeah, so I mean, I have to give the caveat that right now, this is all experience-based observation and opinion, but we are setting up a study, and I find it really interesting. So this is another place where, as a vein specialist, you have an opportunity to really help patients. There are a lot of people who are currently naysayers, and I think they'll change their mind over time.

But there's a couple of things about pelvic congestion that are 100% true, and then there are things that I believe. So we'll start with the things that I think are 100% true, right?

One thing we have to look at is why the results in gonadal vein embolization and treatment of that are less successful in women than they are in men, right? So the data is better in varicocele than it is in gonadal vein embolization, and I think the reason for that is that the venous system is a complex, intricate, connected system, and the gonads are inside a woman, and in a man, they're outside, so they're an end organ in men, and they aren't in women.

So it's the same concept of, if you treat the venous reflux just like treating a saphenous vein in the leg without treating the May-Thurner, if you treat the venous reflux and the pelvic varices to some degree without treating an obstructed deep venous system, and you have elevated venous pressures … six months, a year, two years later, those veins will find a way to dilate, to recruit blood flow, and be abnormal again.

And so I don't have a complete dataset to tell you that the answer yet is that we're missing May-Thurner all day long, every day in these pelvic congestion patients, and we're only treating their gonadal venous reflux, and we're not treating their underlying venous obstruction … but I truly believe that, and I don't know whether the data will bare that out.

So the next question that we have to ask becomes the same question in the leg. Do you treat the superficial vein or the deep vein first, or do you treat both? And the same question exists with pelvic congestion, but we have to start at least having the conversation.

Is it the May-Thurner that's making these people symptomatic, or is it the gonadal reflux? Because there are millions of women walking around with dilated gonadal veins after pregnancy, and not all of them are symptomatic, and not all of them are abnormal. There are millions of women walking around with May-Thurner. Not all of them are symptomatic, and not all of them are physiologically significant, right?

So we need to do a lot better data and research on who needs to have their gonadal vein embolized and who needs to have their May-Thurner stented, but I think the next step in that process in figuring this out is to recognize the myriad of symptoms that are exacerbated if not caused by pelvic venous disease.

So start at the top of the patient. Migraine headaches. Everybody talks about vascular migraines and things, right? But nobody talks about the fact that a severe May-Thurner causes collateral blood flow through the epidural veins and probably increases the pressure around the spinal canal and around the dura and maybe increasing intracranial pressures to some degree.

So we see when we stent May-Thurner, and we start asking the question. A lot of these women have chronic migraines. A lot of the chronic migraines resolve or improve significantly after treating pelvic venous disease but particularly May-Thurner.

And then the next thing is there's a guy, Danny Chan, in Texas who's been treating POT Syndrome, right? So postural orthostatic tachycardia syndrome. Okay, this is silly, right? It's a syndrome where you stand up and your heart races. That's what the syndrome is. But it can lead to cardiomyopathy and severe cardiac complications. The cardiologists are not talking about the fact that this may be related to pelvic venous disease.

It's significantly more common in women. It's more common in women who've had children, right? So if you stand up and all your blood pools in your pelvis, you're going to get a release of epinephrine, you're going to have an anxious feeling, your heart's going to race, and that's what's happening in a lot of these women.

Now do we have proof that that's physiologically what's happening completely? No, but in a lot of these patients, they can't find an ablative pathway. They don't understand why this is happening. Now you treat their pelvic venous disease, and it's resolving in a lot of the patients that he's treating.

So I think that still needs to be studied more. A lot of these women are put on anti-anxiety medications, but if you talk to them, they say when this happens, they feel anxious, but they are mentally and emotionally not feeling anxious. So they don't need anti-anxiety medicine to fix their mental problems, right? They need to have the physical problem that's causing this fixed, and I think it's a release of epinephrine that creates that feeling.

[Isabel Newton]
So they're not hysterical?

[Brooke Spencer]
So they're not hysterical. I don't think so, no.

And then the bladder and bowel symptoms that are very similar to the IBS, I've got a bunch of GI docs now who are really interested. We have a bunch of GU docs, the interstitial cystitis, right? If you have a bunch of dilated veins in and around the base of your bladder, you're going to get irritation just like everything else.

I've seen patients with chronic venous obstructions from DVT who've been on long term prophylactic antibiotics for innumerable recurrent urinary tract infections never have an infection again when you stent their iliac vein.

These are patients who've had chronic DVT with a completely occluded iliac vein. It wasn't a question of, does this person have pelvic congestion? These are just chronic, severe venous obstructions, and you treat them, and they're like, "Why? I've never had another urinary tract infection, and I'm not on my antibiotics anymore."

So I think that the venous system is ... think about the anterior shin lesions, right? We pretty much all recognize that when somebody has a big, red anterior shin lesion, cellulitis, there may be a venous component, right? I think the same thing is happening in the pelvis with the bowel and the bladder.

[Isabel Newton]
Do you think that there's going to be a push towards greater recognition of pelvic congestion syndrome and treatment of it, or do you think that there's a lot more work that has to be done?

[Brooke Spencer]
Well, I think there's a lot more work that has to be done, but I think this is like a billion-dollar industry. I think there are millions of women walking around with this problem who are fairly easily fixed, and think there are going to be a lot of naysayers at first, and I think it's going to take a long time. It's going to take some very good data, which is going to be very expensive, very difficult to obtain, but if we can obtain it, and we can do this, then I think that people will start to believe.

I have a 44-year-old woman who is, she did an article, so I don't think it's a HIPAA violation, and I won't use her name, but she put it out there with me. Since age 15, she's had severe pelvic pain. She had three endometriosis surgeries. The first one, one ovary removed, then endometriosis burn, then her uterus and the other ovary removed. She's had colonoscopies. She's an administrative secretary to the CEO at my hospital, and she's been on narcotics.

She's 44 years old, she's been depressed and in horrible chronic pain, and I talked to her about the possibility of May-Thurner because her GYN have started sending a lot of patients to me with chronic pelvic pain that hasn't been explained by other things.

And she had about a 75% stenosis, she had mild cross-collateral filling, and she begged me, "I've seen you put in thousands of stents. I know if anybody can do it, you can do it accurately. I'll accept the risk or the complication, but I cannot live this way."

So I put a stent in her, and I won't say she was pain-free immediately. She had good days and bad days for about a month or a month and a half and then was completely pain-free for three months until she did some weird movement, and then she had a little bit of pain on and off again, and then that's going away.

So she's off all narcotics, off all pain medication, her depression is lifted, she feels like a new person, and it's given her life back. There will be people out there who say that I like to put stents in, right? But I like to put stents in because it's changing people's lives, and I don't think this is a placebo effect.

These patients have had colonoscopies, they've had surgeries, they've had many other things that could be considered an intervention that could lead to them saying "I feel better" out of nowhere, right? So I don't know why placing a stent would be different than those in terms of how much it's changing their life.

So as I've started doing more and more of this, I really thought I would start seeing myself feel like maybe I was being a little bit irresponsible putting these stents in these young women. I mean, they come into the office crying in tears of joy and sobbing, and their life has changed, their relationships with their husband has changed, the dyspareunia gone.

All of these things that were severely their lives are improved, so I'm a big believer. I don't really treat very many arteries, so ... I think we should call this PVD, pelvic venous disease. It's not just pelvic congestion or gonadal reflux, right? But apparently, PVD had already been taken.


[Isabel Newton]
Yeah. So tell me just really quickly, you've done a massive venous reconstruction. What is your typical algorithm afterwards, in terms of the anticoagulation or medication regimen and then how often you see them? How do you treat these patients' followup?

[Brooke Spencer]
Well, this is a really critical point because I have talked a lot to people about this, and I have told them, and they don't always seem to get it, and it's frustrating for me.

I will tell you, you do one of these patients, and whether you have to drip them overnight or not, that's kind of out of the scope of this discussion, but that's what people are looking at now. I don't do that 90% of the time, but sometimes I do, right?

I believe it's the interventional radiologist's job not only to put these patients on Lovenox for a month. So you must see them in clinic beforehand. You must start them on Lovenox beforehand. When they come in the day of the procedure, I always check anti-Xa for low molecular weight Heparin, and I do the procedure with them on the blood thinner so that if I'm done afterwards, they can just go home, but I can adjust their dose and make sure if I'm going to leave them on this fairly dangerous medication for a month that they're on a correct dose because they're almost always too thin at a milligram per kilogram. Young, healthy people, no, but overweight women?

Now, if I have a woman who's 100 kilos, I put them on 80 BID, and then I check their dose, and they're almost always still too high. So learning how to use and manage these medications both before and after is critical.

But if you're going to drip, you're not going to be giving them Lovenox, right? You're going to put them on a low-dose Heparin drip, you're going to give them their drip overnight. When they come back and you finish your intervention, you have to make sure that you are bolusing the patient during that procedure so that they are fully therapeutic at the end of the procedure. You need to be the one to check that PTT or anti-Xa and make sure it was therapeutic in what you need to do, and then you need to make a decision about what to do.

And usually, I will switch them over to Lovenox as soon as humanly possible because Heparin drips are completely unreliable. They're up and down. What I see is often, people say they did a great job on this procedure, they got a great result, but the hospitalists let the Heparin be subtherapeutic for 24 hours, and I my answer is, BS. You did. It's your patient. This is your job. This is a critical part of your procedure. So you don't let a hospitalist or a hematologist manage your anticoagulation in the 24 hours around your procedure.

Now, do you have to be a Coumadin clinic? No, it's totally appropriate to have a primary care hematologist managing a patient's Coumadin longterm, but in and around the time of a procedure, it's critically important that you manage your own anticoagulation because no one else cares and no one else knows what you did the way that you do. And if you don't know how to do it, then you just need to learn. It's not that hard. Interventional radiologists are smart people.


[Isabel Newton]
And when do you bring these people back?


[Brooke Spencer]
So I bring them all back in three weeks. I used to do four weeks. People just tend to say a month because that's how we think, right? But the problem is, Lovenox can be very expensive, and people will run out of Lovenox at a month, and so if you bring them back at three weeks and get an ultrasound and clinical evaluation, you can then make a decision about whether you convert them back to oral anticoagulation or whether you continue them on injectables for a few months.

If you get kind of a marginal ultrasound result and a marginal clinical result, I usually tend to keep them on injectables for three months. It's a small number of people you have to do that with, but if they miss their appointment or they're a little late, they don't run out and have to pay thousands of dollars for another prescription the next month to kind of get them through.


I've even gotten to the point where, if the patients can't afford injectables, I don't do the cases anymore. Too many of them fail. We find a way for that to happen, and if somebody really has need, there is actually a way to apply for a Lovenox subsidy. I mean, we have all of this set up in our office. Obviously, that's pretty advanced. I've been doing it for years, but my office manager will help them get a certificate of need and get their Lovenox less expensive at least so we can do it. These are chronic cases. If it takes a month or two, it takes a month or two, but you don't want them to go through an expensive procedure and then fail because you didn't manage them correctly.


[Isabel Newton]
And what's your go-to oral anticoagulation regimen after Lovenox?

[Brooke Spencer]
I personally like Eliquis the best because I have the most experience with it, and then Pradaxa's okay too. I'm not a huge fan of Xarelto for a couple of reasons.

The reason is that all of the data is not for intervention patients, right? It's all just for standard DVT, and we know that most acute DVT is not acute after two weeks, right? So if they do BID dosing for three weeks, they've stabilized the clot, and then when you put people on once-a-day dosing, they do fairly well after that with Xarelto.

The problem is, these people have all failed standard therapies. They're more resistant, they're more different, they often hypercoagulable, so when you switch to once-a-day dosing on Xarelto in these people, the peaks and troughs are too high. I mean, the half life is even shorter than Eliquis and Pradaxa, which are both BID dosing drugs. A lot of these patients are young and fairly healthy and have a high metabolism, so I've seen the bleeding rates are higher with Xarelto than Eliquis and Pradaxa in the literature. So I'm not a big fan, and I've seen most of my failures with that. That's anecdotal because I haven't published that, but I'm not a big fan.

And I have no problem with Coumadin if someone can actually do the monitoring appropriately, pay attention, and make sure that they're fully anticoagulated. Honestly, I think that it's not as important what drug you're using than that it is being monitored appropriately. If you're going to have a patient on Coumadin, you need to let their Coumadin clinic know or their primary care doctors know that if they are subtherapeutic, they need to be on Lovenox until they're therapeutic. You can't go for weeks getting them from 1.8 back to 2.5.

[Isabel Newton]
Well, thank you so much, Brooke, for sharing all of your really great knowledge. It's been a pleasure talking with you.

[Brooke Spencer]
Thanks, Isabel.


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