1. Evaluation of the Superficial Venous System and When to Treat
American College of Phleboloty 2016
30th Annual Congress
Daniel L. Monahan, M.D., F.A.C.S
Roseville, California

2. No Disclosures

3. Venous Reflux is a Surrogate
Our job is to treat varicose veins, not ultrasound findings.

4. Anatomy of the Superficial Venous System

8. Remember the G’s
Take a History

9. The G’s of Varicose Veins
1. Genetics
2. Gender
3. Gestation
4. Gravity
5. Geriatrics
6. Gluttony
7. Job and Activities – not a “G”, so not so important
The G’s of Varicose Veins

10. Physical Examination

11. Varicose Veins – Location, Distribution, Size, Extent
Swelling, Ankle findings – signs of neglected disease
CEAP
Physical examination

12. CEAP Classification C – Clinical – C0 to C6 Etiologic Anatomic
Pathologic
CEAP Classification

13. CEAP C0 – no visible or palpable signs
C1 – telangiectasias or reticular veins
C2 – varicose veins
C3 – edema
C4a – pigmentation and/or eczema
C4b – atrophie blanche/lipodermatosclerosis
C5 – healed venous ulcer
C6 – active venous ulcer
S: symptomatic
A: asymptomatic
CEAP

14. (REVISED) Venous Clinical Severity Score
VCSS

15. VCSS Pain Varicose Veins Venous Edema Skin Pigmentation Inflammation
Induration
Active Ulcer number
Active Ulcer duration
VCSS

16. “Conservative Measures”
Leg Elevation
Use of NSAIDS
Use of Compression, and Duration
Documentation of Disability

17. High resolution color flow venous duplex Scanning
Everybody gets an ultrasound
High resolution color flow venous duplex Scanning

19. Ultrasound Exam Deep System Superficial truncal veins Perforators
Lateral thigh
Pelvic Veins
Prior phlebitis
Acute superficial phlebitis
Ultrasound Exam

20. Ultrasound Exam What is reflux?
0.5 – 1.0 sec (500 to 100 msec) defines normal, not abnormal
Ultrasound Exam

21. When to Treat
And When Not To

22. What you CAN do
What you SHOULD do
When to treat

24. We are not looking for opportunities to do ablations
We are not looking for opportunities to do ablations. We are looking for opportunities to help patients with their varicose veins.

25. When not to treat

26. The preference for conservatism

30. Thank you