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Physicians Update

 
Winter 2006: Vascular Disease

New Treatments for Venous Diseases Improve Outcomes and Reduce Scarring

From sclerotherapy injection to radiofrequency ablation and stab phlebectomy, minimally invasive procedures are dramatically changing the management of venous disease. “The days of having large scars on the leg are gone,” says Peter Lawrence, M.D., director of UCLA’s Gonda (Goldschmied) Vascular Center. “We now have many different ways of treating venous disease in an outpatient setting that don’t require the large incisions we previously made. In addition to less scarring, this has led to less pain, shorter recovery times and better cosmetic results.”

Venous disease tends to fall into three categories. Spider veins—the unsightly clusters of red, blue or purple veins that most commonly appear on the thighs, ankles and feet—occur predominantly in women and are usually hormonally based. Varicose veins, in which inadequately functioning valves in the veins cause blood to pool and the veins to enlarge, often occur in women after pregnancy and in men from activities that exact high pressure in the veins, including bouts with constipation and certain athletic maneuvers; in other cases, the cause is congenital or unknown. Unlike spider veins, which tend to be no more than a cosmetic problem, varicose veins are often associated with symptoms that include heaviness and fatigue in the leg after prolonged standing. In more severe cases, venous insufficiency—in which the veins fail to adequately return blood from the lower limbs back to the heart—can lead to venous ulcers, which require immediate attention.

“The standard treatment for a lot of venous disease was always removal of the vein through stripping, which usually meant an overnight hospital stay followed by a week of disability,” says Hugh Gelabert, M.D., vascular surgeon at the Gonda (Goldschmied) Vascular Center “Now we’re doing outpatient procedures in which the patient has two to three days of tenderness rather than five to six days, and can go back to work much sooner.” The majority of the population, especially women, will develop some degree of venous insufficiency, notes Deborah Caswell, a nurse practitioner at the center. “Many people come to us because they’ve seen others who have been amputated and they have a sore on their leg or these big, ugly veins and they’re afraid that they are headed the same way,” she says. Caswell assures these patients that they need not be fearful, and provides education to ensure that the complications of end-stage venous insufficiency will be avoided.

First-line Therapies Conservative management of mild venous insufficiency starts with having the patient avoid excessive standing and wearing elastic support hose—graded compression stockings designed to keep the blood from pooling at the bottom of the leg—when standing is required.

For patients whose jobs require constant standing, Caswell counsels toe-raising exercises that help pump blood through the calf muscle. “Venous insufficiency is a disease of gravity, meaning that if your legs are in the dependent position the fluid tends to collect at the bottom and increases the venous pressure, causing aching, swelling and heaviness that is common in these patients,” she explains. “Since very few people can keep their legs elevated 24 hours a day, we rely on some type of compression stockings.” Horse chestnut seed extract is the only medication that has been shown, in small studies, to be equal to compression stockings in controlling the swelling and aching in patients with venous insufficiency, Caswell adds. She also urges patients to exercise and lose weight when appropriate. If discomfort persists after conservative management, or if patients are concerned about cosmetic appearance, one of several minimally invasive procedures may be recommended.

Sclerotherapy or laser treatment are often used to improve appearance. Sclerotherapy involves injection of a solution into the vessel to irritate the inside lining of the veins. A magnifying glass facilitates injections into the smallest veins with solutions least likely to cause significant pigmentation or risk of ulceration. Compression pads push the vein walls together and the compression stockings are worn as the veins heal shut. Says Caswell: “It’s important for me to be very familiar with the anatomy of the venous system. Frequently, patients will come to us after having had numerous sessions of sclerotherapy, and the spider veins keep coming back. We might take one look at them and realize they have an incompetent perforating vein that, if successfully treated with a small procedure by a surgeon, will prevent the spider veins from returning.”

Radiofrequency Ablation

Radiofrequency ablation effectively shuts down the vein by delivering heat to its inner wall through a catheter, using ultrasound guidance. For patients with varicose veins and those with venous ulcers—in which veins deeper in the leg are affected—endovenous therapy using radiofrequency ablation enables vascular surgeons to close off the veins without making incisions. “This is a big change in our practice in the last few years,” says David Rigberg, M.D., a vascular surgeon at the Gonda center. “The classic stripping of the greater saphenous vein—in which we would make a small incision in the groin and just below the knee or at the ankle and run a plastic tube through the vein from one end out the other before essentially ripping the vein out—has been replaced. Instead of a procedure that caused a lot of swelling and bruising, and potentially a great deal of discomfort, we now have one in which we destroy the vein in its original place, using this relatively quick outpatient procedure with minimal postoperative discomfort. It has revolutionized the treatment of venous disease.”

For patients with medium-sized surface varicose veins, vascular surgeons are performing stab phlebectomies, in which the veins are removed through incisions that are so small—approximately one millimeter—they don’t require closing. “These provide a much better cosmetic result, because you can’t see the access site where we went in to remove the vein,” says Dr. Lawrence.

The worst cases of venous insufficiency can lead to ulceration of the skin or more serious problems of the deep venous system. “Chronic venous insufficiency can be very disabling if the patient gets a large ulcer that won’t heal,” says Dr. Gelabert. Venous ulcers are treated with surgery that either bypasses an obstructed vein or reconstructs the valves. Although these are open surgeries, they are performed in ways that are less invasive than in the past.

“We now have techniques that improve the healing process and reduce the likelihood of recurrence,” says Dr. Lawrence. He notes that venous ulcers are preventable—among other things, after an episode of phlebitis, patients should be counseled to wear support hose. Proper diagnosis of venous disease is critical to the success of treatment, Dr. Lawrence notes. In addition to the physical examination, imaging and physiologic studies are important. This includes specialized ultrasound and the magnetic resonance venogram—which has taken the place of the more invasive traditional venogram—to look at the flow of blood in three dimensions. With a wider array of effective treatments now being offered, Dr. Lawrence suggests patients be referred to centers that have the full arsenal.





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