Love your legs again

What is the difference between DVT and EHIT?

January 27th, 2014 | Posted by CenterForVein in DVT | vein-center - (Comments Off)

Endovenous thermal ablation is an accepted method of treatment for superficial vein reflux with a relatively low incidence of procedure-related complications.  Deep venous thrombosis (DVT) is the formation of a thrombus within the deep venous system and is a recognized complication associated with less than 1% of endovenous ablation procedures.  Endovenous heat induced thrombus (EHIT) is and expected result of endovenous ablation of an incompetent superficial vein.  During the thermal ablation, the endothelial lining of the vein is damaged, thus causing an inflammatory reaction.  Thrombotic occlusion subsequently occurs, which then leads to fibrosis and effective closure within the superficial venous system.  In less than 0.5% of endovenous ablation procedures, the thrombus produced propagates in close proximity to or extends into the deep venous system and the EHIT is then classified according to the thrombus extension.  The classification for EHIT propagation within a superficial vein to a deep vein is as follows:

  • Class I: Venous thrombosis to superficial deep junction (SFJ of SPJ), but not extending into deep system.
  • Class II: Non-occlusive venous thrombosis, with an extension into deep system of a cross sectional area less than 50%.
  • Class III: Non-occlusive venous thrombosis, with an extension into deep system of a cross sectional area greater than 50%.
  • Class IV: Occlusive deep vein thrombosis of common femoral /popliteal vein.

All patients at Center for Vein Restoration undergo routine duplex imaging within 2-7 days post endovenous ablation procedure.  If EHIT I or II is identified, serial duplex imaging weekly with observation will be performed until thrombus regression into superficial vein is noted.  Antiplatelet therapy may be initiated, with Plavix most probable in case of EHIT II.  If EHIT III or IV is identified on duplex scan, low molecular weight heparin (LMWH) is initiated and continued, along with weekly duplex imaging and evaluation, until thrombus regression to EHIT I or complete resolution.  The potential for further thrombus propagation after the initial post procedure documentation of EHIT is low.  In most patients, the thrombus usually remains stable initially and regresses or completely resolves within 10-14 days.  Larger superficial vein diameters, concomitant multiple phlebectomy and thermal tip position appear to be associated with EHIT propagation, but further investigation of risk factors continues.

EHIT appears to behave differently than a spontaneous occurring deep vein thrombus (DVT) and may be an ultrasound finding without clinical significance.  However, Center for Vein Restoration, all patients presently undergo post endovenous ablation procedure duplex imaging within 2-7 days per protocol to identify an EHIT or DVT potentially requiring observation or intervention.

As with all medical and surgical practice, expertise arises from education, dedication, fascination, and specialization. While there are certainly practitioners who are excellent at treating many aspects of venous disease, CVR is dedicated to the treatment of venous disease.  Because of this, we have all of the necessary tools (radiofrequency, laser, sclerosants) to treat virtually any condition.  Most practices invest in a single modality and don’t have the flexibility to treat what we do. CVR provides complete vein treatment. In addition, CVR invests heavily in peer review to assure that all patients are treated appropriately according to the most recent guidelines recommended by the Society for Vascular Surgery and the American Venous Forum. In addition, our staff is continually trained in the latest diagnostic techniques and specializes in venous disease. We work closely with many specialties to provide the best venous care. In fact, some vascular specialists choose to send their patients to us.  These are a few of the reasons we are a national authority in vein treatment. In addition to CVR’s ability to comprehensively treat venous hypertension in the lower extremities, CVR also is capable of the evaluation and treatment of lymphatic disease and supra-inginual vein disease.

Restless Leg Syndrome (RLS)

January 24th, 2014 | Posted by CenterForVein in Restless Legs Syndrome - (Comments Off)

Restless legs syndrome (RLS) is a condition in which your legs feel extremely uncomfortable, typically in the evenings while you’re sitting or lying down. It makes you feel like getting up and moving around.  RLS can begin at any age and generally worsens as you age. Restless legs syndrome can disrupt sleep — leading to daytime drowsiness — and make traveling difficult. Moving the legs reduces and may relieve the discomfort. The constant need to move the legs disturbs sleep and can lead to impairment of function in daily life.

The condition was first suggested to be associated with venous insufficiency Dr. Karl A Ekbom in 1944. Doctors who treat varicose veins have long heard from their patients descriptions of throbbing, buzzing, creepy-crawly, pains in the lower extremities–symptoms that sound very similar to those of RLS. Restless legs syndrome has long been accepted as a symptom of venous insufficiency by phlebologists.   When RLS co-exists with venous insufficiency, treating the venous insufficiency can provide substantial improvement in symptoms and subsequently the quality of life.

Restless legs syndrome affects approximately 10 percent of adults in the United States. RLS may begin at any age, including childhood, and affects approximately twice as many women as men. 80% of those affected by RLS also experience Periodic Limb Movement Disorder (PLMD) during sleep, in which the patient has  brief “jerks” of the legs or arms while sleeping.

PLMD causes you to involuntarily flex and extend your legs while sleeping — without being aware you’re doing it. Hundreds of these twitching or kicking movements may occur throughout the night. If you have severe RLS, these involuntary kicking movements may also occur while you’re awake. PLMD is common in older adults;  4 out of 5 people with RLS also experience PLMD.

Venous insufficiency not only causes varicose veins, it can be the underlying cause for a multiple conditions, including lower extremity cellulitis, leg cramps and restless legs syndrome. When patients present with venous insufficiency symptoms, physicians often only check some of the obvious explanations and do not delve deeper to look for the possibility of venous reflux as an underlying cause. Unfortunately, there is a large percentage of people walking around with venous problems who aren’t getting the evaluation or treatment they need. Symptoms of restless legs syndrome may vary from person to person but often include burning, tingling, creeping sensations and the uncontrollable urge to move the legs. This is generally worse at night when laying down and is usually relieved by movement or walking. The symptoms of venous insufficiency and restless leg syndrome are almost interchangeable and many patients with documented severe superficial venous insufficiency and restless leg syndrome will have resolution of their restless leg syndrome after successful vein treatment.

Treating the cause, not just the symptoms

Studies show that the treatment of venous insufficiency can relieve symptoms of restless leg syndrome. According to a study in the journal Phlebology, in patients with restless leg syndrome and venous insufficiency, 98% of patients experienced relief from restless legs syndrome symptoms by treating their venous insufficiency, and 80% had long-term relief.

Given the results of the recent studies, it is recommended that, before patients start taking prescription medication for restless leg syndrome, they request a consult by a qualified vein specialist who can perform ultrasound evaluation to identify whether there is significant underlying venous insufficiency which may be causing or contributing to their problem. There is no downside to getting an ultrasound – there is no radiation involved, no needles, no pain, and it is a physiologic test which reveals which veins are leaking and how much they are leaking. Venous ultrasound for insufficiency is conservative, noninvasive, and it accurately identifies which patients are most likely to benefit from treatment.


Venotonics, also known as venotropics or phlebotropics, are a class of medicinals that have effect on veins and are used to alleviate venous diseases and disorders and particularly venous insufficiency. No venotonic has been shown to cure venous insufficiency or to be as effective as surgical ablation to improve the symptoms of venous insufficiency, but several have been shown to reduce the symptoms of venous insufficiency to a clinically significant degree.

Venotonics can be useful before, during and after venous ablation and can be used in addition to compression. Each of the available compounds exert effects on noradrenergic receptors in the vein wall. This causes prolonged contraction of the vein, reducing the luminal diameter and hence reducing the volume of blood in the “varicose reservoir.” Venotonics may exert their effect on larger veins, but some also have their effect at the microcirculatory level, helping to reduce the effects of chronic venous hypertension on capillary end organs, in particular, skin. This leads to a reduction in transcapillary movement of fluids and thus reduced edema.

Butcher’s Broom Extract (Ruscus aculeatus)

Butcher’s Broom Extract (BBE) appears to reduce the diameter of varicose veins in vitro. BBE is available in the United States without a prescription as an herbal supplement. It is hypothesized that the mechanism of action for BBE may be via increasing cyclic adenosine monophosphate (cAMP) levels within the veins. Because of its ability to increase vein tone, it may have some benefit as a treatment for orthostatic hypotension. Symptomatic improvement in heaviness, fatigue and altered sensations in patients taking butcher’s broom of venous insufficiency is correlated with reduced volume of blood within the varicosities.

Horse Chestnut Seed Extract

Horse chestnut seed extract (HCSE) has been used in traditional medicine as a treatment for varicose veins. In their 2002 systematic review of previous studies for the Cochrane Collaboration, Pittler and Ernst found that there was evidence, based on placebo controlled studies, that HCSE reduced the symptoms of venous insufficiency and that HSCSE is a reasonable short-term treatment for venous insufficiency.  The mechanism of action of HCSE is believed to be via alteration of the transcapillary filtration in a manner favoring edema reduction.

There is one case report of a patient with renal angiomyolipoma (AML), a condition known to spontaneously rupture and bleed, who was taking HCSE. The patient experienced a potentially life-threatening rupture of her AML, and her emergency physician felt this was potentially a side effect of the patient’s use of HCSE. It is not clear that HCSE has the anticoagulant effect the author claims.

Diosmin, Diosmiplex, (Vasculera)

Diosmin glycoside is a flavonoid occurring naturally in citrus plants and can also be derived from hesperidin, a constituent found primarily in oranges. Internationally it is available as a highly purified flavonoid fraction. In the United States it is available as a prescription medication (brand name Vasculera). The generic name for Vasculera is diosmiplex and it is a highly purified flavonoid fraction combined with Alka4-complex, an alkalinizing agent. The addition of the alkalinizing agent is thought to buffer stomach acid and blood pH and thereby combat metabolic acidosis within varicose veins.

Diosmiplex is classified as a “medical food.” The classification of “medical foods” was established by the 1988 Orphan Drug Act and is defined as “a food which is formulated to be consumed or administered enterally under the supervision of a physician, and which is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation.” (source: 21 U.S.C. sec. 360ee(b)(3). — [from the Orphan Drug Act, 1988]). Because the constituents are derived from commonly eaten foods, the medicine is Generally Recognized as Safe (GRAS). The most common side effect of diosmin is dyspepsia, and this is likely another reason for the addition of the Alka4-complex to the product.

The medicine is currently FDA approved for chronic venous insufficiency presenting as hemorrhoids and varicose veins. For acute hemorrhoids, diosmiplex is given three times a day for 4 days and twice daily for 9 days. For varicose veins, edema, stasis dermatitis and venous ulcers, diosmiplex is given once daily as a 630mg dose (600mg of diosmin is combined with 30mg of alka4-complex in each tablet). Although improvement may occur within the first week of treatment, 4-8 weeks may be necessary to see clinical improvement.  The mechanism of action for diosmiplex is at several areas of the pathophysiology of venous insufficiency, varicose veins, venous hypertension and the microscopic pathways that lead to the skin changes associated with venous disease.

The alka4-complex is used to address the acidosis in the microvasculature. Diosmin itself helps to increase lymphatic and capillary permeability and reabsorption of fluid, decreasing interstitial fluid and hence edema. Reduction of capillary permeability and inflammation in turn may also decrease healing time for ulcers. Additionally, Diosmin has been shown to affect the metabolism of norepinephrine and prolong the contraction of varicose veins. In one study diosmin was shown to improve clinical signs, quality of life, and CEAP stage in 65 of 80 test subjects with venous insufficiency during a 30-day trial. In vitro, diosmin appears to have antioxidant, anti-inflammatory and antiproliferative effects.

There has been one case report of a patient who was on diosmin (an over-the-counter formulation) for several years and who was subsequently placed on warfarin. Six weeks after initiation of the warfarin, the patient developed a spontaneous interventricular bleed, which the attending physician felt might be related to the combined use of diosmin plus the addition of warfarin.

Medical Therapy as an Adjunct to Surgical Correction

Venous insufficiency is a chronic condition–and therefore medical management alone requires an indefinite period of continuous treatment to maintain improvement. The requirement of prolonged and indefinite medical treatment may be acceptable in some special populations, such as those whose health is frail, those who have deep venous reflux, those who have severe phobia or additional medical considerations contraindicating surgery. For most patients, venotonics can be a useful adjunct to more definite surgical ablation of incompetent veins.



BREAKING  NEWS   –  The United Kingdom’s National Institute for Health and Care Excellence   (NICE)  has released treatment guidelines for the diagnosis and management of varicose veins. For  the first time, NICE recommends   heat ablation therapy as first line treatment instead of the more invasive and traditional surgical procedures practiced. Furthermore, contrary to what the UK’s National Health Services  and many insurance companies have said before, the new NICE guidelines have recommended that all people with symptomatic primary or recurrent varicose veins should be referred to a vascular specialist for assessment and treatment. The NICE guidelines also state that compression stockings should  not  be  offered to  treat  varicose veins or delay evaluation and treatment, unless interventional treatment is unsuitable.   This recognition welcomes a new era for the management  of patients with varicose veins, who will benefit from a walk-in, walk-out, office-based procedure requiring only local anesthetic and allowing them to return to normal activities the same day.

The National Institute for Health and Care Excellence  (NICE) is a non-departmental public body of the Department of Health serving both the English National Health Service and the Welsh National Health Service.    NICE publishes guidelines in multiple areas, including guidance on the appropriate treatment and care of people with specific diseases and conditions and guidance for  public sector workers on health promotion and ill-health avoidance. These appraisals  are based primarily on evaluations of efficacy and cost-effectiveness in various circumstances. These appraisals must take into account both desired medical outcomes and also economic arguments regarding differing treatments.

The newly  issued  NICE guidelines establish endothermal ablation, which includes endovascular laser and radiofrequency treatment, as the  recommended first  option  in  treating varicose veins. Varicose veins affect up to 3 in 10 adults in the UK, similar to the prevalence in the United States.   Varicose vein disease was found to impact patients’ quality of life comparable with that of congestive heart failure and chronic lung disease. Additionally,  the burden to the National Health Service of managing the impact of untreated varicose veins such as leg ulcers is estimated at billions of dollars annually. Heat ablation is a cheaper therapy associated with less pain and quicker recovery times for patients, compared with traditional surgery such as vein stripping or ligation. Access to appropriate treatment can transform patients’ lives.

Symptoms  of  venous insufficiency, the underlying cause of varicose vein disease, include pain, aching, heaviness, itching, restless leg phenomenon, cramping, hair loss in the lower legs, and skin changes ranging from dryness to extensive dermatitis. Usually these symptoms will worsen as the day progresses and with activities such as prolonged standing or sitting. While these symptoms start out as mild, they can progress in severity if left untreated.

By Robert C. Kiser, DO, MSPH

Restless legs syndrome (RLS) – also called Willis Ekborn Disease – was first described by Chinese physicians in 15291, and 1763 by French physicians2. The condition was first suggested to be associated with venous insufficiency Dr Karl A Ekbom in 1944.3  RLS is characterized by unpleasant or painful sensations (dysesthesias or paresthesias) in the legs and an urge to move the legs. Symptoms occur when the patient is relaxing, inactive or at rest, and can increase in severity during the night or latter part of the patient’s wake period. Moving the legs reduces and may relieve the discomfort. The discomfort and constant need to move the legs disturbs sleep and can lead to impairment of function in daily life.


Restless legs syndrome affects approximately 10 percent of adults in the United States.4 RLS may begin at any age, including childhood, and affects approximately twice as many women as men. 80% of those affected by RLS also experience Periodic Limb Movement Disorder during sleep, in which the patient has brief “jerks” of the legs or arms while sleeping.


Causes and Associations

Restless Legs Syndrome may have genetic causes, and has been associated with low iron storage in the brain as well as diminished dopamine in the basal ganglia (the brain area also associated with Parkinson’s disease). RLS is associated with Parkinson’s disease, diabetes, renal insufficiency, iron deficiency anemia, peripheral neuropathy,5  and multiple sclerosis6. The focus of this article is the association between RLS and venous insufficiency. RLS occurring secondarily from a chronic disease can often be improved or cured by adequately treating the associated condition.  For instance, Restless legs syndrome caused by iron deficiency anemia can be treated by normalizing iron levels. This relationship has been established so strongly that some medical insurers require that a ferritin level be drawn on any patient before initiating another treatment for RLS.



Treatment for RLS depends upon the cause. If a primary condition is responsible, then optimizing treatment for the associated condition may help the symptoms. Frequently, however, no clearly associated condition is known and the RLS is “idiopathic,” or treatment of the underlying condition does not adequately resolve the symptoms. In these cases treatment is directed to the proximate known cause, which is a decrease in dopamine in areas of the basal ganglia. Anti-Parkinsonian medications such as carbidopa-levodopa, pergolide, bromocriptine,and ropinirole will often ease the symptoms.


The Association of RLS with Venous Insufficiency

Those who treat varicose veins have long heard from their patients’ descriptions of throbbing, buzzing, creepy-crawly, pains in the lower extremities – symptoms that sound very similar to those of RLS. Restless legs syndrome has long been accepted as a symptom of venous insufficiency by phlebologists.  It was McDonagh, et al., in 2007 who published the paper, “Restless legs syndrome in patients with chronic venous disorders: an untold story.” This case-control study found a significant difference (at p < 0.05) between the cases (36% prevalence of RLS) and controls (19% prevalence). The clinical difference found between the two groups was a higher prevalence of cramping symptoms in the group with both RLS and venous insufficiency when compared to the control group that had RLS without venous insufficiency.7


The association begs the question as to whether treatment of venous insufficiency (VI) in those who have both RLS and VI, will improve both conditions.  In 2008, Clint Hayes and John Kingsley, et al., published their ground-breaking paper “The effect of endovenous laser ablation on restless legs syndrome,” in the journal Phlebology. This cohort study took patients with ultrasound-proven venous insufficiency and RLS (by NIH criteria) and separated them into operative and non-operative cohorts. The operative cohort received endovenous laser ablation and sclerotherapy. The results: correcting the SVI decreased the mean IRLS score 80%. Also, 89% of patients had a decrease in their score of > or =15 points. Fifty-three percent indicated their symptoms “had been largely alleviated” and 31% reported complete relief of their RLS symptoms. Hayes et al. concluded that patients with diagnosed RLS should be sent for ultrasound evaluation for venous insufficiency prior drug therapy being initiated or continued. 3



Restless legs syndrome is a common disorder with a known association with venous insufficiency. RLS is commonly treated with dopaminergic drugs, but these drugs have numerous short and long-term side effects. When RLS co-exists with venous insufficiency, treating the venous insufficiency can provide substantial improvement in the patient’s symptoms and subsequently the patient’s quality of life.

The Edinburgh Vein Study published in 1999 in the British Medical Journal estimated that over 80% of the total population had reticular varicosities or telangiectasia (spider veins).  However, the prevalence of varicose veins, as reported in studies, has not matched that of reticular varicosities or telangiectasia.  Reported rates of varicose veins in the literature range from 2%-56% in men and from 1%-60% in women.  The prevalence estimates in the literature vary because of differences in the methods of evaluation, criteria for definition, and the geographic regions analyzed.

What we do know is that chronic venous disease is extremely common.  It is estimated that approximately 40-50% of individuals with spider veins have underlying venous disease contributing to the dilated capillary formation.  In the other 50-60% of individuals with spider veins, their disease is limited to the surface telangiectasia and does not represent underlying venous hypertension.  Treatment of these superficial dilated blood vessels can be futile if the underlying disease process is not addressed.  These physical findings should cue doctors in on the possibility that venous disease exists warranting further questioning to see if the individual experiences symptoms in addition to early signs of venous disease.  Any person with spider veins that experience symptoms of burning, itching, aching, heaviness in their legs should be further evaluated by duplex ultrasound. While vein disease signs and symptoms start out as mild, they can progress in severity if left untreated.


It is reported that more than 40 percent of pregnant women experience problems with varicose veins of the legs and/or vulva during their pregnancy. Treating patients during pregnancy is not advised due to multiple reasons.  During pregnancy, the lower extremity venous system is constantly changing. The body increases blood volume during pregnancy. It also decreases the speed that blood returns from the legs to the pelvis.  A higher level of the hormone progesterone also contributes to the veins becoming more dilated.  With childbirth, these factors that stress the leg veins are eliminated.  As a result, in a percentage of women, leg veins return to normal function. Furthermore, during pregnancy the body has a higher likelihood of forming blood clots, thus pregnant women are at higher risk for developing deep vein blood clots especially during surgical procedures.  Lastly, certain medications that may be utilized to treat diseased veins have not been proven safe for the fetus in pregnant women.

For the reasons above, we recommend waiting until after pregnancy to be evaluated for venous disease or varicose vein disease. If varicose veins, leg swelling or painful legs persists for 10-12 weeks after pregnancy, it is best to speak with a vein specialist in order to prevent potential complications like painful skin conditions (ulcers) or clotting of the varicose veins (phlebitis).  We recommend scheduling treatments prior to a subsequent pregnancy if possible.  Pregnancy will only worsen the condition once it exists.  Worsening vein disease may require more extensive treatment if it is not addressed prior to the next pregnancy.

Vein stripping is a surgical procedure usually performed under general anesthesia in the hospital setting to remove diseased saphenous veins and their associated varicose veins. The surgery involves making one or more incisions in the groin or leg to gain access to the diseased vessel.  Next, a special wire is inserted into the vein and the vein is then pulled out from the body. The incisions are stitched up and pressure dressings are applied to the incision.  An overnight hospital stay is not uncommon.  Patients may be advised to avoid any physical activity for days or weeks.  Vein stripping has been associated with up to a 8% risk of infection and up to a 25-60% failure rate due to neovascularization. Because of the high failure rates secondary to neovascularization, the relatively high morbidity and recurrences associated with saphenous vein stripping, as well as, the high failure to strip completely in many patients, vein stripping today is rarely performed.

CVR performs endovenous thermal ablations to treat diseased saphenous veins and associated varicose veins.  Endovenous thermal treatments are minimally invasive, office based treatment alternatives to surgical stripping of the great saphenous vein. Instead of removing the saphenous vein, the vein is sealed closed in place by using a heat source generated by either laser or radio-frequency catheter. The skin on the inside of the lower leg is anesthetized and a small fiber or catheter is inserted through a needle stick into the diseased vein. Pulses of heat are delivered inside the vein, which causes the vein to collapse and seal shut. This procedure is done in-office under local anesthesia. Following the procedure a compression bandage is placed on the treated leg. Patients are able to walk immediately after the procedure and most individuals are able to return to work the same day. Endovenous thermal ablation treatments are FDA-approved for the treatment of the greater saphenous vein. These treatments are the first line recommended treatment option for diseased saphenous veins by the Society for Vascular Surgery and the American Venous Forum.

Prior to receiving vein treatments in our clinics, you may take any medications that are part of your normal routine. Blood thinning medications including Aspirin, Plavix, Aggrenox, Coumadin, Pradaxa, to name a few, are all okay to continue. Blood thinning medications should not affect the success of your treatments.  Taking blood thinning medications during treatments may result in more transient bruising but will provide a protective benefit against developing blood clots after treatment.   When taking stronger blood thinners like Coumadin, your physician may choose to treat varicose veins utilizing foam sclerotherapy injection techniques as an alternative to ambulatory microphlebectomies.  Of note, some medications used during treatments including Lidocaine, Polidocanol and Sotradecol can cause allergic reactions or react with other medications.  For example, Polidocanol, a FDA approved sclerosant agent, contains ethyl alcohol as an emulsifier and can cause reactions in individuals taking Antabuse (disulfiram).  It is always wise to let your doctor know all medications and supplements you are taking prior to starting any medical or surgical treatment.

%d bloggers like this: