What s the Big Deal About Veins? Disorders of the Heart. Risk Factor Modification CAD Myocardial Disease Valvular Disease Conduction Abnormalites PAD

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1 What s the Big Deal About Veins? Disorders of the Heart Risk Factor Modification CAD Myocardial Disease Valvular Disease Conduction Abnormalites PAD

2 Venous Disease DVT prophylaxis or its treatment Pulmonary Embolus Hypercoagulable states Congenital Venous Malformations Anticoagulation Chronic Venous Insufficiency and Varicose Veins

3 Manifestations of Venous Insufficiency Varicose Veins Swollen Legs Skin Changes Skin Ulcers Photos courtesy of Rajabrata Sarkar, MD, PhD. Venous Insufficiency Defined: The inability of the vein in the lower extremities to return blood back to the heart

4 Pathophysiology of Venous Insufficiency Three Systems: Deep Superficial Perforating Venous System

5 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 US Prevalence of Major Diseases-2015 (in millions) Venous Reflux Disease Diabetes Peripheral Arterial Disease Coronary Heart Disease Cancer Stroke Alzheimers

6 Recognize the true suffering PATIENTS ALL OF YOU COUNTRY Nearly 40 million people suffer from venous reflux disease and varicose veins Images courtesy of Paul McNeill, MD and Rajabrata Sarkar, MD Venous Reflux disease is 5x more prevalent than PAD, 2x more prevalent than CAD

7 Of the estimated 38 million people with symptomatic superficial venous reflux. Only 1.7 million seek treatment annually! Over 36 million go untreated! To Improve These Statistics: 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 Heredity Occupation Pregnancy Risk Factors of Venous Insufficiency Obesity Gender Age Sedentary Lifestyle

8 How do these patients present? 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

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12 Diagnosis 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 Distal Augmentation Normal valve closure after augmentation Abnormal valve closure after augmentation

13 Detoxified by Liver Cleared or filtered by kidneys Oxygenated and CO 2 removed by lungs Not cleared of dying red/white blood cells by spleen Endovascular Techniques Thermal Ablation Radiofrequency Laser Chemical Surgical Intervention Archaic Barbaric Obsolete

14 Detoxified by Liver Cleared or filtered by kidneys Oxygenated and CO 2 removed by lungs Not cleared of dying red/white blood cells by spleen What to expect? 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 Case Presentations

15 HPI: PmHx: Case 1: Edema 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. DM, HTN, sleep apnea Medications: Metformin 500mg, bid Lipitor 40mg, qhs Captopril 25mg, bid Aspirin 81mg, qam Lasix 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.

16 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. HPI: Meds: Case 2: Neuropathy 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. Neurontin 600 mg by mouth twice a day Cymbalta 60 mg by mouth every morning Edluar 10 mg by mouth daily at bedtime ACE I and B-blocker ASA 81 mg by mouth every morning Vitamin B and D supplements STATINS HAD BEEN DISCONTINUED BECAUSE OF HIS LEG PAIN! Case 2: Neuropathy PmHx: PE: CAD HTN Neuropathy Fibromyalgia 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

17 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! HPI: Meds: PmHx: PE: Case 3: Ulcers 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. Norco Negative except for the HPI Morbid obesity. B LE 2+ edema with large B 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.

18 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% sotradecol directly 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!

19 HPI: PmHx: Meds: Case 4: Restless Legs 48y/o Female, Schoolteacher presented to our clinic with C/O legs moving restless throughout the night. She stated that the sx impeded 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. None Requip 6 mg by mouth 3 times a day PE: Dx: Tx: F/U: Case 4: Restless Legs 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. Venous u/s revealed several incompetent perforators and B severe Anterior accessory venous reflux starting at the saphenofemoral junction. The simple use of recommended compression stockings at 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 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!

20 HPI: Meds: PmHx: PE: Dx: Tx: 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. None None Cramps 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 Venous ultrasonography was negative with the exception of bilateral Vein of Giacomini severe reflux. 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 These cases illustrate 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. Where are we going? 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

21 The Coronado Vein Center is attempting to answer the question of why and how exercise: Improves quality and quantity of life Lowers hypertension Improves performance and stamina Produces a favorable metabolic profile

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