Dispelling Myths About Superficial Venous Insufficiency by Robert L Worthington-Kirsch, MD, FSIR, FCIRSE, FACPh, RVT, RPVI
In medical school, I learned two things about Superficial Venous Insufficiency (SVI): that varicose veins are a cosmetic problem with no significant health implications, and that treatment options are neither effective nor durable.
Here is the reality today: Neither of these are true.
Venous Insufficiency is caused by failure of the valves that control the direction of venous blood flow. Veins in the lower extremity dilate under normal physiologic load. In some people, normal physiologic stressors (i.e. dependent positioning of legs, pregnancy, aging) cause irreversible structural changes to the vein wall, ultimately leading to malfunction of the valves. This leads to pathologically high pressures in the veins of the lower extremity. The poor drainage of venous blood and higher-than-normal pressures in these veins cause symptoms associated with SVI (i.e. heaviness, aching, fatigue and swelling) as well as the sequelae of SVI which can include chronic edema, venous stasis dermatitis, lipodermatosclerosis (scarring and retraction of the subcutaneous tissues or the ‘brown leather collar’ appearance at the ankle) and venous ulcers. Additionally, the higher pressure within these veins can approach arterial pressures, so bleeding from a ruptured varicosity can be life-threatening. Untreated SVI also has been found to significantly increase a patient’s risk for DVT/PE.
From a quality-of-life perspective, the discomfort, heaviness and aching associated with SVI can lead to decreased physical activity, thus contributing to a morbid lifestyle. And, people who suffer from chronic varicose veins are often deeply ashamed of the appearance of their legs.
SVI is present in over 30% of adults, more than twice as many as have CAD. The quality-of-life impact of SVI is similar to that of CHF, COPD or DM. Venous stasis ulcers account for at least 70% of ulcers seen in wound care centers. There are 2.8 million Americans with venous stasis ulcers, with 20,000 new ulcers annually. Care of venous stasis ulcers accounts for 2-3% of healthcare expenditures ($1-1.5 billion/year). Each ulcer episode costs about $15,000 in wound care.
Once a patient has developed an ulcer, coordinated care is essential to treat both the ulcer and the underlying venous hypertension. Ulcers will heal with appropriate treatment of the underlying SVI, but the damage to the skin and soft-tissue is often irreversible. Treating SVI before skin damage or ulcers develop is obviously ideal.
Here’s the good news: the treatments for SVI developed in the last 10-20 years really work on 90% of all patients, with little or no down time. Minimally invasive techniques include thermal ablation of the saphenous trunks using either radio frequency or laser energy, followed by treatment of large branch varicosities with injection therapy using microfoams. These procedures have technical and clinical success rates exceeding 90% in the hands of experts, and extremely low complication rates.
All are done under local anesthesia on a walk-in, walk-out basis. There is minimal disruption of patients’ busy lives. Emerging technologies hold the promise of even less imposition for the patient. After a treatment course and recovery period, which may take several weeks, approximately 90% of patients report that they are much improved or better.
SVI is a chronic progressive disease. Because it is caused by a structural abnormality of the vein wall, we cannot cure this disease. But we can, and do, manage it very well. After treatment, long-term follow-up of patients is important to monitor for progression of disease and the need for further treatment. Our goal needs to be prevention of irreversible changes associated with SVI, decreased risk of VTE and improvement of quality of life in our SVI population. We can achieve these goals for our patients.
Robert Worthington-Kirsch, MD, FSIR, FCIRSE, FACPh, RVT, RPVI is an Interventional Radiologist who has been practicing in the greater Philadelphia area since finishing his Residency at Mercy Catholic Medical Center in 1990. He is Chairman of the CME Committee of the American College of Phlebology. Dr Worthington-Kirsch has been practicing at the Vein Clinics of America office in Wayne, PA since 2012, and is Director of Research for VCA.