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When we talk about vascular health and vascular disease most people think about arteries. When we talk about the circulatory system you have arteries and veins. Arteries carry blood from the heart to the toes and veins are what carry blood back from the toes up to the heart. More specifically in the vein system you have a deep and a superficial vein system. Your deep vein system is considered sacred. It is absolutely necessary. We don’t like to touch it with intervention. It is the one we get concerned about when we talk about blood clots. You can get blood clots in both the deep and superficial vein systems. The superficial vein system isn’t as dangerous if you get a clot in that part of it. The deep vein system runs very close to the bone and that is why we consider it a deep vein system.
The superficial vein system can be pictured like branches of a tree. It comes off that deep vein system in particular areas and it comes closer to the surface of the skin. Not only does it include the spider veins you can see on the surface and the big ropy ones you can see as well, it also exists in a plane of tissue you can’t necessarily see and because you can’t see it people often times mistake it for the deep vein system. In fact it is part of the superficial vein system.When we talk further about vein insufficiency more specifically, that is the area we are targeting when we talk about vein interventions and things we can do to make the legs feel better.
Venous insufficiency affects more age groups and it is ten times more prevalent than peripheral artery disease (PAD). I think the reason it doesn’t get talked about as often as peripheral artery disease is that it is not lethal. You have heart attacks and you can die. You have clots or blockages in the arterial system and you can lose a limb. With venous insufficiency, this is not necessarily the case. Although it can progress and be risky, it is not as life threating as its partner in crime, the arterial system. It is more prevalent than arterial disease. The cost is $150 million in the United States or $1 billion per year worldwide. It is very expensive health care concern, especially now in the United States when we are talking about health care changes and that type of thing. The cost of hospitalization is very high with venous insufficiency because of the incidence of recurring infection and leg wounds / leg ulcers. This is a little more about prevalence of venous insufficiency. About 30 million Americans suffer from it. Only 1.9 million seek treatment and 447,000 of those patients are actually treated. I think some of this has to do with the fact that the treatment for vein insufficiency used to be vein stripping. Vein stripping and vein ligation is very barbaric. People were hospitalized up to six weeks because of the chance of blood clots. Thankfully, in the past 10 to 15 years technology has advanced dramatically and we will talk about those changes a little bit later on.
The biggest and most prominent venous insufficiency factor is genetics. Most people have a parent or grandparents that had bad veins and it passes on down the line. The onset of vein insufficiency in women is about the age of 35 and in men it’s a little older at 45.
Things in women that can make venous insufficiency worse:
In pregnancy, with the increase in blood volume and hormonal shift, this increases the prevalence of the vein insufficiency and speeds up the time. The other thing that contributes to it is hormone replacement. When we first started replacing hormones in women we used to slam them with these huge doses of estrogen and progesterone. Those massive doses increased the incidence of vein insufficiency. It is not so prevalent now with the bioidentical hormones. They have dialed down birth control pills and that type of thing. So now, it is not as much of a factor but it certainly used to be. Things such as smoking, hypertension, and obesity – a lot of those contribute to vascular compromise; however, usually most of those contribute more to the arterial type of disease.
We are going to go through the venous anatomy very quickly. These slides are very specific and get quite more medical than we need to be. Again, we talked about the superficial and the deep vein systems. This is an example of the great saphenous vein (GSV). The GSV comes from inside of the ankle and runs all the way up to the groin where it meets the deep system. Then you have a small saphenous vein (SSV) which starts on the outside of the ankle and runs through the middle of the calf and runs behind the knee. Remember the GSV and SSV aren’t the only two superficial veins in the legs. They are like branches of the trunk of a tree. So from those veins come all of the veins we usually see on the surface of the skin. This is just an example of those branches of a tree. This is your great saphenous vein here and this is two of the larger branches that come off in the thigh. Then you have several behind the leg and down into the calf as well.
So very briefly – what causes vein insufficiency? Essentially I like to relate it to stretching a rubber band out. You can stretch that rubber band out so many times and then you can’t make it regain its elasticity. That is very similar with veins. Because of gravity and values that exist within these veins, once they become weak and dilated, the veins always remain stretched out. For that reason often times we get the symptoms we do. So if we are standing in a stationary position for a long period or if you are sitting for long periods of time, such as on long flights or long drives, the blood settles in pools in these weak veins and that is what causes leg or ankle swelling, night leg cramps, leg fatigue, leg heaviness, restless legs and lower extremity numbness and tingling. Some people progress into itching, recurrent infections of the legs, and then eventually wounds if it progresses to that point.
This is one of the classifications that we use that are required to classify how significant varicose veins are. The reticular veins are the ones you see on the surface of the skin, the little red wispy, almost spider vein-like eruptions. The varicose veins are the larger ones that almost look like little ropes or cords under the surface of the skin. Edema is a fancy word for swelling. A lot of people will get swelling around the ankles. If ankle swelling gets real significant it just builds and progresses up the leg. Pigmentation or eczema - a lot of times with vein insufficiency, when that blood settles and pools in these veins, the skin starts to lose the nutrients it needs to stay healthy on the inside so that the body starts to try to protect its self. It starts to toughen up the skin and then the skin can turn brown. If you are pale or fair skinned, your skin turns a little bit darker. If you are darker complexed, sometimes it will actually turn black. It normally progresses and then you wind up with lipodermatosclerosis, another fancy term. The tissue starts to turn and break down and cause leg ulcers or ankle ulcers.
Let’s get into vein treatments very quickly. Conservative treatments include exercise. The more active you are, the less discomfort you will have in your legs in any vascular condition. If you have arterial disease, you are challenging the arteries to pump the blood further down into the toes so you get better circulation and on the venous side of things, because these veins are weak and dilated and they actually exist outside of the muscle, you have to do everything you can to try to get that blood up to the heart. Being as active as possible is fantastic. If you are sitting in a car for a long period of time, you can do ankle rolls and foot pumps that will help to encourage the blood to get back up to the heart. Any straight leg exercises- if you don’t have bad knees and you can do it, straighten out those legs and flex those muscles. It helps the blood get back up to the heart and it cuts your risks of developing a blood clot. Elevation of the legs also helps. Anything above the heart is the best. If you are sitting on a stool you may not notice as much of a result as if you are lying with your feet elevated.
They are probably the bain of everyone’s existence, especially in Phoenix when it is 115 degrees outside. Nobody wants to think about wrestling with compression stockings, let alone wear them every day. They do help because of the external support helps support these veins and improve blood circulation back up to the heart. A lot of the athletic companies are starting to produce stockings. Runners, football players and baseball players wear them. Actually it is that compression mechanism on the outside of the body that helps the legs feel better – and they come in fun colors. They do help. A couple of misnomers about compression stockings – they do not prevent venous insufficiency from getting worse and they do not keep you from developing additional abnormalities in the veins. The only reason I recommend you wear them is they help with swelling and to cut your risks of blood clots, especially with travel. If you are going to be sitting in a car or plane for longer than two or three hours you need to put the compression stockings on to help support the circulation and cut your risks of blood clots. You need to be fitted for most medical grade stockings. If you go to the grocery store and buy them, they can be extremely tight, particularly behind the knee and that can be very painful.
The Unna boot is a little more extensive. If you have wounds or anything of that sort below the knee then you can utilize those to help with the swelling.
The surgical stripping is what we talked about before. It is completely barbaric in my opinion. They actually use a crochet hook, for those of you who crochet, to go in and physically strip the vein out of the leg. What we have found in the recent ultrasound data is that it actually causes more trauma to the branches of those veins that were stripped out so people develop accessory vein insufficiency at a much higher rate after they have had stripping.
The thermal ablation has been out on the market for approximately 10 years now. There are two types of thermal ablation and if you are interested I have a short video I can show you as to how it is done. Essentially the vein is accessed under ultrasound guidance with a needle puncture. It is almost like when you go to give blood or to have your blood drawn. They puncture your vein with a needle but instead of drawing your blood out we actually insert that ablative technology into the vein we are treating. With the thermal ablation you have to surround those veins with a numbing medicine because, as the name implies, it uses heat energy to close these veins off and that is about the equivalent of 120 degrees Celsius, so not tolerable. Putting our hand on the stove is not recommended. We surround those veins with numbing medicine and as we turn those laser fibers on and it actually closes those veins off from the inside. It is a great technology. There is no down time. With the recovery for that treatment we want you to be as active as possible afterwards and take some anti-inflammatories and be in a compression stocking for about three or four days after the treatment. Some people prefer to wear the compression stockings longer because, honestly, that area is a little bit tender and sore for about seven to ten days. After that three or four day time period it is completely up to you as to whether you wear the compression stocking or not.
There is a radiofrequency technology and a laser technology. They both are the same identical technique. The energy that closes off the vein is slightly different. We use both of these technologies in our office and there are various reasons why you would choose one over the other. Honestly, the end result is identical. They work very nicely.
The newest technology, which I think is very cool, is called non-thermal, non-tumescent closure. The reason it is called that is you don’t have to use heat energy to close the vein off. Tumescent is a fancy name for numbing medicine. There is one company that makes it and that is Medtronic. You access the vein under that same needle puncture with ultrasound guidance but instead of closing the vein off inside with a heat technology you actually use an adhesive to close these veins off from the inside. There was a neurosurgeon that was closing off malformations in the brain with the same adhesive and he thought – if I can inject this into the brain, why can’t we close veins off with it. They changed the velocity of this adhesive and it works extremely well. After the VenaSeal procedure, you don’t have to wear compression. The down time is slightly less than thermal ablation because there is not the same inflammatory responses that goes along with that vein closure. I think that this is probably, in the long run, going to be the preferred technology.
The down side with it now is it is so new the insurance companies haven’t come up with CPT billing codes for it yet. I am hopeful in the next year we will be able to bill for that as well. The other plus with the adhesive closure is you can treat several veins at the same time, whereas with the thermal ablation technology, you can only treat 2 veins at a time. If you have multiple veins that are abnormal that means multiple visits to the office which is much more time intensive from a patient’s perspective. With the adhesive closure you can treat up to, very technically, 100 cm of vein at a time. For most people, it means getting both legs taken care of in the same day.
The final treatment is the sclerotherapy. This is a big blanket term for a solution we inject into the veins you can see on the surface of the skin. There are different doses of that same sclerosant and there are different chemicals you can use. It is the same as people used to call saline. It is not a saline solution it is something called sodium tetradecyl, but because it had sodium in it people equated it to salt so it started being called saline. It is not saline it is actually considered a detergent. It is an irritant to the vein and it actually closes the vein off from the inside. It is a very nice adjunct to these other technologies if you have larger underlying vein insufficiency. If you have little wispy spider veins and you don’t have any underlying issues you can use the sclerosant and it works very nicely. If you have larger underlying vein disease it is kind of like pulling leaves off a tree to trim it, they just grow right back because that pressure underneath is still there and it washes that solution right out of those veins – so it fails.
This is an illustration of the thermal ablation. This is the laser technique, EVLT. It is a direct beam laser and it is a continuous pullback method and you deliver so much energy per centimeter to get successful closure of the vein and that is based on a certain number of variables. As long as you go to somebody who is knowledgeable in this technique the results should be fantastic without any risks of complications.
The radiofrequency closure, RFA, is a different type of thermal closure and it actually closes within the 7 cm little coil. Instead of it being a direct beam laser this is a segmental closure so you actually close 7 cm, pullback a little bit and close another 7 cm.
This just briefly talks about the efficacy of the thermal ablation closures. Honestly they are very parallel between laser and thermal. Studies show about a 96% success rate. Honestly, I think ours is a little bit higher. I haven’t seen an incidence of these veins reopening. We have a gentleman who comes in and his veins are just massive and he doesn’t behave himself. Leave it to the guys to misbehave. Then, the vein has a higher risk of reopening. I haven’t had any women with these veins having had one of these treatments and the vein has reopened.
These are some complications with varicose vein ablation. Honestly, we don’t see much of it. Bruising is the biggest one. If you bruised before the procedures you will bruise with the procedures. We just recommend the use of Arnica. It comes in a gel, a tablet and cream form. It works very well, even if you bump into something and bruise your arm, put a little Arnica on it and it helps break down the bruises.
I wanted to briefly go over how we diagnose venous insufficiency. When you come in for an office visit we ask you to fill out a screening form. This form is in the folders you have. We like to evaluate what types of symptoms you have. Often times people have not just one type of vascular disease but both. We like to evaluate for arterial and venous disease. Arterial disease symptoms are very specific and venous disease symptoms are very specific. If we can find out which bothers you the most and pair that with a thorough ultrasound we can better tell you what treatment options you have and what is going to be best to make your legs feel better. When we look at veins on ultrasound we look at time and we know anytime blood settles in pools it causes increased risks of deep vein thrombosis (DVT) or blood clots. When we cut ourselves, our blood pools and that is what helps us stop bleeding. When blood pools in these veins we know that it has a higher risk of clotting and that is why we like to evaluate for chronic venous insufficiency. Not just from a symptomatic perspective but also risks. What we look at – what Karlea looks at on ultrasound, because she is the ultrasonographer, is time. So the veins should get the blood back up to the heart in a timely fashion. What is that threshold – a half a second. Blood should not pool in an area of a vein for more than half a second. We have some patients who come in and are very symptomatic and they have one or two seconds of reflux or backflow of the blood until the pressure builds up enough to get it going forward. We have some patients that have upwards of seven seconds of pooling of blood. Seven seconds is a long time. Usually when you cut yourself and you hold pressure on it for a few seconds it starts to clot. When we get upwards of six or seven seconds we get more concerned about the risks of blood clots.
So now that we have defined, "varicose veins are caused by..." we look at varicose vein treatment. The reason to treat these diseased veins are symptomatic – leg swelling, leg fatigue, leg heaviness and leg aching. Nighttime leg cramps is a big one, especially in the calves. A lot of people think that is an electrolyte imbalance, but for people that have chronic venous insufficiency, often times their night leg cramps are associated with vein disease, not an electrolyte imbalance. That is one of the things we can evaluate on an ultrasound. Restless legs is another one. If you have a hard time getting to sleep at night and your legs feel like you need to be up dancing that can be associated with vein insufficiency. Chronic wounds – if you bump you chin and it flat out doesn’t heal and it has been around for a couple of weeks or a month and you feel like it should be gone – that pooling of the blood can increase healing time and that is why the wound will not go away. Also recurrent infections of the skin, usually below the knees, is another symptom. The combination of all of these factors can cause recurrent skin infections. 07/21/2016
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