The Vascular Disease of the 21st Century

With the widespread awareness of arteriosclerosis by physicians and the public, as well as the availability of excellent preventive and therapeutic options, the diagnosis and treatment of arterial disease has matured. In contrast, the public and even some physicians are not very familiar with venous disease and its wide spectrum of symptoms. As more than 30 million people in the United States live with venous insufficiency, experience longer lifespans and have access to no ideal preventive therapy, the awareness, diagnosis and treatment of venous disease may dominate vascular medicine in the 21st century.

Louis Prevosti, MD, FACS, FACPh, Medical Director and Founder of VEINatlanta, considers venous insufficiency “the vascular disease of the 21st century” because of its prevalence, the increased understanding the medical community has reached about its process, and the innovative treatments available to address it.

“Venous insufficiency is almost ubiquitous,” Dr. Prevosti notes. “If you study women over 40 in the United States, approximately 40 percent will have some venous dysfunction in their legs. Men are about half as likely to have insufficiency, but the prevalence for each demographic increases with age.”

However, that does not mean the disorder is essentially geriatric in nature. Dr. Prevosti emphasizes that people in their 30s can experience symptoms caused by venous insufficiency. And among adults of all ages, up to 20 percent may be affected, according to the Vascular Disease Foundation. The challenge is to increase physician awareness of the numerous and often nuanced symptoms of venous insufficiency so the condition can be diagnosed accurately.

A Disease with a Thousand Faces

Leg pain and swelling are often associated with venous insufficiency, but a host of symptoms can arise from deficits in venous structure. One-directional valves in the leg veins meant to keep blood flowing to the heart can fail, allowing blood to reflux and pool. When this occurs, patients often complain about achy, heavy or tired legs, as well as bulging veins. Sometimes these symptoms improve with walking or with elevation of the legs.

Additionally, venous insufficiency can underlie a number of other complaints, according to Dr. Prevosti.

“I believe venous insufficiency is involved in the majority of complaints about night cramps and restless leg syndrome,” he says. “That’s important because any primary care physician will tell you these are commonly raised concerns. In the past, physicians had few options available to treat these symptoms. We could check pulses to assess arterial function and check electrolyte and hormone levels, but these tests would often reveal nothing abnormal.”

In consequence, physicians frequently attributed such complaints to the normal aging process or labeled them as idiopathic.

But venous insufficiency also commonly presents with hair loss in the lower extremities, skin discoloration in the calves and ankles, non-healing eczema, or a range of other symptoms.

“It turns out that only a segment of the population affected by venous insufficiency has the traditionally recognized symptoms,” Dr. Prevosti says. “There’s a large set of patients who present with foot numbness, tingling sensations, unexplained neuropathy in the legs and feet, unexplained knee and foot pain, and itching or burning sensations.”

Moreover, he explains, diagnosis is not always precipitated by evident symptoms. Asymptomatic patients often need no treatment, but compression stockings can be used to keep painful symptoms at bay, he adds.

Making the Call

With so many potential indicators of venous insufficiency, how can physicians be absolutely sure of a diagnosis? If symptoms are mild, surveillance is an appropriate measure, but when a physician suspects diseased veins are the source of persistent discomfort or significant pain for a patient, referral to VEINatlanta for diagnosis can be the first step toward treatment that markedly reduces pain and improves quality of life.

The diagnosis of venous insufficiency is often missed by venous ultrasound, but experienced professionals at VEINatlanta use office-based venous duplex ultrasound exams as well as special positioning and provocative maneuvers to definitively identify the condition.

“We’ve seen exponential improvement in the ability to diagnose with office-based, noninvasive testing,” Dr. Prevosti explains. “Treatment has similarly progressed from invasive surgical interventions to outpatient procedures using local anesthesia.”

Because venous insufficiency doesn’t pose the mortal threat of other cardiovascular conditions, such as coronary artery disease, physicians aren’t always quick to refer patients for treatment, notes Dr. Prevosti. There may also be lingering hesitation related to physicians’ memories of a time when available treatments were both painful and invasive, and required several weeks of postoperative recuperation.

“Prior to the turn of the 21st century, vein stripping and high ligation were used to treat venous insufficiency,” Dr. Prevosti says. “Both were unpleasant operations, performed under general anesthesia, and required weeks of recovery time. Studies showed as many as 50 percent of patients had recurrent signs and symptoms of venous insufficiency five years after treatment. Physicians didn’t want to send patients for painful treatments that often led to a high recurrence rate of symptoms. But new technology has revolutionized care.”

The Paradigm Shift

Contemporary treatment modalities offer minimally invasive procedures from which patients can recover quickly. What’s more, these new technologies have astoundingly high success rates.

From a myriad of treatments he uses to address the spectrum of venous disease, Dr. Prevosti uses minimally invasive endovenous ablation for venous insufficiency. He performs the in-office procedure using ultrasound guidance to thread a thin catheter through the diseased vein. Radiofrequency or laser energy heats the vein wall, shrinking the collagen and closing the vein. The procedure takes approximately 25 minutes and stops the backward flow of blood, without the need for painful surgery.

“Endovenous ablation has elevated long-term success rates from the 50 percent associated with vein stripping to more than 90 percent,” Dr. Prevosti notes. “During the ablation procedure, we leave the most proximal area of the saphenous vein intact to allow the tributaries around the saphenofemoral junction to drain into the femoral vein. This prevents neovascularization, which can cause recurrent varicose veins.”

The radiofrequency generator monitors a thermistor at the tip of the catheter, which prevents tissue from overheating. Additionally, the physician is alerted if the catheter is misplaced.

Patients leave the same day with their leg wrapped in elastic bandage. Although they are instructed to avoid strenuous activities for several days, patients are encouraged to walk and resume normal activities the same day. After seven days of wearing a compression stocking, activity restrictions are lifted.

While radiofrequency energy is Dr. Prevosti’s preferred method, he also uses laser ablation for short segments or small-diameter vessels, such as refluxing perforator veins.

Full Spectrum of Treatment

In addition to innovative endovenous ablation therapies, Dr. Prevosti can deploy a number of other similarly successful modalities for venous insufficiency. When the disease presents as bulging varicose veins, he incorporates ambulatory microphlebectomy into the care plan.

Another office-based procedure utilizing local anesthesia, ambulatory microphlebectomy is a minimally invasive means to remove diseased veins. Dr. Prevosti makes small nicks in the skin above the vein and uses special instruments to remove the vein in small sections. Patients follow similar recovery schedules as those who have undergone endovenous ablation.

When refluxing veins aren’t amenable to ambulatory microphlebectomy and endovenous ablation, Dr. Prevosti uses ultrasound-guided sclerotherapy. While monitoring the vein on the ultrasound monitor, he maneuvers a fine needle into the abnormal vein and injects polydocanol — a medicine that can be injected as a liquid or foam — into it, prompting a chemical reaction inside the vein’s lining that causes the vein to close.

Ultrasound guidance enables Dr. Prevosti to treat veins that cannot be seen by the naked eye because of their depth. Prior to this treatment, there were no good treatments for these veins.

Treatment for a Better Life

The 20th century saw tremendous strides in the understanding, treatment and public awareness of arterial diseases such as peripheral artery disease, heart disease and cerebrovascular disease. Dr. Prevosti sees analogous progress in addressing venous insufficiency. The technological advancements have been made, but awareness of the minimally invasive techniques available hasn’t yet reached the level necessary for patients who would benefit from treatment to routinely receive the care they need.

“Treatment for venous insufficiency enhances quality of life,” Dr. Prevosti says. “For the most part, the disease doesn’t cause life-threatening complications, such as stroke. But as we move to the next level of health, which includes reducing long-term symptoms that cause discomfort, treating venous insufficiency effectively eliminates some of the most common complaints primary care providers hear.”

For more information about VEINatlanta, visit veinatlanta.com or call 404-446-2800.

Source: MD News May 2014, Metro Atlanta Edition