I have not written for a while because so much of my time out of work is spent on appealing denial of payments by Novitas, the Medicare administrator for Texas. They have denied care for patients who have had treatments that are considered as class 1 evidence for management by all the major vascular societies, including the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease) endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation, and Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). In 25 years of doing this work, I have never encountered such nonsense. I thought I was the only one going through this trouble. Then I find out that a cardiology colleague of mine in South Dallas has the same issue. By word of mouth, I talked to a cardiologist in Illinois who just went through the same problem. I bet there are more physicians that are being inappropriately denied payment for standard of care by Novitas. Nothing against the profession, but I found out my cases were reviewed initially by a licensed vocational nurse (LVN). Hell, even many physicians don’t fully understand what we do and why. To add fuel to the fire, apparently Novitas keeps 12% of the amount of money that they recoup from physicians such as myself as a bounty. When I reviewed a case with one of the Novitas nurses early in the course of this appeal, she told me “Well you know sometimes people need to have an amputation of their leg rather than an attempt at limb salvage.” THERE IS SOMETHING GOING ON HERE, AND I WOULD LOVE TO HEAR FROM OTHER PHYSICIANS, BILLING PEOPLE, AND HEALTHCARE PROVIDERS ABOUT THEIR PROBLEMS WITH NOVITAS OR ANOTHER MEDICARE ADMINISTRATOR.
A young lady who saw my previous article of compression hose asked me to discuss the topic of when to treat vein issues more aggressively. To recap, venous reflux that can lead to varicose veins, pain, swelling and and a generalized uncomfortable sensation in the legs, particularly in the calf area. Sometimes, so called restless legs syndrome may be due to venous reflux. The goal of management is to move the vein blood out of your legs. Conservative management includes an exercising program, anything that uses the calf muscles like walking 20-30 minutes a day, which promotes movement of the vein blood back up the legs. Remember, venous reflux leads to vein blood sitting in your legs veins, and there is no medications currently FDA approved to treat these symptoms except for pain medications (although there are some herbal and European products that have been reported as helping). In addition, prop your legs up, be careful about your weight (the more weight you carry the harder your veins have to work), and wear compression hose. If that does not help with your symptoms, then consider an aggressive approach to the problem
The vein system is made of the Deep Veins, and the Superficial Veins. There are also connections between the two called Perforator Veins. There are one way valves in both the deep and superficial venous systems, that normally allow blood to go up the vein. These valves snap shut and prevent the backward flow of vein blood, particularly when you sit or stand. By the way, leg vein valve issues are completely unrelated to heart valve issues. As gravity tries to pull the blood back down, if the valves are not competent, then blood tends to accumulate in the leg veins. In time, the veins tend to swell and lose their structural integrity. Veins have an elastic component to them, and as they overstretch, the elastic component is damaged, and they act more like plastic bags, rather than elastic structures. This leads to varicose veins and many of the symptoms associated with venous reflux.
A venous Doppler test is performed to make sure there are no issues with the deep vein valves or evidence for previous blood clots. In addition, the superficial system is assessed to check the competency of the superficial valves, and to measure the size of the vein both when lying down and when standing. Most people with varicose veins have problems with their superficial venous system, which includes the Greater Saphenous Vein (GSV) which runs from the groin down to the ankle on the inside part of the leg, and the Lesser Saphenous Vein (LSV) that runs from behind the knee to the outer ankle.
For patient who doe not get relief of their symptoms with conservative management, we will discuss a more aggressive approach with why we call ablation of the saphenous vein. Essentially, the goal of the ablation procedure is to shut down the GSV or LSV. People usually ask me at this point, “don’t I need this vein?” The answer is yes, normally you do need that vein, but right now it is hurting you rather than helping you. The blood in the faulty vein is flowing backwards down the leg rather than up towards the body, and thats why you get the symptoms of pain, swelling an varicose veins. Their are essentially 2 technologies that are currently popular for ablating the GSV or LSV, but there are others being developed. The first technology is radio frequency ablation (RF), and the second is laser ablation (EVLT). I prefer the RF but they essentially both do the same thing, which is damage the inner lining of the vein and shut down the backward flow of vein blood. The procedure takes about 30-45 minutes to do in the physicians office using local anesthesia, and either oral sedation or I.V. sedation. The inside of the vein has no sensation, its the outside surrounding tissue that has pain fibers. We used whats called tumescence anesthesia where we infiltrate dilute numbing medication all around the vein under ultrasound guidance. If this is done properly and with some patience, the procedure itself should not be painful. If you have pain during the procedure, its because the numbing was not done completely. Most people return to work within a could of days after the procedure, because the recovery is so much better than we used to see when we stripped veins. There are other techniques that are being developed with injection of whats known as a sclerosing agent into the vein to close the fault vein down, but we can talk about that at another session if anyone is interested, because RF and EVLT dominate the current treatment market.
So the question becomes, do I need to have the aggressive approach with ablation of the vein done? It really depends on the severity of your symptoms, and how much your veins and leg swelling are bothering you. Its not like an artery problems like coronary artery disease where you might have a heart attack if you are not treated for chest pain. Vein issues are more of a lifestyle problem. “How much are my veins and swelling bothering me, and am I ready to have a more aggressive vein treatment?” Some patients will have huge varicose veins, but they have mild symptoms and prefer to just leave the vein issues alone; that is a perfectly reasonable approach. Other patients will have a lot of symptoms of pain and swelling, and will want to have the ablation procedure for relief of their symptoms. In general, insurance companies will cover the ablation procedure if you have worn grade 20-30 mmHg compression hose for over 3 months, and have significant symptoms that limit your work or lifestyle such as performing your normal activities of daily living or exercising. Some insurances (especially Cigna) can have a rider on your policy that does not allow ablation procedures no matter what.
There are certain circumstances I do recommend strongly that patients have an ablation procedure performed. If you have a venous stasis ulcer, either healed or open, then an ablation procedure really works well to close the ulcer. You can look up venous stasis ulcers on the internet, but these are painful sores that form on the inside or outside ankle and take a long time to heal. The ablation procedure performed properly and for the right reason not only helps to close the ulcer, but also reduces the risk for recurrent ulcers. Once you have a venous stasis ulcer, the risk for recurrent ulcers is about 50%. If you have the ablation procedure performed, the risk for recurrent ulcers falls to 9%. I had a patient with a 20 year history of a venous stasis ulcer on his right ankle who healed his wound within 4 weeks after the ablation. Interesting side note, he had Cigna insurance, and despite the fact that we had pre-approval for the procedure, after the ablation Cigna refused to pay because they said it was not in his policy or some other BS like that, so I ate the cost of the RF ablation kit which is about $625. Oh well, at least his wound finally healed up.
Other situation where I recommend strongly that you have an ablation procedure is if you have had bleeding from varicose veins. If anyone has experience this event, it is very scary for patients. It looks like you cut an artery because blood comes out at high pressure due to the venous reflux. It is a painless event, and usually leads to a picture of blood all over the place (hog slaughter is how one patient described it…well we live in Texas). Its actually simple to control if this ever happens to you. Just wrap the bleeding area with compressive dressings snugly, get your butt on the ground and your feet propped up on the wall, and don’t unwrap anything for 30 minutes. When you get your legs up straight, the vein blood drains back into the body and reduces the vein pressure in the bleeding vein. Ablation needs to be performed for bleeding veins to prevent further bleeding. What we usually do it inject the offending vein with clerking agent to scar it up and clot it, and then set the patient up for the ablation procedure as soon as possible.
Other situations when I recommend ablation is for patients who have a lot of venous stasis changes (brown discoloration of the skin), or repeated bouts of cellulitis. Essentially, the reason some patients get this problem is that with venous reflux, the skin becomes permanently damaged due to the chronic high vein pressures. This can lead to a permanent staining of the skin (venous stasis discoloration) as well as possibly recurrent skin infections (cellulitis). I think I will address this issues at a later session. Time to go to work
I wear compression hose to work every day. After 25 years of vascular surgery practice, my leg veins have taken a beating. If I don’t wear compression hose, my legs ache, swell, and I tend to not sleep well because my legs trash around at night. About 30% of the so called “restless legs syndrome” is actually related to vein issues rather than some type of neurologic problem. Before you try medications such as Requip for restless legs syndrome, wear good medical grade compression hose daily for a week and see how your legs feel.
There are numerous risk factors for vein problems or Chronic Venous Insufficiency (CVI). Women tend to get the problem more than men. Family history of varicose veins is a big risk factor, as well an occupation where you sit or stand all day. Cosmetologists, nurses, physicians, hair dressers, truck drivers, teachers especially come to mind when thinking of occupations that predispose to vein problems. I also see plenty of secretaries and airplane stewardesses and other people who tend to be on their feet or sitting for prolonged periods of time. The typical signs and symptoms of CVI are swelling, particularly at the ankle and calf, varicose veins, a dull aching and discomfort in the legs below the knees. There can be a brown skin discoloration. Sometimes when the legs swell and contract, you can get a red rash like skin changes, that eventually turn brown. The latter stages (what we class class V or VI) venous stasis disease is when one develops ulcers, typically over the inner or sometimes over the outer ankle, although it can also form at other sites. I have been doing this so many years, I can spot it a mile away. CVI is so under diagnosed quite frankly because the primary care physician has so many other things to take care of that they dont’ have a chance to really look at the legs. Vein problems are actually far more prevalent that arterial problems but far less diagnosed. If you have unexplained leg swelling, its a good bet that is is either from vein problems, or medications, and less likely a del vein thrombosis. Other contributors to swelling include congestive heart failure, liver and kidney disease, and lymphatic issues.
The treatment of CVI is usually conservative. I recommend 30 minutes a day of walking at a steady pace. Its not good enough to be walking all day short distances as most patients tell me they do. Its the continuous long distance walking that helps. When you walk, the calf muscles have a pump mechanism that helps to push the vein flow up. CVI and varicose veins occur because the one way valves are not working well (more at a later date). There is no god medication for CVI, so the whole goal is to get the vein blood out of the legs. Weight control is also important. The more weight you carry, the harder the veins have to work, just simple hemodynamics. Elevate your legs as much as possible when you are not walking. The analogy I use is when I drop my hands, my veins really pop out. When I lift them up, they collapse. So you want the vein blood to get out of your legs by elevating them. Lastly, I wear compression hose every day. I use 20-30 mmHg compression hose. I put them on in the morning after I shower, and take them off when I work out. You will notice that some long distance runners wear compression hose when they are running. I don’ find it necessary to wear them when I am working out, but if it makes your legs feel better, there is no harm done. You certainly don’t need to wear compression hose when you go to bed because your legs are already elevated.
There are more aggressive approaches to vein problems, but I will get into vein issues in depth at a later stage. I would recommend to people that they stay away from the vein centers that are popping up all over the place. I hate to make sweeping statements, but I would suggest to you that if your only tool is a hammer, the whole world looks like a nail. Vein centers support themselves by doing procedures. Get another opinion from a physician who tries conservative management first before recommending vein surgeries.
One last note on prevention. I recommend that all women who learn that they are pregnant wear at least knee high 20-30 mmHg compression hose throughout their pregnancy. The blood volume and hormonal changes of pregnancy can cause irreversible changes to veins that show up at a later date. I also recommend if you have a strong family history of vein problems, or are in an occupation where you sit or stand a lot, you wear compression hose. I will really get into leg vein issues and work-up of swelling of the legs at a later post. It is a long and complicated discussion, but I see at least 5 new patients a week for work-up of leg swelling. It is a poorly understood issues, and again most primary care doctors just have too much on their plate with documentation and requirements etc to really spend time on working this problem up.
Venous insufficiency and varicose veins are not well understood by most physicians. The etiology is varicose veins is usually linked to an underlying valve problem, whether its in the deep or superficial venous system. Essentially all vein blood in the legs is supposed to move up towards the body. Unfortunately, since we stand or sit most of the day, gravity is always fighting us and trying to pull vein blood back down towards the ankles. There are one way valves in the deep and superficial veins that normally close and prevent the backward flow of vein blood. When those valves are not working well, blood tends to back up the veins and cause dilatation of the veins. Over time, this leads to permanent damage to the vein wall, due to loss of elasticity. As a result, varicose veins develop. Typically, the valve problem is in the superficial venous system. Symptoms of venous insufficiency include varicose veins, swelling, pain and a dull heaviness of the legs, skin discoloration, and in severe cases ulceration of the legs, typically at the ankles
Perhaps one of the least understood problems we as vascular surgeons face is venous insufficiency. Venous insufficiency affects approximately 200 million Americans, and is far more prevalent that peripheral vascular disease (PAD). The reason why it is so under diagnosed is that it can take many different forms and symptoms, raging from leg swelling, to spider and varicose veins, to skin discoloration, to frank ulceration of the skin with non-healing wounds (see picture). I will post another time about varicose veins and venous insufficiency. In this post, we will deal with leg swelling. In my opinion, venous insufficiency is either the most or second most likely cause for leg swelling. Typically, the swelling occurs below the knee, is relieved by elevation, and lead to minor discomfort, to severe pain. The diagnosis is made by history and physical examination, followed by a venous Doppler. The venous Doppler is best done by a vascular lab that is sensitive to studying vein valve function. As obvious as this sounds, it is not often studies as a routine in most vascular labs. Next time I will go into the work up and management of venous reflux and leg swelling
So I have been thinking about putting down all this stuff I have learned though 4 years of college, 4 years of medical school, 5 years of general surgery training, 2 years of lab research, 1 year of vascular surgery fellowship, and 23 years of vascular surgery practice! I have forgotten more than I remembered, but there are definitely some things that are so repetitive in vascular surgery that I need to put them down in writing. What we work up and take care of in vascular surgery is so alien to other physicians that it needs to be explored. One of the first posts that I am going to cover is leg swelling issues, and work up and treatment options. I see approximately 30-50 new patients a month, of whom at least 20 will be for evaluation of leg swelling