Chronic Venous Disorders

Varicose veins commonly develop during pregnancy, especially in women with family history of varicose veins. Other than genetics, there are many inherent reasons, why women develop varicose veins during their pregnancy. The increase in the hormone “Progestrone” during pregnancy causes destruction of the “ Venous valves” and distention of the venous walls. Further, the growing uterus puts severe mechanical pressure on the “ inferior vena cava “ , which results in engorgement of veins in the limbs . Additionally, there is a tremendous increase in the blood volume and venous capacity during pregnancy that contributes to the failure of the venous system. Varicose veins are more common with twin or multiple pregnancies, for the obvious increased physiological and mechanical stress on the venous system. It is not uncommon for women to develop varicose veins , if they gain too much weight during pregnancy or they have obesity.

Varicose veins during pregnancy are often symptomatic and present with pain, numbness, tingling, heaviness, night cramps and are not very cosmetically appealing. These varicosities are of much clinical concern , for they become highly painful, precipitate “Restless legs Syndrome “and pose the risk of “phlebitis “ or “blood clots” , Deep vein thrombosis ( DVT) . Usually veins in the legs are the ones most commonly affected, as they work most against gravity, but it is common to get varicosities of the “Vulva “or the “rectum” ( hemorrhoids ) during pregnancy.

Treatment of the varicose vein during pregnancy is a therapeutic challenge. Often varicosities appearing during pregnancy may spontaneously regress after delivery. Thus therapeutic approaches are often planned before pregnancy on a prophylactic basis to prevent complications of varicosities during pregnancy. Even though varicosities appearing during pregnancy are physiological, but any spontaneously appearing varicose vein, with symptoms of pain and swelling, poses a high clinical suspicion for life threatening DVT and it should be thoroughly investigated with Duplex ultrasound examination. In case if DVT is detected, then anticoagulant drug therapy is considered under expert medical supervision. Compression garments, including stockings and non elastic bandages are routinely prescribed in all cases of pregnancy related varicosities. These, not only relieve the symptoms of the varicosities but also prevent complications, especially DVT. Early, Phlebologist have routinely treated varicose veins during pregnancy with “Sclerotherapy “, a procedure were a “ sclerosant “ drug is injected into the varicose vein to close off its blood flow. Even though sclerosant drugs are relatively safe, but they have the propensity to cross the “placental barrier and their effect on the fetal development are still unknown. Presently, sclerotherapy is not routinely recommended as a treatment modality for the management of varicose veins during pregnancy. Sclerotherapy additionally poses the risk for precipitating DVT in pregnant subjects, for a heightened blood coagulation system in them. There are many herbal oral medications touted over the internet for the management of varicose veins, but the safety and the efficacy such treatments in pregnancy has not been established. “Cochrane Review ”, reports results from three trials involving a total of 159 pregnant females with varicose veins , who were treated with a herbal medication , “ Rutoside ”. It was revealed that herbal medication could relive symptoms of varicose veins in pregnancy but could not offer a long term cure. Also researchers could not establish the safety of such treatments in pregnancy.

The presently there are no recommendations for the use of definitive treatments, including Endovenous Laser Treatment ( ELT ) for the management of varicose veins during pregnancy. Experts recommended delaying definitive treatments till three to six months post delivery. This allows physiological varicose veins of pregnancy (see treatment options here) to regress spontaneously and also it buys time for the body to become normal, from the heightened coagulation state. Overall, varicose veins during pregnancy are best managed conservatively, but it requires expert monitoring for prevention of complications.

Reference:

1. Bamigboye AA,Smyth R . Interventions for varicose veins and leg oedema in pregnancy .Cochrane Database of Systematic Reviews 2007.
2. Weiss RA ,Feied CF,Weiss M. Vein Diagnosis and Treatment . McGraw Hill USA 2001.
3. Luebke T, Brunkwall J. Systematic review and meta-analysis of endovenous radiofrequency obliteration, endovenous laser therapy, and foam sclerotherapy for primary varicosis. J Cardiovasc Surg (Torino) 2008; 49: 213-33

A recent study of the occurrence of Restless Legs Syndrome (RLS) in patients evaluated in a phlebology practice, suggests that RLS appears to be a clinical syndrome that commonly overlaps in patients with venous insufficiency and chronic venous disorder (CVD).

In total, 174 consecutive patients and 174 matched controls were included in the study. A prospective questionnaire and clinical evaluation were used. The International RLS Study Group (IRLSSG) 4-point criteria were used to objectively establish the diagnosis of RLS. The symptom severity of those who had RLS was assessed with the 10-point IRLSSG severity questionnaire. Detailed history, physical, and Duplex ultrasound evaluations were performed to establish the presence or absence of venous insufficiency (reflux > 0.5 seconds on compression/augmentation) and CVD, according to current clinical, etiologic, anatomic, and pathologic (CEAP) criteria.

Of the 174 consecutive patients studied (22 Male and 152 Female), 63 (36%) met the clinical criteria for having RLS. This compared with only 34 of 174 (19%) in the control group (p<0.05). In the RLS-positive study group, 62 of 63 (98%) were found to have venous insufficiency and chronic venous disorder. By comparison, 31 of 34 (91%) of the RLS-positive control group were found to have CVD. Thus, the prevalence of CVD in both the RLS-positive study and control groups was similar; however, this was significantly more than the prevalence of CVD in the RLS-negative controls (p<0.01). There were only 3 (9%) of the RLS-negative controls who had CVD. RLS-positive patients were typically women (p<0.01 vs. men) who were more than 40 years of age (p<0.01 vs. less than 40). It should be noted that a history of leg cramps was significantly more common in the RLS-positive patients (p<0.01). It should also be noted that none of the RLS patients gave a history of anemia, chronic renal failure, or had an established psychiatric or neurologic disorder that others have described as being highly associated with the diagnosis of RLS.

RLS appears to be a clinical syndrome that commonly overlaps in patients with venous insufficiency and chronic venous disorders. Prospective, blinded therapeutic trials are underway to evaluate the effect of definitive treatment for CVD on sequential RLS scores.

If anyone has any thoughts on the study, please feel free to comment below.

I recently conducted a research study regarding the effectiveness of using Endovenous laser ablation (ELT), with ultrasound-guided foam sclerotherapy, for the treatment of GSV and SSV reflux. ELT is already known to be an effective treatment, and ultrasound-guided foam sclerotherapy is also becoming an increasingly accepted treatment for varicose vein disease.

I’d like to share some of my results, and look forward to getting any of your feedback and questions.

In this prospective, consecutive series of 503 patients, there were 157 men and 346 women (median age: 51, range: 18-83) that were treated. After informed consent was obtained, 391GSVs, 73 SSVs, 15 cranial extensions of the small saphenous vein, 27 anterior accessory great saphenous veins, 8 posterior accessory great saphenous veins, and 15 non-saphenous veins were treated with ELT. Ultrasound-guided foam sclerotherapy was provided during the same treatment session for varicose branches that were not amenable to treatment with ELT. After ultrasound-guided foam sclerotherapy and tumescent anesthesia ELT was performed. All of the patients were strictly monitored and had Duplex ultrasound scanning to evaluate for DVT at 24-72 hours. Thorough duplex scanning was performed at one week and at one, three, six, and twelve months. In the future, after patients have had venous Duplex ultrasound follow-up at twelve months, they will be seen annually thereafter.

At twelve months, reflux was only seen in four sapheno-femoral junctions (1.02%) and one sapheno-popliteal junction (1.30%). Further continued branch vein reflux, seen on ultrasound at one month, was treated with additional ultrasound-guided foam sclerotherapy. No DVT, superficial phlebitis or thrombophlebitis, or superficial burn occurred. All presenting venous stasis ulcers were closed (100%) and all Quality of Life indicators were substantially improved at one, three, six, and twelve months. Initial venous dysfunction scores averaged 9.45, with a range of 4-23. At one month, the VDS average was 6.40, with a range of 1-15. At twelve months the average dropped to 4.93 with a range of 1-9.

In my study, ultrasound-guided sclerotherapy, given concomitantly with ELT, was found to be safe and effective in treating the GSV, SSV, their tributaries and non-saphenous veins. Further study with additional cases, more long-term follow-up, and supplementary in depth assessment of factors that may be related to treatment failure is under way.

I hope you found this information useful. If you have any questions or comments, please let me know.  You can read more at our website www.veinclinics.com, which is a patient resource for varicose veins and spider veins information.
Ted

The information found on this website is not designed to replace the patient/physician relationship.

The topic of venous leg ulcers is a wonderfully challenging one because there are so many possible components to it, but fortunately it is fairly straight forward for most patients.

It is my opinion, based on 25 years of treating leg ulcers, that the underlying problem is “venous pump failure” and the diagnostic work up and treatment is ultimately focused on this. Venous pump failure (VPF) is what goes wrong with the “peripheral heart” usually resulting in some degree of calf hypertrophy, and accompanied by varying degrees of peripheral edema (similar to the edema of cardiac pump failure). In patients with “minimal” edema, and failing to heal, I will look at the ulcer edges with a magnifying glass where I often find hidden edema. This must be eliminated also.

I usually begin by noting the largest calf circumferential measurements and the narrowest ankle measurements. Other contributing factors are painful ambulation (from painful ulcer, painful knee and ankle joints) which prevent an adequate calf contraction (which causes a reduced venous output). So getting rid of the leg pain is the primary goal, and boosting the venous pump output with isometric compression is next. I like to get the patient walking without pain (and wearing isometric compression) on the first treatment session.

I see varicose veins in ulcer patients as representing the “leaks” in the peripheral pump, and its management by medical methods making more sense than surgical management (too crude and too much unnecessary tissue damage from surgery) especially since the introduction of venous “mapping” and foam sclerotherapy.

Failure to heal is often due to inadequate evaluation or getting the wrong treatment (e.g., skin grafts) while missing the underlying venous reflux.

And to answer the important question posed by my learned colleague about the role of isometric compression: it works by not only increasing the venous output during calf contraction, but more importantly the higher venous output is followed by a much greater negative phase in the deep venous system. This is the important function of the venous pump because it removes the venous blood and edema from the peripheral tissues. (This is what we measured when we performed PPG and LRR tests.)

I see the edema as drowning the tissue in and around an ulcer as well as competing with the micro-circulation, and when the edema is removed, the healing is usually rapid.

Brian McDonagh, MD

The information found on this website is not designed to replace the patient/physician relationship.

Hello and welcome to the Chronic Venous Disease Forum! This site is dedicated to the discussion of all things venous. This forum wil provide a space for those involved in the treatment of chronic venous disease and venous hypertension, with all its intricate, challenging, and sometimes frustrating manifestations, to discuss their thoughts, insights, treatment philosophies and methods, as well as provide tips, tricks, and techniques to further benefit the phlebology community as a whole in our treatment. Please feel free to post comments and opinions, within the boundries of good taste of course, ask questions, or present an interesting case.

I would like to start off by posing a question for my colleagues. When treating a patient with a venous ulcer, the ultimate solution is treating their underlying vein disease of courese. What role do the short stretch wraps play in treatment of this manifestation of chronic venous insufficiency? Obviously, if their is signifficant edema present or the patient is having pain in the affected area, the wraps can be of great benefit. If neither of these conditions are present however, do the wraps aid in the actual healing process? I understand the physiology of the calf muscle pump as the “peripheral heart” and how the short stretch wraps are superior to traditional elastic wraps due to their augmentation of the systolic phase of the pump without compromising the diastolic phase. In the absence of signifficant edema to improve, is there enough of an effect on the underlying venous disease to aid in healing the ulcer, or is doing short stretch wraps just a waste of the physician and patients time and treating the underlying vein disease is all that matters?

Again, welcome all and I appreciate any replies on the above question

Sean McWilliams M.D.

The information found on this website is not designed to replace the patient/physician relationship.