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Chapter(10( Perforators( ( Ronald(Bush,(MD,(FACS( Peggy(Bush,(APN,(CNS,(MSN(


Welcome'to'the'Vein'Experts'Online'Educa6onal'CME'Program.( Original'Release'Date:'12/9/13( Termina6on'Date:'1/31/2016( Price:((25.00(for(Vein(Experts(Members(&($40.00(for(NonJ Members(J(Processing/CME(Fees( ( ( (


•  'This(acNvity(has(been(planned(and(implemented(in(accordance(with(the( accreditaNon(requirements(and(policies(of(the(AccreditaNon(Council(for( ConNnuing(Medical(EducaNon((ACCME)(through(the(joint(providership(of( The(University(of(Toledo(and(VeinExperts.org.( •  The(University(of(Toledo(is(accredited(by(ACCME(to(provide(conNnuing( medical(educaNon(for(physicians.( •  ( The(University(of(Toledo(designates(this(enduring(acNvity(for(a(maximum( of(1.00(AMA#PRA#Category#Credits™.((Physicians(should(claim(only(credit( commensurate(with(the(extent(of(their(parNcipaNon(in(the(acNvity.( (( '( '( (


For(nurses,(we(are(also(able(to(issue(a(cerNficate(of(aWendance(staNng(the(course(is(AMA( approved,(which(may(be(eligible(for(credit.((Nurses(are(responsible(for(submiXng(the( cerNficate(to(their(board.((Please(note(only(one(cerNficate(can(be(issued(for(each(purchase.( ( Disclosures:( ( Ronald'Bush,'MD,'FACS,(faculty(and(planning(member(discloses(he(is(on(the(Speaker’s( Bureau(for(Dornier/Refine(USA(and(is(contracted(with(Water’s(Edge(Dermatology(and( Soffer(Health.(( Richard'L.'Mueller,'MD,(faculty(and(planning(member,(discloses(he(receives(grant/research(support( from(Vascular(Insights,(LLC(

Ariel'Soffer,'MD,(FACC,(faculty(and(planning(member,(discloses(he(is(on(the(Speaker’s( Bureau(for(Cutera(,(consults(for(Angiodynamics,(&(does(research(for(BTG.( Peggy'Bush,'APN,(planning(member,(has(no(disclosures(or(financial(interests(and(is( employed(by(Midwest(Vein(&(Laser(Center.( Becky'Roberts,(planning(member,(has(no(financial(interest(or(other(relaNonships(with(any( manufacturer(of(commercial(product(or(service(to(disclose.(( ( (( (


Perforators( This(acNvity(describes(how(to(evaluate(perforators(and(their(role(in(venous( pathology.( ' Learning'Objec6ves:(

'( As(a(result(of(this(acNvity,(the(parNcipant(should(be(able(to:( ( Recognize(the(role(of(perforators(in(venous(disease.( ( Describe(how(to(eecNvely(treat(perforators.( ( IdenNfy(perforators(of(the(popliteal(fossa(and(their(role(in(the(pathogenesis(of(venous( disease.( ( Formulate(a(treatment(plan(based(on(perforator(locaNon.( ((

(( ((


Mission:( (Our(objecNve(is(to(provide(current(evidence(based(informaNon,(as(well(as( new(technology(that(is(being(developed(for(the(treatment(of(venous(disease( presented(in(a(virtual(format.(( (( Target'Audience:( (The(target(audience(for(this(acNvity(includes(physicians(and(other(health(care( professionals(in(Cardiology,(Dermatology,(IntervenNonal(Radiology,( Phlebology,(Surgery,(Vascular(Surgery,(Wound(Care(Specialists(who(care(for( paNents(with(venous(disease.(( (


Thigh(Perforators( •  Formerly(known(as(Dodd’s(&(Hunter’s( •  Important(eNology(of(reJcannalizaNon(ader( thermal(ablaNon( •  Connect(femoral(vein(to(GSV( •  May(be(source(of(recurrent(veins(or(primary( source(of(varicosiNes(independent(of( saphenous(


Ultrasound(of(Thigh(Perforator(


Thigh(Perforators( •  Most(thigh(perforators(respond(to(foam( sclerotherapy(1%.(This(can(be(done(at(Nme(of( ablaNon( •  However,(our(policy(is(to(only(inject(if( perforator(persists(ader(thermal(ablaNon( •  Discuss(with(paNent(the(possible(need(for( further(treatment(


Lateral(ReNcular(Vein(Perforator( •  Commonly(found(if(careful(study(is(done( •  Most(are(thrombosed(with(concurrent(foam( injecNon(of(lateral(reNcular(vein( •  Larger(perforators(>3(mm(if(not(addressed,( may(cause(recurrent(veins( •  Lateral(reNcular(perforators(connect(to(the( femoral(vein( •  Most(are(located(superiorly(in(upper(thigh(


Lateral(ReNcular(Vein(Perforator( •  Inject(foam(into(lateral(reNcular(vein(in(close( proximity(to(perforator( •  Visualize(with(US(foam(traveling(into( perforator(


BuWery(Needle(Inserted(Distal(to(Perforator(


Video(of(Lateral(ReNcular(Perforator( Ader(Foam(


The(Calf(Perforator( •  The(paraNbials(formerly(known(as(Boyd’s(&( Sherman( •  1st(paraNbial(popliteal(vein(to(GSV(below(knee( 3J4”( •  Factor(in(both(recurrent(veins,(saphenous(reJ canalizaNon,(or(primary(varicosiNes(


Technique(for(Assessing(Insufficiency( ( •  •  •  • 

Compress(foot(or(calf(below(perforator( Antegrade(flow(is(abnormal( Retrograde(flow(is(normal( If(perforator(>(4mm,(it(is(probably( incompetent(


Treatment(for(Calf(Perforator( •  Endovenous(ablaNon(of(GSV(across(perforator( orifice( •  Foam(sclerotherapy( •  Foam(and(thermal(ablaNon(combined(


ParaNbial((2)(Sherman’s( •  MidJcalf( •  Connects(GSV(to(posterior(Nbial(vein( •  Source(of(recurrent(veins,(saphenous( insufficiency,(or(primary(varicosiNes( •  If(possible,(start(ablaNon(below(the(perforator(


US(of(Sherman’s(Perforator(


Perforators(of(the(Popliteal(Fossa( •  Gastrocneimus( •  Popliteal( •  Both(the(above(have(similar(presentaNons( •  Varices(posterior(calf( •  Popliteal(origin(more(central( •  Varices(from(gastrocneimus(perforator(usually(more( lateral(( •  Anatomy(of(perforator(and(popliteal(fossa(allows(only(1( treatment(opNon(–(Foam(sclerotherapy(


Foam(Sclerotherapy(of(Perforator( •  If(perforator(is(>(3(mm(or(tortuous(in(course,( then(inject(foam(at(fascial(level( •  Remember(foam(is(rapidly(deacNvated(( •  Usually(2J3(cc(of(1%(is(used( •  Do(concurrent(phlebectomy(if(possible(–( beWer(cosmeNc(results( •  Follow(up(US(1(week(and(reJinject(perforator( if(necessary(


Foam(Sclerotherapy(of(Perforator( •  No(incidences(of(DVT(in(our(experience( •  Dorsiflex(foot(ader(foam(injecNon(or( compress(calf(


The(Posterior(Tibial(Perforator( (CockeW’s)( •  Three(levels( •  Connect(posterior(branch(of(saphenous(and( posterior(Nbial(vein( •  May(become(incompetent(due(to(superficial( or(deep(reflux( •  May(revert(to(competent(if(superficial(reflux( addressed( •  Incompetent(>(3mm(and(both(antegrade(and( retrograde(flow(–(foot(compression(


US(of(CockeW’s(Perforator(


CockeW’s(Perforator( •  May(be(associated(with(varices,(ulcers,(or( isolated(skin(changes( •  Treatment(necessary(if(perforator(pathologic( •  For(posterior(Nbial(perforators,(use(both( thermal(injury(and(foam(sclerotherapy( combined( •  If(possible,(combinaNon(therapy(is(beWer(due( to(calf(muscle(pump(


Technique(of(Perforator(Treatment(

(Use(19Jgauge(needle(with(400(micron(ďŹ lament)(


Conclusion( •  Perforators(are(common(cause(of(recurrent( varices(and(saphenous(recanalizaNon( •  Thigh(perforator(may(thrombose(ader( thermal(ablaNon,(but(if(they(remain(patent,( treatment(needed( •  Except(for(calf(perforator,(the(treatment(is( foam(sclerotherapy(alone(


Conclusion( •  Phlebectomies(if(appropriate(may(be(done(in( conjuncNon(with(perforator(treatment(


References( •  Labropoulos(N,(Mansour(MA,(Kang(ss,(Glovicki(P,(Baker(WH.(New( insights(into(perforator(vein(incompetence.(Euro#J#of#Vasc#and# Endov#Surg(1999;18(3):228J234.( ( •  Labropoulos(N,(Tassiopoulos(A,(BhaX(A,(Leon(L.(Development(of( reflux(in(the(perforator(veins(in(limbs(with(primary(venous(disease.( J(Vasc(Surg(2006;43(3):558J562.(

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Chapter(10(Exam( Perforators( Complete'the'exam'&'evalua6on'below'and'email'your'results'to' pbush@veinexperts.org'along'with'your'contact'informa6on.'( '( A'score'of'80%'or'greater,'must'be'achieved'on'the'postZtest'and'be' completed'in'less'than'3'a[empts.'' ( 1.'Thigh'perforators'may'be'the'' a.(Source(of(recurrent(varices( b.(Can(be(treated(with(foam(sclerotherapy( c.(Important(in(recanalizaNon(ader(thermal(ablaNon( d.(All(the(Above(

((


Chapter(10(Exam( Perforators( 2.'Lateral'Re6cular'perforators'are' a.((Rarely(found( b.(Treated(with(foam(sclerotherapy( c.(Should(all(be(avulsed( d.(Usually(located(around(the(knee( ( 3.'Para6bial'perforators' a.  Can(be(treated(with(foam(sclerotherapy( b.  Foam(and(thermal(ablaNon(combined( c.  EVLT(of(the(saphenous(vein(in(associaNon(of(the(perforator( d.  All(the(above( (


Chapter(10(Exam( Perforators( 4.'Perforators'of'the'popliteal'fossa'–'Which'response'is' incorrect?' ( (a.(Are(the(gastrocneimus(&(popliteal( ( (b.(Have(similar(presentaNons( ( (c.(Are(eecNvely(treated(with(a(thermal(( ( ( ( ( (((((ablaNon( ( (d.(Are(treated(with(foam(sclerotherapy(

(


EvaluaNon( (( How(well(did(this(acNvity(present(the(objecNves?( (( Excellent((Good( ( (SaNsfactory( ( (Poor(( (( (( How(do(you(rate(the(overall(usefulness(of(the(online(material(to(meeNng(your(needs?(( (( Excellent((Good( (( (SaNsfactory( ( (Poor(( (( (( How(do(you(rate(the(overall(presentaNon(material?(( (( Excellent((Good( ( (SaNsfactory( ( (Poor(( (( (


Was(any(commercial(bias(presented(in(the(material?(( ( No( (Yes((Please#explain)#(( ____________________________________________________(( (( I(will(be(able(to(change(my(clinical(pracNce(as(a(result(of(parNcipaNng(in(this(acNvity.( (( Yes( (No(( (( (( What(topics(about(venous(disease(would(you(like(to(hear(about(in(the(future?(( (( ____________________________________________________(( ((( (( (


(

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Contact'Informa6on( ( '( Name(&( CredenNals_______________________________________________( (( Address( ________________________________________________________( (( Phone(Number( ___________________________________________________( (( Email(address(___________________________________( ((

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Chapter 10 Perforators