A 23-year-old female triathlete presented with varicose veins in her left calf and knee for 5 years. Physical exam found varicose veins in her left calf and knee up to 6 mm in size, as well as mild swelling in her left calf and thigh. Duplex ultrasound found incompetence in her common femoral vein and varicose veins in her greater saphenous vein, but no deep vein thrombosis. Angioplasty and stenting of her left common iliac vein improved her symptoms and reduced her varicose vein size. Six months later, she underwent ultrasound-guided foam sclerotherapy to further treat her varicose veins for cosmetic concerns.

2. Steve Elias MD FACS
Director, Center for Vein Disease
Englewood Hospital and Medical Center NJ
Clinical case
Iliac vein obstruction

3. History
• 23 y/o female triathlete
• VV L calf & medial knee X 5 yrs.
• Swelling, pain after training, “tight” calf
• Affects ability to train and compete
• Worse end of day and during menses
• Cannot tolerate compression therapy
• No history of DVT or SVT

4. Physical Exam
• Pulses intact when supine
• VV L medial calf/knee – 5-6 mm
• Mild L calf/thigh +2 swelling when standing
• Absent: skin changes, ulcers

5. Duplex US
• No acute or chronic DVT/SVT
• Incompetent CFV (reflux 1.8 sec) phasic flow
• Competent FV, Popliteal vein
• L GSV: SFJ 9mm, mid calf 7.5mm
• VV reflux > 3 secs
• VV: 6 – 8 mm medial calf

6. Management
• 1. EVA GSV and Excision VV
• 2. EVA GSV
• Compression
• 3. Other diagnostic studies?

7. Venogram 1

8. Venogram 2

9. case

10. Area= 108

11. Area =13

12. Area = 418

13. Management ?
• 1. EVA GSV and Excision VV
• 2. EVA GSV
• 3. Angioplasty/Stent
• 4. Angioplasty/Stent & EVA GSV ± Excision VV

14. Actual Management
• Angioplasty/Stent only
• GSV 4 months later 7 mm competent
• Symptoms improved, no pain
• 6 months later had USG foam sclerotherapy of the VV (now
3mm) for cosmetic concerns

15. Teaching Points/Controversies
• Young patient & quality of life issues - triathlete
• Developed VV age 16 yrs. – unusual
• Cannot tolerate compression – outflow
• Some pelvic symptoms
• Stent in a young person
• Need to wait 6 weeks – 3 months for GSV/VV
• High index of suspicion for pelvic issues
• Not sure what is the “right” answer

16. Dr. Elias went for his undergraduate studies at The Johns Hopkins University, then to the Medical
School at SUNY Buffalo NY, where he also did his surgical residency at SUNY, Buffalo Millard
Fillmore Hospital. He did a Vascular Fellowship at Englewood Hospital and Medical Center.
He is the Founder of the American Venous Forum Fellows Course in Vein Disease which educates
graduating physicians about the management of vein disease. His clinical interests include all
aspects of minimally invasive vein care, both procedure development and teaching. Venous
education of new and current practitioners has been the cornerstone of his commitment to
modern vein care and its impact on patient outcomes. Dr. Elias has lectured, written and taught
about vein disease both nationally and internationally. He is also the Founder and Course
Director of the annual Expert Venous Management Summit. He is the Medical Director of VEIN
Magazine and the Medical Editor of the American Venous Forum’s Newsletter, Vein Specialist. He
has been Principle Investigator/Investigator in multiple clinical trials and performed the first in
man ClariVein procedure. He is a Distinguished Fellow of the American Venous Forum, Society
for Vascular Surgery, American College of Phlebology, and the American College of Surgery. He is
a Fellow of the American Board of Venous and Lymphatic Medicine and Fellow of the American
College of Surgeons. He has been the Director of Mount Sinai Vein Center and the Columbia
University Vascular Vein Programs.
Steve Elias MD FACS
Director, Center for Vein Disease
Englewood Hospital and Medical Center NJ
Commentary Dr. Nicos Labropoulos, Director of ScIENCE
Dr. Elias has done a great deal on venous education in US and the world. He has championed courses both for the
Trainees and the specialists. At the same time he has been an Editor for various Vein journals running them with his
common sense, wisdom and humor! Definitely he is one of the world ambassadors on vein disease.