BackTable / VI / Podcast / Transcript #52

Podcast Transcript: IVUS for Iliac Vein Compression

with Dr. Mark Lessne and Dr. Michael Cumming

Dr. Michael Cumming and Dr. Mark Lessne discuss the utility of Intravascular Ultrasound (IVUS) in the diagnosis and treatment of Deep Venous Disease, including patient selection, appropriate assessment of stenoses and assistance with stent placement. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) IVUS Limitations

(2) Imaging Modalities in Iliac Vein Compression

(3) IVUS Use Cases

(4) IVUS Wire Technique

(5) IVUS Education and Technology

(6) IVUS for Young Patients

(7) Treating Deep and Superficial Venous Diseases

Earn CME

Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs. Follow the button below to claim your credits on CMEfy.

Stay Up To Date

Follow:

Subscribe:

[Michael Barraza]
Why don't we go ahead and start by having both introduce yourselves. Tell us where you are and what kind of practice environment you're in. Let's start with you, Doctor Cumming.

[Micheal Cumming]
So I'm in a limbo. I left my freestanding practice a little over a year ago and I'm waiting out a noncompete, so I'm just doing locums for the last year, and we'll be reopening the news center early in 2019.

[Michael Barraza]
What about you, Mark?

[Mark Lessne]
Yeah, so I've been in Charlotte, North Carolina for a little over five years as part of a vascular interventional specialist of Charlotte Radiology. We are a large non-university affiliated group. But actually there's no academic center in Charlotte, so we're sort of the de facto academic institution here. I cover three hospitals. I'm only hospital-based at this point except for some vein centers, but for any sort of procedures outside of that, and that's just superficial veins. So I'm in a hospital setting and obviously we'll have different cost considerations, which one I'm sure we'll get into than an office-based lab.

(1) IVUS Limitations

[Michael Barraza]
That's right. Well, one of the things that gave us the idea for this topic was a Twitter discussion that the two of you were both involved with. It involved a tweet, Mark, that you had posted back in July. And basically what it said was, "Iliac vein compression requiring stent, not so fast compression results without salvo and no impeded flow in phonography. IVUS is a complementary tool, not an absolute." And there's a really good discussion that followed. Can you just tell me basically what prompted that tweet and basically how you feel about this? Are we over-treating this, are we over diagnosing it and how does IVUS play into that?

[Mark Lessne]
Yeah, so going right to the money question, huh? So yeah, I think IVUS is a critical tool for treating venous and I'll argue other vascular pathologies. But just like any other tool, it can be abused and overused and misunderstood. And I do think that the pendulum swung a little bit from where no one was really recognizing deep venous insufficiency, and pelvic insufficiency and nonthrombotic iliac vein compression to now there are some places that are a little bit more capricious and cavalier. And I think we need to make sure that we understand that the totality of our devices and our clinical exam and the presentation must come into consideration, not just one tool.

[Micheal Cumming]
Completely agree, Mark.

[Michael Barraza]
Well, you had a very interesting response to that and I think it was very enlightening, it said to be contrarIAN and we don't know that measuring the area during valsalva actually means that the vein is normal. And you said you use area measurements as a surrogate for physiologic function. I was hoping you could kind of explain what you meant by that.

[Mark Lessne]
Right. So I mean, IVUS is a great tool for measuring areas of veins. And this has become this surrogate for what does a physiologic significant lesion? We started off at 50% in narrowing as being significant. And I think those of us that have done a fair bit of this decided that number, that threshold is probably too low and that 60% might be a better number, but we really don't know. I mean, when you really take the time with IVUS and you watch how the vein changes during respiration and other physiological challenges, it's fascinating, but we really don't know what any of this means. What I really mean by that is, what tool do we have that can stenting this patient is going to relieve their leg symptoms? And we don't have a good answer to that question.

(2) Imaging Modalities in Iliac Vein Compression

[Michael Barraza]
So, and I think we need to make sure we get into this at some point. Now it's probably as good a time as any. Looking at these in particular for May-Thurner, you know, how are you stratifying these patients for treatment? I mean, I would imagine a lot of this actually comes before you get the patient on the table through the imaging clinic?

[Micheal Cumming]
Well for me, I CT everybody and do a CT venogram, and we basically acquire it like a CT angio just later and using that and building a 3D model with true center line, reconstruction through the veins, and then actually doing area measurements, it's really time consuming. And historically I've used a third party to do all the 3D work. But if you really take your time and you have a good CT venogram, you can really create very detailed anatomical images and area measurements in the vein. You simply can't do it off axial imaging, our brains just can't process that information the way a 3D tool can.

[Michael Barraza]
Okay. The CT venogram that you're getting, I don't know if you have any of the information handy, the protocol you use particularly in terms of the re formats. Can you tell us anything about that?

[Micheal Cumming]
So just using a third party and 3D software, you go down and pick your center line through the IVC and then down both iliac systems. And then from there you can get true perpendicular area measurements of the vein and you come from the common femoral vein back up to the IVC. And I've found when you get good at the CT software, the 3D software, you can have really a high degree of correlation between the IVUS and the CT. So this can help us sort of triage patients who don't necessarily need to get on the table.

[Michael Barraza]
Okay. How long is it before you start imaging?

[Micheal Cumming]
I think our techs actually were triggering off the common femoral vein before having the stand up.

[Michael Barraza]
Okay, that makes sense.

[Mark Lessne]
Our protocol, and I will tell you those centers that do this well.. I think for a lot of centers it's a little bit of a struggle. So we do a fixed delay, and we've wrestled with everything from 120 to 180 second delay. I will tell you some of our CT venograms are absolutely beautiful and some of them look like non-contrast studies. And so I think it's a bit of an art, and you just have to be committed to it and sort of have someone who's championing this to make sure it's done correctly and works with the CT techs to make sure that you will find your protocol for your patient population.

[Micheal Cumming]
Mark's absolutely right. You have to have somebody that's going to take ownership, and champion the study, and the time to read them, this is really time consuming. You make it better by having a 3D tech do the models for you. But if you're in a practice trying to churn IVUS, these are not good studies to do.

[Michael Barraza]
Are you able to see much in the way of the collaterals that you'd see on like a real catheter venogram? And I've struggled to see those like I can on a MRV venogram.

[Micheal Cumming]
I think it's hard to differentiate collaterals, particularly if you're doing this in the situation of pelvic congestion and the pictures really aren't as pretty as an MRV, I would agree.

(3) IVUS Use Cases

[Michael Barraza]
Okay. Well, to get back to kind of the basics, I guess. Mike, what all are you using IVUS for, either on the venous or arterial side?

[Micheal Cumming]
I use IVUS pretty much routinely, so the majority of my PAD new cases, I'll use IVUS. Obviously any iliac vein compression, pelvic venous congestion--those are great cases for IVUS. I hate not using IVUS becauseI think it gives us rate delineation, pathology gives us very accurate measurements, and it saves on fluoro time.

[Michael Barraza]
Okay. Mark, what about you?

[Mark Lessne]
Yeah, so I'll use IVUS for all my venous interventions, especially chronic venous interventions within the acute setting. If I'm lysing another day, if I'm not doing a single session, then I usually defer IVUS until I'm done and ready to sort of finish up the job. But I'll tell you, Mike made some really important points that I want to make sure we don't gloss over them. He talks about how we use IVUS and how we think about that in terms of looking for 50% narrowing in iliac veins, and we're looking for cross sectional area. And all of these things are somewhat arbitrarily defined by our gut, and our expertise--for whatever that means. Even there's a big trial, the video trial, which showed that IVUS changes clinical management in a good percentage of patients.

The problem is, and this is the point that Mike made that can't be understated, we never show that it changes clinical management for the better. So there's no study that shows, "Oh, when I use IVUS, the villalta score decreases, quality of life increases." All we know is that when I use IVUS, I angioplasty and stent it whereas before I wouldn't have, but we really don't know. So I think getting familiar with IVUS is important, but I think we have to know its limitations. So you asked me where I use it, I use it as a complementary tool in almost all my chronic venous cases, but along with flow dynamics of venography.

[Michael Barraza]
Out of curiosity Mark, are you using it for your central venous cases as well?

[Mark Lessne]
Yeah, it's a good question. So I would say I have a very large thoracic venous obstructive practice and I will use it for areas of questionable concern. So in other words, a patient comes in with arm swelling and they've gotten nothing on venography. I've used it for them to identify webs that can be subtle. The other thing is there is a compressive syndrome in the chest called left brachiocephalic, or a nominate, which is the less preferred term of vein compression syndrome, and where it gets compressed between the sternum and the aorta and IVUS can be helpful there. So I will use it, but it's certainly not as routine and they do in the lower extremity and pelvis. You can use it for problem solving and the thoracic veins as well.

[Michael Barraza]
Yeah. Mark, I think it'd be interesting to talk a little more about IVUS and iliac veins and false positives, and how to avoid them and what your experience has been with them.

[Mark Lessne]
Yeah, I think that's a great question. I think it's a difficult topic. So I think the important thing for our listeners is to know, I suspect Mike feels the same way, no one gets on our table for even an evaluation unless their clinical symptoms warrant it. In other words, just because we see reflux, just because we see something on CT scan, that is almost irrelevant. The only thing that matters is that a patient has a clinical presentation that may be compatible with nonthrombotic iliac vein compression syndrome. And so once they’re on the table, the IVUS I think is to confirm that

Now in terms of false positives, I've seen false positives in patients with fibroids, and that can be specifically difficult because obviously a lot of women come in with pelvic pain, pelvic pressure, maybe some varicosities. But is it just compressing for their fibroids? In which case maybe fibroid embolization or if they're wanting to retain fertility, myomectomy or whatever it is, maybe better to really rate the compression then can find them to a stent the rest of their life. Same thing with respiratory variation. I've seen some very dramatic examples where you have almost near complete obliteration of the vein and then a patient breathes deeply and it's wide open. So a fixed stenosis is really what I'm looking for.

[Micheal Cumming]
Agree Mark. I have a hard time with that non-fixed lesion and really believing that that's hemodynamically significant. But I think that speaks a lot to your intent to treat and your desire to treat. You could make IVUS look positive and just about any patient, have them take a big breath in and the vein disappears. The other sort of technical limitation I think is, as the vein sort of draped around S1 and L5, the catheter can be biased against one wall of the vein and you can't see through the bone. And often you'll miss a lot of normal vein. So you can draw your area measurements wherever you want and create a stenosis that really isn't there.

(4) IVUS Wire Technique

[Michael Barraza]
Yeah. Mike, while we're on that topic, can I ask you, I know there's a lot of people who avoid Amplatz, super stiff wires or wires at all for IVUS and we'll do a wireless IVUS just to avoid deformation of the vein. What is your technique for that?

[Micheal Cumming]
Right. And that's actually a great point Mike, it's really interesting to play with it because you can watch your IVUS as you pull the wire in and out or go to this floppy segment of a super stiff wire and see the way the catheter biases things differently and changes your imaging and changes your measurements. So I think for me, I generally don't pull the wire, but if I feel like it just doesn't look right to me, or the catheter is really biased against one wall, I will try to switch wires, pull wires to do that. How about yourself? What's your approach to that?

[Mark Lessne]
Yeah. To be honest, I have not been doing that as much, but the more I sort of think about it and talk to other people, I think what you're doing makes a lot of sense, because clearly you're changing the anatomy, especially with some increased stiff wire. The other thing that I think we all need to be cognizant of is when we talk to patients in clinic, what do we ask? Worse at the end of the day or beginning of the day, worse when you're on your feet or lying down? So how do we do these procedures while we lie them down? We lie them prone sometimes for a CT scanner and IVUS. So we've already sort of taken away a lot of the physiologic scenarios that cause their symptoms. And so we just need to be aware that we're sort of artificially looking at these veins. But that said we know that what we do helps if we do it appropriately, but I think we have to be aware of these wire position--prone versus supine considerations.

[Micheal Cumming]
Totally agree. We're not in a physiologic state laying flat on that table. And I think some of this stuff comes into play when we're looking at those with more mild disease, like C3 type patients. And we could argue with placing the stent on a thrombotic C3 patient, but some of them are pretty miserable. And they're active, they're athletes, and they have a lot of leg pain and discomfort. But on the table, laying flat is not that remotely close to sitting on a bike for a long distance ride or running a marathon. So, right. You could argue, even in your instance where when they valsalva and the vein blows up, just because this stuff just goes away with the vein blowing up, that maybe those people are symptomatic. And they do have a functional stenosis that you can remove by having them valsalva. But again, not a physiological state.

[Michael Barraza]
I found it interesting. I mean there's an ongoing discussion right now on SIR Connect and somebody had brought up seeing the diagnosis of right sided May-Thurner, like I've never even heard of that. I mean, are you guys seeing patients for this at all?

[Micheal Cumming]
Yeah, I actually have a beautiful example of a right sided May-Thurner on my website, just a phenomenal case.

[Mark Lessne]
Yes. I really enjoy the cases on your site.

[Micheal Cumming]
Well, thank you. So this scenario is a guy, actually a hardcore cyclist, had a typical medial malleolar venous ulcer, and he had a lot of superficial venous disease in the leg. We did a CT venogram, and between the bifurcation of the right common iliac artery, his iliac vein was passing right through that bifurcation and he had almost no flow at rest on venography through that stenosis. And we actually treated his iliac vein before we did a superficial venous disease and his ulcer basically healed without touching the superficial venous disease.

[Michael Barraza]
No kidding. I've never seen it. That's cool.

[Mark Lessne]
I've seen patients who were referred because someone told them that it's impossible to have a compression of syndrome on the right. Well, clearly we know that's not true. Now in terms of terminology, some people refer to it as a May-Thurner variant or right-sided non thrombotic iliac vein compression. But to be honest, whatever it is, I think we just use the term either compressive etiology, in which case it doesn't matter what side or chronic Venous, the pelvic venous insufficiency because clearly we know, as Mike pointed out, there are patients who have disease on the right from a compressive lesion. I mean, someone with widespread lymphoma technically can have compression of their right, but we're not going to call that May-Thurner, right? So I think the terminology is fun to know, but at the end of the day, evaluate the patient and just like Mike points out, you just got to be on the lookout for it.

(5) IVUS Education and Technology

[Michael Barraza]
Okay. To get back to kind of into the basics of this Mike, how long have you been using IVUS and what's the learning curve like for somebody who's using this as a new user?

[Micheal Cumming]
I've been using it probably heavily since the late 2000, so like 2008 sometime around then. And again, really starting off with iliac venous disease. And it’s becoming an increasingly part of my daily use. So rare for me in a PAD case to not use IVUS.

[Michael Barraza]
Did either of you go to any kind of training course or just kind of pick it up on your own? I had to pick it up on my own.

[Micheal Cumming]
Yeah, I did do a course on it, I think there still is a learning curve. When you're looking at some of these lesions and trying to understand, particularly in the PAD world, understanding plaque morphology, what are the implications of the plaque morphology that you see, how is this going to impact your treatment approach? There's that learning curve, a little bit of learning curve with the console. And we haven't really dived in--we haven't even talked about it at all--but we do have two different technologies on the market that are really quite different from one another. And maybe we should have a little bit of discussion about that and on that.

[Michael Barraza]
Yeah, let's do that. Because basically, I just Volcano and that's what I know. What are the different types of technology?

[Micheal Cumming]
So there is the Boston Scientific device and then the Volcano device and the volcano device is a phased array transducer, whereas the Boston Scientific device is a single transducer that is mechanically rotated, and so is really quite different. I've done some work in a pig lab with trying both catheters side by side and the imaging from the Boston Scientific platform has significantly better resolution than the Volcano device, but the Boston Scientific platform requires a labor-intensive set up in the console design. I'm not a big fan of the console design. It's a little harder, probably I'd say even a lot harder to use than the Volcano. Volcano's done a very nice job in that console. The buttonology is very easy, whereas the Boston scientific definitely has a longer learning curve.

[Mark Lessne]
Yeah. So in terms of when I started using it, we actually did not use a lot of those in my training, and to Mike, to answer your question, when I first got out and my first job was, which was at a large academic center, we had the Boston Scientific device. I think it was from 1822. And I'm pretty sure I used it once and realized that this is insane. It was the Galaxy to show you how old it is. So clearly the technology is much improved on both the Phillips and the Boston Scientific platforms. But my first experience was I think probably with the Galaxy from Boston Scientific.

[Mark Lessne]
Since that time I've moved exclusively to the Phillips PV catheters. So I don't have much experience with the new model Boston Scientific devices, but yeah, there's idiosyncrasies with both. And the other thing is compatibility. So for our arterial work, you have the Pioneer, which is an IVUS guided re-entry device. So there's certain things you, if you select a device, obviously cost like Mike mentioned, resolution, ease of use, and then also compatibility with other devices you may want in your lab should be a consideration.

[Michael Barraza]
And then this is, if you're using, I mean, are you guys using 035 or 018. We only have 035 where I am.

[Mark Lessne]
Yeah. So let's talk about that. That's really an important point. So, 035 is clearly my workhorse for venous disease. I will tell you the catheter says 8.5 French, that's not true. It goes through an 8 French sheath, which is again my workhorse for venous work. For the arterial side, I would advocate to avoid the 018, the 014--I'm talking about PV--the 014 catheter is actually the better catheter in my experience. And you can change the field of view. So even if you're not necessarily in something where you would routinely use the 018 system, the 014 does fine. And we've actually gotten rid of all our 018 catheters in general.

[Micheal Cumming]
I completely agree. Mark, the 014 catheter is superior, the 018 catheter, and I don't know if they fixed this, but our catheter failure rate was a fair bit higher on the 018 system. And Volcano acknowledged that there actually was the manufacturing difference between the catheters and the 018 was more prone to breaking or failing during use. So I just stay away from the 018.

[Michael Barraza]
Okay. Yeah. I'll admit I have not used it in any PAD cases. Is it pretty easy to tell if you're intraluminal or subintimal?

[Micheal Cumming]
It's phenomenal for determining that. But again, we could argue whether or not this is important or not, but just a typical SFA occlusion, antegrade crossing, easy re-entry and to the distal SFA above knee pop. And IVUS, and I was clearly extra vascular or well, subintimal for a large part of the recant. And so I kind of stopped and thought about it, and I did a quick ATA puncture retrograde, and a wire just ran right up into the sheath and then IVUS again. I'm true lumen the whole way and does that really affect the patency, the intervention? I think so.

[Mark Lessne]
Me too.

[Micheal Cumming]
But again, whether it didn't make any difference, I don't know, but certainly probably reduced the amount of artery it needed to be treated. And I think I got away with no stents. So I would argue IVUS really played an important role there.

[Mark Lessne]
Yeah. The other thing is we always talk about IVUS as an anatomic tool. I'll give you two scenarios where that's not necessarily true. The one is in arterial system, there's a chromaflo setting, where you can actually see flow through the artery and Michael Barraza, to answer your question, you see very nicely the dissection plane and flow in the true lumen, if you're a subintimal or if your true lumen, you obviously see no dissection plane. The other thing is if you have slow flow, you can actually see just like on a transcutaneous ultrasound, the rollout formation. So hypoechoic blood flow that's not clot, but it's clearly slow flow and that is if we need to appreciate IVUS can give you.

[Michael Barraza]
And then what about in terms of sizing? I mean, do you find it to be pretty accurate?

[Micheal Cumming]
Again, yeah. In terms of sizing, I think IVUS is the only way to size a vessel. That's probably one of the primary reasons I use it for PAD work is balloon selection because you truly can see everything. Angiography? I really think it's a terrible tool, it's very limited, it really is, as we know a luminogram, you don't really see the extent of disease, you cannot truly see the walls of the artery, so IVUS is more accurate. And play around with it, do a run, have your tech, do a measurement of the angio, and then go to IVUS and you will see how often angio is wrong and IVUS this is better.

[Mark Lessne]
Yeah. And to tell you how sort of important that point is. A lot of the below knee paclitaxel trials failed in the past few years. And I think part of the reason was undersizing. If you look, a lot of their sizes were in the two millimeter, high two millimeters, low three millimeters. And most people who use IVUS for peripheral artery disease will tell you if you run it down a tibial, it's not that common that you're getting a two and a half millimeter vessel. Most of us are using at least three and a half millimeter and in some cases four. So I think sizing is so important and that you're ruining trials by sizing incorrectly in which case that probably translates to not getting good clinical results or as good clinical results as you could with appropriate sizing. Now that said I don't use IVUS every time, for various reasons for peripheral artery disease, but clearly have been using it more and more over the past couple of years.

[Micheal Cumming]
Yeah. Mark, that's a great point. Your eyeballs are really terrible and we should not be using eyeballs to pick balloon sizes. And down in the tibials, when you're getting down into these small balloons, there's a big difference between a two millimeter and a three millimeter balloon. In terms of the area of the balloon, it's an enormous difference. So that half millimeter or one millimeter really matters and it's not unusual to use a three, 3.5 millimeter balloon, particularly in the proximal tibial arteries, in the CATP trunk that's four millimeters or five millimeters. You do see them, and yet I'd be wary about calling a five millimeter balloon off the shelf to balloon something in a tibial or a TP trunk without knowing it really could take a 5 millimeter balloon and the IVUS gives you the confidence that you're not aggressively oversizing.

(6) IVUS for Young Patients

[Michael Barraza]
I'm with you. And one last topic I wanted to bring up is whether or not you're using IVUS in pelvic congestion syndrome cases and if so, how are you using it there?

[Mark Lessne]
Yeah. So for me, pelvic congestion syndrome the only time I really evaluate IVUS is if I'm looking for concomitant non thrombotic iliac vein compression, which again is not uncommon in pelvic congestion, chronic pelvic pain or chronic venous insufficiency. Not only that, but keep in mind the left renal vein, the gonadal vein and the iliac vein, they're all a circuit. And so they all interplay with each other. And I will tell you that's really important for management. So for me, embolizing a gonadal vein is almost always going to be my first line therapy. Before I try an iliac in a young woman, and certainly my goodness, I'll raise heaven and earth before I put in a stent. So renal vein stents I think are really sort of a no go for me, 99.9% of the time. But IVUS is important to exclude the other etiologies and to prognosticate. So if I've treated a patient with pelvic congestion and I embolize the gonadal vein, even if I don't send them that setting, at least we have an explanation.

[Micheal Cumming]
Mark, I agree. And I mean we could spend probably an hour talking about pelvic congestion, and it's just remarkable how much we've learned in the last decade about this disease. I tend to think of it as primary pelvic congestion, which is ovarian vein and competence, and secondary pelvic congestion, anything either related to iliac vein compression or a Nutcracker phenomena or Nutcracker syndrome. I pretty much will IVUS all of these patients, maybe not their renal vein, but certainly their iliac vein. Some people have shifted their treatment, if there is iliac vein compression, that that should be the primary treatment with stenting and relieving the compression. But I have a hard time with that because then you've got the long term problems of stent patency and that gives me a lot of concern, particularly in a younger patient, who is in this population that we're treating. So I would rather go ahead and coil off an ovarian vein, knowing that the long term potential negative consequences of that are really very small.

[Michael Barraza]
Yeah. And you know, just last time I think you bring up another important point. It's these young patients and a lot of these are young patients that we're seeing. And that's something that I've struggled with, particularly in cases of thrombotic May-Thurner, is trying to find ways around putting a stent in a 25-year old and how to manage it after he doesn't have any pearls for that.

[Mark Lessne]
Yeah. Well, I'll tell you probably it's a different ballgame, because that patient certainly already declared themselves as having deleterious anatomy that's going to be clinically symptomatic. I'm assuming they're thrombus was significant. In terms of management afterward, I am somewhat aggressive, especially for post thrombotic stents. I will use Lovenox for a month, assuming the patient and their insurance will tolerate it. And then I generally switch over to a DOAC. The question of antiplatelet agents on top of that? I've wrestled with back and forth, sometimes I'll lean toward using aspirin, knowing that the data is low, but the risk is pretty low. And it certainly depends on the extent. So if I have a patient that I need to stand all the way to the lesser trochanter, that patient is clearly getting anticoagulation with Lovenox and antiplatelet therapy.

[Michael Barraza]
Mike, do you agree?

[Micheal Cumming]
Yeah, for non thrombotics, asking someone to do a month of Lovenox, that's a big ask. It's a pretty miserable month. I probably changed my approach constantly on what the right answers for these people. I had a period where I was doing no anticoagulation post non thrombotic inclusions. And you can take it as far as the guys at Michigan, who are extremely aggressive inner anticoagulation with both dual antiplatelet and and Lovenox. We need some more data to really understand what is best. I think in the thrombotic scenario, it's easy to be really aggressive. The non thrombotics, it's a hard question to answer. This was a great discussion because there's so many ways to slice and dice the management of these patients. For my approach to patients with C4, 4B, C5 or 6 disease, that's a combination of deep and superficial venous disease until proven otherwise. So I investigate all of those patients as if they have a form of iliac vein compression in addition to looking at their superficial venous systems.

[Mark Lessne]
Yeah. Mike, you're kind of looking at it like a claudication versus CLI almost. You treat the C5, C6 disease differently. And I think that that makes a lot of sense to me. That's sort of bringing it back to the clinical picture of the patient. By the time you have ulceration, I'm sort of okay saying, "Okay, all hands on deck." And there's actually some good studies that show that the incidents of iliac vein compression in venous stasis ulcers is not negligible. So I certainly think I agree with the approach of treating those patients differently than the less severe patients.

[Micheal Cumming]
Right. And there is an older paper out there, but what are the relative contributions of a pelvic venous insufficiency or iliac vein compression and superficial venous disease to someone with the C4, C5, C6 disease. And if you had to pick one, which one would you fix if they both had significant iliac vein compression and great saphenous vein incompetence? My thinking has evolved--I would probably treat the deep venous disease before I would treat the superficial venous disease. I think it's really important.

[Mark Lessne]
For ulceration? Yeah, all hands on deck. I will do both. So I will treat any underlying deep venous disease, but at the same time also treat their superficial disease including, and this is an important point, including sclerotherapy at the ulcer bed to get a lot of those sort of local refluxing veins.

(7) Treating Deep and Superficial Venous Diseases

[Micheal Cumming]
All right. Mark, actually I completely agree with you, but it brings up an interesting question. If you know somebody has significant iliac vein compression, would you do the superficial venous disease first or do you do their deep venous disease first? Do you think there's a risk of a lower extremity DVT by doing a superficial treatment without dealing with the outflow?

[Mark Lessne]
It's a great question. I don't know the answer to that. To be honest, you sort of think, well their outflow is already sort of impaired because they're refluxing anyway. And so I hate saying it, but the bottom line is the way we treat these patients is based on scheduling--whoever can get in, So whether they can get into our vein center for superficial vein treatment first or in the hospital where we do our deep venous stents, but we have no set algorithm as to deep has to be done first, superficial has to be done first, but I think you bring up a great point, Mike. I don't know if you have, what do you do in terms of, do you have a set schedule?

[Micheal Cumming]
Like I mentioned earlier, I've just gone to this. I feel the deep venous disease should be treated first and then do the superficial venous disease afterwards.

[Mark Lessne]
Yeah, that's interesting.

[Micheal Cumming]
Yeah. I don't know if it's right or not, but it's kind of been a change in my approach.

[Mark Lessne]
Exactly. I'll tell you where we wrestle with is exactly what I said, which is just scheduling. Our vein clinics are sort of backed up. And so I think most of the time we ended up treating their deep venous disease anyway, not for any smart clinical reason, but just because of scheduling. But I think that approach makes sense to me.

[Micheal Cumming]
Yeah. You know, I think the other thing that may affect, depending on what market you're in, where in my area, the CMS still pays for venous ulceration without a three month waiting period. But I've been in other areas where the LDC, they still need to do three months of compression therapy before you can treat their superficial venous disease. And yet you can put them on the table tomorrow and take care of their iliac veins. So it's an interesting problem.

[Mark Lessne]
Yeah. And if you're in a market where that's true, where you need to compress a patient for three months before treating their disease from an ulcer perspective, man, you should lobby the heck out of that. That is absolutely absurd. And recent studies have really shown that early treatment of superficial venous insufficiency in the setting of ulcers is clinically beneficial for patients, no question. You should appeal and lobby as much as you can.

[Micheal Cumming]
Yeah, absolutely.

[Michael Barraza]
Well guys, I think that covers pretty much everything that I had in front of me. Is there anything else that you guys wanted to discuss that I didn't hit on?

[Mark Lessne]
Cost? But I'll tell if you are starting a practice and you're in hospital, one of the ways that may work, and I've done this on multiple occasions, especially when you're starting, before you can justify your volume and then get your own, is to split it with someone. So IVUS in the cath lab or a vascular lab--that's often a good start. The other thing is once some angio suites have it built in, and I think if you're getting a new angio suite, you should ask to have it part of it. Even if your volume can't justify it, and the argument is, well, let's plan for future growth rather than build an angio suite for a few million dollars, and then realize we missed a huge piece of equipment.

[Micheal Cumming]
Yeah, it's such a necessary tool. It should be part of any new angio suite. And I don't think there'll be a cardiology department that does not have IVUS. So if you are in the scenario where you're getting pushback from administration or wherever it comes from, you could try and share with cardiologists.

[Michael Barraza]
Well guys, I think that probably covers just about everything. This was an incredibly insightful discussion and I'm grateful to both of you. I'd also like to thank our sponsor RADPAD, contact info@radpad.com for a free radiation evaluation and no brainer radiation protection cap. And as always, you can find all of our other podcasts episodes iTunes or apps or Spotify. Thanks again everyone.

Podcast Contributors

Dr. Mark Lessne

Dr. Mark Lessne is a practicing interventional radiologist with Charlotte Radiology in North Carolina.

Dr. Michael Cumming

Dr. Michael Cumming is a practicing interventional radiologist in Minneapolis, MN.

Dr. Michael Barraza

Dr. Michael Barraza is a practicing interventional radiologist (and all around great guy) with Radiology Associates in Baton Rouge, LA.

Cite This Podcast

BackTable, LLC (Producer). (2019, November 11). Ep. 52 – IVUS for Iliac Vein Compression [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com 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.