Thank you dr cho thank you to the institute for the privilege of speaking to this group today and thank you for coming. All right so my it's about varicose veins and Phlebitis, two very different topics although not completely unrelated. And my goal is really to just briefly describe some of the characteristics of varicose veins and why they occur. And really focus on some of the data regarding phlebitis and management. And hopefully help us treat some of these patients which are not an uncommon population. So in general varicose veins are a manifestation of venous hypertension and derived from valvular insufficiency. When we think about the patient with varicose veins. Really it's one spectrum of a classification system which is very useful to know the seed classification as it helps us understand where along the spectrum of severity of disease a patient with varicose vein fits. So as you can see here it's categorized the sea to patient. And that's a patient with a standard varicose veins. Not patient varicose veins and edema but just varicose veins. But the spectrum, as you can see can be fairly advanced to the point of ulceration. If venus hypertension is not managed appropriately with first the core tenets of managing venus hypertension and venus insufficiency which includes compression, elevation, walking exercise, getting that cuff calf pump to work and then um certainly therapies, procedural therapies has indicated Phlebitis is defined as a superficial venous thrombosis. And well the prevalence can range anywhere from 3 to 11% among the general population. 50 to 60% of patients with varicose veins are thought to be to have S. V. T. And the symptoms start with pain warmth, redness, a palpable cord often confused with cellulitis. So it's not very uncommon for me to see a patient for varicose veins and evaluation for varicose veins. And they're actually just completed a course of antibiotics mostly because of the presentation can mimic uh an infection but it's really just an inflammatory condition and it's at the skin level since the varicose cities are at the dermal level. And so it presents with the symptoms that again can be confused with cellulitis but they are not. Uh phlebitis is again associated with varicose veins but not exclusive to varicose veins. Risk factors for phlebitis include advanced age, obesity, history of DVT SV. T. Trauma patient patient and oral contraceptives, pregnancy and mobility as we all know, hyper equitable states and malignancies. So well what's the big deal? I think when you think about the way we've trained or maybe the sort of more common understanding of phlebitis is it's not a big deal. You know, get some insides warm, compresses compression, get an evaluation if there's obvious varicose veins. Well let me just share a little bit of data saying it's a little more than not a big deal. So there's a certainly good data showing that following the first episode of SV. T. You have actually increased risk of number one recurrence. So short term follow up studies show that after our first episode of S. V. T. You're at six times greater risk of recurrent S. V. T longer. Data looked at progression to DVT or PE. And one study found that at the three year mark you have a 2.5 old risk increased risk of progressing to DVT or PE. So this is not a small um increased risk I think. And so there for this certainly helps guide some of the management. The greatest risk occurs in the first three months following the S. V. T. And these risks are even higher in a patient who has no varicose veins present because then we start wondering about patients underlying condition which is approach robotic state with the need for work up for trump affiliates and malignancy. The other characteristic that is a little bit higher risk is an S. V. T. At the thigh or upper leg or that which is near the junction to the deep vein. So several studies have evaluated the medical management of patients with phlebitis and they've looked at various things including length of S. V. T. Uh distance to the staff, no formal junction. And um in particular one of the most impressive studies looked at a randomized controlled trial uh and evaluated the dosage and the different therapies that should be used. And uh for example the Callisto trial which is probably the better of the trials looked at arista or extra versus placebo. In lower extremity SV. T. Patients had over five centimeters of SV t. Three centimeters from the junction. They randomized 3000 patients subcutaneous or extra 2.5 B. I. D. Dose versus placebo for 45 days. And this really had a remarkable decrease in the primary outcome. Which was a composite score of death from any cause with symptomatic VT E. Including P. E. D. V. T. And S. V. T. Extension. And so at 47 days it was .9% for extra and 6% for the placebo. Studies which have looked at dosage have shown that There is a decreased risk of treating at least for 30 days with an intermediate dose. Um Low molecular weight Hepburn. Um And there is a trial comparing Xarelto and a trickster but this is um it shows similar composite primary event outcomes but it is a non inferiority trial. So not quite as good a study. So from this understanding of the risk and some of the data I think it's fair to say that if a patient presents with phlebitis um you can certainly diagnose that on clinical exam. You can then use an ultrasound to help you understand what their risk factors may be or how you may manage them. And so this is this is actually useful clinical practice guidelines from Ruh system in our emergency rooms. Which I think is very useful and it kind of uses some of these similar studies and some of the similar data to help guide management. So if on duplex ultrasound um you have a superficial venous thrombosis of less than five centimeters from the saffron thermal junction or an S. V. T. That is greater than five centimeters. It's very reasonable to treat him as a DVt. If they don't have these then you can use a risk gratifying categorization. If the patient is high risk with certain characteristics, moderate risk or low risk to then guide the therapy or the need for therapy that they may benefit from. So in the low risk patient you may be okay doing insides warm, compresses an elevation and compression and an evaluation if there's a presence of varicose veins. Um But in the moderate patient you may want to choose a different algorithm which does include a re extra or a river oaks even. And in the high risk patient you can certainly consider them as a higher risk and treat as a DVT. And then furthermore for this algorithm. Um Certainly a follow up in 7 10 days is encouraged to make sure that the program um based on your therapy that the SPT has not progressed that the symptoms are improving and there's no need for either repeat imaging or reconsideration. Maybe upgrading their anti coagulation One step further and this is a very nice guideline. It just came out in 2021. It's from the European Society for vascular surgery. It uses very similar data it provides the level one what level data is available for the different decisions along the algorithm. But importantly, if a patient has an S. V. T. In varicose veins um class to a data suggests that it's very reasonable to have that patient evaluated for venus insufficiency and be considered for venus intervention to prevent recurrent S. V. T. Patient without varicose veins. Those are the patients you really want to work up for thermal phileas, uh potential for malignancies and other rheumatologist and inflammatory conditions. And with that I will end. Thank you for the five minute council. Mhm.