Varicose Veins and Venous InsufficiencyInsufficiency · PDF fileVaricose Veins and Venous Varicose Veins and Venous ... Venous Insufficiency ... determine which treatment is best suited

Spotlight Series: Interventional RadiologySpotlight Series: Interventional Radiology

Varicose Veins and Venous Varicose Veins and Venous InsufficiencyInsufficiency

What is venous insufficiency?What is venous insufficiency?

Spectrum of DiseaseSpectrum of Disease

Spider veins and Spider veins and telangiectasiastelangiectasias

Small reddish and purple veins near the Small reddish and purple veins near the skin surface (treatment usually consideredskin surface (treatment usually consideredcosmetic and not reimbursed by insurance)cosmetic and not reimbursed by insurance)


Reticular veinsReticular veins

Blue or green deeper veins under the Blue or green deeper veins under the skin surface (treatment usually consideredskin surface (treatment usually consideredcosmetic and not reimbursed by insurance)cosmetic and not reimbursed by insurance)


Varicose veinsVaricose veins

Large bulging veins that are easily palpableLarge bulging veins that are easily palpableto the touch (usually symptomatic and to the touch (usually symptomatic and treatment most often covered by treatment most often covered by insurance)insurance)


Venous ulcersVenous ulcers

Breakdown of the skin related toBreakdown of the skin related toFailure of the venous system and Failure of the venous system and Venous insufficiency (usually Venous insufficiency (usually symptomatic and treatment mostsymptomatic and treatment mostoften covered by insurance)often covered by insurance)

Common myths and misconceptions Common myths and misconceptions surrounding varicose veinssurrounding varicose veins……

““They are something I will have to learn to live withThey are something I will have to learn to live with…”…”““They are only of cosmetic concernThey are only of cosmetic concern…”…”““There is nothing I can do about themThere is nothing I can do about them…”…”““I donI don’’t want to undergo major surgeryt want to undergo major surgery…”…”““My doctor said he doesnMy doctor said he doesn’’t treat themt treat them…”…”““Just elevate your legsJust elevate your legs…”…”““DonDon’’t treat these veinst treat these veins……you might need them later for heart you might need them later for heart surgerysurgery…”…”

Prevalence of Venous InsufficiencyPrevalence of Venous Insufficiency

Venous disease is more common in women and increases with age.Venous disease is more common in women and increases with age.

Coon WW et al. Venous Coon WW et al. Venous ThromboembolismThromboembolism and Other Venous Disease in the Tecumseh Community Health Studyand Other Venous Disease in the Tecumseh Community Health Study. Circulation 1973; 48:839. Circulation 1973; 48:839--846.846.

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40

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20-29 40-49 60-69

Women

Men

Causes of Varicose Veins and Causes of Varicose Veins and Venous InsufficiencyVenous Insufficiency

HeredityHeredityThere are no specific There are no specific ““varicose vein genesvaricose vein genes””, but they , but they do tend to run in familiesdo tend to run in families

OccupationalOccupationalThose with jobs requiring long periods of standing Those with jobs requiring long periods of standing are more commonly affectedare more commonly affected

Causes of Varicose Veins and Causes of Varicose Veins and Venous InsufficiencyVenous Insufficiency

Sex and hormonesSex and hormonesDuring the menstrual cycle veins become more During the menstrual cycle veins become more distensible (dilated) due to hormonal influencedistensible (dilated) due to hormonal influencePregnancy causes the veins to distendPregnancy causes the veins to distend

AgeAgeParts of the vein wall thin and lose elasticityParts of the vein wall thin and lose elasticity

Common SymptomsCommon Symptoms

Leg heaviness and achingLeg heaviness and achingExercise intoleranceExercise intolerance““RestlessRestless”” legslegsNight crampsNight crampsEdema (swelling)Edema (swelling)ParesthesiasParesthesias ((““pins and needlespins and needles”” sensation)sensation)Pain or tenderness along the course of a veinPain or tenderness along the course of a veinSkin changesSkin changes

Edema and Edema and hyperpigmentationhyperpigmentation (swelling and darkening of the skin)(swelling and darkening of the skin)Stasis dermatitis (skin becomes rough, dry, scaling, thickened)Stasis dermatitis (skin becomes rough, dry, scaling, thickened)ulcerationulceration

Common SymptomsCommon Symptoms

Symptoms generally are least in the morning and Symptoms generally are least in the morning and worsen throughout the dayworsen throughout the dayWorsened by long periods of standingWorsened by long periods of standingPeople often report use of over the counter People often report use of over the counter medication and support stockingsmedication and support stockingsVeins often worsen during pregnancyVeins often worsen during pregnancyProgressive worsening of veins and symptomsProgressive worsening of veins and symptoms

Superficial Venous InsufficiencySuperficial Venous InsufficiencyEtiology of Primary DiseaseEtiology of Primary Disease

Normal valves in the veins allow blood to flow Normal valves in the veins allow blood to flow only towards the heartonly towards the heartAs these valves fail and no longer function, As these valves fail and no longer function, blood flow and pressure can now flow back blood flow and pressure can now flow back towards the feettowards the feetVeins in the leg dilate and varicose veins formVeins in the leg dilate and varicose veins formDeeper veins act as the Deeper veins act as the ““root of the problemroot of the problem””and cause veins near the skin to dilate and cause veins near the skin to dilate –– these these are the varicose veins that we see and feelare the varicose veins that we see and feel

Superficial Venous InsufficiencySuperficial Venous InsufficiencyEtiology of Primary DiseaseEtiology of Primary Disease

Superficial Venous InsufficiencySuperficial Venous Insufficiency

Ultrasound shows a dilated vein arising in the deeper tissues Ultrasound shows a dilated vein arising in the deeper tissues –– this this is the is the ““root of the problemroot of the problem”” causing more superficial veins to causing more superficial veins to

dilatedilate

Superficial Venous InsufficiencySuperficial Venous Insufficiency

This ultrasound image shows reversal of the normal flow This ultrasound image shows reversal of the normal flow direction and shunting of blood towards the feetdirection and shunting of blood towards the feet

Surgical Ligation and StrippingSurgical Ligation and Stripping

Traditional therapyTraditional therapyPossible complications of surgeryPossible complications of surgery

Paresthesia, infection, bleeding, scars, blood clotsParesthesia, infection, bleeding, scars, blood clotsProlonged recovery periodProlonged recovery periodIncreased costsIncreased costsGreater risks and costs associated with general Greater risks and costs associated with general anesthesiaanesthesia

Endovascular Varicose Vein RxEndovascular Varicose Vein Rx

Therapy of varicose veins has been Therapy of varicose veins has been revolutionizedrevolutionized by endovascular by endovascular

techniques such as techniques such as endovenousendovenous laser laser therapy.therapy.

Endovascular Varicose Vein RxEndovascular Varicose Vein Rx

The search for less invasive techniques to treat varicose The search for less invasive techniques to treat varicose veins has led to the development ofveins has led to the development of

EVLT EVLT –– use of laser to treat veinsuse of laser to treat veinsUltrasound Guided SclerotherapyUltrasound Guided Sclerotherapy

(liquid and foam)(liquid and foam)

Diomed 810 nm Diode Laser

EVLT ProcedureEVLT Procedure

EVLT procedure replaces more invasive EVLT procedure replaces more invasive traditional surgerytraditional surgeryThe procedure uses laser to The procedure uses laser to ““sealseal”” the veinthe vein

PostPost--procedureprocedure

Ultrasound confirms closure of the treated veinUltrasound confirms closure of the treated vein

Other Treatments of Varicose VeinsOther Treatments of Varicose Veins

PhlebectomyPhlebectomy

Used on larger varicose veinsUsed on larger varicose veinsAfter cleaning the skin with a surgical prep, the skin After cleaning the skin with a surgical prep, the skin is numbed with a local anestheticis numbed with a local anesthetic““MicroMicro--incisionsincisions”” are made with a needleare made with a needleVaricosities are removed with a specially designed Varicosities are removed with a specially designed instrumentinstrumentThis is repeated over the course of the enlarged This is repeated over the course of the enlarged varicose veinvaricose vein


SclerotherapySclerotherapy

Usually used for smaller spider veins, but can be Usually used for smaller spider veins, but can be used on any size veinused on any size veinInjection of a Injection of a sclerosantsclerosant agent chemically seals the agent chemically seals the veinveinVariationsVariations

US guidedUS guided““foamfoam””


SclerotherapySclerotherapy

The Vein Center at Atlantic Medical The Vein Center at Atlantic Medical ImagingImaging

All patients are evaluated by one of our physicians at All patients are evaluated by one of our physicians at our Vein Center in Galloway.our Vein Center in Galloway.Ultrasound examination and physical examination will Ultrasound examination and physical examination will determine which treatment is best suited to your needs.determine which treatment is best suited to your needs.All procedures and follow up appointments will be at All procedures and follow up appointments will be at the Galloway office.the Galloway office.Procedures are done as an outpatient with light oral Procedures are done as an outpatient with light oral sedation and local anesthetic.sedation and local anesthetic.Minimal recovery time is needed.Minimal recovery time is needed.


Dr. Michael Dr. Michael SchmidlingSchmidling

Board certified radiologist with fellowship training in IntervenBoard certified radiologist with fellowship training in Interventional tional Radiology Radiology Certificate of Added Qualification in Vascular and InterventionaCertificate of Added Qualification in Vascular and Interventional Radiologyl RadiologyCoCo--Director of Vein CenterDirector of Vein CenterPrevious experience opening Vein Center in central New JerseyPrevious experience opening Vein Center in central New Jersey


Dr. Rajesh PatelDr. Rajesh Patel

Board certified radiologist with fellowship training in IntervenBoard certified radiologist with fellowship training in Interventional tional Radiology Radiology Certificate of Added Qualification in Vascular and InterventionaCertificate of Added Qualification in Vascular and Interventional l RadilogyRadilogyCoCo--Director of Vein CenterDirector of Vein Center

Pre-Treatment 1 Wk Post-EVLT

ResultsResults

ResultsResultsPre-Treatment 1 Wk Post-EVLT

Pre-Treatment 2 Wks Post-EVLT

ResultsResults

ResultsResultsPre-Treatment 2 Wks Post-EVLT

ResultsResultsPre-Treatment Post-Treatment



Pre-Treatment Post-Treatment

ResultsResults

ResultsResultsPre-Treatment 4 Wks Post-EVLT



Pre-Treatment Post-Treatment

ResultsResults

Endovenous Laser Treatment Endovenous Laser Treatment --ResultsResults

94 %94 %99 %99 %100 %100 %100 %100 %

218 / 231218 / 231245 / 247245 / 247151 / 151151 / 15172 / 7272 / 72

< 1 Year< 1 Year1 1 –– 2 Years2 Years2 2 –– 3 Years3 Years> 3 Years> 3 Years

Continued OcclusionContinued OcclusionClosed / No. TreatedClosed / No. TreatedFollowFollow--Up (Yrs)Up (Yrs)

• Followed 3 – 42 months (mean of 20 months)


98% (686/701) closed at 3 98% (686/701) closed at 3 -- 42 months42 months223 limbs followed at least 2 years 223 limbs followed at least 2 years demonstrate continued occlusiondemonstrate continued occlusion

Min R, Khilnani N, Zimmet. Endovenous laser treatment of saphenous vein reflux: long-term results. JVIR 2003; 14: 991-996.


> 99% of patients report resolution of symptoms> 99% of patients report resolution of symptoms

> 99 % of patients would recommend EVLT to > 99 % of patients would recommend EVLT to othersothers

Bruising & mild / moderate tenderness (resolving Bruising & mild / moderate tenderness (resolving in < 2 wks)in < 2 wks)

NONO skin burns, DVTs, or paresthesiasskin burns, DVTs, or paresthesias

Endovenous Laser Treatment Endovenous Laser Treatment --ConclusionsConclusions

Successful ablation of > 97% of limbs treated with Successful ablation of > 97% of limbs treated with endovenous laserendovenous laserContinued closure of more than 220 vein segments Continued closure of more than 220 vein segments followed for > 2 yearsfollowed for > 2 yearsResults comparable or superior to other options Results comparable or superior to other options available for treatment of GSV refluxavailable for treatment of GSV refluxEVLT offers these benefits with lower rates of EVLT offers these benefits with lower rates of complication and avoidance of general anesthesiacomplication and avoidance of general anesthesia

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Varicose Veins and Venous InsufficiencyInsufficiency · PDF fileVaricose Veins and Venous Varicose Veins and Venous ... Venous Insufficiency ... determine which treatment is best suited