1. Debate: Never Perform Thermal and Chemical Ablation in the Same Setting Ron Bush, MD, FACS Midwest Vein & Laser Center Dayton, OH

2. Foam as an Adjunct to Thermal Ablation Any situation that may cause failure of thermal ablation with recanalization Neovascularity Perforator Large refluxing branch

3. 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

4. Histological changes occurring after endoluminal ablation with two diode lasers (940 and 1319 nm) from acute changes to 4 months. (Bush, 2008)

5. Potential Complications A Clot in an Unwanted Location

6. What does the literature say?

7. Treatment of Incompetent Vein of Giacomini (Thigh Extension Branch) (Bush, 2007)

8. Introducing endovenous laser therapy ablation to a national health service vascular surgical unit - the Aberdeen experience

9. Findings 18% of patients (129) had both foam sclerotherapy & thermal ablation at the same time No complications noted using this combination

10. 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

11. 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

12. 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%

13. Always Perform Thermal and Chemical Ablation in the Same Setting Posterior Medial Calf Perforators

14. Treatment: Posterior Medial Calf Perforator

15. Posterior Medial Calf Perforator

16. Why I Stage Foam Sclerotherapy? It may not be necessary to do at same setting

17. Why I Stage Foam Sclerotherapy? Insurance Reimbursement is Beneficial to you and Your Patient

18. 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)

19. 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)

20. 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!

21. Conclusion Is Speechless!

22. 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)