In this episode, Dr. Aaron Fritts interviews Dr. Raghy Kolluri, the system medical director of Vascular Medicine at OhioHealth, about his workup and treatment algorithm for severe venous disease.

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SHOW NOTES

To start, Dr. Kolluri reviews the CEAP (Clinical, Etiological, Anatomical, Physiological) classification of venous disorders and describes how patients commonly get referred to his practice. The majority of his patients fall into the C4 through C6 category (presenting with skin changes, lipodermatosclerosis, and/or recurrent ulcerations) and get referred by podiatrists and wound care clinics. Dr. Kolluri feels that treating severe venous disease is very rewarding because he has the opportunity to manage outcomes from a vascular and overall clinical standpoint.

Next, Dr. Kolluri walks through a typical workup. He emphasizes the importance of taking a thorough history, with special focus on past DVT, trauma, and foreign body placement (stents, filters, DeWeese clips). These characteristics could be evidence for deep venous disease. On the other hand, a venous ulcer with a more benign history signifies superficial venous disease. An ultrasound venous insufficiency study, as well as CT venogram, will determine location and severity of disease. If both superficial and deep venous disease are present, Dr. Kolluri will first address the deep disease.

He outlines Varithena, radiofrequency ablation, endovascular laser ablation, and foam sclerotherapy as treatment options. Varithena and foam sclerotherapy are endovascular options for patients with tortuous veins. However, Varithena should not be used in patients at high risk for venous thromboembolism, as there is less precise control over treatment. Most commonly, Dr. Kolluri relies on radiofrequency ablation. He also describes his method for laser ablation and foam sclerotherapy with sodium tetradecyl sulfate. Additionally, Dr. Kolluri shares his innovative Sclerotherapy-Assisted Phlebectomy (SAP) technique and how it increases accuracy and minimizes blood loss. He emphasizes that phlebectomy of the saphenous vein should not be overused, as it can preclude the possibility of future bypasses. Overall, his background in thrombosis and anticoagulation helps him customize treatment for each individual patient.

The doctors focus on a central theme that venous insufficiency is a chronic and progressive disease, and continued follow up is essential. This involves management of co-existing conditions like lymphedema, peripheral arterial disease (PAD), and infected ulcers. Collaboration with other medical and surgical specialties, occupational therapists, and the patients themselves is essential for ensuring that patients can make appropriate lifestyle changes and follow up throughout their disease course. Finally, Dr. Kolluri shares insight on the push to make vascular medicine an ABIM-certified specialty.

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RESOURCES

Ep. 111- Underutilization of Foam Sclerotherapy:
https://www.backtable.com/shows/vi/podcasts/111/underutilization-of-foam-sclerotherapy

CEAP Classification of Venous Disorders:
https://www.ncbi.nlm.nih.gov/books/NBK557410/

Incidence of and risk factors for iliocaval venous obstruction in patients with active or healed venous leg ulcers:
https://www.jvascsurg.org/article/S0741-5214(10)02617-0/fulltext

American Vein and Lymphatic Society (AVLS):
https://www.myavls.org/annual-congress-2022.html

Foam Sclerotherapy Augmented Phlebectomy (SAP) Procedure for Varicose Veins: Report of a Novel Technique:
https://www.ejvesreports.com/article/S2405-6553(18)30044-6/fulltext

OSU Lymphedema Center:
https://cancer.osu.edu/for-patients-and-caregivers/learn-about-cancers-and-treatments/specialized-treatment-clinics-and-centers/lymphedema-center-of-excellence

The clinical characteristics of lower extremity lymphedema in 440 patients:
https://pubmed.ncbi.nlm.nih.gov/31992537/