Phlebology for the Internist not a vain effort

Phlebology for the Internist not a vain effort G. Davin Haraway DO,FACOI,FACCWS,RPhS Tulsa Vein Institute We are talking about veins but don t ever forget to check the arterial status 1 st thing! 1

The acute leg swelling and Painful Leg IF DVT on your mind think Wells score Send to the ER as this can be a life and/or limb threatening condition also If DVT is not found they may have another condition that may need emergent treatment i.e. acute cellulitis or Necrotizing fasciitis or Arterial occlusion I would recommend that you send them with an order for D-Dimer if referring them to the ER - most will draw but some do not. If they have Superficial thrombophlebitis they could have up to a 40% chance of having a concurrent DVT in the same OR THE OTHER LEG so get bilateral studies not just the symptomatic leg so same recommendation of ER. This could look like Cellulitis but typically along the course of a vein. Treatment of superficial thrombophlebitis typically would consist of NSAIDS and Compression hose at least 20-30mmhg (yes tender to get on but will typically provide relief rapidly) these patients typically have disease that will need treatment a vein center (and may not be their 1 st episode) This does not require antibiotics (unless substance was injected) A subset of Superficial thrombophlebitis may be best treated with anticoagulation if extensive (involves the SFJ), hypercoaguable state, or history of active cancer Stasis Eczema(dermatitis) Is typically a manifestation of advanced venous Disease and can be helped greatly by treatment of the underlying REFLUX Steroid creams mask the underlying real problem Hypercoaguable state factor V leiden,prothrombin G2021A,antithrombin III deficiency, Protein C and S deficiency, Lupus anticoagulant, Anticardiolipin syndrome, elevated Factor VIII levels Screening for this is not typically recommended with 1 st DVT IF it can be explained and no family history or recurrent fetal loss. Phlebology What s that about? Davin Haraway DO,FACOI,FACCWS,RPhS 2

Prevalence of Chronic Venous Disease 1 in 22 or 4.5% or 12.2 million people in the USA are affected by varicose veins Incidence increases with age and is more common in women with over 40% of women in their 50 s suffering from some sort of venous disorder Across all ages and gender, 60% of Americans suffer from venous disease and its sequelae National Heart Lung and Blood Institute (NHLBI) http://www.nhlbi.nih.gov/ Population Tulsa County 603,403 Age 35-65 143,512 Female 51% 73,191 Male 50% 71,756 Age 40-49 - 41% prevalence 23,106 Age 60-69 - 72% prevalence 16,833 Age 40-49 - 24% prevalence 13,260 Age 60-69 - 43% prevalence 7,096 50% pathologic reflux 11,553 50% pathologic reflux 8,416 50% pathologic reflux 6,630 50% pathologic reflux 3,548 17-46% GSV reflux 1,964-5,314 17-46% GSV reflux 1,430-3,871 17-46% GSV reflux 1,127-3,049 17-46% GSV reflux 603-1,632 Total patients that would potentially just need GSV treatment by endothermal ablation range from 5,124 to 13,866 if symptomatic. A portion of these patients will need Phlebectomy and /or Ultrasound guided sclerotherapy in addition to endothermal ablation all of which are reimbursable procedures by most Insurance carriers when symptomatic. This assumes that all patients were healthy on a population basis. Age 35 64 years total 143,512 from Tulsa City Statistics 77% of this age group are 35 54 years old and 23% age55 64 years old. 3

65 and older 50,508 Female 72% prevalence 31,007 x 0.72= 22,325 Male 43% prevalence 19,501 x 0.43 = 8,385 17-46% GSV reflux 3,795-10,269 17-46% GSV reflux 1,425-3857 Medicare age patients with potential GSV reflux could be treated with endothermal ablation if symptomatic would range from 5,220 to 14,126. Medicare has coverage criteria for symptomatic patients. Patients from age group 35 to over 65 total 10,344 27,922 in the Tulsa County The Spectrum of Chronic Venous Disease telangiectasias superficial phlebitis varicose veins lipodermatosclerosis venous ulceration 4

Who should be screened? Patients with typical symptoms of venous disease with a constellation of symptoms and/or signs of: varicosities that are symptomatic; or a history of Venous Ulcerations; or no skin changes at all and symptoms could include: Aching Heaviness (#1complaint) or fatigue in legs usually better with ambulation (different from claudication) Pain: throbbing, burning, stabbing Cramping Swelling (peripheral edema) Itching Restless legs Numbness Leg ulcerations usually on the lower leg could be medial or lateral ( with acceptable arterial circulation) What s their ABI not to miss Arterial disease! THE UNIFYING EVENT THAT CAUSES SYMPTOMS AND SIGNS OF VENOUS DISEASE IS AMBULATORY VENOUS HYPTERTENSION What do you tell your patients about this? (30% risk of venous ulceration due to GSV distribution and already skin changes at the ankle) 5

Or this? And this is.. Lipoedema characteristic cut off sign at the ankles and no edema Of feet these patient typically complain of sensitive skin Weight loss only works to a certain degree usually hereditary Treatment Liposuction and mild compression (usually will help If they can stand it 6

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Frequently asked questions Aren t Vein Practices just cosmetic and spa centers? No - Phlebology practice encompasses a wide range of Services. As with other practices may deal with Deep system problems (such as May/Thurner syndrome thrombolytic therapy and stenting/coiling vascular malformation) to only superficial disease GSV/SSV/Perforator and or tributary disease to the reticular and telangiectasia OR both. Board Certification pathway in Phlebology is thru American Board of Venous and Lymphatic Medicine - Recognized by AOA and AMA as distinct primary or secondary specialty Certainly patients may initially present with the intent of a Cosmetic outcome but the evaluation always begins with a History/Physical AND a Duplex Ultrasound specifically for REFLUX (different protocol for DVT). Surprising Number of patients when carefully questioned about their leg discomfort have Symptoms that can be attributed to Venous Disease. 12

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Pelvic congestion syndrome Pelvic Congestion Syndrome Affects thousands of women in the U.S. More common in multiparous women Due to reflux in the ovarian veins, iliac veins, etc. May result in severe pelvic discomfort during the pre-menstrual period, after intercourse, and with prolonged standing May be effectively treated by blocking the reflux with embolization and/or pelvic vein sclerotherapy Venbrux AC et al J Vasc Interv Radiol 2002; 13:171-178 15

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Venous Disease is a Hereditary Disorder 134 families were examined. The risk of developing varicose veins was: 89% if both parents had varicose veins 47% if one parent had varicose veins 20% if neither parent had varicose veins Cornu-Thenard, A, J Dermatol Surg Oncol 1994 May; 20(5):318-26. The beginnings of venous disease may be found as early as childhood Diagnosable Vein disease Actual Varicose Veins 740 pts 10-12 y/o 518 pts 14-16 y/o 459 pts 18-20 y/o 2.5% 12.3% 19.8% 0 1.7% 3.3% Phlebologie. 1990 Nov-Dec;43(4):573-7. Weindorf N, Schultz-Ehrenburg U. 18

Inactivity aggravates venous disease 2,854 patients with varicose veins, working in a factory 64.5% had jobs standing in one place 29.2% had jobs requiring prolonged periods of sitting 6.3% had jobs allowing frequent walking during their shift Santler, R Hautarzt 1956; 10:460 Each pregnancy worsens the condition 405 women with varicose veins 13% had one pregnancy 30% had two pregnancies 57% had three pregnancies Brand FN, et al The epidemiology of varicose veins: the Framingham Study Am J Prev Med 1988; 4:96-101 19

Anatomy and physiology of the venous system in the lower extremity Deep venous system: the channel through which 90% of venous blood is pumped out of the legs Superficial venous system: the collecting system of veins Perforating veins: the conduits for blood to travel from the superficial to the deep veins Musculovenous pump: Contraction of foot and leg muscles pumps the blood through one-way valves up and out of the legs 20

Venous Valvular Function Valve leaflets allow unidirectional flow, upward or inward Dilation of vein wall prevents opposition of valve leaflets, resulting in reflux Valvular fibrosis, destruction, or agenesis results in reflux 21

Doppler exam: Normal flow Illustration by Linda S. Nye Doppler: Reflux Illustration by Linda S. Nye 22

REFLUX: its contribution to varicose veins Illustration by Linda S. Nye Pathophysiology: 2 components REFLUX Dilatation of vein wall leads to valve insufficiency Monocytes may destroy vein valves Retrograde flow results in distal venous hypertension OBSTRUCTION Thrombosis and subsequent fibrosis obstruct venous outflow Damage to vein valves may also cause reflux Both contribute to venous hypertension The presence of both is far worse than either one alone 23

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Frequently Asked Questions What does my poor circulation have to do with my swelling? We educate our patients on distinguishing between arterial and venous circulation and go over their particular factors for their swelling verbally and with a diagram. Draw Diagram How I educate patients on their Edema. 25

Edema All edema is lymphedema CHF Left and/or Right, cirrhosis, Renal failure = Diuretics + compression Venous insufficiency = compression not diuretics Lymphedema = manual decongestive therapy + compression Not diuretics Don t forget Thyroid Lipo Edema characteristic Cut off sign at ankle Can have all three PhleboLipoLymphedema Be sure to check ABI if compressing Caution if ABI <0.8 CHF (left and/or Right) Kidney disease Liver Disease Lymphedema Lipo edema Hypothyroidism Varicose Veins Exacerbating factors obesity/pulmonary hypertension 26

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Test Patient : What could be wrong with this guy??? I.e. would you send him for an ablation procedure? CHF (left and/or Right) Kidney disease Liver Disease Lymphedema Lipo edema Hypothyroidism Varicose Veins Exacerbating factors obesity/pulmonary hypertension What i see 31

CEAP Classification C = Clinical C0 - no visible venous disease C1 - telangiectasias or reticular veins C2 - varicose veins C3 - edema C4 - skin changes without ulceration C4a pigmentation or eczema C4b LDS or atrophie blanche C5 - skin changes with healed ulceration C6 - skin changes with active ulceration E = Etiology (primary vs. secondary) A = Anatomy (defines location of disease within superficial, deep and perforating venous systems) P = Pathophysiology (reflux, obstruction, or both) What to Expect Their 1 st appointment typically takes approximately 1.5-2 hrs. depending on the complexity of their disease. After review of their condition You should receive the consult with my findings and recommendations to the patient. I Would like your help My typical recommendations would include exercise, weight loss, continue compression, and leg elevation when resting. NSAIDS or analgesic medication for discomfort and schedule for procedure /further testing or follow up. If there is another potential cause of their swelling or a condition that would exacerbate their condition then I may recommend they see their PCP for further evaluation of their Pulmonary status, Cardiovascular status, Endocrine status Lymphedema referral and/or wound clinic referral( if they have an ulceration). 32

History History of problem: onset, pregnancies, prior DVT, immobilization Associated symptoms and relationship to heat, menses, exercise and compression Current medications Family history Previous treatment and result Goals of patient Physical Examination Examine patient in the standing position, from the groin to the ankle Inspect and palpate for varicose and telangiectatic veins Check the medial and lateral malleolar areas for skin changes suggestive of chronic venous insufficiency (e.g., corona phlebectatica) Inspect the abdomen for enlarged superficial veins if ilio-femoral thrombosis is suspected 33

Telangiectasias Also known as spider veins due to their appearance Very common, especially in women Increase in frequency with age 85% of patients are symptomatic * May indicate more extensive venous disease * Weiss RA and Weiss MA J Dermatol Surg Oncol. 1990 Apr;16(4):333-6. Lateral Subdermic Plexus Very common, especially in women Superficial veins with direct perforators to deep system Remnant of embryonic deep venous system 34

Reticular Veins Enlarged, greenish-blue appearing veins Frequently associated with clusters of telangiectasias May be symptomatic, especially in dependent areas of leg Varicose Veins Great Saphenous Distribution Most common finding in patients with varicose veins Varicosities most commonly along the medial thigh and calf but cannot assume location indicates origin At least 20% of patients are at risk of ulceration 35

Great Saphenous Insufficiency Skin changes are seen along the medial aspect of the ankle The presence of skin changes is a predictor of future ulceration * * Kirsner R et al. The Clinical Spectrum of Lipodermato-sclerosis, J Am Acad Derm, April 1993;28(4):623-7 Varicose Veins Small Saphenous Distribution Less frequent than Great Saphenous involvement Varicosities may be seen on the posterior calf and lateral ankle Skin changes are seen along the lateral ankle 36

Skin changes suggestive of chronic venous insufficiency Corona Phlebectatica (C1) Atrophie blanche (C4b) Pigmentation (C4a) Healed ulcer (C5) Venous Ulceration Over 50% of patients have only superficial venous disease; superficial venous disease may be primary factor in 50-85% of patients * <10% have only deep venous disease Results from ambulatory venous hypertension, which leads to WBC activation, TCpO2, local release of proteolytic enzymes * Shami SK et al. J Vasc Surg 1993; 17:487-90 37

Venous Ulceration Impending ulceration Lipodermatosclerosis (C4a) Venous ulceration (C6) Are Vein procedures covered by my insurance? By and large if a patient has symptomatic venous disease with duplex findings of Reflux and enlarged size veins(variable to the insurance) of the GSV and or SSV and tributaries then Insurance will typically cover their treatment Of course some insurances are more strict. Insurance LCD Also dictate mostly that the axial Veins of the GSV/SSV must be treated first before tributary disease can be covered Foam and Liquid Sclerotherapy of veins less than 3mm and no reflux typically are not covered and are treated if symptomatic or at the desire of the patient for a more esthetic outcome on a Cash basis. (most SYMPTOMS are improved with treatment of the above however the end result is driven by the patient for cosmetic appearance). 38

Do I have to wear Compression stockings? Compression stockings are a very important part of treating chronic venous disease Depending on where the patient is on the spectrum of their particular disease process they may be recommended to always wear their compression hose(especially if Deep Reflux) or they may not need to wear their hose after their treatment if ALL reflux has been treated and no further symptoms. HOWEVER All insurance Carriers start with a period of conservative treatment which includes Compression hose NOT TED hose typically 20-30mmHg compression VENOUS DISEASE IS A CONDITION OF CHRONICITY AND MUST BE FOLLOWED NEW AREAS OF REFLUX WILL LIKELY DEVELOP IN THE FUTURE AND MAY BE DEALT WITH EXPECTANTLY to not notify a patient of this would disappoint the patient. CONSERVATIVE TREATMENT OF VENOUS DISORDERS 39

Compression Therapy Provides a gradient of pressure, highest at the ankle, decreasing as it moves up the leg Reduces reflux of blood Improves venous outflow Increases velocity of blood flow to reduce the risk of blood clots Photo courtesy of Juzo Compression Therapy Reduces symptoms of aching, fatigue, pain, and swelling Increases fibrinolytic activity Increases TCpO2 Mainstay of treatment for venous ulcers NOTE: Graduated compression therapy and wound care will heal venous stasis ulcers. Elimination of the reflux will reduce the recurrence. 40

Elastic compression stockings Must be graduated Calf high generally sufficient Replace q 6 months to assure proper pressure Available in a variety of strengths, styles, colors, and fabrics Graduated compression is not the same as T.E.D. hose T.E.D.s are meant for nonambulatory, supine patients T.E.D.s are indicated to decrease the incidence of thrombosis T.E.D.s do not provide sufficient pressure for ambulatory patients 41

Compression Strength 8-15mm Indications Leg fatigue, mild swelling, stylish 15-20mm Mild aching, swelling, stylish 20-30mm Aching, pain, swelling, mild varicose veins 30-40mm * Aching, pain, swelling, varicose veins, post-ulcer 40-50, 50-60mm * Recurrent ulceration, lymphedema * Requires a prescription Gradient compression hose At least Calf high 20-30mmhg Thigh high or panty hose may be more comfortable depending on the situation Open or closed toe depending on concurrent condition such as diabetes, neuropathy or concurrent arterial disease. The clock starts ticking when they began their compression so If you document it I can use that date for their insurance approval. Where can they get them? DME store LKM, Freeland Brown, Fidelity Lymphedema, can purchase over the counter ( typically sized by the calf and thigh circumference and outseam) Yes some fit better than others but if symptoms helped and continue despite their stockings and reflux found good chance they will respond to treatment. 42

If they have an Ulcer This is a good patient to send to both the wound center AND Tulsa Vein as the wound centers are great at getting them in compression, evaluating the wound for proper dressings/home health, debridement, biopsy, and education. We can work on the Cause of the Ulceration REFLUX -and try to get the ulcer healed faster and maintain skin integrity with intervention such as endovenous ablation and foam sclerotherapy or other techniques. Likely their Ultrasound will prognosticate if they have single, double or triple component disease meaning superficial or Deep or perforator disease or all three. 43

Evaluation and treatment of Venous Ulcerations We will get into this Summarize Compression mainstay of treatment of venous ulcerations showed no help of healing with ligation/stripping HOWEVER reoccurrence rate decreased with ligation/stripping with Evidence of Eschar Study Several flaws in methodology Society for Vascular Surgery and American venous Forum recommendations Grade 1B compression therapy for healing venous ulcers Grade 1B if patient is candidate for Ablation of symptomatic varicose veins without ulcers over chronic compression Grade 1A ablation of incompetent superficial veins in addition to compression therapy for reduced reoccurrence rates for Venous Ulcerations 44

Endothermal and Non thermal Ablation Venefit Procedure Coviden/Medtronic Endothermal Laser Ablation Mechanical Occlusion Chemical Assisted ablation (Clarivein) Venaseal (cyanoacrolate) Varithena Microchemical Foam ablation Steam ablation Foam ablation Stripping Local Microphlebectomy 45

91 CURRENT APPROACHES TO THE TREATMENT OF VARICOSE VEINS ALWAYS TREAT THE TRUNK FIRST IF REFLUX FOUND Radiofrequency Closure Technique Outpatient procedure approximately 60 min. long Local tumescent Temperature at vein wall controlled >90% closure at 2 yrs FDA-approved for RX of Great Saphenous Vein 46

93 Treatment of telangiectasias Sclerotherapy most effective Laser may be helpful Multiple treatments usually required Reduces symptoms in 85% of patients Improves quality of life Weiss RA and Weiss MA J Dermatol Surg Oncol. 1990 Apr;16(4):333-6. Sclerotherapy of Telangiectasias: Technique Injection of sclerosant solution causes damage to endothelium which leads to fibrosis of vein 47

Treatment of Reticular Veins Frequently associated with telangiectasias, their Rx may enhance results of sclerotherapy of telangiectasias Visualization may be improved with transillumination Ultrasound-guided Sclerotherapy Nearly any size vein can be treated Needle location inside vein, as well as movement of sclerosant and response of vein (spasm) visible Efficacy enhanced with foamed sclerosant Photo courtesy of CompuDiagnostics, Inc. 48

Sclerotherapy Results Before After Ultrasound-guided sclerotherapy of the Great Saphenous Vein and sclerotherapy of branches Photos courtesy of Steven Zimmet, MD, FACPh Surgical Treatment of Varicose Veins: Vein Stripping Vein stripping used to remove Great and Small saphenous veins Yields 60% long term improvement Neovascularization a problem Usually requires general anesthetic courtesy of John Bergan, MD Butler CM, et al Phlebology 2002. 17:59-63 49

Surgical Treatment of Varicose Veins: Phlebectomy Very esthetic method of removing varicose veins Usually requires only local anesthetic Especially useful for tributaries of GSV, SSV 50

Treatment Results Before After Endovenous obliteration of the Great Saphenous Vein and phlebectomy of tributaries Photos courtesy of Steven Zimmet, MD, FACPh Superficial Thrombophlebitis: Management In the presence of varicose veins, DVT found in 10-20% Initial RX includes graduated compression and ambulation NSAID s for pain Antibiotics rarely needed 51

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Meet the Staff! Kelly Nichols Front office Reception Lori Bolman Medical assistant Tammy Haraway yep she s related Keeps track of everything/everyone And myself My Contact Information And a big thank you for attending! We hope to Grow with you! Tulsa vein Institute 81 st and Lewis 918-701-2020 office 918-701-2021 Fax My Cell phone number 918-814-6438 53

Spectrum of Venous disease G. Davin Haraway DO, FACOI,FACCWS, RPhS Tulsa Vein Institute 26 y/o female with hx of port wine stain left leg from birth, as infant had varicose vein from knee down and "had checked out" but doesn't remember who. started having bulging noticeable vein in thigh when in college but non tender. past two years has been enlarging. this July went trip flying to California while there noted both legs and ankles swelling but subsided when she got back. and more bulging left leg vein. approx. 3 weeks ago went to Podiatrist and had cortisone shot left heel for plantar fasciitis. before shot had some local phlebitis left inside knee and now tender along the left leg knee and thigh. runs about 4 miles a day. now with restless legs. now has edema at end of day. elevation helps. has not worn compression stockings before. has taken ibuprophen and ice feels better. Podiatrist told to schedule appt here. Medical History 54

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No DVT Mild Deep reflux on left Severe SFJ and GSV reflux left Isolated 4cm non compressibility and superficial phlebitis of Distal thigh Proximal Calf GSG Severe refluxing varicosities upper thigh and calf With port wine staining congenital syndrome diagnosis entertained Deep System: Duplex exam of the bilateral deep venous system demonstrates coaptation of vessel walls with compression and intact Doppler signals with distal augmentation, no intraluminal echoes are observed throughout the CFV, FV, POP, and tibial veins. No evidence of DVT. Mild evidence of deep venous reflux on left Superficial System: Largest Vein Diameter: RGSV:0.17 cm LGSV:_0.62_cm RT SFJ is intact without pathologic reflux. Right GSV is small and shows no pathologic reflux except for distal calf of 1812ms of reflux LT SFJ is enlarged at 0.67cm shows >2958ms of pathologic reflux and GSV is enlarged at 0.62cm with maximal reflux of 2352ms. severe reflux of the calf GSV is also present with >2292ms of pathologic reflux and large tributary disease. Active phlebitis of 4cm segment of the distal GSV present Impression: 1. No evidence of DVT. 2. mild left deep venous reflux. 3. NOSevere reflux of the Rt. GSV. (suitable for ablation) 4. NOSevere reflux of the Rt. SSV. (suitable for ablation) 5. Severe reflux of the Lt. GSV. (suitable for ablation) 6. NOSevere reflux of the Lt. SSV. (suitable for ablation) 7. Bilateral unremarkable PTV perforators. severe varicosities noted to the left medial calf amiable for phlebectomy Davin Haraway DO,FACOI,FACCWSResults 56

Long story HGB 5.8 at IR evaluation but plans for further eval once anemia evaluated most common Fe def from menorrhagia but risk if GI source Next visit clot extension despite NSAIDS and compression urgent RF ablation proximal to clot in GSV. And second opinion Saw popliteal clot at second opinion removable filter placed and Lovenox 40mg started. (abnormal Iliac anatomy suspected with filter placement) GI eval scheduled per PCP - HGB improving on Fe Eventual IVUS May Thurner anatomy and stent deployed No obvious Av malformations detected to thigh port wine stain. 3monnths Xarelto life long ASA saw GYN in between all this and had hypercoag panel neg Scheduled for RF ablation of residual GSV and Phlebectomy and US guided sclerotherapy in future. Diagnosis Klippel Trenaunay like syndrome (no bony over growth) and persistent lateral vein not apparent Parkes-weber (above plus av fistula) I do not feel she has but was discussed Some evidence of genetic translocation t(8;14)(q22.3;q13) Billy Corgan lead singer for the Smashing Pumpkins 57

dogma Do what is Only right in your God (attending s) eyes - or May you never pass with your Ass(etts) intact You could probably think up more Learn your basics well but Keep an open mind for improvement and Change! To learn you must realize that you do not know (that s mine) 58