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Unwinding the Tortuous Path: Pearls for Imaging & Interventions in Varicose Veins

Oct 06, 1:30 PM

KREST Kochi in association with IRIA Kollam has organized a fascinating talk on “Unwinding the Tortuous path: Pearls for Imaging & Interventions in Varicose Veins”. Varicose veins are a common condition involving swollen, twisted veins that you can see just under the surface of the skin. Join us to get a deeper understanding of the imaging and radiological interventions to treat these torturous veins.

[Music] good evening all welcome back to another crest kochi program and this time in association with ira column chapter and it's my own home chapter we have and i welcome dr umesh krishnamurti past national iria vice president professor and head of department of radio diagnosis at ms ramaya medical college bengaluru ansa is also the organizing chairman of coming national ira conference to be held at bengaluru in january 2022 and may i request professor dr umesh krishnamurti sir to welcome this evening's gathering over to you sir good evening dear members first of all as dr judy said i would like to welcome all of you for the national conference which is going to be physical conference in january 2022 from 20th january to 23rd so everything is updated in the website and please do you're all welcome we wholeheartedly welcome you now coming to the main thing uh it it gives me a it's honor to introduce dr rajesh kumar and he's just before i introduce he's a very i've come across with him interacted with him in a very short period but he's a wonderful human being that's most important for a person whether you are a radiologist cardiologist he's been a very nice human being my interaction with him is a very short spirit but he's a wonderful person and rajesh is a consultant radiologist at mavin hospital which he is also the chairman of the hospital and he has done his uh dmrd from osmania and he has got himself trained as an intervention radiologist from singapore general hospital and he has done lot of work about ten thousand cases that's what i when i was interacting with him i came to know and he showed me some images beautiful images of both where the patient came to him and after the treatment what was their uh appearance of the very sweet he has done an excellent job and he has got a vast experience so it's a great honor to uh to listen to his talk and uh in addition to this he's been secretary of telangana i think from 16 to 18 and he's also a chairman of the atomic energy regulatory body and he has worked in various capacities as a in the conferences and in the national conferences also and i don't need to tell more about him the moment you listen to his lecture you know what what's the amount of work he has done so what do you applaud this all the thank you sir we have dr rajesh nagala radiologist and chairman of maven medical center hyderabad for his talk on unwinding the torches path pearls of imaging and intervention on varicose veins welcome sir and the platform is all yours thank you thank you my sir for such kind words i don't know whether i deserve that sort of phrase thank you kerala chapter and fulham chapter of ira for having me thank you dr judy and dr nivedita and uh so today my topic is uh as you know unwinding with the torches path you can see such a torturous veins before the treatment so post treatment you can see the results so we have unwinded the torches part out there so imagine are interventions in varicosings so coming to what are varicose means so varicose veins are dilated often palpable subcutaneous veins in the legs so the term varicose veins comes from the greek word meaning grape light and was thought to have been used as a medical term by hypocrites in 460 bc so looking at the definition of varicose veins this is very important so we have spider beams or the telongic cases which are less than one millimeter in diameter and the intradermal so they arise from the capillaries whereas this reticular means and the varicose veins that you are seeing they are subdermal or subcutaneous so the reticular veins are about one to three millimeters in diameter they are usually torches subcutaneous veins are greater than three millimeters or three millimeters in diameter and they arise from these saphenous wheels uh the sapness tributaries or non-saphenous spiritual leg beans so looking at the venous drainage of the lower limb we have predominantly two groups the deep venous system and the superficial venous system these means of the lower limb carry deoxygenated blood back to the heart and these two systems are connected by the perfect remains so deep means are located underneath the deep fascia of the lower limb and are accompanied by the major arteries so this art itself in ah sending the blood bank when they are pulsating they are also going to have a effect on the beans so deep winds and then come to coming to the super surveillance they are often in the subconscious tissues and ultimately they drain back into the deep lanes so perfectors are means which are originate from the supervision veins and pierce the fascia in a oblique manner and then connect to the d-pins so if you are looking at the deep veins what do we have we have the external electrine then we have the femoral vein the profunda femoris then the popliteal vein and below the knee you have the paired wings coming to the superficial veins we have the great sadness green and this small staff industry so looking at the perforators i think you all are aware of the names of the void pocket and dot perfect hundred and perpetual this is this is an old terminology that we are using so a lot of uh uh radios still are using this uh uh nomenclature so i think uh this has to be avoided and the new perforated normal feature you looking at is based on the location of topography of the perforators so if you're looking at the ankle and the foot perfectors you have the foot perpetuate the dorsal foot perforator the medial lateral and the plantar foot perforators coming to the ankle perforators you have the medial ankle the lateral and the anterior ankle perforators then coming to the leg perforators you have ah these are the more important ones the medial leg perforators the para tbl and the posterior tibial actually they correspond to the pocket perforators then we have the anterior leg the lateral leg and the posterior leg computers again in the posterior leg you have the medial gastrocnemius lateral gastroenterous interchange and the para activian carpets coming to the knee perfectors you have the medial again according to the anatomy medial lateral suprapatillar intrapatellar and the popliteal posture compressors so this is the terminology that you need to use avoid the technology that you're using earlier so coming to the tie again you have important perfector that is the perfect of the femoral canal and the inguinal perforators then you have the anterior lateral thigh and posterior type of fitters these are the perfecters in the tie looking at perforators we have again two types of perforators that can exist exit perforator and the entry perforator this exit perfect is very important because they are associated with a bunch of varicose veins and overlying skin changes are often noted so if you see pigmentation and if you scan at that level of the pigmentation you might find this exit to a perforator and the flow here is uh normally outwards that that means these are incomplete perforators then here the entry perforators entry perforators are distilled to their bunch of airport cities and they're not associated with any skin changes and flow is mostly normal towards inside that's when the supportion of the deep winds then if you are looking at the perfecter sink you have the direct perforating means which connects from the supervision of the deep beams then we have the indirect perfecting means which connect from superficial beams with the of venus sinusoids and then into the deep means then we have a branching uh configurable which have multiple branches you can see that clearly in the diagram then coming to the variants that we need to be aware of there are multiple variants i've just put a few which are more common here uh you might have a segmented hyper pressure of the gsv then duplication of the gsp is very important you have to identify that because the successor again depends on whether you have identified and treated the duplicated gs3 which is it might be incompetent then you have the accessory staffing switch that can be anterior lateral or posterior medial veins then coming to the ssd uh about three to three point five percent of operation have a duplication of the ssv and sometimes the sfc doesn't end at the sp junction uh it might enter the thigh posteriorly it might be a intersafeness green or a gia community then we're talking about the anterior accessory structure this is very important because this is a important source of varicose veins and relatively this is one win which causes recurrence of varicose veins after stripping and ligation because they do not strip this way and it again connects sfj with the lateral venous system uh it tracks along the lateral side of the thigh basically so again a very important source of uh varicose veins so relatively high incidence of anterior axillary surface will replace inflation with gst request is also seen so you need to look for this before you go for a treatment of the varicose veins that mark it and even the perforators are talking about we need to mark them before we go for treatment so what are types of varicose veins here we have the primary varicose veins the secondary and the recurrent varicose primary varicose means uh maybe because of congenital incompetent walls at the sfg and the spj or sometimes they incorporate perfectly themselves or there may be tangential absence of the vessel walls itself or there might be a and this is without a coexisting deepness disease that is without a dvd or yeah deep in reflex so secondary varicose means is always secondary to dvt or obstruction to flow that can be because of pregnancy a pelvic tumor or retroperitoneal fibrosis in the abdomen and sometimes uh secondary to an av fistula very rare i have not seen this sort of varicose veins and again recurrent is very important um because if you're going for a stripping and ligation uh about 30 to 40 percent recurrence is always there so you see a lot of recurrence uh post surgery patients and sometimes you have recurrence after ablation that is if you are not done updating properly or if you're not well trained to do abrasions so coming to etiology we have a hereditary that is the number one contributing factor approximately 25 percent of women and 15 percent of men have varicose ins in our population and if both parents are affected about 90 percent of children can have varicose veins and if one parent is affected 25 percent of men and 62 percent of women can have varicose veins that is the number one contributing factor other factors uh important one is obesity because even success of the treatment sometimes is not good if a patient is very obese with a bmw more than 35 success rates are slightly less because obesity causes increased venous hypertension lack of exercise people who who are sitting for a long time or standing in one position like the professional we are talking of next line can have varicose veins it can be secondary to trauma of the legs or second to a surgery on the legs then aging is another factor because we involve start failing then hormone changes this is another very important factor patients perimenopausal stages in [Music] time of pregnancy and people who are taking ocps can have this sort of varicose veins because there is a increase in progesterone levels and this causes the vein walls to relax and the bulge of the weeds so what are the signs and symptoms you have you can have a directed torture since which you can very clearly see you can have a spider veins you can have a regular veins you can have an ankle flare you can have a staphylobarics then you have aching heavy legs and cramps with legs mostly in the evenings then you have ankle swelling and shiny discoloration of the skin around the ankles that's called the guitar zone then you have status dermatitis venous eczema you can have some patients with chronic venous eczema with the oozing of the serious fluid and things like that then minor trauma to the leg can cause severe bleeding also and sometimes takes a long time to heal then we have lipo temperature sterosis uh utter blanche or a champagne bottle sign then we have restless leg syndrome that is again lex getting cramps and heaviness in the evenings so if you can look at the picture you can see the ankle flare this is a fan shape mode of a distribution like like spider veins like intradermal very thin small means this actually indicates early sign of advanced venous disease it can be either a dvt or it can be varicose veins so this should not be neglected thinking that just a small sweater beans that can be just a cosmetic thing so this can be a sign of advanced venous disease then you're looking at the champion bottle sign here what happens the skin above the ankle shrinks due to underlying fat necrosis or atrophy and then there's a prominent edematous calf so you can see how the leg looks like like a inverted champion bottle and then you can see the saphenovarix like a ball like thing and the upper thigh near the groin that is a dilatation at the top of the gsv due to value or incompetence this can reach size of golf wall or even bigger than that this is very soft and compressible and immediately disappears online though and this can exhibit a expensive cough impulse and demonstrate a fluid drill also so what are the likely complications you can have you can have a pain in the legs you can a heaviness inability to walk or stand for long hours the repeated infections accelerates in the leg this is one of the commonest presentation people come with syllabus in the leg thinking that there is some skin issue other things but uh when you scan and see this is because of varicose veins then you have thrombophlebitis and sometimes dvt also then there might be skin changes dermatitis leading to itching and then which produces skin loss and various ulcers development of carcinoma that is uh documented but uh not seen one and long-standing venous cells as you do see charge number that's what they say then again as i mentioned severe bleeding from minor trauma can happen and the bleeding is like a fountain actually you can see it just comes out like a fountain so patients just see that they're really scared and they immediately rush to the hospital so that is one one of the complications then coming to the status uh pathophysiology you have a it can be primary and secondary reflex that is incompetence leading to blood pooling in the legs this again in turn leads to wind wall dilatation and venous congestion and venous stasis leading to edema this again further leads to inflammation and pigmentation because of hemostatin deposit deposits in the skin then there could be very capillary fibrin coughing again this is uh important due to venous hypertension extrapolation of the fibrosis so leading to a loss of subcutaneous tissues under the skin you have seen the picture out there i'll show more pictures there leading to atop a blanche and ah lipodum discloses however branches like white skin patches that you have in the skin that i think i show you coming pictures then this leads to tissue anoxia cell death and ultimately um ulceration observation is the last stage of varicose veins so how are veins varicose veins diagnosed so basically what all you need is actually a color doppler scan that should be good enough but if you're a physician just physical examination can be done the body fiddle work test and history also can give a picture that you can see the veins there sometimes you might need a ct mri venogram to rule out a may thunder syndrome otherwise very rarely ask for then uh air platismography here we don't do much it records the pressure in the limbs and i think we are not very much comfortable so as i said venus doppler sonography is the only test that you mostly need to diagnose varicose veins here you need a high frequency linear probe which is more than or equal to 5 hertz on doppler you need to look for a dvt look for a deep venous reflex then look for superficial vein incompetence and extent of reflex size of gsv and ssv perfectly size and incompetence then any tangential anatomical variants of the structural veins routine arterial workup is also needed to rule out any peripheral artery disease things like that and you can mention the depth of the skin surface so this is the venous inception protocol step one is to rule out a chronic dvt uh look for reflex test of the d-pins and identify reflex in gsp ssv identify incomplete perspective this is a insufficiency protocol before you go for treatment so how do you grade venous reflex grade for normal venous replacement refrigeration is less than 0.5 seconds that is the rapid closure of venus walls moderate reflexes reflect duration of point uh not not 0.5 to 1 seconds that is my to moderate retrograde reflex significant reflexes when the reflex duration is more than one second here the large volumes of retrograde flow is there so if you are coming to the sf junction complex itself you want to grade it it is like grade one is incompetence only on wall silver in standing grade two is incompetence only and wall support in standing as well as in superimposition great three is incompetence uh spontaneous understanding grade four encompass uh spontaneous and standing and spin as well so looking at the perforator so what are the pathological perforators because see most of the times you might not be able to elicit the incompetence on a doppler that is because only it's about 40 to 60 percent uh sensitive or doppler so but if you are seeing a vein perfect equal to a more than 3.5 we take it as a pathological computer and a reflex of equal to more than 500 milliseconds of reticular flow so [Music] we will go for uh varicose veins treatment this is also very important pelvis venous reflex or pelvis congestion syndrome because 20 percent of the females with leg varicose veins have major contributions from the pelvics periphery depletes so most of the physicians do not ask for this but this is a very important thing that we should look for especially the females when they come with the varicose veins and this is analogous to varicose in men these are dilated pelvic pins more commonly seen on the left side uh standard for diagnosis trans catheter vinography non-invasive you have mra and the color doppler so what are the diagnostic findings on ultrasound you have multiple directed tubular structures around the ovary and the uterus so three common criteria are directed torches means we diameter more than four millimeters slow blood flow that is uh less than three centimeters per second and dilated argument into the myometrium that communicates with the pelvic varicosities this uh doppler also can help in differentiating pelvic virus varicosities from cystic dixor masses mri you can see uh t1 weighted images show serpentine provides t2 weighted images your heterogeneous signal intensity due to again slow flow in the directed veins on the contrast enhanced image you have delayed enhancement of the directed torture space venography again retrograde ovarian vinography ovarian bean measures eight to ten millimeters here and you have a uterine venous engagement and a filling of a value piece across midline or filling of valve over channel and type varicosities then coming to deep in incompetence again this is also very important this is a very serious condition but uh still there is no proper treatment that uh unsolved the clinical problem so deep venous reflex can be either segmented or axial segmental is that is limited to a segment of the deep wing whereas actually it is an interrupted reflex from the groin to the calf so what the atrg of dp reflex it can be primarily deep in in competence uh vulnerable incompetence or maybe because of the dvt like post-traumatic syndrome so what treatments are available for dbt uh these are done only in few centers actually the aim of the dbr treatment is to reduce the increased ambulatory venous pressure so we have basically surgeries that is a reconstruction of the venous wall that is what called valvuloplasty then we have transplanting segments with competent walls usually taken from the axillary wind transfer then we have venus transposition uh transpo transportation of the femoral vein into the great uh softness weed or into the deformable as far as the tunnel wall is competent then what happens if there is a concomitant uh submitted deep and superior veins reflex so we have to look at the overload theory basically so superior venous incompetence leads to overflow into the deep system through the perfecter presence so direction and incompetence of the walls of the d-pins occur so if you are stopping um treating the surface of venous system and the varicosities with suffice venous abduction this leads to resolution of the deep reflex and about third one third of the patients improve though you are not directly treating the deep vein reflex so just by treating the superficial venous reflex you are going to help in treating the deep end reflex also so coming to the standard classification for chronic venous disease we have the ceap classification uh which takes into account the clinical class the etiology anatomical and pathophysiology of the disorder so if you are looking at the cap in c 0 you have that the normal thing no visible or palpable signs of venous disease c even as i said it is a spider veins or reticular veins c2 you can see proper varicose veins c3 is a stage of edema and c4 we have a pigmentation lipodurate steroid of a blind shape c5 is a stage of healed venous cells and c6 is non-healing active venous sensors so going to cap again if you look at the etiological classification it can be either congenital it can be primary uh wall failure or it can be secondary to uh dbt so looking at anatomical it can involve the sufficient veins it can involve the perfect veins or the deep winds then pathophysiological classification pathology can be because of the reflex it can be because of an abstraction or simultaneous reflex and abstraction or sometimes no venous pathophysiology can be identified so if you are looking at c1 as i said it is a spider and the reticular means you are small means you are seeing as i said spider means are less than a millimeter regular means one to three millimeters you can see proper visible varicose veins this is the c2 you can see that in the thai and the proximal graph then this is edema stage of edema and actually you could see some sort of facilities also there coming to c4 you can see the skin changes this is what i was talking if you see the right uh picture that is the white patches you're seeing that is the atrophy blanche you can see the pigmentation also the skins here so you're seeing skin changes you can see the uh one two uh field also and one uh healing cancer so this is c5 stage basically you can see two ulcers that have healed already and one which is healing so coming to c6 this is a non-healing dancer uh it's quite deep actually you can see the one around the medial mariolis pretty deep uh this is a chronic non-healing ulcer so c6 stage so ah looking at the venous clinical serial index uh this is again complementary to cap classification uh takes in uh it has about 10 clinical parameters from simple pain to ulceration so basically it is to see how the patient is improving or deteriorating discontract the patient's condition so you can look at the table here you can see from pain you have venous edema varicose veins in duration ulcerations and it has got different scores that you can keep a track of the patient whether they are improving or not so coming to a treatment what sort of treatment do you have for varicose veins it is either conservative or definitely so def considerate treatment is just leg elevation some leg exercises that you need to do uh including the calf other exercises and then where the compression is talking and maybe treat uh repeat of the underlying conditions like if you have value tumor something like that order dvt so if you are going for definitive treatment then we have treatments based on the method of win disruption you have a chemical that is where you inject medicines into the veins you have sterotherapy and a superglue then we have thermal treatment where there is a heat introduced into the veins you have laser you have an uh radio frequency abrasion and then you have microwave abrasion coming to a mechanical you have the stripping or the libertarian that is not our field then we have a combined mechanical chemical that is the moca here we have rotating fiber as well as some again skill that is injected so what are what are treatment protocols so if you have signs and symptoms of cvi uh initially conservative management includes the compression therapy the response is satisfactory contains the treatment this unset unsatisfactory response are advanced the clinical disease uh go for a testing non-visit testing like the doppler or as i said ap that is so if it is a non-acute abstraction then if you have a dvt and none of nano heat abstraction go for a vinogram or a ct mr vinogram and transit venus standing if it is because of reflex you need to go whether if it is if it is superficial you consider updation of the gsv and ssv or some phones literally you are stripping if the reflex is the deep venous perform reflex videography and consider earlier we discussed about the wind wall replacement and transactions then if it is perforated incompetence again you can do an ablation or a phone skill therapy or steps by the master surgeon we don't do that again so if it's just a muscle pump dysfunction you need to do consider excess program involving the cough muscles so what are the indication for uh treatment uh any incompetent special beans uh whether it reflects at the gsv or ssv or in the gsv and s itself ah patient is symptomatic uh you need to consider going for treatment and p 2 onwards so basically these are the indications for going for treatment so what are the contraindications you have absolute control indications are nil however relatively there are multiple contraindications where there is a acute infection you do not [Music] go for treatment unless you treat the infection itself then if it is a dvt and the target wind acts as a collateral then again you do not need the varicose veins yeah in pregnancy again you do not treat uh in pregnancy wait for a period of six months uh for the lot of people develop in the pregnancy but you have to wait for uh three to six months for the varicose veins to resolve sometimes they resolve so again obesity as i said if there is a bmi more than 35 satisfactory results are not there uh if you have acute dbt or a sufficient number of low batteries again you don't go for uh treating the patient immediately and if the severe peripheral heart disease with a b of less than 0.5 again the contraindication uh if there's severe hypercognible syndrome or thrombophilia again you do not go patient is immobile and not able to walk again because immediately after treatment the important thing is the patient should be made to walk results depend on how how much the patient is walking a patient should not be resting so again if there's a decomposited lex feeling either because of chf or liver failure or something like that again you do not go for a varicose treatment patient is allergic to local anesthetic again we are not going to treatment and then terminal disease or malignancy again so briefly about the aba that we are talking about normal abi is 1 to 1.4 and less than point five as i said is involves a severe ideal disease and then you need to refer to a vascular species to treat the first partial disease then if it is more than one point four it means it is again severe disease where there is calcification in the arteries and artists are non-compressed so what are the treatment modalities available we have multiple uh manually it was your treatment you have rfa you have a independence data treatment you have microwave operation and then ultrasound guided forms to therapy you have mocha and the super glue so if i don't have pointer here because this is a presentation on the phone if you see on the top one that is the rfa covering machine one on the top left is the electrotronic machine below that is we have the angiodynamics laser machine and below that one which is lighting up is the echo microwave machine the one on to the bottom of the screen is this foam that we use sodium tetradical sulfate uh and then we have the rotating fiber for mocha then we have the super glue gun there okay now coming to rfa basically this is a bi polar directed me uh rayather me involves heat there uh temperatures here are reaching up to 120 degrees um at the tip of the fiber the heat produced here destroys the collagen in the wind wall and also by direct contact between the catheter and the wheel wall the vein is damaged and the vein shrinks around the catheter as the vein is being treated and after rfa the bean is smaller and ultimately over period of time the bean gets observed and disappears so there is no cooling and pulling of the vein like in surgery then coming to uh endovenous data treatment uh uh what does this stand for laser stands for light application amplification by stimulated emission of radiation so laser light is monochromatic life that is a single wavelength light produced from a laser medium and then amplified to produce a powerful beam here you can see that temperature reaching up to 800 degrees where as you have seen in the rfi is only 120 degrees so mechanism of action is direct contact with the venous walls as well as by indirectly by boiling of blood and generation of steam bubbles and this causes clot formation in the blood vessels causing the wells to occlude and it does not immediately cost in case of the which is ultimately the of course the blade resistance becomes fibrous and is observed so if you are seeing that the images one on top is the radial fiber one below is the bare fiber that you are seeing so coming to the new modality the this is a very new modality that fortunately ah i was the one who launched this in india uh in 2019 after i launched this in india this same team went to united kingdom and they launched 15 days later in uk it marked with this clinic so microwave has advantages of both rf and laser one good thing is you do not need external compression here and fiber does not have to be in contact with the wind ball and here the power passes from the side of the tip directly to the green wall and effects of water in the bead wall where as you have seen rfa affects the collagen in the wheel mold and recurrence are very low as compared to other abrasion techniques even eblt and rfa and significantly lower risk of skin burn due to much lower temperatures reaching at the tip of the fiber that is around 80 degree centigrade so you have seen it is 80 degrees in the microwave 120 degrees in rfa and 800 degrees in evlt so and here you do not need a safety goggles for the medical team compared to when you are doing a laser you need a safety toggles so what is an alternative to laser you have you have a foam sleeve therapy you have mocha and the super glue super glue that is cyanoacrylate i'll come to that yeah so what is foam steel this is again very common technique that we use here there is a chemical injected into the vein intentionally to damage the endothelial lining uh leading to chemical flow batteries or inflammation so commonest used the skeletons are the sds and the bolder kernel i use sts mostly 20 hypertonic surroundings also mentioned but i have no experience with that so basically if you look at this picture you have a uh three-way then uh attached with two two lower locks ranges so we you take about two cc of uh the skeleton uh mixed with the 8 cc of it so you make a 10 cc of foam so you can see just injecting into the directly to the varicose veins and then immediately the green occluse so whether you should use a liquid or a foam for us when you are using a sclerosis so what happens if you are using liquid liquid slowness gets washed away from the blood quickly when the bean diameter is over three millimeters so actually you want the skewers to act on the bean wall if it is washed away very quickly you will not have very very good rhythms so foam has the advantage of filling the vein and staying longer and calling spasm so here you need lower concentration and volume of sts or the sclerosis so as i said foam is created by mixing sts with romaine in a one to four ratio so if you are taking one cc it is you are making about five cc of uh form for spider beans uh i use basically the liquid uh sclerosis in a ratio one is to twenty actually small amounts of liquids and we use a 30 gauge insulin syringe to inject so for larger means the sts liquid is made into foam basically otherwise it gets washed away very fast and it will not have a effect on the wind walls so who are the patients who uh get forms through therapy yeah the forms philosophy can be effective in any vein but overall tends to be less successful than other treatments uh more effect this is more effective in smaller varicose veins compared to bigger veins and large varicose veins with reflex at the sfj and spj they will have about 15 to 20 percent chance of the injection not working with the single treatment multiple sessions of foam skills that we might be needed so and it's very good for residual or recurrent varicose cities following surgery you can use foam structure so how much is safe is foam safe yeah even if you're using large amounts of foam it's pretty safe especially if you're doing a liquid uh phosphate remains you are using very low concentration as i said one is 20. so it rarely causes any issues and if you're injecting foam uh uh recommended guidelines are 10 to 15 ml of foam has a maximum volume of foam in one sitting and if you're injecting slightly away from the deep veins the chances of dvt is very less so it's pretty safe to inject foam also so what are the possible complications of phones to their feet these are all again transient or mild you can have a visual disturbance like some sparkles in the vision that again disappears from about 15 seconds slight blistering uh and rarely ulceration of skin again if you this is again because of extravagation if you're not injecting directly into the vein if you're not taking proper uh precautions yes this can happen uh dvd as i said is very rare if you're injecting slightly away from the defense because where the solution joins the difference then transient stroke again very rare i have not seen one again large means become very hard and lumpy so patient comes back to you saying that he's feeling a hard lumpy rope-like feeling of the beans so you can have some brown staining along the vein then you can have some bruising because again it's a chemical that you're rejecting so it can have some phlebitis then some patients can have allergy again very rarely see matting can happen at the site of the injection so again all are pretty rare and minor complications so coming briefly to the mocha or the clariwind it has a blunt ending rotating fiber that agitates inside the vein wall and rapidly spins inside the wind and then it traumatizes the endothelium and allowing more effective sclerosis of the v because immediately we will be injecting skewers in solution is again injected and this helps in closing the vein so again i've got a pointer but you can see the rotating fiber in the picture down so coming to the other uh non-uh thermal technique that is the ven acid or the super glue we call it here a small amount of blue is placed in the wind to a small catheter and vein is shut by process of hardening of sclerosis and eventually gets observed by the body but again the disadvantage with the venice it is no long-term studies are there and sometimes you can have a foreign body granuloma reaction even up to nine months later after injecting so sometimes this is the under you'll need multiple sessions of phones which [Music] so i'm not very again comfortable with this sort of treatment then looking at the moca advantages and the vinas i said they are both non-thermal no risk of thermal damage to nerves or skin burns and you do not need a tumescent anesthesia and all you can do with one injection instead of multiple injections in evenly because you need to do diminishing along the way then here uh fast regular time and so you can go back to work immediately uh there's no scarring there and no need to wear compressed stockings in being acid that's the advantage for the patient is like a like a office procedure come into the clinic and go immediately and most of them do not need any pain medication so as i said disadvantages are no long-term studies are available and subsequently therefore often needed and of course our insurance companies are not covering it because it is more expensive than laser or rfa because single vial of this blue though mark is around 95 000 uh they supply around 65 000 but pretty expensive so keep benefits of evenly rfa and microwave lesser currencies there much safer than surgery can be performed at a local anesthesia or sedation the patient is apprehensive then they can be minimally invasive there's no scarring so excellent clinical aesthetic results are there the decade procedure rapid recovery and immediately patient can go back to work so what are the parameters again i just go through it very fast because it might be too much for the common radiologist so laser induced thermal reactions can be regulated by multiple laser parameters important things are the fluence that is the joules type of administered energy whether the continuous or the pulse wave including the wavelength so if you're looking at the parameters the wavelength each chromophobe four has its own absorption spectra that is the water has its different observation spectra and the hemoglobin has a different absorption spectra so absorption by water becomes stronger and wavelength becomes longer so earlier we had 8 10 940 980 nanometer diode lasers which were observed by deoxygenated hemoglobin then followed by 1320 and 1470 and now we have 1940 also narrow leathers these are more absorbed by the water in the wind walls whereas if you have seen the lesser wavelengths are observed by the deoxygenated hemoglobin and again depth of tissue penetration decreases in inverse proportion so if you are using a higher wavelength laser the chance of perfection will be much less so patient treated with higher wavelengths have lesser post of brain um and use less painkillers and less likely to have ecmosis so if you can see this of this spectra for water you can see you know to the left uh 810 940 and 980 are observed by the uh deoxy natured hemoglobin and if you the wavelength is increasing you can see it's being absorbed by the water in the vein walls so other parameters i said type of administering laser energy whether you are using a pulse mode or a continuous mode but nowadays it is mostly for laser it is continuous modally we do not use a pulse mode in the pulse mode fixed amount of energy is given at equal distances again that distance and you can determine so in continuous mode the laser is pulled back and constantly at a again predetermined speed and this is an important parameter in context mode full pullback speed what happens is if the evil is if you are not pulling but continuously if you are keeping it by chance we are not used to some i've seen a surgeon a vascular surgeon using a the continuous board as a pulse mode and the hole of the leg was bird basically so you need to pull the laser back when you are doing with a continuous force so coming to the other parameter this is a fluid or jaw this is the single most important parameter to quantify the amount of energy given the amount of jobs depend on the wattage you are using whether you are using 6 watt 10 watts 12 watts under duration of treatment so basically fluency is voltage into duration so you can how many seconds you are treating so studies have suggested that energy goes greater than 80 jobs per sec centimeter results in successes of 800 and mathematical model suggested that 65 and 100 jobs per centimeter were needed for varicose veins of three and five millimeters expected to destroy the intima irreversibly so when we are treating uh we target um that we should give exalts of about 80 to 100 jobs that's how i target depending on the size of the beans so size of the venus slightly bigger then i give a little more wattage so again administering high voltage for short time has a vaporizing effect and low wattage for longer time has a cog lighting effect and commonly used wattage is 10 to 15 watts is commonly accepted in evela i use maximum around 10 to 12 not more than that so complications of ula you have minor and major complications ah again bruising this is again this was the statistics before uh we are using the tumescent anaesthesia now we have very good teams and energy pumps we have so bruising is much much lesser now rest of the complicates again are all self-limiting they resolve very quickly major complications look at skin bonds again if you're not doing properly the dimensions is not good dbt is pretty rare more than 10 years of practice i have not encountered one dbt i should and then polymer embolism also theoretical you can see 0.1 percent uh not one called narbingery sometimes yes uh some patient complaint of paresthesia because you have the sadness of the swollen are very close to the spiritual beings but again this self-limiting again resolves in three to six months time so if you're coming to nerve injury even if you're taking a very good precautions even that emissions is very good the needle stick injury itself can cause a serious nerve injury here both the nerve and the nerve sheet are disrupted causing zero messes then the thermal injury itself can cause neuropraxia where the burn injury causes transient conduction block of motor and sensory function without nerve degeneration as i said again they all recover maybe maximum six months time so what are the post uva instructions patient is encouraged to walk as much as possible so we tell the patient is not a surgeon that you're undergone you need not rest you go for walk then avoid hot baths rigorous activities running jumping and weight lifting for about two to four weeks then the patient has to wear tight surgical stockings for about 15 days and some medications are given antibiotics a painkiller anti-inflammatory antacids and a phlebotomy so post question what do you do you ask the patient to come uh 24 hours later to ensure that there was a proper treatment and operation was done check for any complication signs and repeat the scanning of the one three and six months interval so if you look at the picture on the left uh yeah see the wind there and then post ablation actually you can see all just a fibrous cord so some of the pictures you can see the large churches which are shown in the initial slide which was totally resolved with our treatment look at the other patient little big big huge wings they come pretty late to us they expect miracles but yes i should we are able to give some good results again torches means same patient other patients this is one interesting case where you see eczema of the foot this patient had been going to a dermatologist for years together patient did not improve he came to us we scanned him we had seen a very big inter-tarsal perforator so inter tattoo perfect treating is pretty complicated literally vertical but perpendicular literally so i bent a function needle and introduced a bear fiber into it and burned the inter tassel uh updated intertours incorporated then the results you can see on the right side excellent results patient was very happy you can see that again the non-using receptors are shown earlier the healed totally affected treatment again large ulcer treated ulcer healing this is another interesting case again a similar history patient even at a amputation of the toe you can see the second toe was amputated large elsa here he had been to even you can see the skin graft out there that also failed and then he came to us again there was a actually the two inter-tarsal perfectors we closed and it healed totally this is another patient patient was bedridden could not get up from the bed for a very obvious patient you can see the height the calf size there very bad patient i didn't want to take the patient for treatment but i was the 13th doctor they were consulting i told them i might not give good results but they were willing to go for treatment uh i closed i think about eight to nine perfectors below the knee they're huge perforators then uh you could see that on the left side uh predict gratifying uh results here so you can see what you do for a prevention uh elevate next while sleeping regular exercise and wearing stockings regularly and no continuous sitting standing for more than 30 to 40 minutes and of course you have to lose weight and of course visit your intervention radiologist for a regular checkup so what are the pulse that you need to take out from the this thing uh important thing is venus mapping prior to process is very important because see when you are treating you might not have the patience to search everything so map your veins mark them on the skin and then take the patient for treatment so again you need to evaluate deep means because sometimes the deep means are very very big with reflex tell the patient the success might be a little less a patient has to [Music] do some exercise of the calf and other things then again i said philippine evaluation look for pelvic venus congestion treatment of accessory saphenous is again very important that is the anterior lateral and posterior medial axis sometimes those are the main causes of the you will see a small saphenous wind gsb but these are the main means so you need to treat them and perforated marking see a lot of doctors do not treat lateral calf perforators again this is very very important for the success of your treatment you look for the lateral calf perforators mark them and i don't think many people are doing ablation of the perforators but we do a lot of people are putting foam and things like that uh are doing a lot to me but we modified our techniques uh using a puncture needle uh bent the puncture needle and using a bare fiber to upgrade this operators and of course regular follow-up of the patients are very important a lot of patients neglect thinking that treatment is done and they don't come for a follow-up so tell the patients they need to come for regular follow-up some reference and thank you any questions thank you sir for an interesting topic on a subject which is new to many amongst us we have to agree with professor mesh krishnamurti regarding the excellent improvement post therapy images and the take home pearls from the city of perth hyderabad uh we have we have a couple of queries from our viewers so uh how to differentiate anterior accessory uh stephanos vein from other superficial veins see anterior axis beam again joins the sf junction so you have traced from the subjunction itself and it goes to the lateral side of the thigh so if you are tracing from the top you can easily trace it along the lateral side side and you can you can even demonstrate a reflex at the junction accessory as well uh subjunction so that's pretty easy when you are doing a transfer scanning now you'll see two winds coming out of the subjunction one is the gsv and then you see the accessory okay sir so uh regarding deep venus reflex and how to see it and the doppler effect that was one of the questions yeah again as similar you do it in a standing position you look for the reflex while salva is there for you even the compression techniques you can use to but however we don't treat that much here yeah only few centers in india do that uh techniques which i've told you uh mostly it's all the kaffir exercises and other things the compression stockings they use they use a if it's a different difference you use class three compression stockings instead of the class two so yeah okay sir and if shorts are finished vein terminates higher is it necessary to mention regarding the reflux if there is a reflex and if the tributaries yes you need to if it is a small bean it don't need to any center any particular center that you would [Music] even i do conduct workshops uh but now after kubit has stopped doing that uh maybe again after post march i'm trying to do that you can contact me over there thank you sir i think that's about it definitely sir thank you sir and i think that's about it uh and that was dr rajesh on his talk on unwinding the torch's path now uh i go ahead i welcome dr shara chandran secretary of column city chapter for the vote of thanks dr ladies and gentlemen a very good day good very good evening to all uh it gives me immense pleasure to deliver a lot of thanks at this event to all the dignitaries present in this platform and i would like to say it was an excellent talk by dr rajesh nikola and it was very eye-opening to many of the radiologists here who might be young radiologists who might be present here to persuade a path on the varicose veins and the pose treatment which nowadays in many hospitals the surgeons have taken up that area has been taken up by many of the surgeons are doing that actually we can say as a radiologist we can do a terp expansion here taking this exactly we always talk about erosion we would like to see more of these techniques into radiologists rather than it is being taken up by more of surgeons are also doing this but you see the results they're not at all very good because it's all duplicated sometimes the surgeon has the radial just mark for them and again radio is not he's a diagnostic radiologist he doesn't know what mark for the surgeon to treat so the successes will not be that great yes i would like to thank dr umesh krishnamurti also on behalf of iaria kulam and chris kochi and in this occasion we would like to on behalf of kula mayara act chapter we would like to give our full support to dr umesh krishnamurti and dr ramesh as a part of dream team on the run of the on the run in the upcoming ira national election uh we wish you both of you all the best and we hand our full support to the dream team i think i also thank the i'd also thank chris kuchi for uh doing such a wonderful event which is very much beneficial to the pgs as well as young radiologist who's coming up and i would like to thank the technical team of netflix uh for such a wonderful platform and making such events very easy and smooth and these days in this pandemic time it is very comfortable for all of us to attend such events if not for the id platform here and i would also thank dr judy for such a wonderful comparing and madam is very well known for her activities in kerala team and thank you so much sir it was a good talk thank you thank you hand over to doctor thank you dr i think uh register would like to say thank you dr raj for that wonderful presentation thank you my request as the secretary of ira kerala to you is to conduct workshops here in kerala at we want our radiologists to start doing it all over kerala sure so my i request you to support all the young radiologists all those who are interested in this turf expansion in kerala your guidance and i wish you all the best for the future elections and which you are contesting as the vice president thank you very much you are doing a wonderful job for me and the dream team i know that thanks for the support and hope dream team itself means not only me but all of the dream team with all your support thank you sirs thank you jose

SPEAKERS

dr. Sarath Chandran

Dr. Sarath Chandran

Consultant, Kim's Health Hospital, Kollam

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dr. C. Kesavdas

Dr. C. Kesavdas

Consultant Neuroradiologist, Thiruvananthapuram

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dr. Judy Mary Kurian

Dr. Judy Mary Kurian

Professor Travancore Medical College, Kollam

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dr. Umesh Krishnamurthy

Dr. Umesh Krishnamurthy

Professor & Head, Radiology at M. S. Ramiah Medical College Bengaluru

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dr. Ramesh Shenoy

Dr. Ramesh Shenoy

Consultant Radiologist | Kochi

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dr. Sarath Chandran

Dr. Sarath Chandran

Consultant, Kim's Health Hospital, Kollam

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dr. C. Kesavdas

Dr. C. Kesavdas

Consultant Neuroradiologist, Thiruvananthapur...

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dr. Judy Mary Kurian

Dr. Judy Mary Kurian

Professor Travancore Medical College, Kollam

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dr. Umesh Krishnamurthy

Dr. Umesh Krishnamurthy

Professor & Head, Radiology at M. S. Ramiah M...

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dr. Ramesh Shenoy

Dr. Ramesh Shenoy

Consultant Radiologist | Kochi

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