Hello, I'm Christy Willocks from Ballard CVA Heart in Kingsport, Tennessee, and this is our fourth and final module. In this module, we'll talk about venous disease and venous thromboembolism. These are my disclosures. In this module, we will learn a little bit about venous anatomy, identifying your patients with chronic venous disease, and what things we can do that are both invasive and or non-invasive for those treatments. We want to recognize our patients with VTE, as well as determine their acuity level and appropriate treatment measures. Here are some additional references and reading materials. So a few statistics about venous disease. About 15% of the population is affected by a simple varicose vein. Additional 5-15% are afflicted by chronic venous insufficiency, which is a larger, more complicated problem. Estimating the overall cost burden can be a little bit difficult because it varies from something as simple as a varicose vein all the way into a lifelong issue with swelling, pain, and ulcerations. The goal in patients with venous disease is to prevent ulcerations and long-term issues. The Journal of Vascular Surgery estimates that a treatment of a venous ulcer to be an average of $15,000, which is crazy to think about, with a range of anywhere from $430,000 to $50,000. So think about how much money and hospital space is occupied caring for patients with chronic ulcers that tend to reoccur. Now VTE is a little bit different family, but there's about 300,000 to 600,000 of PEs and DVTs annually in the U.S., and that is your blood clots. Quick review of our venous anatomy. You have your superficial anatomy that we're all familiar with that includes your greater saphenous vein as well as your small or lesser saphenous vein. Between your superficial system, which is the ones that you typically see in the office, they're veins that you can see dilated, is your perforator veins. Those are the ones in between that lead to your deep veins. And they help us out with our deep veins because the names of the deep veins correspond to our arteries. So you have your posterior tibial, your anterior tibial, your popliteal, your femoral artery common, all the way up to your IVC, so those pair of names. And also in the lower part of the leg, you have venous sinuses, and that's a valve-less area within the calf that propels the blood to the veins every time that calf muscle contracts. One of the hardest working parts in our body are our venous valves. They help get the blood out of our legs and direct that back to the heart. These are bicuspid valves that direct one-way flow, again, back to the heart. It works to equalize the pressure in the venous system. These are present in both the superficial and deep veins. And if you think of these as the way that they work, we have a whole lot of these from the level of our ankle all the way up to our knee because they're doing the hardest job to pump that up because it's the furthest part away from our heart. By the time we get up to the femoral vein and the inferior canava, we don't even have valves any longer. So they really do hard work at the bottom part of our legs. What happens when these valves don't work efficiently? A little bit of common sense. The blood goes the opposite way. They reflux. The blood pulls there, and then we have venous hypertension in the lower part of our legs. Tone complete in that circle. When we have venous hypertension, that happens when the valves don't work right and or if the patient has decreased muscle tone. So if you have a patient that has muscle atrophy for some reason or has had a stroke, those patients will be more likely to have venous hypertension. I'm not talking a whole lot about upper extremity DVT, but that is something that you see more commonly, not so much related to valve dysfunction, but because the patient's had a central venous catheter pick line. So you want to look for those things in that particular group of patients. What are our sources of valve dysfunction? Does the patient have a clot or have they had one in the past? So we'll talk a lot about in this presentation, something called post-thrombotic syndrome, and that's where the patient has had a large enough clot burden that those valves have become damaged. When those valves become damaged, the patient can have lifelong swelling. They can be high risk for future clots. And if the patient has the active clot, what your body tries to do is get the blood around that active clot to get it back up. But if it's not able to do that, then you have, again, increased venous hypertension. If the patient's had an injury or surgery, that can certainly cause valve dysfunction. If they've gained weight rapidly, such as pregnancy, if they have to stand a lot or sit a lot at their job, the muscle tone we talked about, and then of course, venous disease does tend to run in families. Chronic venous disease symptoms can include heaviness. They'll complain of having achy and tired legs. They will have spotter veins or varicose veins. And this is where you want to take a good history. How long have you had swelling? Are you on meds that cause swelling? You don't want to automatically assume that all swelling is venous disease. Is there a pattern, particularly if they lift their legs up or if they've slept overnight, does the swelling get better? And then as the day progresses, does the swelling get worse? So if they have that particular pattern, that almost always tells us that there's some venous insufficiency going on there. Have they noticed some skin color changes, rashes? Are there wounds on the feet? Have they had history of wounds before? All those things are possibilities. On your physical exam, you may see that these patients have varicose veins. That is a dilated, saccular, or compressible vein that you can see very easy. This is usually the greater saphenous vein. They may have hemocyterene staining, and this is a result of leaking capillaries that release iron from the blood cells. They may have lipodermatosclerosis, and that's where the tissue at the bottom part of the leg will become red and thick and inflamed looking. They may have venous ulcers, and those are those large, shallow ulcers that happen around the ankle. Swelling, we talked about. You want to make sure there's no other reason for the swelling. They may have Y atrophy, which is a circular or scarred area where they've had remote ulcerations and things of that nature in that area. So just some pictures here. Again, you can see this patient has some fairly large venous varicosities. This patient here, of course, has some hemocyterene staining. I will tell you that it's not uncommon when patients first develop this that they will call our office and say, oh my goodness, you need to see me this week. My feet are turning black. One that's not black, it's brown, but it does cause them a lot of stress. It's very important to explain to them that this has happened because your leg was swollen, your ankle was swollen, those blood cells became compressed, the iron came out of the blood cells, and now you have this stain. So it doesn't necessarily mean acute ischemia if we were thinking towards arterial disease, but that's more a sign of venous disease. Here you see a superficial ulceration. Here you have a patient with lipodermatosclerosis, and you can also see a little atrophy blanch here kind of in the middle of that presentation. When you do your physical exam, you want these patients to stand up so you can better evaluate their varicosities. They are, of course, reactive to pressure, so standing is when you're going to see the most of those occur. Where the varicosities are will help you know where the disease is underlying. So if the patient has it in their medial cap or their thigh, you will see that they will have GSV or branch reflux. If it happens in their lateral thigh, it tends to be your anterior accessory vein. If it's a cap ulceration at the lateral malleolus, that tends to be your small saphenous reflux, and if they have ulcers at the ankle, that tends to be your perforators that are refluxing. So in this particular category of patients, they use a classification called CEEP, and that's the easiest way to identify kind of in one short little statement everything you need to know about that patient's venous disease. The C is clinical. That ranges anywhere from 0 to 6, 0 being no signs of disease, 6 being active venous ulcer. The etiology would be congenital, primary, or secondary. Your anatomy would be either superficial, perforator, or deep, and then your pathophysiology being plain reflux, obstructive disease, or a combination of both, and there's a link on that slide if you wanted to read more about the CEEP classification system if that's something you're going to do in day-to-day practice. So a couple types of tests for venous disease, one is measuring venous reflux by APG, and in this particular test, what you're looking for is if they have deep venous insufficiency, you're going to see very high residual volumes due to the pulling of the blood. So it uses cuffs and tiptoe maneuvers to see how much residual volume is left in that particular area. If the patient has low residual volume, then that calf is squeezed, it's done a good job, and there's no reflux. Something similar to that that I would say is probably done more in most offices is a simple reflux test where you use compression. That compression can just be a hand on that part of the leg, and then once the hand is released, you see if the blood kind of backs up or how long it takes to get back to the heart. Some very important measurements here when it comes to reflux, if the patient has greater than 0.5 seconds, that is the definition of reflux. You want to know how long the reflux takes, you want to know the size of the vessel, and you also want to know the area. Those are important things to know, especially for your insurance purposes if you're trying to get interventions paid for. This is just an example of a compression study. So think about this part right here being where the sonographer's hand was on the patient's leg, and then once that was released, instead of seeing a very quick 0.2, 0.3 refill, you see 1.5 seconds, so much longer than what you'd anticipate for it to head back to the heart. Other reasons that you may get a duplex is the patient may have a clot. That particular vessel may appear non-compressible, it may be larged, you may be able to see like in this picture here, you can see that thrombus sticking to the wall, and you may even have no color flow whatsoever. I will tell patients that have had very long extensive clot to the leg, when we get these venous ultrasounds, going back to where patients sometimes will have these damaged vessels, even if you get the patient anticoagulated and you get this clot to go, you always see a little bit of fibrous tissue on this vessel wall, so that means that they're more prone to have clot in the future. So if they ever get into their computerized chart and say, well, what does this chronic blah, blah, blah, blah mean? That's what that is explaining is where there's some chronic debris on that vessel wall where they had that clot before. If you need better visualization, especially if they have a very long segment of clot, that's where your CTMR venogram comes into play, and then you can certainly do venography if you are going to consider intervention for some of these very long clots. Now what are our treatments for chronic venous insufficiency? We want to start with something simple, which is leg elevation. You want to have them get their legs above their heart for 30 minutes, three to four times a day. Some people will kind of prop their feet up on a stool. We really want them to get their legs up. Not only do we want our arterial patients to exercise, we want our venous patients to exercise. It can be something as simple as heel ups, getting the feet up and down. We want to improve that muscular venous pump, or we want to improve the strength of that gastrocnemius muscle, so we're squeezing those veins and those valves to get the blood back up. Now if we're not able to do well with leg elevation exercises, which is probably where they are when they come to you, then you're going to consider compression stockings. Compression stockings help compress those veins and the valves to prevent that backflow. But we have to be careful when we use our compression stockings because if they have arterial disease, then you're going to squeeze that artery. Let's say that ABI is 50% or less and you put another squeeze on that, then you may get somebody in ischemic range. So it may not be a bad idea if you can't feel the pulses in the feet with your hands to get an ABI before you prescribe compression stockings. You will want to tell the patients to lose weight. Of course, if they're overweight, not stand too long, not sit too long. You want to prevent ulcers, so you want them to take good care of their skin, keep it clean and moisturized. There are some dietary supplements that patients can try. Most of these are things to help with inflammation. You have horse chestnut that has a little bit of research to it. There's some flavonoids and other things like that that these patients can try as supplements. You want them to identify ulcerations or cellulitis early, come to you with that so you can begin treatment hopefully before it gets any worse. So let's talk about compression stockings. Compression stockings come in three different patterns. You can get knee high, thigh high or waist level. Low grade, you can even get at the pharmacy less than 20. Medium is the most common, that's 20 to 30 pressure and then high is greater than 30. So your patients with a post-thrombotic syndrome, again, thank those patients that had big long clots. They tend to have significant venous hypertension because of the valve damage. They may require the higher strength of compression stockings. Compression stockings have been shown to improve healing times of ulcers and may even prevent ulcers. So in this picture here, this is not your typical compression stocking. This is something you can find different brands of this, but you have a nylon sock here and then you have this compressive wrap, particularly like this, just because patients have a really hard time getting compression stockings on. In this particular one, they can take their hand and kind of tighten that up. We want to do whatever we can to improve compliance. This is another assistive device to help the patient get that compression stocking on. You can ask them to put it on very first thing in the morning before the swelling begins. That will be helpful. You want to help them know that there are different products available. So if they try your typical compression stocking first and they're having a really hard time with that, recommend something different like a compression wrap. If the patient is wearing a compression stocking and they're not very comfortable or it's causing some tissue breakdown, you want to make sure they go somewhere that has experience with measuring patients so they get the right thing for them. If they refuse to wear the compression stockings, you can consider pneumatic compression as an option. And then there's also compressive bandages, and these are patients that have active wounds and that is an Uniboot. And anybody that's been around healthcare knows that magic of an Uniboot in a patient that has an ulceration and keeping that fluid out so that wound can heal. So when are indications for invasive treatment? Well, you can base it even on just cosmetic concern. A lot of vein treatments will help the appearance of the varicose vein and the spider veins. So that is something that you can consider for that particular group of patients. You can also use treatment if patients have very severe symptoms. So it's a wide range of patients that can benefit if the patient is bleeding from the varicose veins because they're very superficial, if they keep getting superficial thromboplebiasis, if they're having ulcerations. All these are reasons to consider asking for insurance reimbursement. Of course, you're going to be more successful with that in some of the more medical reasons versus the cosmetic concerns. A lot of your insurance companies will mandate that the patients at least do a trial of several months of compression therapy. The type of treatment is determined on the severity of the disease and, of course, the amount of reflux and the location of that. So we're going to go through some of the options for treating venous insufficiency. This list is probably not all of the options out there, but just so you're kind of aware of what some of the treatments are. There's sclerotherapy, which you see here in this picture, and that's where they inject a sclerosing agent into the vein. It damages the endothelium, so it closes the vein. This is particularly good for your tiny little veins like you see in the picture, the spotter veins or reticular veins. These procedures, however, all of them have some degree of complications or may have complications, and that can include hyperpigmentation, necrosis. You can have allergic reaction or thromboplebiasis. So you want to review all those things with a patient before they get into even a simple treatment. Saphenous vein stripping, I mentioned that. I think that that was pretty trendy maybe in the 80s, but patients really don't have vein stripping done like they did before. This has been replaced by less invasive procedures. When it is done, it's usually done in patients that have very large veins, greater than 10 to 12 millimeters. Thermal ablation techniques are fairly popular. Most offices will either choose to either have radiofrequency or laser options available. And the purpose of this is that you take your catheter into the diseased vein, you use the heat related to that to damage the endothelium, which ultimately will close that vessel. It's good for larger veins. It's got a good safety profile. You will need to use some local anesthetic or Tamacid. The complications with this are it can cause some discoloration in the skin. You can develop a heat-induced clot or E-hit. So these are patients that you want to make sure that even after the procedure is done that you follow them for a DVT. They can have scarring or thrombopleviitis. You want to ask these patients to wear compression therapy after their procedure until their follow-up and then get your ultrasound and see how they're doing with that. Some other options include non-thermal options and this is where mocha where you have a rotating catheter that irritates that lining while at the same time injecting a sclerosing agent. Chemical ablation, we talked about sclerotherapy. You also have varathena which is a microfoam that can be injected with ultrasound. These treatments are good for smaller veins. They have a very good safety profile. Most always these things are being done in the office. It doesn't require a topical anesthetic. They may be a lot less uncomfortable than the heat type procedures. And then as far as a non-thermal, non-tumescent, non-sclerosant, you have venaseal which is adhesive or a glue that you inject to kind of close the vessel. Last couple here is your STAB phlebectomy. I don't like the name of that but it is after these patients have had RFA, ELT, they've had a procedure that treats the majority of the vein. If they have some residual treatment there, small incisions are made and then a little hook goes down and kind of pulls up that residual and that is can be removed from there. This can cause some bruising and inflammation. These patients will also need compression stockings and then Tribex is where they use a light when they're doing their phlebectomies. And the purpose of using the light is so there's a lot less of those little small incisions because you can see a little bit clearer where you're going with that. So we're going to switch gears here to DBT, PE, and BTE. So a DBT is a deep vein thrombosis and that happens where a clot forms in the deep veins of our legs and that can happen for multiple reasons. We'll go through several. A PE on the other hand is where of course when that DBT decides to take a road trip, it breaks off and it heads towards the lungs. BTE is about 600,000 cases a year and about 25 to 40 percent of those are idiopathic meaning we have no idea why these patients get these clots or PE's which is very scary again for a provider and a patient to not know why things are happening. Who are at most risk for DBT and PE? Those are patients with clotting disorders, immobilization for a long period of time, if they've had a recent surgery which would be your abdominal or orthopedic surgeries are the highest risk, if they've had a massive trauma, pregnancy, your smokers, your cancer patients are very hypercoagulable and hormone therapy also induces a slightly higher chance because it causes some hypercoagulable state. What are our symptoms of DBT? DBT, sudden pain, swelling, warmth of the extremity, and redness. I think we were all taught that if you had unilateral swelling of one leg that you should always get a venous ultrasound. I would completely agree with that. If a patient comes in with a PE, on the other hand, they may have chest pain, they may have shortness of breath, they can pass out, low blood pressure, and cardiac arrest. Hopefully you catch it before you get to that cardiac arrest. So those patients can come in very very sick. First-line treatment for BTE, which the word for venothroma embolus, is anticoagulants and that includes heparin and Levinox. It includes your Doax, which are your direct oral anticoagulants, your Eliquis, your Xarelto, your Pradaxa. All of those drugs in that family are considered first-line treatments or anticoagulants and then you still have your Coumadin and your Warfarin there too. So this is a little bit of common sense stuff here, but when you read text about treatment of BTE, they try to break the treatment down into three different phases. First phase, of course, is when you first make the diagnosis anywhere to 5 to 21 days. Treatment phase is from the end of that 21 days for the next 3 to 6 months. And then the thing that there's usually the most question about on our end is extended phase, from the end of the treatment and beyond, whether these people need lifelong anticoagulation. So that would be your extended phase. In 2021, CHEST organization came up with some anticoagulation guidelines. There's about 29 statements of how best to treat patients with VTE and I'm going to try to kind of summarize some of that for you here. If a patient presents to you with an acute isolated DVT, they do not have symptoms and they are not high risk for blood clots, you want to monitor that patient in two weeks. If that patient comes back to you in two weeks, you want to see if that clot has extended. If they do, you want to start them on anticoagulation therapy. If they have symptoms and risk factors for extenuation, you want to go ahead and start that anticoagulation. If a patient presents to the ER and they have a sub-submental, which is in the very distal portion of the lung PE and they don't have a DVT, those are patients that you could also monitor. But if a patient comes in with a PE that's not a sub-submental PE, but they don't have any symptoms, you want to treat them the same as a symptomatic patient because you don't really know the source of that PE. If a patient has an acute DVT alone, anticoagulation therapy is a first-line therapy prior to considering more invasive measures. If they present to you with acute PE, you want to look at their acuity. If the patient comes in very sick with low blood pressure, they're not high risk for bleeding, in some cases these patients are taken for some systemic thrombolysis. Now I put in here that that means weak evidence. So the CHESS guidelines listed things that have not been well researched or may be overturned in further versions of their guidelines. So right now they do recommend for the patients that have the low blood pressure, not high risk for bleeding, that they may get thrombolytics. If the patient continues to deteriorate despite using anticoagulation therapy, you want to still consider thrombolysis. Systemic thrombolysis is still preferred over catheter-directed treatment. Again, weak evidence. This is one of those situations where it's good to know the providers in your area and are they routinely handling acute PEs with intervention versus systemic thrombolysis. The recommendation here is really when the patient has reached hypotension, bleeding, shock, that's when you consult an expert for catheter-assisted thrombus removal. So that would be I think really primarily based on where you live and the expertise in the area where you are, how best to treat that patient with acute PE that is deteriorating. If a patient has a VTE, again, first-line treatment is now your DOACs versus coumadin used to be the older treatment that we used. If a patient has cancer, DOACs are still the first line over low molecular weight heparin. And if a patient has antiphospholipid syndrome, they fall into a special category where those patients still require coumadin and monitoring for their coumadin. If the patient needs to be on extended phase anticoagulation, two recommendations, they prefer still the DOACs, either the Vixenbam or the Roxabam, and a low dose of DOAC is preferred over aspirin alone or no therapy. So how do you determine who gets what type of treatment? And it's like a lot of things that you do in medicine where it's kind of a risk-benefit type ratio thing. If the patient has a very clear reason why they developed the clot, post-op, long trip, sedentary for a brief period of time, then you would think that those patients would be low risk for having a return of a clot. If they have persistent factors, maybe they're overweight, not likely to lose that weight, things in that category that would put them at moderate risk. If you have no clue why they developed that clot, again, moderate risk. But if they're a cancer, hypercoagulable state, then those patients are at high risk versus the screening for bleeding. So what's the likelihood that they may get another clot versus what's the likelihood that these particular patients may bleed? Have they bled recently? Do they have anemia? Do their kidneys not work well? Are they already on other antiplatelet therapy? Are they old? They have cancer. So those things, you want to look at both ends of that before you proceed with long-term treatment. The other thing you want to identify is how this patient presents to you, whether it be your primary care office or cardiology office, ER, urgent care. If a patient presents to you very unstable with a huge swollen leg, even though anticoagulation is still going to be your first step, you don't want to send these patients home on Eliquis, and we'll get a duplex in two weeks. So be very careful when you're assessing these patients how sick they may be before you make that kind of quick decision to anticoagulate and send them home. Some patients need IV heparin. Some may need a procedure. There are instances where a DVT can be life and limb threatening. Of course, a PE, we all know, can be life-threatening. And we want to make sure that And we want to prevent two things. With a DVT, you want to prevent that post-thrombotic syndrome where the patient has lifelong issues with the leg because of the valve damage. And with a PE, you want to prevent long-term RV failure where you'll see on the echocardiogram that that right ventricle no longer does the work that it was able to do before. So those are the things that you want to prevent if these patients present very ill. So one of the situations where a patient can present to you extremely sick is phlegmasia serrula dolens. You may not see this many times. I've had the, I don't want to say the good fortune, but I have been able to see it several times. And I'm happy to be able to identify what it is because I have seen it in the past. What this is, is a rare but true emergency where all of a sudden these patients get a massive quantity of DVT. Because they get that massive DVT, that leg will swell and the swelling is so massive that then you compress the arterial system. So then you kind of have a double whammy. These patients also will develop shock. They can get PE. They've got a mortality rate of about 30 to 40 percent. These patients will present with swelling. Their leg will be blue. They'll have pain. And you may even think that it's kind of an acute ischemic presentation. But the key here is that they'll have this massive, sudden onset of swelling that you would not necessarily see in the arterial patient. Risk factors for this condition are malignancy, femoral vein catheterization, heparin-induced thrombocytopenia. Your patients with antiphospholipid syndrome, surgery, heart failure, or pregnancy. And the treatments for this are aggressive anticoagulation, thrombolytics, and even venous thrombectomy. So in this particular patient that we had, went out of order there, but you can see this left leg was blue, purple, absolutely huge. And this is post-treatment where you see a normal looking leg again. So this one is what you would call a save. We made a note here is when these patients get high dose of lytics by whatever route, you can expect some breakdown. And that's one of the most common calls we get. If there's some blood in their urine, that's completely normal after these particular types of procedure. Intervention for VTE can consider systemic thrombolysis that may decrease their mortality. But as we all know, systemic thrombolysis comes with a very long list of why we shouldn't give the patient systemic thrombolysis and a lot of bleeding risk. Another option is catheter-directed thrombolysis, and that includes your aspiration catheters, your lytic delivery, and mechanical thrombectomy. So with a catheter-directed thrombolysis, there's two main types here. One is just a plain catheter that goes into the area of the clot, and you give them lytic therapy directly to that clot, not the systemic, but directly to that clot for 24 to 48 hours. And that patient absolutely hates you for 24 to 48 hours because they're in the bed getting blood thinner directly into that clot. Another option is ECOS. It also gives the patient TPA. The difference with this one is it uses ultrasound to help penetrate that clot. It also requires 24 hours, sometimes plus, of treatment. It's a little more costly than just a plain infusion catheter, but it is felt to be helpful in some patients with extensive clot burden. Now your mechanical thrombolysis, I like to think of this as being at the dentist. You've got this catheter that pushes the water when you've got your suction catheter kind of drawing it out. So the same effect is it's kind of pushing forward with the saline while it's got something behind it that's sucking the water out. The purpose of these particular type of procedures, the mechanical thrombolysis, is you want to get that clot out in one setting so there's minimal residual damage to the patients. And again, this is for patients that have really long, severe segments of disease, not necessarily just your phlegmation patients, but it can happen in patients that just have really long DVTs and come in acutely. These patients can also get pulse spray lytics directly to that area of the clot at the time of the procedure. We most recently had a patient that was a beekeeper. He came in after having several bee stings to the leg. Don't know why that caused it because he was used to bee stings, but he had a huge DVT going from popliteal all the way up to his common iliac vein. And we were able with mechanical thrombolysis to go in and get that clot out so that patient can get back to beekeeping, so if he chooses to, in a very short timeline. Now he'll still need compression therapy and he'll still need anticoagulants, but instead of being on just oral anticoagulants for a long time waiting for that clot to resolve, he was able to restore normal function in a much quicker timeline. Some more devices, you have aspiration treatment, which can mean that you just suck it out kind of with a typical syringe. Penumbra has a whole family of devices that are suited for these long clots and long sections. They even have this lightening technology that will help the provider be able to identify the areas of clot so all the clot is removed at the time of the procedure. AngioVac is for very large veins and requires very large access, so it's not done very commonly. There's two types of Inari devices that combine both aspiration mechanical aspects. So in the FlowTriever, this particular device has these little nitinol discs here and it kind of pulls the clot back again into the suction device. A ClotTriever is moved past the area of the clot and then it's inflated and pulled back again trying to get that clot out, and then occasionally we use stenting and that would be May Turner. We'll talk about that. So this is what you call a success story here. This is not my bee patient, but a different one, but anybody in medicine loves to see good chunks of clot, right? But these are really neat cases to see how well and quickly these patients recover after the clot's removed. May Turner syndrome is where there is excessive compression of the left iliac vein at the crossover of the right iliac artery. So you can see here in the diagram where the artery is pushing over on this vein, and what happens is these people will be prone because of that compression to develop clot all the way down. So it'll start up as high as here and down. These patients do benefit from stenting of this vein in order to improve the blood flow and to stop this kind of compression mechanism here, and then you can do additional measures to help the patient get rid of that clot all in one setting if that's what your interventionalist chooses to do. And then last but not least are your IVC filters. IVC filters have got kind of a bad name in the press lately because when we did them 10-15 years ago, we never thought about removing them. IVC filters should really only be used for patients that aren't able to take anticoagulation therapy, and the goal here is if a patient has a DVT, you want to protect the lungs from that PE. So you put that filter in place, but what happened a lot of times were these tines over time would kind of migrate out into the vessel wall and cause problems. So a lot of the products out there for IVCs now are removable or movable. When you put an IVC filter in, you want to make sure that you discuss with a patient that this device will either need to be moved every so often or it will need to be removed at some point in time. You rarely want to leave the IVC in place long term like we used to do. If the patient's able to start anticoagulation, you still want to get these patients on anticoagulation. So in conclusion, early detection and treatment of venous disease of course is important because we want to prevent ulcerations. First line treatment for PE DVT is always your anticoagulation treatment, but if that patient presents to you acutely ill, we want to consider if more aggressive measures are required because the thing we want to prevent in that situation is with your PE patients, you want to prevent your RB strain and your DVT patients. We're moving towards trying to reduce that post-thrombotic syndrome. Here are additional references and as always if you have any questions, please email us at academy at medaxiom.com.

venous disease

venous thromboembolism

venous valves

chronic venous disease

anticoagulation therapy

compression stockings

deep vein thrombosis