When Varicose Veins a Circulatory Problem and how to screen. By Ariel D. Soffer, MD, FACC NCVH MIAMI, 2015

Transcription

1 When Varicose Veins a Circulatory Problem and how to screen. By Ariel D. Soffer, MD, FACC NCVH MIAMI, 2015

2 Bio-Ariel Soffer, MD, FACC Fellow of the American College of Cardiology since 1998 with post-graduate training at Cedars-Sinai, UCLA/USC. Associate Clinical Professor at Florida International University School of Medicine. Published the first article on the importance of venous insufficiency in the cardiovascular practice, Endovascular Today, 2007 and second one in Founder of "Soffer Vein & Vascular" (Cardiovascular-Based Multi-Specialty private practice with 7 offices throughout South Florida) Headquarters in Aventura, Fl. Co-Founder of AppwoRx - Patented clinical photography applications used commonly in the venous space.

3 Dr. Soffer s Relevant Disclosures Consultant for Angiodynamics ( ) Consultant for Diomed (2006) Consultant for Vascular Solutions ( ) Consultant for Sigvaris ( ) Principal Investigator for BTG s Varisolve Trial ( )

4 Journals and Media Essential Insights On Treating Chronic Venous Stasis Ulcers Volume 25 - Issue 7 - July 2012 Nanjin J. Park, DPM, Latricia Allen, DPM, MPH, Guosheng Gu, MD, and Vickie R. Driver, DPM, MS, FACFAS Podiatrists are in an ideal position to help address this clinical issue as part of the limb preservation effort. It is essential to understand the pathologic mechanisms causing the ulcers in order to develop the most evidence-based treatment plan. However, it is helpful to understand the challenges inherent in the lack of standardized diagnostic testing for chronic venous insufficiency. Likewise, it is critical to understand the factors that place patients at risk for progression to ulceration. 2 Cleveland Clinic wound care program pairs podiatrists and cardiologists to help patients avoid amputations -----By Brie Zeltner, The Plain Dealer on November 27, 2012

5 What does VI typically look like?

6 Did you know? Most patients seek treatment to relieve symptoms rather than cosmetic concerns.

7 Multi-Disciplinary Care Diagnosis Detection is very cost effective and treatment is relatively inexpensive. H&P can be effective and focus on any leg discomfort and early vein appearance, skin changes or swelling.

8 Multi-Disciplinary Care Considerations If undetected it can be mistaken for many ailments such as Restless Leg Syndrome Skin Diseases Non-Healing Ulcers and Wounds CHF (Bilateral Leg Edema)

9 Edema CHF vs. VI In the Unites States, the most common diagnosis for hospital admission is Congestive Heart Failure or CHF One of the most common signs of CHF is leg swelling (edema) seen by cardiovascular specialists and podiatric specialists (as well as other disciplines). One of the most common circulatory disorders (albeit woefully undiagnosed at less than 10% of affected people have been identified) is venous insufficiency which is commonly associated with edema

10 Figure 1 Edema VI CHF VENN DIAGRAM published by Soffer, Jaslow, et al, Veins, November 2013 The intersection of VI (venous insufficiency) and CHF (congestive heart failure) with Edema represents an important and challenging area of differentiation. The large areas of Edema with VI alone (without any CHF) represent areas of medicine that have potentially easily curable Edema and should not be mistaken for the less curable CHF that is treated completely differently.

11 Figure 1 Edema VI CHF VENN DIAGRAM published by Soffer, Jaslow, et al, Veins, November 2013 The intersection of VI (venous insufficiency) and CHF (congestive heart failure) with Edema represents an important and challenging area of differentiation. The large areas of Edema with VI alone (without any CHF) represent areas of medicine that have potentially easily curable Edema and should not be mistaken for the less curable CHF that is treated completely differently.

12 Importance of Proper Diagnosis Unfortunately for clinicians and patients the treatment of these two forms of edema are completely different, and therefore mistaken diagnoses and treatments can be disastrous to our entire health system Thankfully, the advances in clinical tools such as Doppler Ultrasonography have made diagnosis and differentiation of these disorders readily available in outpatient offices.

13 Venous Insufficiency

14 Primary Causes of Leg Edema Veins in the legs are responsible for transporting blood up to the veins of the torso, where it is then returned to the heart. The veins of the legs have valves that prevent the backward flow of blood within them. Venous insufficiency (VI) is incompetence of the veins that occurs because of dilation, or enlargement, of the veins and dysfunction of their valves. VI leads to a backup of blood and increased pressure in the veins, thereby resulting in edema of the legs and feet

15 Pitting Edema

16 Edema Levels

17 Proper Ultrasound for Venous Insufficiency

18 Primary Causes of Leg Edema VI is a problem that is localized to the legs, ankles, and feet. One leg may be more affected than the other (asymmetrical edema). Often both legs are simultaneously affected as the underlying anatomic pathology often is mimicked bilaterally. In contrast, systemic diseases that are associated with fluid retention (most common one being congestive heart failure) almost always cause the same amount of edema in both legs, and can also cause edema and swelling elsewhere in the body. The response to therapy with diuretic drugs in patients with venous insufficiency tends to be unsatisfactory. This is because the continued pooling of fluid in the lower extremities makes it difficult for the diuretics to mobilize the edema fluid. Elevation of the legs periodically during the day and the use of compression stockings may temporarily help the condition, but ultimately venous insufficiency is a mechanical problem that responds to mechanical solutions commonly performed today such as thermal or chemical energy ablation.

19 Common Causes of Venous Insufficiency: There are several conditions than can cause the valves and veins to work improperly: Any problem that increases pressure in the veins in the legs can stretch the veins. This can damage the valves, which leads to even higher pressures and worsened vein function. A clot in a vein will block blood flow back through the vein, which can increase pressures, often permanently damaging the vein or valves even after the clot has dissolved. Leg injury or surgery can damage the veins or valves. Increased body weight (eg, pregnancy, obesity) can increase pressure in the veins of the legs, and this can usually irreparably damage the veins and valves. The muscles in the legs play an important role in the circulation of blood, acting as a pump. Standing or sitting for prolonged periods without walking can decrease the movement of blood out of the legs and lead to increased pressures in the veins and pooling of blood

20 Common Causes of Congestive Heart Failure: Coronary Artery Disease High Blood Pressure (Hypertension) Diseases of the heart muscle (Cardiomyopathy) Disorders of the heart valves

21 CHF vs. VI Treatments considered beneficial for both Graded Compression Stockings Leg Elevation Treatments considered to be possibly beneficial in one diagnosis while possibly detrimental for the other Long term diuretics Digoxin Recurrent hospitalization

22 Compression Socks and the Cardiovascular/Podiatric Patient Excellent preventive tool Many highly compliant new varieties Excellent periodic symptomatic tool Excellent Travel Aid Potentially useful resource for practice revenue.

23 Conclusion: Edema of the legs is a very common and uncomfortable sign of underlying disease. With the advent of Doppler Ultrasonography, accurate diagnosis and appropriate treatment can be readily administered. As the common causes and treatment paradigms are very different for the two most frequent causes of edema (CHF and VI) it is very important that proper diagnoses are made. NIH and others have shown the absolute importance of a multi-disciplinary approach (in particular the podiatric and cardiovascular communities) to reduce the impact of venous insufficiency and its circulation related consequences to our patients.