What’s the Big Deal About Veins? - Amazon S3s3-us-west-2.amazonaws.com/capa-wp/wp-content/uploads/2016/11/... · Varicose Veins Swollen Legs Skin Changes ... •Eliminate the misconceptionthat

What’s the Big Deal

About Veins?

• Risk Factor Modification

• CAD

• Myocardial Disease

• Valvular Disease

• Conduction Abnormalites

• PAD

Disorders of the Heart

Coronado Vein Center, Redding CA




Venous Disease• DVT prophylaxis or its treatment

• Pulmonary Embolus

• Hypercoagulable states

• Congenital Venous Malformations

• Anticoagulation


Chronic Venous Insufficiency and Varicose Veins

Skin UlcersSwollen Legs Skin Changes Varicose Veins

Photos courtesy of Rajabrata Sarkar, MD, PhD.

Manifestations of Venous

Insufficiency


The inability of the vein in the lower extremities to return blood back to the heart

Venous Insufficiency Defined:



Pathophysiology of Venous

Insufficiency


Venous System


Three Systems:

•Deep

•Superficial

•Perforating

Venous System


• Venous Hypertension

• Leukocyte Trapping

• Release of Proteolytic Enzymes

• Destruction of CBM

• Leakage of Plasma Proteins

• Tissue Hypoxia

• Dermatitis & Lipodermatosclerosis


Magnitude of the Problem

PREVALENCE

IGNORED

MISDIAGNOSED


0 10 20 30 40

Alzheimers

Stroke

Cancer

Coronary Heart Disease

Peripheral Arterial Disease

Diabetes

Venous Reflux Disease

US Prevalence of Major Diseases-2015

(in millions)


Recognize the true suffering…

PATIENTS

ALL OF YOU

COUNTRY

Images courtesy of Paul McNeill, MD and Rajabrata Sarkar, MD

Nearly 40 million people suffer from

venous reflux disease and varicose veins


Venous Reflux disease is 5x more prevalent than PAD, 2x more

prevalent than CAD

•Only 1.7 million seek treatment annually!

•Over 36 million go untreated!

Of the estimated 38 million people with

symptomatic superficial venous reflux.


• Increase the awareness!

• Eliminate the misconception that this is just a cosmetic disorder

• Remind the patients that, in the right hands, this has a straightforward cure

• Come to the realization that disorders such as unexplained swelling, nocturnal leg cramps, and restless legs are not treated by telling patients “there is nothing we can do that really works”

• Let’s become cognizant of the fact that these patients suffer every minute of the day, not just when they are in your office complaining about the symptoms


To Improve These Statistics:

•Heredity

•Occupation

•Pregnancy

•Obesity

•Gender

•Age•Sedentary Lifestyle

Risk Factors of Venous

Insufficiency


• Edema

• Spider Veins

• Varicose Veins

• Skin Changes

• Restless Legs

• Burning/itching not uncommon

• Ulcers

• Nocturnal Cramps

• Pain often described as an ache, fatigue, or heaviness

How do these patients present?


• Antegrade flow: Blood flow toward the heart

• Patency: Vessel is clear of obstruction and flow is present

• Compression: Vein wall collapses when pressure applied over vein with transducer

• Occlusion: Complete closure of a vessel with no flow present

• RETROGRADE FLOW: Blood flow away from the heart

Diagnosis


Distal Augmentation


Normal valve closure after augmentation

Abnormal valve closure after

augmentation



• Detoxified by Liver• Cleared or filtered by kidneys• Oxygenated and CO2

removed by lungs• Not cleared of dying

red/white blood cells by spleen

•Thermal Ablation•Radiofrequency

•Laser

•Chemical

Endovascular Techniques


•Archaic

•Barbaric

•Obsolete

Surgical Intervention



• Detoxified by Liver• Cleared or filtered by kidneys• Oxygenated and CO2

removed by lungs• Not cleared of dying

red/white blood cells by spleen

• You can expect your patient to have complete resolution of the symptomatology related to venous insufficiency

• You can expect a decrease in the incidence of complications related to DVT, venous ulcerations, unnecessary hospitalizations and antibiotic treatments

• You can expect that patients who have restless legs or nocturnal cramps due to venous insufficiency (large portion) can come off of the medications that were unnecessary to begin with

• You can expect your venous insufficiency population to be much happier with their care

• You can expect to be happier by improving the flow of your patients

What to expect?


Case Presentations


HPI: 60y/o Female, RN who responded to DTCA Frustrated with LE edema FOR OVER 20 YEARS, puffiness, heaviness, aching at end of day. Had been treated with lasix empirically for over a decade.

PmHx: DM, HTN, sleep apnea

Medications:Metformin 500mg, bid Lipitor 40mg, qhsCaptopril 25mg, bidAspirin 81mg, qamLasix 40mg, bid

Exam 180lbs., 5’4” vitals WNL and OTW unremarkable with the exception of B 3+ pitting edema.

Case 1: Edema


“Usual Causes” of edema were nonexistent including:

• No Hx of heart failure, • No h/o renal insufficiency, • Hypoalbuminemia, • Portal or pulmonary hypertension • No TR of significance. • No calcium channel blockers, • OR ANY OTHER APARENT REASON for her edema.

Case 1: Edema


Dx workup: Included venous ultrasound which revealed severe bilateral GSV reflux.

Treatment: Radiofrequency ablation of bilateral GSV with foam sclerotherapy at 2 week intervals post RFA

Results: Since then, she has taken no Lasix in the last 3 years the iatrogenic cause of her hypokalemia! More importantly, she can sleep better and complete her standing obligation without pain and suffering! Her PMD is much happier as well not having to deal with the issue.

Case 1: Edema


HPI: 72y/o Male, businessman who responded to DTCA because of LE asymmetrical pain and discomfort described as “all night long” pinpricking and paresthesias. Unable to travel because of sx exacerbation with driving. He denied edema. “Everything would be perfect if I could just get rid of this damn pain!” He was dxed with Neuropathy despite no previous hx of DM or other known causes of neuropathy. He was experiencing severe side effects from his meds including a sensation of “being out of it” and having to hold his medications on days of meetings or presentations.

Meds: Neurontin 600 mg by mouth twice a dayCymbalta 60 mg by mouth every morningEdluar 10 mg by mouth daily at bedtimeACE – I and B-blockerASA 81 mg by mouth every morningVitamin B and D supplementsSTATINS HAD BEEN DISCONTINUED BECAUSE OF HIS LEG PAIN!

Case 2: Neuropathy


PmHx: CADHTN“Neuropathy”“Fibromyalgia”

PE: Healthy well developed gentleman. Completely unremarkable exam with the exception of tender varicosities which were asymmetrical. CV exam was unremarkable including excellent symmetrical pulses. DTRs were intact as was the remainder of his neuro exam. He had no edema

Case 2: Neuropathy


Dx : Included venous ultrasound which revealed severe right GSV and left SSV reflux

Tx: Radiofrequency ablation of right GSV and left SSV with adjunctive therapy including microphlebectomy and foam scleortherapy

F/U: Asymptomatic!, no longer takes Cymbalta or Gabapentin. No further need for B complex given for neuropathy.

TAKES STATINS!

Case 2: Neuropathy


HPI: 56y/o Male, gainfully employed who responded to DTCA because of LE pain and discomfort, discoloration and non-healing wounds of over 3 years duration. He had been evaluated and treated at a wound clinic under the care of a vascular surgeon on and off for years. He described numerous hospital admissions and countless rounds of antibiotics as well as 2 failed skin grafts.

Meds: Norco

PmHx: Negative except for the HPI

PE: Morbid obesity. B LE 2+ edema with large B 12-15 cm deep ulcerations in distal legs with pre-tibial fascia involvement and extensive areas of necrosis. Purulent exudate from the ulcer. Severe stasis dermatitis and large varicosities.

Case 3: Ulcers


Dx: Quick initial and informal U/S revealed full blown severe reflux of both the R and L GSV. Complete U/S revealed no evidence of DVT and completely ruptured GSV valves from the origin at the SFJ and extending throughout the length of the

Tx: Urgent B GSV ablation and foam injection using 1% sotradecoldirectly into the ulcer led to cessation of exudate, relief of pain and sx in just one week. Complete closure of the ulcer in just 6 weeks. Prior to intervention, the pt soaked his dressings at least a couple of times a day

F/U: It has been nearly 2 years with absolutely no recurrence of the ulceration or his symptomatology!

Case 3: Ulcers


HPI: 48y/o Female, Schoolteacher presented to our clinic with C/O legs moving restless throughout the night. She stated that the sximpeded any kind of rest or decent amount of sleep for the previous 15 years. She said that it was as if her legs had anxiety and found the feeling difficult to describe. She also c/o aching and heaviness and overall “bad discomfort”. She had been seen at Stanford University and UC Davis dept of Neurology. She had failed everything from valium, muscle relaxants and narcotics. She mentioned mild to modest improvement with Requip.

PmHx: None

Meds: Requip 6 mg by mouth 3 times a day

Case 4: Restless Legs


PE: Moderately obese with only trace to 1+ pitting edema which she states worsened when standing for long periods of time. Her legs were slightly tender to palpation and varicosities were palpated in her calves B. She had no skin discoloration and had numerous spider veins.

Dx: Venous u/s revealed several incompetent perforators and B severe Anterior accessory venous reflux starting at the saphenofemoral junction.

Tx: The simple use of recommended compression stockings at 20-30 mmHg offered superior symptom relief compared to Requip. Intervention of bilateral anterior accessory saphenous veins as well as perforators lead to resolution of symptoms in their entirety

F/U: 3 years later, she remains completely asymptomatic. Equally important is the fact that she is no longer falling asleep while working which was the results of moderate to high dose of Requip. Naturally, she was very happy and told us that we not only gave her “legs back but also my life”. She moved back into the same bedroom as her husband after sleeping in separate beds for several years!

Case 4: Restless Legs


HPI: 52-year-old police officer who presented to our Vein Center because of discomfort in his lower extremities described as aching throbbing fatigue discomfort. What really bothered him most however were debilitating leg cramps. With respect to his varicose veins, he was told previously “not to worry about them”. He responded to our advertisement regarding the frequent association of leg cramps and venous insufficiency.

Meds: None

PmHx: None

PE: His physical examination revealed a muscular well-developed gentleman with normal vital signs and an unremarkable exam with the exception of obvious varicose veins, 2+ pitting edema and mild stasis dermatitis just proximal to the ankles bilaterally

Dx: Venous ultrasonography was negative with the exception of bilateral Vein of Giacomini severe reflux.

Tx: He underwent radiofrequency ablation of these veins followed by extensive foam sclerotherapy and microphlebectomy in both lower extremities with complete resolution of his nocturnal leg cramps

Note: The etiology for lower extremity muscle cramps remains poorly understood. Most treatment is empiric with inconsistencies in our approach and management. The treatment varies from empiric electrolyte “replacement” to

aggressive therapy including benzodiazepines and narcotics. There are approximately38 million Americans with venous insufficiency with a large portion of these patients complaining of muscle cramps. Treatment in many of the patients that

experience debilitating cramps leads to a significant amelioration and often complete resolution of symptoms

Cramps


• How poorly venous insufficiency is understood by the medical community and how frequent it is either misdiagnosed or ignored

• How poorly we do in the recognition of venous insufficiency contributing as an etiology to common disorders like RLS, “Neuropathy” and lower extremity muscle cramps

• The degree to which misdiagnosis leads not only to lack of appropriate treatment but also to iatrogenic results.

These cases illustrate


• Knowledge of the venous system and its true physiology is still in the diaper stage

• Understand venous physiology and disorders has, and will undoubtedly continue to provide a wealth of knowledge that we believe will unlock some of the mysteries of poorly understood disease states such as HTN, sleep apnea and sepsis to name a few

• The Coronado Vein Center has taken a leading role in investigation and research

Where are we going?


•Improves quality and quantity of life

•Lowers hypertension

•Improves performance and stamina

•Produces a favorable metabolic profile

The Coronado Vein Center is attempting to

answer the question of why and how exercise:


Thank you


Documents

What’s the Big Deal About Veins? - Amazon S3s3-us-west-2.amazonaws.com/capa-wp/wp-content/uploads/2016/11/... · Varicose Veins Swollen Legs Skin Changes ... •Eliminate the misconceptionthat