Chapters Transcript Video Veins, Venous Insufficiency and Varicose Veins Nedaa Skeik, MD, discusses veins, venous Insufficiency and varicose veins. Welcome to cardiovascular conversations with Minneapolis Heart Institute. Your podcast for the best and cardiovascular content. Cardiovascular Conversations is a new, creative and engaging content source for the latest and greatest in cardiology topics and innovation. Way are your hosts, Fred Amuse and I'm Jason Hicks. Enjoy the podcast. Everyone, welcome back to cardiovascular conversations. Today we had the distinct pleasure of sitting down with Dr Need Escape vascular medicine specialist with MH I. He is discussing Venus insufficiency and the various options for treatment that patients have who are suffering with this doctor. Skate did his fellowship, training and vascular medicine at Mayo Clinic, and he brings a wealth of experience in the realms of clinical medicine and research. In addition, he heads the section of vascular medicine, and he is the medical director of the Vein Center, among various other leadership roles at Minneapolis Heart Institute. So while we don't condone Stasis way, hope you stay right where you are and you'll join us right now for some vain talk with Dr Steak. Here we go. Let's start with a little anatomy path of physiology and background. So there are two different groups of veins. The Deep may in veins that helped to carry the blood from the lower extremity back to the heart. Uh, this group is supported by a superficial surface veins that help to support the divan system by carrying more blunt extra blood from the lower extremity back to the D veins in the growing area, back to the heart, the devein system. When we talk about devein system starting from the growing down, we're talking about common, ephemeral, ephemeral, uh, profound or deep, ephemeral and popular Teal and calf feigns So these are the D veins and we don't usually touch these things because they are the main plumbing, if you will. And there is also the surface group. If you wanna name a few of them, the main couple of them you know, greater softness vein, which runs in the inner side of from the ankle all the way up to the growing that dumps the blood to the common criminal vein at this stuff in a federal injunction, there's also the small, short softness fan at the back of the calf that helps to kind of the blood from the around the ankle and calf and dump it down to the popular t elven through this suffering of probability of the junction, there are superficial luck, smaller branches around. So this is kind of the main kind of in vain anatomy that we're talking about. So yeah. So Venus insufficiency. We hear the staff in this vein come up time and again and it seems like this is kind of the big dog vein when we talk about Venus insufficiency. Is this vain? In particular, kind of. The big culprit is this. Where a lot of problems there in lie that is correct. And that's caused by, you know, evolve incompetence, if you will. And that leads to kind of reflux ing the blood bouncing the blood down to the lower extremity, which actually increases the pressure in the veins. And and hence the branching and the very cause it is off the greater or small softness veins. What are their names are there for? Other than just Well, you have varicose veins. But what else do you see? General symptoms. You know, people can talk about leg heaviness, you know, aching swelling, um, dryness, tightness, itching, irritation, complaining of cramping at night and waking up with cramps and in terms off findings, patients could see really larger veins. We call those very close veins. If there are 33 millimeters and bigger, we call those varicose veins. And if there are 3 to 6, we call those small varicose veins and above six millimeters. We call those larger, very close veins and also some patients They have spider or tell inject Asia. We're talking about a less than one millimeter off the diameter of a vein, a particular vein. Those are kind of between one and three millimeters off veins. So these are of manifestations. But also, you know, if you wait too long, which you shouldn't, you know. Then we start seeing patients with skin discoloration or hyperpigmentation. Sometimes, unfortunately, patients can come down with Stasis, ulcers or bleeding very positive when the blood actually stays longer than the veins in the legs, some of their blood cells. Actually we call that exert externalization, gets out off some of these red blood cells, get out of the vessels and the him a globe and gets broken, and the iron and hemoglobin actually stains the skin, and it actually starts and chronic inflammation. And at least to this dermatitis, if you will. It's it's It's painful. It's usually patients have redness and irritation and paying and and inching What Stasis dermatitis. Okay, like we sometimes confuse it for cellulitis. We probably people on antibiotics. Often you also see this ISAT lipo dramatic sclerosis. Yeah. So with that chronic inflammation being place and the subcutaneous fat or in a fat issue really get gets replaced by a sclerosing, our sclerosis or fibrosis And this is pretty late stage of off the disease. And and if you don't really pay attention to that, patients can also rate because that skin is not normal anymore. What is the incidents of actual vein disorders with, uh, majority the population, so actually, based on different studies, chronic van abnormalities, we can see up to 50% off of individuals. It's pretty prevalent in the Western Hemisphere, you know, probably because of the lifestyle and genetic predisposition and very close friends. If you think about very close friends, which we defined earlier, you know, we see that impacts about 25 to 50% of females and about 77 tow 40% of males and to have some sort of varicose veins. But typically a little bit later in life. Yeah, so it's actually, you know, risk factors if you wanna talk about risk factors. Eso, um Advanced age is one of the risk factors, but I you know, I've diagnosed significant venous insufficiency in teenagers, you know, most likely because they have a genetic predisposition. Both parents, you know, usually have the disease should see the vascular special about nine years of age. Sadly, you can't pick your parents eyes. It's safe to say that after childbearing after pregnancy, there they become more prevalent. Problem? Yeah, Yeah, absolutely. So talking about risk factors, we start talking about the advance. It also hormonal exposure, you know, during pregnancy or or contraception or hormone replacement actually tend to kind of increased risk of unison sufficient and very causative formation. You talked about, you know, family history. Also, we talked about that, um, and also lifestyle. I think we have to mention that patients who stand up for the most part, like surgeons or procedural ist like myself and sitting too much or standing too much, you know, tend to increase risk of of units insufficiency, because when you stand or sit too long, you don't pump because I call walking is a pumping mechanism because each time you step or make a step your your calf muscles pump the blood back to the heart. And if you don't, you get more swelling and get more vain disease thrombosis. If the patient has history off deeper, superficial in thrombosis is another risk factor for venous insufficiency. We call that post traumatic syndrome trauma is another risk factor. Have patients come down and say, Hey, I've never had any issues Just just after I had my leg trauma started to notice These very cause it is showing up. Smoking is another risk factor is well, too. And there are some rare, um, congenital hereditary diseases like Lipitor Nani syndrome, which is very rarely that we see next segment coming right up. Diagnosis scoring and conservative therapies. SIHP classification is one of the most common ones that we use. In addition to the V. C. S s just a brief interjection here about Seep and VCs s, which doctor skate will discuss in more detail shortly. Seep stands for clinical ideology, anatomy and path of physiology. It is a classifications system used by vascular medicine specialist to diagnose and compare patient populations with chronic Venus disease V. C. S s stands for Venus. Clinical severity score. Let's jump back into the discussion now and Dr Skate will describe the CPE classifications system, followed by VCs s scoring. Based on the clinical presentation of the patients, we kind of there is class year two, Class six class. There is no visible veins or spider veins at all in the class, one with something. Inject Asia's of spider ridiculous veins to smaller veins. And then stage two when patients have very close veins. And if the patient started, have some swelling or oedema that stage three. And when you start to have the skin changes like hyperpigmentation or Lipitor matter sclerosis, Stasis dermatitis. That's kind of, uh, we started talking about stage four and stage 5 50. Patient had and also it's healed. And Stage six is, uh, is actually patients when they haven't open active ulcer. The V. C s s actually Venus. Clinical severity score takes in consideration mawr factors. So we tend to use thes scoring system to kind of, um, you know, what are we dealing with? Is this a mild case that we can just get by conservative therapy. Or this is actually more severe case that we probably should not wait long before we start procedure, procedural treatment or intervention. So we're also talking about the number of anatomical segments that are typically affected by this disease to right. So obviously I'm guessing the bigger tributaries or the more involved tributaries. They're gonna be increased on that grading skills that corrector yes. So in terms of the length of the segment that's affected, definitely determines the severity of the disease. For instance, if you're talking about the greater softness, van incompetence, if the whole vein is incompetent, right, that's actually more. You get more severe symptoms for, for the most part, than if it's just in the thigh that's incompetent and then also the reflux in seconds. You know, if the patient has a reflux time off five seconds arm or you tend to Seymour vein disease manifestation than if you were to get to have just the, uh, reflux of a second or two you know, for the for the average practitioner, primary care or otherwise. What is important for us to document on our patients when we examine them? I think it's very important for the primary care physician, Thio, to be worst on the manifestations of venous disease. Even even sometimes a spider or particular vein might be an iceberg. Soapy patients can have an underlying greater softness vain, but because they're young and they're very active, right, they don't necessarily show these large recoveries, even with significant clear softness or small softness being incompetence. So I would say any manifestation of a van disease should set the alarm for referral because, as I mentioned, um, you know, patients could have significant venous insufficiency with little manifestation. Sometimes you wait so long and the patient comes down with rumble phlebitis or clot in the superficial vain. Once the patient clots the superficial vain, it is hard toe intervene on that vein. So exactly so I would start, you know, the compression therapy process and then send them to have a venous insufficiency ultrasound. There are two different vein ultrasound that you can order in the system. One is just to rule out DVT, which is okay, but I think we could just order a venous insufficiency ultrasound, which is more detailed ultrasound looking at just not the anatomy, but also the function of the vein to look at the reflux, and then we'll be happy to take it from there. And we'll take care of this, you know, scoring and and then for their management for you. Let's just say we're in the middle of a pandemic on, um, if things really come to a grinding halt again and there's a long wait to get in to see somebody like you. Dr. Steak, what other things can the primary care provider offer? The patient you had mentioned compression? Um, stockings, I think earlier alluded to elevation walking exercises, that pumping. Um, is there anything else that that can be done before any sort of invasive procedure is entertained? Is compression and actual treatment, or are we talking like a stopgap to prevent the? That is a very good question. It actually helps with the symptoms, not necessarily changing the process of the disease. That's very good question. But as soon as you take the impressions talking off and you stop wearing them, you know you start to get these constellation off symptoms again. But you know, to your point, I think you know, for the primary care physician you know, especially in this pandemic, we could start conservative therapy. You know, I favor thigh high over knee highs, because if there is a reflux and the greater softness spin on the thigh and only use knee highs, and that's probably not appropriate. So, um, so I do with Thigh High 20 authority millimeter Mercury for a pressure. And I would recommend using those stockings and wearing these stockings in the daytime and take them off at night. That's proven to reduce symptoms other, you know, consider therapy Modality Is walking exercises, actually, um, leg elevation at the end of the day. You know, um, sometimes I write a prescription for regulation. Skin care, you know, watch for your skin. Make sure you don't bump your leg against something because you could have a leg ulcer. There are some medications, like, you know, over the counter that you horse just not see distracts that you see on the on the shelves. Sometimes people come down here. I said, Well, you know, I use it. It works Well, if it works for the patients, find you can continue on it. Um, aspirin. I don't really use aspirin. Vory commonly because aspirin. You guys know now that aspirin, um, even baby aspirin. For the long run, it can lead to increased risk of major G. I bleed or gastrointestinal bleeds Pentax a file in or Pentax a felon. You know, however you want to say it is, You know, some people I use it and and it it's not proven 100% to help with the Venus symptoms, but some studies showed it might. So this is another medication that you might consider. I use, like importance theories for patients with Stasis, dermatitis or itching if the patient has also we talk about also management or wound management with debridement and and so forth moving right along, Let's get into some of the invasive strategies. Let's talk about a case. So we've got our patient who has been dealing with some varicose veins. Maybe these little Spider Act Asia's or tell inject Asia's by my legs were just kind of uncomfortable. I've noticed this coming on over the last year to dock, and, um, this is, ah, 45 year old woman who's gravity for and, you know, works on her feet a lot. So she's seen her primary care provider. He said, Yeah, let's try these compression stockings and she's done that for several months pretty diligently, but it's still there. So what? What do I do now, Doc? Well, I'm going to refer you to this vascular medicine specialist, Dr Steak. I think you're gonna like him a lot. She presents to see you. What sort of options are you gonna discuss with her? And what sort of what is that conversation look like? Sure, I'll come to that question before I answer this question. You asked me earlier because we live in a pandemic now on patients really, really get worried about coming to the hospital to see a provider. So if they if the primary care physician thinks that we should see the patient early on, there's an option for virtual visits and ideo we perform actually video calls so we'll be able to see the patient to really live. And we will be able to examine the patient by, you know, looking at their legs or whatever. The area of interest is so going back thio that patients so if any given patient, they try compression stocking, celebration, walking societies. They still have these symptoms that we mentioned earlier then it's time. If it's, you know, if the patient hasn't seen us is still kind of refer the patient to us. And I would again order venous insufficiency, ultrasound and based on which, you know, we can start making decision about some van procedures because if you have moderate, severe vein disease, you have not responded. Thio Conservative therapy. Then we start talking about vein closure procedures or van procedures, and I definitely recommend these van procedures for patients with moderate to severe disease early on because you know you don't wanna wait again to develop late stages, which can be permanent changes like thesis dermatitis. Sleep a tremendous sclerosis, uh, in thrombosis. Once you get this, it's it's hard. And if if you get if you develop on also, this is kind of a permanent scarring there. So definitely I would recommend early on evaluation and appropriate procedure at the right time. And then 45 is young. Absolute. Nobody says that even 17 hours. This is a young eso age shouldn't be really a deterring factor to start thinking about procedure early on as it's based on this disease severity not on age per se. So let's fast forward here a little bit. Then her older son comes back. She was moderate to severe disease and she says, What should we do next? Okay, so there are different, actually, um, treatment options available, actually, different modalities and options. So for mild disease, then we offer the patient treatment called slow therapy, which is using a sclerosing agent like sort of the call of political all too close thes smaller, ridiculous spider veins that'll inject ages. And it's an outpatient procedure that we use thes small needles to inject this solution, and it's actually detergent detergent. What it does is causes inflammation and sclerosing closure of these smaller veins. Um, if the patient has moderate to severe disease with significant involvement off the greater softness and or small softness veins, then we start talking about the, you know, vein closure procedures. There is a thermal ablation or using heat to close the vein. And then there are different, actually, two techniques that we use if you use laser. We call that in the Venus Laser revelation on diffuse really frequency. As an energy source, we call that radio frequency ablation, and so also there is a recent technique that I really love doing as well. It z called chemical adhesive embolization using San Accolate. It's a glue. It's actually super glue. Believe it or not, we just you know, we go with the Catherine. The greatest softness Venus most often is being, and we actually apply or inject glue as we take the catheter out. So you guys are cutting down a medical costs. You can go to any hardware, Hank and get some superglue, and I think we'll just do the kids. Don't try this at home. Yeah, exactly, exactly. There is also another technique we call that mechanical inclusion chemically assistant of mocha, if you will not. The mocha that you drink on dis is actually Katha that revolves very, very fast and what it does. It actually irritates and injured the vein wall, and at the same time you inject that sclerosing agents moving out, and that's actually closes the vein. There is also a technique called intravenous microphone. Using very Athena is, which is actually political. All, um, it's a it's a it's a foam square off therapy that we apply into directly into the greater softness, feeling or small softness, vain. What is exactly so because imagine that you heat the catheter 220 Celsius, almost with radio frequency ablation. But it's actually a solution. No, no sailing that has bicarb like chicken and ethnic friends, so that helps to kind of cool down the vein again. To miss an anesthesia is required for thermal ablation, but it is not required for the other methods. If the vein is straight and and it's the size is not that large and talking about one centimeter or less than I used the chemical adhesive embolization. Actually, the Z Venus Seal is another. It's actually the trade name for that. And then sometimes if the patient has very large, very positive we talk about staff, Lubeck commits a surgical option. So what we do is we create small steps around along that vein, and then we pull it out with the surgical hooks, and we take that van out completely. In addition to the to the to the V enclosure, Um, I performed really frequency ablation or being closure procedure, using whatever. Whatever technique for the greatest softness Wien. And combine that with staff lumpectomy for the larger vein and ultrasound goddess. Clearer therapy for the smaller branches on by my approach, um, is actually doing, you know, all of these in one session. This is this makes our center different from other centers. We tend to take care of, you know, one leg or both legs at the same time, doing whatever it's it's needed, especially nice in the midst of a pandemic if you can limit your your actions exactly. And then for somebody who has, say the gambit like you were just discussing, what is the what's the What's the recovery process on that? And then, like, what are some of the discharge instructions you give these individuals? Make sure that they're taking care of this. Absolutely. It's, um, you know, it's an outpatient procedure. We do it on the local anesthesia, but sometimes depending on the patient and the severity of the disease and the procedure that we're gonna do, especially if we're gonna do staff lumpectomy, we do it on their Ivy Morris sedation. On den. We place a compression, uh, stocking, you know, addressing and then compression stocking for two days. Usually, patients don't need pain medication. When they leave home, we tell them that they should walk, you know, the first day. They should walk 15 to 20 minutes every hour and elevate for, you know, 45 to 40 minutes the second that they can do as much walking as they want to patients. We tell them, actually that they expect to have some bruising Source can readiness some skin discomfort for about a week or two, and it gets better if we perform. Staff flew back to me. We tell them that they're going to see some oozing from the stab areas, and we tell them to kind of apply compresses and cold compresses over these areas. If it happens for the most part in the depending on the patient profession, they could go back to work within 3 to 5 days. We perform a post procedure ultrasound in a week to ensure that there is no complication. Well, now we've treated the problem. Let's see what happens down the road. What is actually happening when you oblate this vein? So you mean the blood has to go somewhere now? Right on and and then after after you do this procedure, is it Is it gonna come back based on the technique? Actually, this success rate for the thermal ablation and the chemical adhesive closure ranges between 90 actually 200% and the other techniques about 80 85 to 90%. But in in a year or three years, there's data about, you know, uh, closure rate goes down to about 75 to 85%. Um, but the problem that sometimes they have genetic predispositions so they might form or very positives from different resources that, you know, like accessory veins. Some patients develop form. Actually, sisters toughness fans after you closed the main, the appropriators toughness, man. So it is determined by the genetic and environmental factors. One of the complications that I saw here was this e hit e wanted you to talk about that e hit is stands for India Venus Heat induced thrombosis. Andi, it sounds horrible. Aptly named, I took a real hit e hit. Yeah, right. Um, yeah, it sounds horrible, you know, But it's not that bad, actually. You know, if you think about it So it's actually we see this complication after thermal ablation, because it's it's on its on its on its name, uh, heat induced thrombosis. So if you use a heat technique laser ablation or radio frequency ablation. Um, sometimes that closure off that vein, um, the promise that forms the sclerosis that forms in the vein. Some patients have been density for more of a thrombosis that propagate into the deviant system. So there are different stages, like, you know, stage one, Stage 23 stage three, stage four from our experience actually publish our data. Most of these patients actually, um, resolved their cloth within 30 days for he hit three or four when there is a deviant thrombosis. My approach is being life to give ah director romantic going on like rocks, even or a picks event for for a month and then bring them back in a in a month and check. And the rate for e head in general based on the publication deviant thrombosis is a complication for this being closure procedure was seeing less than 1% in general. So those patients with previous is sort of deep or superficial interim boss that tend to have higher risk of developing deviant thrombosis again. Now, the size of the vein, if they fail in size, is actually the median size of 1.6 centimeter more we've actually seen in our serious that we just published that That's a risk factor for developing ahead as well. To do you ever anti coagulate them for a period of time after the procedure or before the Yeah, so So that's a very good question. There is no whole a lot of data. The antique regulation should be based on the indication. If the patient does have an indication of frantic calculation, then we continue anti calculation, even on the day off procedure. If the patient has a history of deviant thrombosis with the van disease, this is actually a contra indication for vain closure for superficial reasons. Because, as I mentioned earlier from the anatomy that the surface veins are there to support the defense. If this is Stephen System is diseased with thrombosis or stenosis or whatever, you should not For the most part, uh, consider closing the superficial vain Yeah, yeah, eso active infection, pregnancy. You know, we did not. Although we see a lot of pregnant patients with very positives, we tend not Thio really treat patients during pregnancy. What are some of the predictions you give to patients as faras? The goals of their therapy that they should be, um, they should understand following the procedure. Like, what can I expect that if this is if this turned out like it's supposed to? And what I would also add to that is you had mentioned what they should do for a week or two. After what long term should they do? Tow, Hopefully help prevent the recurrence that we discussed? It's very important to really explain to the patient what they're getting into. We tell them also post procedure. You will have bruises. You will have sore skin. You know, Redskin, you'll be a little bit you know, you will have some discomfort for about a week or two, and and then we tell them by two months you usually should see the full results of the procedure. I would give them two months before you consider doing anything else. It's a process. So this is another thing that I discussed with the patient. You know, treating your veins is a process is not one time and you're done completely. What can they do to help to reduce the risk? I think lifestyle is very important. I think you know, avoid long periods or sitting or standing, Stay active, you know, lose weight. You know, if we're isn't a problem, for the most part, we tell them you don't have to wear compression stockings all the time after 2 to 4 weeks. But then afterwards, if you don't have any remained disease, you don't have any deviant incompetence or deviant disease. Then you know, we just say, you know, you don't have to accept. You know, if you're going for a long road trip or flight or planning for a long day on your feet, then I would wear the compression stuff as needed. Some of the post, um, ablation procedures that on some of these people were really profound. Very Katsidis are fantastic. And I think that's that Zey huge selling point as opposed symptomatic change. People are what they're like. Well, potentially look fantastic. I was very surprised how well, and probably feel more importantly, feel even better. Well, thank you, Thank you. Once again, this has been fantastic. Doctor Need s cake. Vascular medicine specialist with Minneapolis Heart Institute. Great conversation today with Dr Steak. We plan to talk to him again sometime soon. About anti coagulation. Until then, thanks again for joining us, and we'll see you next time on cardiovascular conversations. Thanks for listening to cardiovascular conversations with Minneapolis Heart Institute. 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Some of the opinions of the hosts and guests are their own and not those of Minneapolis Heart Institute or align a Health Created by Related Presenters Nedaa Skeik, MD, FACC Specialties: Internal medicine Vascular medicine View full profile
