Diagnosis and Treatment of Venous Disease Part 2 of 2 by Domenic A. Zambuto, MD, RPVI, Regional Medical Director
To best understand their condition patients must know that there are two sets of veins within their lower extremities. The purpose of all the veins is to collect the used venous blood. The blood needs to be returned to the heart. The heart then recycles the used blood by pumping it through the lungs. In order to accomplish this the body must pump the blood uphill against gravity. To do this efficiently the veins need to have one-way valves. The valves allow the blood to go one way, back to the heart. The valves prevent blood from flowing downhill. Gravity is an extremely strong force. As a result blood would naturally flow down the veins in the leg rather than uphill against gravity. The valves prevent this downward flow.
The major veins within the lower extremities are the deep venous system which are veins that are deep to (inside) the muscles. These veins do almost all the necessary pumping work of pumping blood out of the veins in the leg back to the heart. These veins are almost always normal. They can become abnormal after severe trauma or after the development of blood clots in the legs.
The superficial veins are the minor veins within the lower extremities. These are located in the outer inch or so of the leg. These exist from the skin down to the muscle layer. It is these veins that are often diseased. The underlying abnormality is a congenital one in which some of these veins do not properly formed their valves. As a result blood flows the wrong way within these minor superficial veins. The blood flows downhill with the assistance of gravity. The blood finds its way to the normal veins which get overloaded with all this extra blood that has to be pumped out of the veins in the legs. As a result the veins are over pressurized. The high pressure causes the veins to get stretched and enlarged. In addition the high-pressure triggers inflammation which destroys the valves within the good veins. As a result the good veins lose their valve function over time and become bad veins. When this happens additional blood flows the wrong way, further overloading the venous system. This leads to the further development of abnormal veins, more visible varicose and spider veins, and a more rapid deterioration of the good veins within the lower extremity. The whole process accelerates with time.
Currently patients who desire to do something about their chronic venous insufficiency have two major choices. The first choice is conservative therapy. This includes the use of gradient compression stockings. As described previously, gradient compression stockings limit the abnormal flow of blood in the superficial veins by squeezing them partially shut. By doing this there is a slowing of the progression of disease and there is also an improvement in symptoms for most patients. The biggest challenge is that most patients find it very difficult to wear gradient compression stockings all day, every day. To be most effective the stockings must be worn when the patient is upright. Most major insurance carriers still require patients to undergo a trial of conservative measures prior to initiating definitive therapy. Those who have failed compression stocking use can undergo therapy.
The best approach to treat chronic venous insufficiency is to eliminate all sources of abnormal venous flow. By doing this there is a great reduction in the development of new abnormal veins overtime. No veins are removed. All treated veins are closed and reabsorbed by the body over time. By reducing as much abnormal venous flow possible the patients have a substantial improvement in their clinical symptoms. There is a substantial reduction in the risk of the development of new venous ulcers, bleeding episodes and the development of superficial thrombophlebitis.
The best approach to eliminate the abnormal veins is to work in a systematic manner. The biggest upstream abnormal diseased veins should be treated first. These represent the “source veins”. These larger sized abnormal veins bring a large amount of abnormal blood flow into the leg. By eliminating these veins first, the downstream vessels become easier to treat (by dramatically reducing the amount of abnormal blood flow). Some actually improve to the point that no treatment of these downstream veins is required. Only abnormal veins are treated (eliminated). The source veins are called axial or truncal veins. These are the largest of the superficial (minor) veins. Most often we think of veins like rivers and streams with smaller veins flowing into larger and large veins (normal situation). Another approach is to think of the veins like a tree. We treat the trunks of the tree first, then we treat the branches and ultimately we treat the twigs. Thinking about the veins that must be treated in this manner is how we treat veins in a state of the art approach. The trunks are treated one way, the branches another way and the twigs yet another way. The best outcomes and the fewest treatments are needed by treating systematically from the source vein down to the small veins (in that order). It also allows for a thorough approach to the diseased veins.
Figuring out which veins are good and which veins are bad is done with a detailed ultrasound study of the veins. Ultrasound provides several advantages. It is non invasive, it involves no radiation; it is relatively inexpensive and when performed properly is very accurate. An ultrasonographer performs the exam under the supervision of a physician who interprets the study. All of the veins in the lower extremity are evaluated. Valve function is evaluated by measuring the flow in the vein while simulating exercise (we squeeze the leg). The study must be done upright in order to properly evaluate the valves. Typically it will take at least 30 minutes per leg to evaluate all the veins. Evaluation of the superficial veins without the patient upright will likely miss a significant portion of the diseased veins (remember we want to know what gravity is doing to the blood flow in the veins).Ensuring the ultrasound exam is done properly is a critical part of high quality vein disease diagnosis and ultimately treatment. The Sonographer should be properly trained in the performance of the vein ultrasound exam. A quality assurance program is something to look for. If a quality assurance program is in place this means that the studies are being monitored to ensure they are being performed to a high standard. While not an absolute requirement, an accredited ultrasound lab can be a sign of a quality facility. Ultimately it is about the care taken by the sonographer in evaluating the veins of interest. Many offices will sketch out the superficial veins. This allows for a simple way to communicate the findings and the specifics of how the patient’s veins are put together. This also serves as a great tool to follow the treatment progress on subsequent ultrasound studies.
Once the leg is properly evaluated with ultrasound, treatment is started on the abnormal axial (truncal) veins. These are the veins treated with the catheter based thermal ablation. After these veins are treated a follow-up ultrasound is performed to ensure no blood clot has occurred (a rare complication of the procedure). Following treatment of these “trunks”, a repeat ultrasound is done to evaluate the “branch” veins. Any “branches” (tributary veins and the varicose veins connect to them) that are abnormal are treated with sclerotherapy. This is often performed with ultrasound guidance. Using ultrasound guidance the abnormal vein is injected while watching with ultrasound. This ensures that the appropriate vein is treated and that the proper amount of drug filled the diseased vein. Using ultrasound guidance allows Sclerotherapy to be done on all the diseased “branch” veins in the superficial layer of the leg. This is a huge advantage from the old technique of only treating veins at the skin surface. Performed after proper treatment of the upstream refluxing (diseased) truncal veins, sclerotherapy can be expected to successfully close about 70% of the treated veins with one session in the average patient. The remaining veins that do not close are typically partial failures. It takes about 2 weeks before it is clear which veins have closed properly. A follow-up ultrasound is done and any incompletely treated veins can be retreated with repeat ultrasound guided Sclerotherapy. This process can be repeated until all abnormal veins below the skin surface and outside the muscle layer have been treated completely. At this point if there are abnormal veins in the skin that have not been treated by what has been done so far, they can be treated with Sclerotherapy. Ultrasound is not needed for these veins. They are visible at the skin surface and are treated with visual sclerotherapy (injecting the veins while looking at them). Just like with ultrasound guided sclerotherapy not all injected veins will fully close with one session of injections. These can be retreated as needed usually at a minimum of two week intervals.
Once all abnormal veins have been thoroughly treated the patient is given time to heal. During this time the body will absorb the treated veins. The venous blood flow is normal in the treated leg at completion of the treatments. As a result the patient symptoms resolve. The treated veins typically take at least one year to be fully reabsorbed. At the skin surface the visible diseased veins will look different and slowly will disappear. It is common to feel hard “lumps or cords” below the skin surface during healing. These hard areas are treated veins. With time these go away as the treated vein is reabsorbed by the body. This takes time. Most patients are mildly sore immediately after treatment and most discomforts are substantially improved within one week after any treatment. With healing some of the treated veins may re-open instead of disappearing. Good follow-up to find and treat these veins (as needed) should be part of the patient care plan. Long term even when all abnormal veins have been properly treated some new disease may occur (loss of valve function with abnormal blood flow in the affected vein). Long term follow-up strategies should exist so that patients are not allowed to have a substantial progression of new disease (varicose veins). Proper long term follow-up should help the patient maintain good vein health in their legs over a lifetime.
There are some new technologies emerging that may further improve the treatment strategies. These new technologies are aimed at the treatment of the axial (truncal) veins. This includes the use of glue, freezing and chemicals (modified sclerotherapy) to close off the truncal veins. There is limited world wide experience with these technologies compared to endovenous laser and radiofrequency ablation procedures. None of the new techniques has been shown to be superior to the established technologies. It will take some time to see where (if at all) these new approaches fit into the modern treatment strategies for vein disease.
There is much good news for the patient who has varicose and spider veins. This summary represents a compilation of my experience with diagnosing and treating vein disease since 1989. Please use it as a guide when seeking care. Ask questions of your care provider. Your specific treatment plan should be based on addressing your symptoms in combination with your findings on physical exam and on a properly performed ultrasound study. The good news is that even with outstanding treatments today there is active research looking to further improve the quality of vein care.
You can find Dr. Zambuto at the Vein Clinics of America clinic in Canton, CT and you can reach his office by calling (860) 693-4060.