Relationship-Building Between The Wound Clinic & Vein Center: Q&A Session

In this exclusive interview, Caroline E. Fife, MD, FAAFP, CWS, FUHM, medical director of St. Luke’s Wound Clinic, The Woodlands, TX, and Today’s Wound Clinic clinical editor, speaks with Joseph T. Jenkins, MD, FACS, RPVI, RPhS, RVT, ABVLM (Diplomate), CWSP, from the Tri-State Vein Center, Dubuque, IA, about best approaches to collaboration between wound clinics and venous specialists.

Caroline Fife (CF): More than 50% of the wounds we see are not in the distribution of the great saphenous vein (GSV). Does ablation help those? 

Joseph Jenkins (JJ): “Venous ulcers are generally located about the medial aspect of the lower leg and medial malleolus. Areas exposed to trauma, such as the anterior shin, can easily develop venous ulcers. If an ulcer is noted in the region of the lateral malleolus, venous insufficiency within the distribution of the small saphenous vein might be the reason. One rarely sees venous ulcers arising above the knee.  Venous ulcers are not associated with the plantar aspect of the foot. Endovenous ablation procedures are not just performed on the GSVs. A vein specialist will thoroughly evaluate the patient with a venous duplex ultrasound. The veins causing the patient’s problem will be identified. Ablation procedures directed at the veins showing insufficiency and associated with the ulcer are beneficial in the wound management.”

CF: Is ulcer location a factor at all in patients who I would refer from the wound clinic?

JJ: “With the reports of 70-90% of leg wounds having a venous component, one needs to evaluate the extremity for the source of the insufficiency.¹ The GSV accounts for a majority of venous reflux. However, venous reflux involving other truncal veins, such as the small saphenous vein, anterior accessory saphenous vein, or posterior accessory saphenous vein, may be the reason behind venous ulcers outside of the great saphenous distribution. Another reason for an ulcer outside the region of the GSV is a perforating vein. These veins connect the superficial veins and deep veins. Valvular incompetency within the perforating veins plays a large role in chronic venous ulcers. A perforating vein may be identified under the ulcer bed or nearby. They can be remote to the wound and give rise to varicosities about the ulcer. Endovenous ablation of the source of the venous insufficiency is beneficial to healing.”  

CF: When I order a venous duplex scan from my hospital’s vascular lab, the information in the report is “no deep vein thrombosis (DVT).” I know the patient will still undergo complete venous imaging as part of the evaluation for ablation. I reason that, since I don’t need a venous ultrasound to initiate compression in a patient who has no symptoms of a DVT, there’s no reason for me to get one at all. I’ve stopped getting venous imaging. Instead, I just refer the patient to a vein specialist. Is there anything wrong with this logic (patients without any symptoms of an active clot)?

JJ: “The majority of hospital venous ultrasounds are to rule out a potential life-threading DVT. In the face of an acute DVT, concern about dislodging the clot is on everyone’s mind. Referral to a specialist who does thrombolysis for treatment of an acute DVT is definitely appropriate. Compression for the treatment of the swelling that accompanies venous ulcers, along with meticulous wound care, has been the hallmark of wound healing. The logic of referral to a vein specialist for the definite venous duplex ultrasound is spot on. The ultrasounds performed in my office involve imaging of the deep and superficial veins of the legs. We are looking for problems within the deep system to include acute and chronic DVT, occlusion, stenosis, or venous insufficiency. The superficial truncal veins, tributary veins, and perforating veins are evaluated for problems. A detailed map of the veins causing the patient’s venous insufficiency is constructed. This type of detail is only going to be obtained from a vascular ultrasound lab under the direction of a vein specialist.” 

CF: I can’t figure out when is the best time to refer patients with venous ulcers. Do you recommend that we refer patients with active ulcers on Day 1, or is any time in the clinical course OK?

JJ: “The best time for referral would be before the development of a venous ulcer. However, that is unrealistic. The first time that patients know they have a problem is after the ulcer develops. I am of the belief that the earlier the patient is referred for definitive care, the better the patient’s outcome. The ulcer does not need to be healed before I perform endovenous ablations. Even with the endovenous ablation procedures complete, meticulous wound management and compression therapy will need to be carried out. The goal for treatment of the venous insufficiency is twofold: 1) reduction in ulcer recurrence and 2) shorter time to wound healing. One study that compared GSV surgery with compression to compression alone in patients living with chronic venous ulcers showed a reduction in ulcer recurrence rates.² A current trial is looking at the question, ‘Does early endovenous ablation expedite ulcer healing?’³ The estimated completion date is June 30, 2019. My experience is that there is benefit.”

CF: What about massive circumferential ulcers, or ulcers with very high biofilm?

JJ: “My experience has been that, even with these types of wounds, endovenous ablation procedures are beneficial. As stated before, the ulcer does not need to be healed before I carry out the various endovenous ablation procedures. The source of the venous insufficiency needs to be treated.  Vein specialists and wound specialists must have a synergistic relationship (ie, wound specialists providing the local ulcer care and the vein specialist treating the underlying venous etiology for the ulcer).”

CF: What about patients on anticoagulants? Do you have to stop those before you do the interventions?

JJ: “I do not stop anticoagulation medications prior to intervention. The majority of the interventions require small stab incisions or needle punctures. The patients taking anticoagulation medications may experience more bruising than those who are not on these meds. I have heard of patients with atrial fibrillation being taken off Coumadin for the endovenous ablation procedure, and the patients experienced a stroke. The endovenous ablation procedures have a low-risk profile. Why subject a patient to a complication of this magnitude?” 

CF: Are there any absolute contraindications for ablation? I am looking to spare the patient the trouble of being referred.

JJ: “The only absolute contraindication for performing endovenous ablation would be a patient who has had a history of a major DVT and chronic thrombus occluding the entire deep vein system of the leg, to include the iliac veins. The superficial vein system is providing the conduit for blood return. One does not want to shut down the superficial veins in such a person. The only way to identify such a patient starts with a thorough venous duplex ultrasound. Thus, even this patient warrants a referral. As an aside concerning these types of patients, there are centers that are providing advanced interventions that remove the old thrombus from pelvic veins along with venous stenting to help these patients.” 

CF: We’d like to keep better records of the procedures that are done. We don’t always get good communication from vein doctors. Can you help? 

JJ: “The closing of the referral loop is a significant problem. The prior Meaningful Use program and now the Medicare Access and CHIP Reauthorization Act/ Merit-Based Incentive Payment System continues to address the issue. My opinion is that the Centers for Medicare & Medicaid Services (CMS) only puts the onus of this problem on the referring providers by requiring that the physician transmit the patient’s medical record electronically. As a specialist, I rarely refer a patient to another provider. I am excluded from reporting this measure. I should have been required to send notes and procedure reports back to the referring physician. Thus, the referral loop would easily be closed and the requested information about which procedures the patient had done would be readily available to you.”

CF: Could you provide some sort of form or checklist with the most common interventions, so we could know what you did?

JJ: “I operate a one-doctor vein practice. My practice’s lifeblood is referrals. I do my best to send letters to referring physicians with details about the care the patient received. The procedures include endovenous ablation of truncal veins (radiofrequency, laser, mechanochemical, non-compounded chemical ablation, and adhesive closure). Tributary veins would be treated with phlebectomy (removal) or sclerotherapy. The perforating veins for the most part are treated with thermal ablation techniques or ultrasound-guided sclerotherapy. The checklist is a great idea. My recommendation again would be to develop the synergistic relationship with your vein specialist. He/she should comply with requests for information. If not, consider another provider.” 

CF: What kind of information is useful to you when we refer patients from the wound center?

JJ: “Information that deals with the duration of the ulcer, current wound management, compression techniques in use, prior vein treatments, medications, wounds size, history of DVT, history of venous ulcers, and reports from any peripheral arterial studies that may have been ordered are things that come to mind. This information, along with the venous ultrasound report I need to submit to health insurance companies for prior authorization of the vein treatment.”

CF: Patients often ask, “Will this procedure make my wound heal faster?” I don’t think we can say “yes.” What would you say?  

JJ: “I believe that endovenous ablation of the source of the venous insufficiency does help the healing process. The literature is lacking. As stated before, there is a study in progress to try and answer this question.³ I am also involved with the American College of Phlebology’s PRO (physician and patient reported outcome) Vein Registry. Currently, there are more than 100,000 patient encounters from multiple centers. Data concerning all my patients with vein problems to include those with venous ulcers are being collected. As this specialty registry grows, the hope is that questions like this can be readily answered.” 

CF: Patients often ask, “Will this keep my wound from coming back?” I think the answer is “maybe,” because I am seeing more patients coming back to me for wound care who had an ablation previously. What would you say? 

JJ: “I agree with the ‘maybe’ answer. The hope is that we can reduce the number of recurrences and the length of time between recurrent ulcerations. Another aforementioned study did show a reduction in recurrence rates for venous ulcers when GSV surgery with compression was compared to compression alone.² There are numerous connections between the deep vein system and the superficial vein system of the leg. I see about 30% of my patients back with recurrent venous reflux problems. That number includes patients with and without venous ulcers. With the different techniques available to treat recurrent venous insufficiency today, we are able to intervene with minimally invasive procedures to the source of the recurrence.” 

CF: Patients living with venous ulcers ask, “If I have this done, will I still need to wear compression?” I say, “Yes, but maybe not as strong a compression garment.” Is it reasonable to assume that a patient with a venous ulcer will still need to wear compression after an ablation?

JJ: “The answer you give the patient is the same that I give my patients. We are creatures that should not be standing upright in one place for long periods of time or sitting with our feet in a dependent position for a long period of time. However, that is where we function most of the time. My patients who have undergone endovenous ablation for a venous ulcer are instructed to wear knee-high compression stockings (30-40 mm Hg compression) daily. That being said, there are significant numbers of patients who are not compliant with this recommendation. In these patients, any compression is better than none. I get a fair number who will wear 20-30 mm Hg knee-high compression stockings.” 

CF: Medicare coverage policy on ablation is specific. Can you provide a simple guide to the criteria for which Medicare covers venous intervention?

JJ: “The criteria concerning medical necessity used by Medicare for endovenous ablation procedures depends on where one practices. I practice in Iowa. WPS Health Solutions in Madison, WI, handles my claims.  A vein practice in Dallas, TX, has a different Medicare managing partner. That partner uses different criteria. In 2017, CMS called a meeting of the prominent vein specialists in the country to see if national guidelines/criteria could be established. After the meeting, the consensus was that there was a scarcity of literature to set definitive criteria for vein care in the Medicare population. Patients with venous ulcers are looked at differently by health insurance providers. I believe this is secondary to the financial burden that venous ulcers place on the healthcare system. Medicare data for 2014 reported a spending of $1.02 billion for venous ulcers, and when the ulcer was infected the total spent was $1.5 billion.⁴ This data did not include private payers. Medicare does not preauthorize venous ablation procedures. I make sure to document the same information that my private payers are requiring for my Medicare patients. Therefore, regarding the request for the information concerning what I need from a referring wound specialist: I can’t remember a denial from a health insurance company concerning a patient with a venous ulcer.” n

References

1. Fife C, Walker D, Thomson B, Cater M. Limitations of daily living activities in patients with venous stasis ulcers undergoing compression bandaging: problems with concept of self-bandaging. Wounds. 2007;19(10):255-7.

2. Barwell JR, Davies CE, Deacon J, et al. Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): randomized controlled trial. Lancet. 2004;363(9424):1854-9.

3. Early Venous Reflux Ablation Ulcer Trial (EVRA). ClinicalTrials.gov. Accessed online: https://clinicaltrials.gov/ct2/show/NCT03286140

4. Nussbaum SR, Carter MJ, Fife CE, et al. An economic evaluation of the impact, cost, and medicare policy implications of chronic nonhealing wounds. Value Health. 2018;21(1):27-32.