When To Consider An Aggressive Treatment for Venous Reflux and Varicose Veins

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

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