Had a closure done today. Dr could not get by my knee in the vein. Any suggestions?
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Doctor Answers 9
Double access vs Proximal ablation
There are situations that can impair catheter advancement in a diseased vein. Active SVT or clot in the superficial vein, prior SVT with significant vein scarring, vein tortuosity and in some cases even vein spasm. Sometimes these situations can be overcome with changes in leg position, or manipulation of the guide wire or laser fiber and sometimes they cannot. One option is to do a double access with two catheters, in essence access the higher segment and close it off, followed by accessing the lower segment and closing it off. Another option is to simply treat the proximal or higher segment of the vein followed by ultrasound guided sclerotherapy of the lower segment. Depending on the size of the lower segment one option may be better than the other. Having closed off the higher portion of your vein should still improve your circulation. If needed, the lower portion can be treated at a later time. Hope this helps.
Thermal ablation of proximal saphenous vein
If the refluxing segment is at the saphenofemoral junction (at the groin) then ablating the above knee greater saphenous vein may yield a good result. As a matter of fact, there is an ongoing debate amongst vein specialist as to whether the below knee saphenous vein needs to be treated in every patient. A thorough evaluation of the points of reflux and reentry on ultrasound allows a case by case decision.
Having said this , there are ways around the inability to cross the vein segment. A guide wire may help or another access above the difficult segment. Sometimes a combination of thermal ablation and sclerotherapy may be used .
There are ways...
Im sorry to hear about your experience. There are times that it is difficult to navigate the GSV but as an interventional radiologist we have many tricks up our sleeve. I typically use a very slick wire to traverse the segment and then pass the device over the wire. As far as will it help, it may but you may need to have the non treated segment retreated or potentially injected with foam.
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it sounds like your history of venous disease has affected the ability for catheterization of the GSV at the desired level. This can be from a history of phlebitis in that vein segment or just tortuous or twisted vein segment that won't allow the guide wire to pass through. This is not an uncommon occurrence when performing EVLT on a complex varicosity. Generally, one would like to keep access in that area and perform a second access site above or more proximal to that segment. Foamed sclerotherapy is always a great option at that first sight as it would spread throughout that difficult segment and close it off with the compression therapy after your EVLT.
You would have had a phlebitis in the past or possibly you had vein injections in the past. This is not a DVT as he is in the superficial veins not the deep veins. It is fine as long as he is closing the refluxing portion of the vein. The problem often is caused by veins not working correctly in the thigh portion of the leg but you see the problems with the veins further down the leg. I would wait and see what happens after the procedure as this is very common and the results are usually excellent
Knee area couldn't be closed
Very good question and it can happen that the superficial veins have sclerosis because of previous phlebitis. If you look at the patho-physiology of venous insufficiency there is usually significant reflux involving the proximal thigh GSV. By treating the proximal GSV the refluxing part should be fixed and if there are persistent veins or symptoms those can be treated with sclerotherapy. Depending on the preoperative ultrasound sometimes I will ablate the GSV with two access points.
EVLT - endovenous laser therapy in Williamsville NY
I have done EVLT since 2007 and sometimes, in cases where there has been SVT (NOT DVT), the catheter can not be manipulated past areas of scarring near vein valves. In that case, you can ablate the vein using 2 access points. Access point 1 could be in the lower leg to get the leg area ablated below the knee. Access point 2 could be in the lower thigh, bypassing the are where the catheter could not he passed. The area in between the 2 can be injected with sclerosant solution under ultrasound guidance.
Hratch L Karamanoukian MD FACS
It is thought that for best results access should be done below the knee and ablation should be performed from the junction (groin) to access point. Sometimes there are barriers that prevent catheters from advancing, such as previous scar tissue, multiple branches, or intraluminal narrowing. In my experience, 98% of the time this can be resolved with using a combination of guide wire and external manipulation.
In your case, I would likely do an ultrasound guided sclerotherapy injection next,or chemical closure to close off the segment of your great saphenous vein that was not ablated.
Expectations with EVLT
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.