Debate: Never Perform Thermal and Chemical Ablation in the Same Setting

Ron Bush, MD, FACSMidwest Vein & Laser Center

Dayton, OH

Foam as an Adjunct to Thermal Ablation

• Any situation that may cause failure of thermal ablation with recanalization

• Neovascularity• Perforator• Large refluxing branch

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

Histological changes occurring after endoluminal ablation with two diode lasers (940 and 1319 nm)

from acute changes to 4 months.

(Bush, 2008)

Potential Complications

Treatment of Incompetent Vein of Giacomini (Thigh Extension Branch)

(Bush, 2007)

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

Findings

• 18% of patients (129) had both foam sclerotherapy & thermal ablation at the same time

• No complications noted using this combination

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

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

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%

Always Perform Thermal and Chemical Ablation in the Same Setting

Treatment: Posterior Medial Calf Perforator

Posterior Medial Calf Perforator

Why I Stage Foam Sclerotherapy?

Why I Stage Foam Sclerotherapy?

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)

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)

CPT Codes: 76942 & 36471

Total Reimbursement:

Aetna - $654.40UHC - $323.78Medicare - $294.40

If you perform thermal ablation at the same time, reimbursement is cut in half!

Conclusion

Is Speechless!

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)