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Debate: Never Perform Thermal and Chemical Ablation in the Same Setting Ron Bush, MD, FACS Midwest Vein & Laser Center Dayton, OH
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Foam as an Adjunct to Thermal Ablation Any situation that may cause failure of thermal ablation with recanalization Neovascularity Perforator Large refluxing branch
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Foam as an Adjunctive Use of foam prevents continued flow If there is prolonged flow, before the following sequence occurs, then there is chance for recanalization
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Histological changes occurring after endoluminal ablation with two diode lasers (940 and 1319 nm) from acute changes to 4 months. (Bush, 2008)
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Potential Complications A Clot in an Unwanted Location
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What does the literature say?
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Treatment of Incompetent Vein of Giacomini (Thigh Extension Branch) (Bush, 2007)
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Introducing endovenous laser therapy ablation to a national health service vascular surgical unit - the Aberdeen experience
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Findings 18% of patients (129) had both foam sclerotherapy & thermal ablation at the same time No complications noted using this combination
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Review of Literature Previous two papers demonstrate safety of foam sclerotherapy use in conjunction with thermal ablation Limited literature available on combination therapy Common daily practice
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Never Perform Thermal and Chemical Ablation in the Same Setting Never, Never, use foam for neovascularity in combination with thermal ablation No literature to support this, only personal clinical experience
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Never Perform Thermal and Chemical Ablation in the Same Setting >300 patients with neovascularity treated with foam, only complications occurred in 3 patients with adjunctive thermal ablation 1 patient developed femoral thrombosis necessitating filter placement and anticoagulation 2 patients developed partial thrombis of the femoral vein greater than 50%
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Always Perform Thermal and Chemical Ablation in the Same Setting Posterior Medial Calf Perforators
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Treatment: Posterior Medial Calf Perforator
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Posterior Medial Calf Perforator
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Why I Stage Foam Sclerotherapy? It may not be necessary to do at same setting
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Why I Stage Foam Sclerotherapy? Insurance Reimbursement is Beneficial to you and Your Patient
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CPT Code: Ultrasound Guidance Procedure 76942 – Ultrasound guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation Aetna - $510.40 UHC - $130.81 Medicare - $153.36 (American Medical Association, 2011)
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CPT Code: Ultrasound Guidance Procedure 36471 – Injection of sclerosing solution; multiple veins, same leg Aetna – $144.00 UHC – $192.97 Medicare - $141.04 (American Medical Association, 2011)
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CPT Codes: 76942 & 36471 Total Reimbursement: Aetna - $654.40 UHC - $323.78 Medicare - $294.40 If you perform thermal ablation at the same time, reimbursement is cut in half!
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Conclusion Is Speechless!
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References Bush R, Shamma N, Hammond K. Histological changes occurring after endoluminal ablation with two diode lasers (940 and 1319 nm) from acute changes to 4 months. Lasers Surg. Medicine. 40(10):676-9,2008 Bush R, Hammond, K. Treatment of Incompetent Vein of Giacomini (Thigh Extension Branch). Annals of Vascular Surgery 21(2):245-248, 2007 Mackenzie R, Cassar K, Brittenden J, Bachoo P. Introducing endovenous laser therapy ablation to a national health service vascular surgical unit – the Aberdeen Experience. European Journal of Endovascular Surgery. 38(2):208-12,2009 American Medical Association. CPT ® 2011 Standard Edition. Vol. 4. 137 & 261. (American Medical Association, 2011)
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