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Dr. Cynthia Shortell (Durham, NC). I would like to start by commending Dr. Marston and his colleagues on an extraordinarily thoughtful, well-organized, and scientifically sound paper about a highly relevant topic to those of interested in venous disease. Specifically, the authors address the relevance of deep reflux in the setting of the treatment of superficial reflux. In the 1990s, Dr. John Bergan was one of the first people to identify the fact that some deep reflux can be corrected by treating superficial reflux. While a large percent is corrected, there are a significant number of patients with deep reflux in whom superficial ablation does not correct their deep reflux. In this paper, Dr. Marston and his colleagues finished that thought very nicely by identifying the means by which patients who will improve and those that will not can be differentiated. I do have a few questions for the authors. First of all, duplex evaluation does not provide optimal evaluation of iliac vein involvement; and specifically one is concerned about iliac vein obstruction, and you did mention a significant number of your patients had a secondary etiology. Albeit infrequently, this can play a significant role in looking at infrainguinal reflux and its presence changes the management of this problem markedly. How do you decide in your practice whether or not to look for iliac vein lesions such as stenosis and occlusion and how often is this necessary in your opinion? Next, in the manuscript I was surprised to see that you didn't specifically discuss perforator status on your patients. Do you routinely look for them, and what role do you think perforators play in the improvement of symptoms and the change in VFI after ablation? Specifically, do you think that the treatment of perforators ever changes a high MRV to a low MRV? I was wondering if that might be a way to change the prognosis for some of those high MRV patients. I was interested in the fact that you treat all patients with varicose veins at the time of your EVA; we actually do a staged treatment. I was wondering if that reflected the fact that you were in the camp that believes all patients with varicose veins should have them removed if they are large because they serve as a later reservoir for reflux and they contribute to recurrence, or whether this was more of a convenience of practice protocol. I also wanted to know how hard the measurement of MRV was for a non-academic lab as most venous labs are. Is it something that could readily be applied in general practice so that the non-academic practitioners could use this as a way of differentiating the appropriate from the nonappropriate patients, although one wonders if that is something that one wants to do. Then, what is your follow-up protocol? You addressed this a little bit in one of your slides. Do you use the VCSS and the VFI as sort of a screening tool to do follow-up duplex? We know that a significant number of patients will progress or recur after treatment and I was wondering if you do any routine follow-up duplex of the entire venous system or only as clinical symptoms warranted. Lastly, I was interested in knowing what your personal practice is now. Do you offer ETA with patients with the high MRV? What is your percentage of indication for deep venous intervention, what sort of intervention do you use? Have you had any experience with percutaneous valves?

Dr. William Marston. Thank you Dr. Shortell for those insightful comments. We do look for iliac vein obstruction and perforator involvement in all limbs with venous insufficiency. Since Drs Raju and Neglen have educated us on the frequency of iliac involvement, we have become more aggressive in looking for and treating iliac outflow obstruction. Our thoughts on incompetent perforators have been well documented in the past in a study in which we found that the majority of incompetent perforators are no longer incompetent after superficial surgery and varicosity ablation alone. So our preference is to treat the superficial disease first, and if the perforators remain, we will treat them later. We have not yet studied the effect of iliac vein stenting or perforator ablation on MRV, but I think that is an excellent question. I personally like to take the varicosities for the more severe patients, the classes 4-6, and get all those out of there up front. For less severely affected patients, you can manage the varicosities however you want based on your practice situation and your patients' preferences. The MRV is not a difficult measurement to make and if you just look at the reflux waveforms instead of just looking at a report, it is easy to tell the difference between a low and high MRV. It is an easy measurement for the vascular technologists to do and it doesn't take much time, less than 20 seconds per tracing. Basically, my practice now is to always consider ablating the superficial system in patients with combined deep and superficial disease as it is possible to get some improvement even in the severe cases. But I think it is really important to tell the patients ahead of time that if they have a high MRV it is possible that their symptoms may not improve entirely. You might need to perform further intervention to correct their symptoms. In higher risk patients with combined disease and a high MRV, it may be better to avoid superficial intervention as there is a lower chance of symptomatic improvement.