Lower Extremity Venous Disease and Treatment of Post-Thrombotic Syndrome

Treatment for lower extremity venous disease (including varicose veins and ulcers) includes:

• Venous ablation for reflux (thermal, non-thermal)
• Phlebectomy / high ligation and stripping
• Sclerotherapy
• Venography and intervention (iliocaval stenting, renal vein stenting, ovarian vein& embolization)
• Open venous bypass / endophlebectomy

Patient History 

Chronic Venous Insufficiency (CVI) manifests as leg swelling, varicose veins, and in more advanced stages skin changes and ulceration. Patients complain of various degrees of pain,  aching, heaviness, itching, burning, swelling, and bleeding affecting the lower extremities. The symptoms are exacerbated by prolonged standing, activity, and heat and are more pronounced at the end of the day compared to the morning. Leg elevation and compression bandages may alleviate symptoms.  

A history of venous thromboembolism (VTE), May-Thurner syndrome (MTS)/Non-thrombotic iliac vein lesion (NIVL), pelvic radiation, or pelvic malignancy should be sought.  

Patients complaining of pelvic pain, especially premenopausal women with irregular menses,  pelvic heaviness, or dyspareunia could have pelvic congestion syndrome or nutcracker syndrome.  The differentiation of pain related to venous disease from other common causes of lower extremity pain such as arterial, musculoskeletal, and neurogenic etiologies is essential.¹¹⁸ In addition, inquiring about the impact of symptoms on quality of life (QOL) and addressing cosmetic concerns is crucial to set the expectations of any therapy.  

Physical Examination 

A thorough exam of the lower extremities should focus on the presence of edema around the ankles, the pattern of varicose veins or spider veins, and skin changes (lipodermatosclerosis).  Varicose veins in the inguinal, perineal, or lower abdominal area should raise suspicion of outflow obstruction or pelvic congestion syndrome.¹¹⁹ Palpating a thrill or auscultation of a bruit can be related to arteriovenous malformation or arteriovenous fistula. On the other hand, non pitting edema affecting the dorsum of the foot, squaring of the toes, and skin thickening are suggestive of chronic lymphedema.  

Venous ulcers typically affect the malleolar area. Tenderness and erythema can be a sign of acute infection or thrombophlebitis. Examination of the pedal pulses is important to rule out concomitant peripheral arterial disease (PAD) prior to prescribing compression therapy. The  clinical staging can be done using the CEAP classification (clinical class, etiology, anatomy, and pathophysiology) and severity of disease can be assessed using the revised Venous Clinical  Severity Score (VCSS).¹²⁰ 

Imaging 

Duplex scanning of the lower extremities is recommended as a first line diagnostic test in all patients with CVI.  Ultrasound can detect acute and chronic deep vein thrombosis (DVT).¹²¹ 

It can also provide a detailed map of the superficial and perforator veins with size and degree of valvular reflux when present. Reflux time ≥ 0.5 second is considered abnormal in the superficial veins and ≥ 1 second is abnormal in the deep veins. A pathological perforator is defined by a  diameter of ≥ 3.5 mm and reflux ≥ 0.5 second located beneath an active or healed ulcer. Blunting of respiratory variation in the common femoral vein is suggestive of venous outflow obstruction.  In thin patients, ultrasound can also be used to evaluate the iliac veins and the inferior vena cava  (IVC) for obstruction, as well as ovarian vein reflux in patients with pelvic venous congestion.¹²² 

Alternatively, cross-sectional imaging using computed tomography venogram (CTV) or magnetic resonance venogram (MRV) can characterize the relationship of the veins and arteries and define the anatomy of other clinically relevant processes (e.g., tumor, lymphadenopathy, retroperitoneal fibrosis, arteriovenous fistula, non-thrombotic iliac vein occlusion, etc.).  

Medical Management and Lifestyle Changes  

The first-line treatment for patients with CVI is compression therapy in the form of elastic  stockings, wraps, or paste gauze boots (Unna boots).¹²¹ 

In patients with no significant arterial insufficiency, a grade of 20-30 mmHg is recommended for patients with varicose veins and edema while a higher grade of 30-40 mmHg is recommended for patients with venous ulcers and wounds.¹¹⁹ Stockings are typically put on in the morning and removed at the end of the day prior to going to sleep. Pneumatic compression devices  (intermittent compression pumps) can be used also to decrease the fluid in the lower extremities  and decrease venous hypertension.¹²³ 

In patients with venous ulcers, local wound care with debridement under local anesthesia and systematic antibiotics as needed is essential to promote wound healing. Ulcers that do not improve after 4-6 weeks of wound care and compression therapy or that have atypical features should be biopsied. Intermittent leg elevation, exercise, and weight loss in obese patients have been suggested as lifestyle modifications to alleviate symptoms.  

Horse chestnut seed extract (i.e., aescin) can decrease edema, pain, and itching in patients with  CVI.^119-120 Pentoxifylline, flavonoid drugs (e.g., diosmin and hesperidin) and other venotonic agents have been associated with healing of venous ulcers and improvement of CVI symptoms.^119,120

Risk Stratification for Surgery  

Saphenous vein ablation, phlebectomy, and high ligation with stripping constitute the common procedures for superficial venous reflux associated with large varicosities. Sclerotherapy is typically performed in an office setting without anesthetic. Venous ablation can be performed in an office setting using tumescent or local anesthesia. Patients are awake and the procedure is generally very well-tolerated.  

More extensive varicose vein surgery can be performed with anesthesia in an outpatient surgery center or hospital.¹¹⁹ 

Patients with very large or tortuous superficial veins, or large subcutaneous varicosities are better suited for high ligation with stripping and / or phlebectomy. Similarly, venography and endovascular venous interventions are performed percutaneously as outpatient procedures under local anesthesia and conscious sedation.  

Open venous reconstruction in the form of bypass or endophlebectomy is reserved for patients with advanced CVI and unsuccessful endovascular therapy. These should be reserved to patients  with advanced CVI who are considered fit for major surgery.¹²⁴  

Risk Assessment 

A comprehensive cardiac and medical risk stratification should be performed for patients prior to open venous reconstructive surgery. A multidisciplinary approach to care can optimize outcomes.  Medical specialists and team members can assist patients with risk factor modification, such as smoking cessation, maintaining glycemic control, normalizing blood pressure and lipid levels,  maintaining antiplatelet therapy and fostering participation in exercise programs, thereby promoting a positive patient experience. Discharge planning should also be considered at time of surgical planning.⁷ 

Venous ablation in the office setting is well-tolerated and no additional evaluation prior to the procedure is required. Patients who are receiving anticoagulation do not need to stop this prior to their intervention. Patients undergoing more extensive varicose veins surgery with the use of  general anesthesia could benefit from medical risk assessment and optimization prior to surgery  especially if they have significant comorbidities, are on dialysis, or have high American Society  of Anesthesiologist (ASA) scores.^{119, 125} 

Similarly, patients undergoing venography with local anesthesia and conscious sedation generally do not require additional evaluation. Patients who have significant comorbidities may need risk stratification prior to venography, especially if general anesthesia is considered. Hydration with normal saline or 5% dextrose/sodium bicarbonate before and after the procedure should be considered in patients who are at risk of postcontrast acute kidney injury. 

Preoperative Labs 

No labs are recommended prior to vein ablation.  

Standard CBC, chemistry profile and coagulation profile are recommended before varicose vein surgery involving monitored or general anesthesia, venography, and open venous reconstructive surgery.¹¹⁹ A normal international normalized ratio (INR) should be documented prior to surgery  

and attention is made to renal function in patients undergoing venography with iodinated contrast material.  

Preoperative Medication Adjustment  

No medication adjustment is needed prior to vein ablation. Patients on anticoagulation can continue their regular regimen as the risk of bleeding is extremely low.¹²⁶ 

Patients undergoing more extensive phlebectomy, high ligation with stripping, or venography should hold anticoagulation prior to surgery. 

• Perioperative antibiotics: Prophylactic antibiotics for open procedures should be  considered perioperatively as for any other surgery, and for endovascular interventions on a case-by-case basis. 
• Anticoagulation and its reversal: If patient is on oral anticoagulation preoperatively, then discontinue them as needed before the procedure to minimize bleeding complication.  DOACs should be held for 48-72 hours before procedure. Warfarin should be discontinued 3-5 days in advance. Please consider bridging with parenteral anticoagulation  (UFH or LMWH) in appropriate patients with high thrombosis risk. 
• Nephropathy: Techniques to minimize contrast nephropathy for endovascular procedures in patients with CKD should be utilized. While many different agents have been studied with varying success, only fluid loading has been consistently reported to be associated with better renal outcomes. If there is no contraindication fluid administration pre, intra and post operatively is recommended. The issue to hold ACEs and ARBs is still not resolved and more research is needed.  
• Allergy: Patients with allergy to intravenous iodinated contrast and scheduled for angiography should get premedication with prednisone 50 mg in 3 oral doses at 13 hours,  7 hours, and one hour prior to procedure, and Diphenhydramine 50 mg one hour prior to procedure. Rescue dosing with IV solumedrol or Decadron can be used as needed. CO2  venography can also be considered as indicated 
• ACE Inhibitors: If significant volume depletion is anticipated, it is suggested to hold ACE  inhibitors and angiotensin receptor antagonists on the morning of surgery and restarting these agents after the procedure, once euvolemia has been achieved. 
• Diabetes Mellitus: It is suggested to hold metformin at the time of administration of contrast material among patients with an eGFR of <60 mL/min or up to 48 hours before administration of contrast material if the eGFR is <45 mL/min and restarting no sooner than 48 hours after administration of contrast material as long as renal function has remained stable. Diabetic patients who receive intermediate or long-acting insulin should receive half the scheduled dose when nil per os (NPO) in preparation for surgery.  Glycemic control should be considered per the current guidelines of the American  Diabetes Association.¹⁸ 

Nutrition Evaluation and Optimization 

Optimization of preoperative nutritional status before any intervention is warranted especially in patients with open wounds and ulcers to promote healing.  

Recommended Preoperative Consultations 

Patients with family history of VTE or recurrent episodes of VTE should get a hematology evaluation to identify hypercoagulable conditions and better determine long-term anticoagulation plan.  

Patients undergoing open venous reconstructive surgery should get a formal medical and cardiac risk assessment. There are well-accepted, published guidelines from most of the medical subspecialties to guide the preoperative evaluation, including those from the American Heart  Association and the American College of Cardiology for the optimal preoperative cardiac evaluation for patients undergoing major and moderate noncardiac surgery.³¹

General: Some lower extremity venous procedures can be safely performed without anesthesia involvement.  

The perioperative anesthesia process should include identifying risk factors and potential intraoperative challenges, with particular attention to h/o hypercoagulable state, including h/o  DVT, PE, pulmonary HTN and/or RV dysfunction due to perhaps chronic embolic disease,  edema/infection of the lower extremity, anticoagulation etc. 

No standardized criteria define patients who may benefit from anesthesia care team involvement;  however, commonly used criteria include: 

• Patient factors: High ASA classification due to co-morbid conditions, risk for respiratory or hemodynamic decompensation, inability to tolerate awake procedure (e.g., anxiety,  post-traumatic stress disorder [PTSD]) or lying supine for a prolonged period of time (e.g.,  back pain). 
• Surgical factors: Complex surgery or anatomy likely associated with increased nociceptive stimulation, duration of the procedure, or fluid shifts; concerns for ineffective local analgesia.  

a. Optimization and Risk Assessment 

Patient expectations should be managed and optimized as well. For example, with limited or no sedation, it is prudent to communicate to the patient that, while he/she will feel surgeon’s touch and may hear OR chatter/noise, the benefits of the sparing use of sedatives (e.g., reduced incidence of delirium, better neurocognitive outcomes, decreased risk of intraoperative disinhibition, confusion or restlessness) may outweigh these inconveniences. 

While general anesthesia (GA) may be more desirable to the patient or may be indicated in certain situations (for instance, extensive or long surgeries, need for advanced monitoring, TEE etc.), it can be associated with higher risk of perioperative complications, especially in the elderly.  

b. Anesthesia Management  

i) Anesthesia Techniques  

Local anesthesia (LA) +/- sedation is the technique most commonly used for venous procedures. 

• Tumescent anesthesia: The most popular form of LA. It involves infusion of a solution of normal saline and lidocaine with addition of epinephrine and sodium bicarbonate to provide analgesia. Other preparations can be considered without the use of epinephrine.  
• Sedation: Commonly provided with benzodiazepine, propofol, and/or dexmedetomidine infusion. Notably, avoidance of perioperative benzodiazepines has been recommended to reduce the risk of postoperative delirium.¹¹⁰ Dexmedetomidine, on the other hand, with its lack of respiratory depression may be an attractive alternative. However, when used in high doses, hypotension and/or bradycardia resulting from Dexmedetomidine may outlast its sedative effects leading to prolonged stay in the post-anesthesia care unit (PACU). 
• Opioids: May be added for analgesia/sedation.  

General anesthesia may be required in select patients who are unable to tolerate sedation, be supine for prolonged period of time, or who require a complex surgical intervention. In such patients, LMA, an inflatable supra-glottic device positioned above the vocal cords, is most commonly used. Since LMA does not enter the trachea, it is less stimulating. However, it does not  protect against aspiration. Consequently, it should not be used in patients at risk for aspiration  (e.g., Gastroesophageal reflux disease [GERD], obesity, diabetes, etc.) or in longer cases.  

Endotracheal tube (ETT, “tube”) on the other hand, does provide better protection from aspiration but typically requires deeper levels of anesthesia (+/- muscle relaxation) for placement and subsequent anesthesia maintenance.  

General anesthesia can be maintained using either: (1) Inhalational Agent (“gas”): Sevoflurane,  with a “sweet” smell, is commonly used compared to Desflurane as the latter has a more pungent smell/taste (i.e., avoid in patients with irritable airway). Desflurane was, however, reported to be associated with a faster emergence;^{96, 97} or (2) TIVA (total intravenous anesthesia; commonly consisting of a combination of infusions, e.g., propofol, opioid, lidocaine, ketamine). TIVA has recently become popular because it may be part of intraoperative multimodal analgesia (when ketamine and/or lidocaine infusions are included). TIVA was also found to reduce nausea/anesthesia (propofol).⁹⁸

ii) Monitoring and Access 

Lower extremity venous procedures are generally less invasive, and these patients tend to have  lower co-morbid burden than other vascular conditions/procedures. Consequently, most patients will need only the standard mandated by the American Society of Anesthesiologists including oxygenation (SpO2), ventilation (CO2 monitor), circulation (ECG and BP) and temperature monitoring. In addition, all patients need an adequate IV access and continuous oxygen supply. 

• Indwelling arterial catheter: May be considered in patients with cardiac, pulmonary, renal, or metabolic conditions requiring continuous hemodynamic monitoring and/or  blood sampling. 
• Depth of Anesthesia Monitor (EEG, or EEG-based device): may be considered in elderly  patients at risk, as increased anesthesia depth has been linked with postoperative cognitive  decline and delirium.^{127, 128} 
• Brain Oxygenation: Monitoring using cerebral oximetry (similar principle as peripheral  pulse oximetry) may be considered in patients with history of or at risk for stroke.¹²⁹ 

iii) Intraoperative Concerns 

The intraoperative course is commonly uneventful, though three potential issues should be  mentioned:  

• Hypotension: The cardiovascular changes associated with aging are largely the result of the stiffening of the heart and the vascular system, leading to systemic hypertension, left ventricular hypertrophy, and to a decreased range of acceptable left atrial filling pressures.  As such, intraoperative hypotension should be treated primarily with peripheral vasoconstrictors (e.g., phenylephrine, an alpha-1 adrenergic receptor agonist) and judicious volume administration.¹³⁰ Notably, fluids should be administered based on clinical evidence of hypovolemia, not simply on the basis of hypotension alone.  
• Kidney Injury: While many different agents have been studied with varying success, only fluid loading (while avoiding overt volume overload) has been consistently reported to be associated with better renal outcomes.  
• Hypothermia in the elderly: Thermoregulation becomes impaired with aging.^{69, 70} Thus,  temperature regulation should be aggressively managed.⁷ 

Postoperative pain after lower extremity venous procedures is commonly well-controlled with the intraoperatively administered local anesthetic and over-the-counter non-opioid analgesics,  such as Acetaminophen or Non-steroidal anti-inflammatory drugs (NSAIDS).  

Nontraditional drugs that have been found to reduce postoperative pain and deserve consideration on an individual basis include gabapentin, ketamine, clonidine, and dexmedetomidine.

Some patients may, however, require supplemental opioids in the PACU: 

• Patients with Renal Impairment:^{131, 132} 
  • Fentanyl seems to be safe  
  • Dose adjustments are required when using morphine (active metabolites  accumulate in renal failure), oxycodone (80% metabolized in the liver, 20%  excreted unchanged in the urine), or hydromorphone (metabolized in liver, but 3- glucuronide metabolite can accumulate and produce neuroexcitatory effects) 
  • Codeine (accumulation of toxic metabolites) and meperidine (accumulation of  normeperidine, which may cause seizures) should not be used.  
• Patients with Hepatic Dysfunction:^131-133 
  • Fentanyl seems to be safe  
  • Morphine, hydromorphone, and oxycodone may not be readily converted to active  metabolites  
  • Codeine (reduced pain control as codeine is a prodrug hepatically converted to morphine), methadone (reduced clearance), and meperidine (reduced clearance and prolonged half-life; risk of seizures) should not be used. 

c. General and Procedure-Specific Concerns 

General intra-operative concerns: Skin preparation (CHG wipe timeout for three minutes to dry), Foley placed by trained staff, shaving performed with clippers, normothermia. 

• Sclerotherapy: 
  • No anesthetic technique required. 
  • Shaving typically not required. 
  • Skin prep: Alcohol wipes are typically the only requirement. 
  • Patients at high risk of thrombosis could be treated with a single prophylactic dose of low molecular weight heparin (LMWH) prior to the procedure. 
  • Ultrasound-guided access of the superficial vein can be utilized and sclerosant injected into the target vessels. This can also be used to massage the sclerosant into distant target vessels.  
  • Ultrasound assessment of the deep vein to rule out DVT and the superficial vein to ensure adequate treatment is performed at the end of the procedure. 
• Vein ablation: 
  • Tumescent anesthesia (500ml solution of 445 ml of 0.9N saline, 50 mL of 1%  Lidocaine with 1:100,000 epinephrine, and 5 mL of 8.4% sodium bicarbonate)  is infiltrated under ultrasound guidance in the saphenous sheath for thermal ablations to provide analgesia and to act as heat sink during cauterization of the vein and prevent damage to surrounding structures. Non-thermal ablations can be performed with only local anesthesia at the access site. Additional sedation can be provided at the discretion of the treating physician.  
  • Perioperative antibiotics and venous thromboprophylaxis are not routinely used. 
  • Patients at high risk of thrombosis could be treated with a single prophylactic dose of LMWH prior to procedure.  
  • Ultrasound guided access of the superficial vein is gained. Also, ultrasound is used to position the catheter relative to the junction with deep venous system.  o Ultrasound assessment of the deep vein to rule out DVT and the superficial vein to ensure adequate treatment is performed at the end of the procedure.  
• Phlebectomy, high ligation with stripping: 
  • Anesthetic technique: General anesthesia, monitored anesthesia care (MAC),  conscious sedation with local or tumescent anesthesia. 
  • Perioperative antibiotics are weight-based, and the initial dose should be  administered prior to incision.  
  • Venous thromboprophylaxis could be administered to patients at high risk for thrombosis. 
  •  Mapping of varicose veins: The veins to be removed during surgery are  typically marked while the patient is standing preoperatively. 
  • Alternatively, intraoperative ultrasound can be used to map the location of the target veins.  
• Venography:  
  • General anesthesia, MAC, or conscious sedation 
  • Perioperative antibiotics are not routinely administered.  
  • Venous thromboprophylaxis not routinely administered.  
  • Full dose anticoagulation is administered prior to intervention (balloon angioplasty/stenting) and ACT is maintained above 200 seconds.  
  • Venous access should be performed under ultrasound guidance regardless of  access site (femoral, popliteal, jugular or other)  
  • Contrast volume should be minimized in patients with renal insufficiency by using dilute contrast or CO2 angiography to avoid contrast-associated acute kidney injury. Intravascular ultrasound can further decrease use of contrast agents and is the preferred modality for identifying venous outflow obstruction and sizing of venous stents.  
• Open venous reconstructive surgery:  
  • General anesthesia, MAC 
  • Perioperative antibiotics are weight based and initial dose should be administered prior to incision.  
  • The placement of central intravenous lines and arterial line for hemodynamic monitoring is determined on a case-by-case basis depending on patient comorbidities and expected blood loss.  
  • Full dose anticoagulation is administered prior to clamping the vessels and  ACT is maintained above 200 seconds.

Steps Prior to Discharge 

Venography:  

• Medication: After stent placement, patients are started on antiplatelets (aspirin or  clopidogrel) if they do not receive any antithrombotic therapy prior to procedure. Patients on chronic anticoagulation can resume medications the next day after the procedure.  Anticoagulation is recommended following deep venous intervention/stenting for chronic ilio-caval obstruction although the duration is still in evolution and is not well established and can vary from 4-6 weeks to a year based on local protocols and different clinical trial protocols.  
• Discharge: Patients remain supine for three hours after the procedure and are typically discharged the same day.  

Open Venous Reconstructive Surgery: 

• General: 
• Patients are admitted to a monitored unit and are assessed for patency of flow and bleeding.  
• Perioperative antibiotics are discontinued in 24 hours.  
• Incentive spirometer use is encouraged immediately after surgery and should be performed every hour. 
• Foley catheter is discontinued in 24-48 hours after surgery when accurate assessment of urine output is no longer necessary.  
• Mobilization out of bed is initiated in 24-48 hours after surgery with gradual increase in ambulation as tolerated.  
• Diet can be resumed within 24 hours when patient is awake and there is no concern for aspiration.  
• Glucose control  

Monitoring: Central intravenous lines and arterial lines are removed when hemodynamic stability is established, and invasive monitoring is no longer warranted.  

Wound Care: Sterile occlusive intraoperative wound dressings are changed on postoperative day two. Alternatively, negative pressure dressings can be left in situ for longer period (typically five to seven days).  

Medication: Antithrombotic therapy is resumed as soon as safe, from a bleeding standpoint. Patients at high-risk for thrombosis can be maintained on low dose subtherapeutic anticoagulation started immediately in the operating room.  

Pain Control: Pain medications consists of intravenously narcotics initially and transitioned to oral narcotics as soon as patient is tolerating diet.  

• Physical therapy and pain control should be initiated. 

Steps After Discharge 

Vein Ablation: 

• General: 
  • Patients are encouraged to ambulate after vein ablation and can resume most activities the same day.
  • Compression stockings are placed at the end of the procedure after thermal vein ablation and are recommended for at least 1-2 weeks after procedure. Non-thermal vein ablation does not require compression therapy after the procedure.  
• Follow-up: Follow up call within the first week after surgery. 
• Office / Telehealth Visit:  
  • A visit to assess clinical improvement and check for complications (phlebitis, hematoma formation, infection, nerve injury) should take place within a month.  Patient should be assessed also for the need of additional procedures (e.g., phlebectomy, sclerotherapy).  
  • Patients should receive follow-up ultrasound to document closure (thrombosis) of the vein treated and to rule out endothermal heat induced thrombosis (EHIT) within 1-2 weeks of the procedure.¹³⁴ 
  • Follow up beyond the first visit can be done as needed.  
• Medication: Patients can use Acetaminophen or NSAIDs over-the-counter pain medications as needed.  

Phlebectomy, High Ligation with Stripping: 

• General: Compression therapy typically in the form of an ACE wrap covering the lower extremity from the foot to the thigh is placed at the end of the procedure after phlebectomy and high ligation with stripping. The compression helps tamponade any venous bleeding in the soft tissue caused by avulsion of the veins and prevents hematoma formation and should be applied for one week.  
• Follow-up: Follow-up call within the first week after surgery.  
• Office / Telehealth Visit: Follow-up to assess clinical improvement and check for complications (wound infection, hematoma formation) within a month postoperative, unless indicated sooner.  
• Medication: Patients can use Acetaminophen or NSAIDs over-the-counter pain medications as needed. 

Venography:  

• Follow-up: Follow-up call within the first week after surgery.  
• Office / Telehealth Visit:  
  • Follow up office visit with ultrasound in a month after the procedure to assess clinical improvement and stent patency.  
  • Long-term follow up consists of yearly office visits for clinical assessment and ultrasound if a stent is placed.¹³⁵ 
  • Medication: Patients can use Acetaminophen or NSAIDs over-the-counter pain medications as needed. 

Open Venous Reconstructive Surgery: 

• General: 
  • Incisions at high risk for wound break down (e.g., inguinal) should be covered with an incisional negative pressure dressing or dry gauze dressing on daily basis for 2-4 weeks after surgery.  
• Follow-up: Follow-up call within the first week after surgery.  
• Office / Telehealth Visit: 
  • Follow up office visit with ultrasound in a month after the procedure should be scheduled to assess clinical improvement and stent patency. 
  • Patients with venous ulcer or wounds should continue with periodic monthly follow up until wounds are completely healed.  
  • Long-term follow up consists of yearly office visits for clinical assessment and ultrasound to document patency of the venous reconstruction.  
• Medication:  
  • Upon discharge, patients should be stable on oral antithrombotic therapy.  Alternatively, outpatient therapy with low molecular weight heparin with transition to an oral anticoagulant is an acceptable option.  
  • Narcotic medications are prescribed for pain control with goal to transition to over-the-counter pain medications (Acetaminophen or NSAIDs) as soon as tolerated. 

References