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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The Alchemist

I like to read books.  I don’t read novels, but like books that make me think.  I recently read a quote that was in the Farnam Street Blog that got me re-reading The Alchemist by Paulo Cuelho, a book that I have read at least 8 times over the past 2 years.  Before I talk about the book, I do highly recommend that you at least take a look at the Farnam Street Blog.  It is an intelligent summary of books and articles that challenge thinking.  The quote was from Joseph Tussman, who was a Professor of Philosophy at Cal Berkeley.  It states “What the pupil must learn,  if he learns anything at all, is that the world will do most of the work for you, provided you cooperate with it by identifying how it really works and aligning with those realities.  If we do not let the world teach us, it teaches us a lesson.”

I first read the Alchemist at the recommendation of a new friend Peter Stickney.  I found out we share a lot of interests, and we have become really good friends.  The first time I read the Alchemist, I initially thought I was reading a simplistic children’s book.  But as I kept reading it, I started to reflect more on some of the message that seemed to spring up to me from someone in my submerged sub-conscious.  Every time I re-read the book, I get something new out of it.  Its one of those things, kind of like watching The Shawshank Redemption that you never get tired of seeing it over and over again.  Here is the link to that Farnam Street Blog page       

The Importance of Compression Hose for Prevention of Leg Swelling and Varicose Veins

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.

High Intensity Intervals for the Elderly!

So sometimes I get out of work, and my legs just don’t want to cooperate in terms of running or doing significant cardiovascular work.  So how to get my cardio in and keep my heart rate above 130 for one minute intervals at least 10 times?  I find that if I try and grind it out by running fast on days like this, I get discouraged.  Its not my heart rate and shortness of breath withe exercise that limits my running on days tike this, it my legs that just feel tight and fatigued.  For example, every Tuesday I am in the clinic all day, on my feet seeing patients.  I have been in practice for 25 years, and I see 50-60 patients on Tuesday.  So my hack is when I get on the treadmill, I get my heart rate up by running slower on a steep incline, say 5-8 degrees at 4 mph.  I usually cycle every 2 minutes, meaning I run at 4 mph at 8 degrees incline, then 4 mph at 1 degree for 2 minutes.  I repeat this cycle for 40 minutes, and get a nice work-out.  I vary the incline on how I feel.  Usually, I will start off at 5 degrees incline, but as I run longer and feel better, I increase the incline on my higher intensity segments.  Try it, it really does work.

Deadlifting

I unfortunately have to agree that deadlifting is probably the most bang for the buck weight lifting maneuver.  As much as I don’t like doing it, the move really improves my core and strengthens my upper body.  As with most other type A personalities, I get addicted to the exercise easily, and try and pack on more weight in order to outdo myself.  I think that why I tore my rotator cuff on the incline dumbbell press.  So I try to think like a mature 56 year old and do reasonable weights.  I learned a lot from listening to Pavel Tsatsouline, the chairman of StrongFirst.  Pavel apparently introduced the west to the kettle bell training program.  A few tricks I learned from him include gripping the bar really hard helps recruit muscles during a lift.  Also concentrating on tightening the core muscles just prior to the actual lift seems to make the effort easier.  He also mentions that the Russian powerlifters usually stick to 6 reps in order to build mass.  There are a ton of videos on Youtube on deadlifting technique by Mark Rippetoe, Dan John, and Ed Coen.  The  one I think that is most informative for us normal sized folks is at the link by Mark Rippetoe.   

Lean Body Mass

I used to think that weight control was just an issue of calories in versus calories out.  Now I have to face the fact that what I was taught many years ago, and spouted off with regularity may not be exactly correct.  I know from my own personal body hacks that the old paradigm of low fat diet did not work, especially after age 50.  I actually eat much more fat in my daily diet.  My morning  starts of with 2 cups of coffee with a single teaspoon of brown sugar, and a spoonful of MCT oil.  I then drink a 42 g Myoplex EAS protein shake (Chocolate of course!) in between seeing patients.  A couple of spoonfuls of natural peanut butter helps.  I also eat 2 handfuls of pistachios, and well as 2 handfuls of almonds.  For lunch, I have protein such as chicken breast and salad.  I have a mid-afternoon snack of greek yoghurt, and then hit the gym.  I usually lift weights for 50-60 minutes, but I don’t take more than a 3-5 minute break between sets. I then do 30-40 minutes of cardio, either treadmill or stair stepper.  I try and do high intensity intervals if at all possible, but sometimes my body just is too tired, so i just try and be persistent and complete 40 minutes of some type of cardio with a minimal heart rate of 100.  As I am finishing my weight lifting part, I take 25 grams of cold ultra filtered whey protein, 25 grams of casein, and 5 grams of creatine in about 12 – 16 ounces of water.  I learned a lot by researching proteins before I made my purchase.  A good general rule of thumb is look at the ingredients on the side of the protein package.  If it is high in cholesterol (greater than 10-20 mg per serving), it is not a good quality protein.  Then I have dinner, usually protein and vegetables.  By sticking to this regimen, my waist size is 30, and my body fat is the lowest it has ben since I was a teenager.  By the way, interesting factoid that most people don’t know.  Waist size of 40 inches or greater in men an 35 or greater in women is an independent risk factor for cardiovascular disease.  In plan English, this means that even if you are not diabetic or have high blood pressure, you are at an increased risk for heart attacks and strokes if your waist size is greater than 40 inches or 35 inches in a male or female, respectively.

Diet and Exercise Over Age 50

My epiphany moment was 7 years ago at age 49 when I woke up at 5 am as I had done for many years, got out of bed and thought to myself “why do I feel like crap?” I have lifted weight since I was 18 years old and have always done regular cardiovascular activity. As a physician, I knew a good bit about nutrition, and felt that I was following a good diet. I ate a low fat diet, balanced carbs and proteins. My paradigm was the old input equals output equation, which I quoted to my overweight patients. But despite what I thought was the correct way of eating and exercising, I realized at age 49 that I did not feel good. I went to Las Vegas to the Cenegenics Institute for anti-aging, was evaluated, and actually took the course and was certified by them in anti-aging medicine. To be perfectly honest, I did not like the gist of the course. They pushed hormone replacement rather than trying to root out the cause of testosterone deficiency in a young male. That introduction led to years of hacking myself and my body with different ways of eating and exercising. I trained for a year with a professional bodybuilder, and got jacked up to 185 pounds on a 5’8” frame. I could barely fit into my lab coat. Then I tore all 4 of my rotator cuff muscles on my left arm doing incline dumbbell press with 80 pounds, and had to have a surgical repair 3 years ago. After years of trying different ways of eating and exercising, I realized that my old paradigm of a low fat diet, input versus output concept was just not correct. So now I eat a diet high in selected fats, and weight train and exercise with much more focus on the outcomes I want to achieve. The results have been nothing short of spectacular.