Expanding Your Vein Business Terri Morrison, RN, B.S., CEO Morrison Vein Institute Scottsdale/Tempe Arizona March 8, 2011
Varicose Vi Vein Market Approximately 40% of the US population has venous disease; 20 50 million people impacted by varicose veins More common in women than in men (20 25% of women, 10 15% 15% of men) 50 % of women at 50 yrs old! Venous disease results in symptoms such as aching, fatigue, swelling, and pain in the legs that can interfere with daily living Cosmetic issues may affect quality of life 1.5M seek Cosmetic or Medical treatment each year There are still 150,000 vein strippings each year: luckily the other 99% will seek minimally invasive, in office procedures with little down time and minimal discomfort At least 20% of patients with venous disease will develop leg ulcers All these patients need support stockings!
NEED 1.5M Seek Cosmetic or Medical Treatment Each Year
THE SPECTRUM OF VENOUS DISEASE telangiectasias Superficial phlebitis varicose veins lipodermatosclerosis venous ulceration
Historical Methods of Vein Care Sclerotherapy has been used in the treatment of varicose veins for over 150 years The first reported attempt of sclerotherapy was by Dr. Zollikofer in Switzerland in 1682 Injected an acid into a vein to induce thrombin formation In 1854, Desgranges cured 16 cases of varicose veins Injected iodine and tannin Due to the high rate of side effects with the drugs used at that time, sclerotherapy was practically abandoned by 1894 In 1946 came the development of sodium tetradecyl sulfate (STS) which is still in use today
Methods of treatment Polidocanol was developed in the 1930 s as a topical anesthetic and marketed as a scleorsant in the 1950 s In 1946 came the development of sodium tetradecyl sulfate (STS) which is still in use today In the 1960 s, George Fagan reported treating over 13,000 patients with sclerotherapy He focused on fibrosis of the vein rather than thrombosis and the importance of compression of the treated leg His procedure became accepted in Europe in the 1960 s His procedure became accepted in Europe in the 1960 s and in the US in the 1970 s
Reticular Vi Veins Enlarged, greenish blue appearing veins Frequently associated with clusters of telangiectasias May be symptomatic, especially in dependent areas of leg
Tl Telangiectasias i 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 Weiss RA and Weiss MA J Dermatol Surg Oncol. 1990 Apr;16(4):333-6.
Treatment of telangiectasias i Sclerotherapy most effective Laser may be helpful Multiple l 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.
Lateral lsubdermic Plexus Very common, especially in women Superficial veins with direct connections to deep system Remnant of embryonic deep venous system
Correct Sclerotherapy Technique
Treatment of Reticular Vi Veins Frequently associated ated with telangiectasias, their Rx may enhance results of sclerotherapy of telangiectasias Visualization may be improved with transillumination Photo courtesy of N. Scott Howell, MD
Sl Sclerotherapy Results Before Photos courtesy of Steven Zimmet, MD, FACPh After
While routine compression after sclerotherapy is still a matter of debate, it is common practice everywhere in the world to perform some sort of compression after surgery or after endovenous treatment of refluxing veins. In a study based on the assessment of independent observers Kern et al have demonstrated that compression stockings in a range of 20-30 mmhg worn for three weeks are able to improve the cosmetic outcome after sclerotherapy of spider veins. Comparable results after sclerotherapy of large veins are missing.
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
Treatment of varicose veins Endovenous occlusion with radiofrequency or laser extremely effective Microphlebectomy Ultrasound guided Sclerotherapy Min R et al, J Vasc Interv Radiol 2001; 12:1167-1171 Rautio T et al, J Vasc Surg 2002; 35(5):958-65
Varicose Veins with Pelvic Origins Begin during pregnancy Increased symptoms during premenstrual period and after intercourse May be associated with pelvic congestion syndrome Opportunity to sell: Pelvic Cradles, V2 Supporters, and dspanx!
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 Photo courtesy of Mitchel P. Goldman, MD
Radiofrequency Closure Technique Outpatient procedure approximately 60 min. long Local tumescent + heparin drip Temperature at vein wall controlled 90% closure at 2 yrs FDA approved for RX of Great Saphenous Vein Photos courtesy of VNUS Medical, Inc.
Endovenous Laser Ablation Outpatient procedure approximately 60 min long Only local tumescent anesthesia required Closure of >93% Great Saphenous Veins at 2 yrs FDA approved for RX of Great Saphenous Vein Photo courtesy of Diomed, Inc.
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 fcompudiagnostics, Inc.
Treatment Results Before Photos courtesy of Steven Zimmet, MD, FACPh After Endovenous obliteration of the Great Saphenous Vein and phlebectomy of tributaries
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
Elastic compression stockings Must be graduated Replace 6 months to assure proper pressure Available in a variety of strengths, styles, colors, and fabrics
Medical or Cosmetic treatments, then everyday. Variety of clients Variety of stockings Juzo Attractive Sheer OTC Juzo Cottton Sock Juzo Naturally Sheer Juzo Basic Casual Juzo Silver Soft, Open Toe Juzo Silver Sole
Compression therapy, to be effective, necessitates the understanding di of the venous system and graduated d medical support stockings. Vein Anatomy - Perforators and Reticular Veins Reticular Vein, Venules and Capillaries Great Saphenous Vein Deep Femoral Vein Perforator Vein (connects superficial and deep veins)
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..sae are indicated dcatedtoto decrease the incidence of thrombosis T.E.D.s do not provide sufficient pressure for ambulatory patients
Goals of Compression Therapy Help prevent thromboembolism in non ambulatory hospitalised patients t Improve venous return from the lower extremities ii with ih venous stasis Counter effects of ambulatory venous hypertension Help control the progression of venous and lymphatic disease by increased contact of skin and dermal tissues with capillaries; reduce and control edema
Goals of Compression Therapy Compression garments, like eye glasses have to do three things to be successful: Control the condition Be comfortable to wear Be reasonably cosmetically acceptable
Effects of Compression Therapy Microcirculation Lymph drainage Improvement Improvement Central Blood Increase shift Venous pump Improvement Arterial flow Increase (intermittent Sources: The Vein Book Chapter 10 compression) Partsch H. Phlebology 2006;21:132-138
Patient Compliance is the Key Study of 166 older women 15% incapable of donning 26% could do only with ih great difficulty Necessity to teach donning and doffing techniques Teach patients to Use Gloves Demonstrate Slippie Gator or other devices Source: Erickson, et al;j. Vasc. Surg.1995:22:629
Ensure the patient gets the right advice, fitting and comfortable as well as..comfortable as well as fashionable medical stocking.
Juzo Soft 2002ATFL 30 40 mmhg Waist Highs give men a fly opening making life a little simpler. They are knit with a unique FiberSoft weave making them their softest medical stocking. These pantyhose are so soft and inconspicuous, you'll forget you're wearing them.
Practical lfactors Overcoming donning/doffing difficulties Is help available to patient? Sources: Rutherford Vascular Surgery 6 th Edition Chapter 156 Hugo Partsch personal communication
Compression Strength Indications 8-15mm Leg fatigue, mild swelling, stylish 15-20mm 20-30mm * 30-40mm * Mild aching, swelling, stylish Aching, pain, swelling, mild varicose veins Aching, pain, swelling, varicose veins, post-ulcer 40-50, 50-60mm * Recurrent ulceration, lymphedema * Requires a prescription
Pharmacologic therapy NSAID s relieve e some symptoms, especially premenses Horse chestnut seed extract (Venastat) may reduce aching and swelling Pentoxyfilline (Trental) and Daflon 500 reduce inflammation, diminish skin changes and may retard the progression to ulceration Schmid-Schonbein, GW et al Angiology. 2001 Aug;52 Suppl 1:S27-34
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Selling to Vein Clients: Phlebologists Start with your own existing database send out fliers, postcards, or email blasts to tell them you are adding compression stockings to you quality yproduct lines Go to the Phone book or on line search services to catalogue the number of phlebologists in your area: dedicated vein clinics, vascular surgeons, dermatologists, plastic surgeons, laser clinics. Look for Vein ads on TV, Radio, Magazines to see who may need your product Provide referral pads with maps to your facility, hours of operation, and what types of compression do you have in stock and how long is the wait time for ordering
What do phlebologists want? They want you to fit their patients Offer choices of size, color, sheerness, mmhg ordered to help ensure compliance Knee High, Thigh high, Panty in graduated compression Deliver in a timely manner Donning and doffing devices
3. What amount (mm hg) of compression do you use for postcosmetic procedures? p Response Percent Response Count 15-20 26.0% 19 20-30 43.8% 32 30-40 32.9% 24 answered question 73
4. What amount (mm hg of compression do you use for post-medical procedures? Response Percent Response Count 15-20 3.9% 3 20-30 50.0% 38 30-40 48.7% 37 answered question 76 skipped question 3
http://www.phlebology.org/ American College of Phlebology A multi disciplinary organization founded in 1986 The ACP has a culture of sharing knowledge, education and practice management to work towards our mission to Advance Vein Care and to establish standards of patient care in phlebology. There are benefits to membership but all are welcome to learn and Advance Vein Care and awareness. With over 2000 members, networking opportunities are excellent. You will also receive complementary subscriptions to phlebology l journals to keep you updated dtd on new therapies, studies, and trends. http://www.phlebology.org/patientinfo/index.html This is a section for teaching clients or patients
For more information: Email: info@morrisonvein.com or contact t Terri: Terri@morrisonveininstitute.com Thank you for attending!