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Dr. Amit Lakkaraju

Dr. Amit Lakkaraju is a fellowship trained musculoskeletal radiologist working in Melbourne and Geelong. He trained initially in orthopaedics before making the move to radiology in 2004. He has completed two fellowships in musculoskeletal radiology initially at Leeds in 2009 and subsequently from Liverpool in 2010. He has been a practicing radiologist with musculoskeletal and venous subspecialty interest in Australia for 13 years. He has completed a pain medicine degree from the University of Sydney in 2017-2018 and has done a number of courses in interventional pain procedures. He also has done post graduate training in venous disease through the Australian College of Phlebology. His interests include interventional pain management, venous disease, sports imaging and functional imaging in musculoskeletal conditions.

Introduction (00:00 – 01:52)

• 00:00 – Dr. Barrett welcomes Dr. Amit Lakkaraju back to discuss venous insufficiency and disorders
• 00:49 – Show introduction and theme music
• 01:21 – Host mentions previous episode about stellate ganglion blocks and D5W

Venous Insufficiency Overview (01:58 – 04:35)

• 01:58 – Dr. Lakkaraju introduces topic: 20-30% of population has venous insufficiency
• 03:16 – Discussion of pain vs. aesthetic concerns in varicose veins
• 03:41 – Pain symptoms: aching, itching, restless leg, neuropathic disorders
• 04:35 – Saphenous and sural nerve involvement in venous disorders

Nerve Complications and Treatment Methods (05:19 – 08:53)

• 05:19 – <1% incidence of saphenous nerve issues post-treatment
• 06:52 – Comparison of laser vs. radiofrequency ablation
• 07:00 – Laser uses 1000-2000°C, radiofrequency uses 120°C
• 08:40 – Discussion of thermal phenomena affecting adjacent nerves
• 08:53 – Introduction to tumescent anesthesia

Tumescent Anesthesia and Procedure Details (09:40 – 15:26)

• 09:40 – Klein solution composition and thermal protection mechanism
• 10:10 – Tumescent anesthesia acts as thermal guard and mechanical separator
• 11:31 – Great saphenous vein ablation from saphenofemoral junction to knee
• 12:55 – Goal: redirect circulation from superficial to deep venous system
• 13:19 – Valve failure mechanism in varicose vein disease
• 15:26 – Analogy to overflowing river creating marshy surroundings

Sponsor Break (16:00 – 19:19)

• 16:00 – Stem Regen supplement advertisement
• 19:19 – Season 6 giveaway announcement

Venous Anatomy and Physiology (19:33 – 24:45)

• 19:33 – 24 valves in great saphenous vein vs. deep venous system
• 20:44 – Muscular pump mechanism differences between deep and superficial systems
• 22:04 – Spider veins as third venous system with feeder veins
• 22:38 – Local scarring causing venous insufficiency
• 23:31 – Collateralization phenomenon requiring comprehensive treatment
• 24:45 – Sclerotherapy agents: polydocanol (preferred), STS, hypertonic saline

Case Study and Treatment Approach (27:00 – 32:08)

• 27:00 – Dramatic before/after case presentation
• 28:03 – Combined great and short saphenous vein ablation with sclerotherapy
• 28:47 – 90-minute procedure with nerve blocks
• 29:57 – Discussion of unilateral presentation and May-Thurner syndrome
• 32:08 – Importance of venous mapping for treatment success

Venous Compression and Inflammation (32:40 – 34:08)

• 32:40 – Discussion of venous engorgement in fibro-osseous tunnels
• 33:30 – Case example of cyclist with scarring and neuropathic pain
• 34:08 – Phlebitis causing adjacent neuritis theory

Second Sponsor Break (34:08 – 36:39)

• 34:08 – Clean ketone supplement advertisement

Phlebitis and Nerve Involvement (37:09 – 41:29)

• 37:09 – Phlebitis more common than compression theory
• 37:58 – Tarsal tunnel syndrome and posterior tibial vein thrombosis
• 39:36 – Intra-venous vs. extra-venous inflammation mechanisms
• 40:55 – Peri-phlebitic changes causing adjacent neuritis
• 41:29 – All procedures done in clinic setting

Procedure Protocol (41:53 – 47:56)

• 41:53 – Ultrasound venous mapping as gold standard
• 43:50 – 90-minute procedure with nerve blocks and combination treatments
• 45:54 – Post-procedure protocol: compression stockings, walking, follow-up
• 46:04 – Major complication: DVT (1-3% incidence)
• 47:12 – Endothermal heat-induced thrombosis (EHIT) management
• 47:56 – Discussion of Nattokinase as natural anticoagulant

Clinical Insights (48:30 – 50:31)

• 48:30 – Educational discussion about deep vs. superficial venous systems
• 49:42 – Higher DVT risk in patients with varicose veins
• 50:08 – Shift from aesthetic to health concern perspective
• 50:31 – Conclusion and thanks

Key Clinical Takeaways

1. Prevalence: 20-30% of population affected by venous insufficiency
2. Pain Component: Often overlooked – includes aching, neuropathic symptoms
3. Nerve Complications: <1% for saphenous nerve, sural nerve more commonly affected
4. Treatment Evolution: From aesthetic focus to comprehensive health management
5. Procedure Safety: DVT is primary concern (1-3% incidence)
6. Comprehensive Approach: Requires treatment of entire venous network, not just main trunks

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