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What happens if the patient is having a bypass and they need the Great Saphenous vein?
Generally, if the Great Saphenous Vein (GSV) is diseased enough that ablation is recommended, then the vein is not suitable for any type of use in a bypass surgery settingeither peripheral arterial bypass or coronary artery bypass grafting (CABG). In this setting, the rendering surgeon will select a different vein, or use an arterial conduit. Rarely, he may choose to use a cadaver vein.

“How do you do a CABG without the Great Saphenous Vein?”
There are multple additional options for bypass grafting. Qualified cardiac surgeons can perform coronary bypass grafting (CABG) surgery without the need for the Great Saphenous. Either other veins, or even other arteries, and sometimes artificial or cadaver grafts can be used. A diseased and dilated Great Saphenous Vein would never be used on the heart. This concern should not be a reason to avoid treating your leg veins, if symptoms are present.

“What medical history issues will exclude a patient from being considered for vein ablation (i.e., clotting issues, etc)?”
Each patient’s individual situation is different. At CVR we take the entire medical history of every patient into account before we make a recommendation for treatment. Cardiac (heart) and pulmonary (lungs) history is very significant as well as other risk factors such as diabetes, hypertension, clotting history, lipid (cholesterol) profile, etc. All of these factors and more will be reviewed with each patient before a recommendation for ablation is made. There are very few factors
that, in and of themselves, will exclude a patient from being a candidate for venous ablation techniques.

Understanding Post Thrombotic Syndrome

July 12th, 2013 | Posted by CenterForVein in DVT | PTS | vein-center - (Comments Off)

By Gautam Shrikhande, MD

In patients with deep venous thrombosis (DVT), the most significant immediate concern is that of pulmonary embolus.  Over the next several months to years, however, development of post thrombotic syndrome (PTS) presents a much more prevalent chronic morbidity.  PTS refers to the signs and symptoms that occur as long term consequences of DVT.  PTS can affect up to 23-60% of patients in the two years following DVT, and up to 10% of these patients may go on to have ulceration.1  The most significant long term sequelae of PTS are a significant loss of quality of life and limitations in the abilities to perform daily activities.2  Signs and symptoms in the leg include swelling, heaviness, aching, cramping, varicose veins, skin discoloration, and ulceration.  The inflammatory response secondary to the thrombus as well as the physical pressure from the thrombus is thought to lead to venous valvular disruption and incompetence.  This valvular incompetence combined with persistent venous obstruction from the thrombus increases the pressure in the veins and leads to a state of venous hypertension.  Risk factors for the development of PTS include proximal DVT, recurrent ipsilateral DVT, persistent DVT symptoms one month after DVT diagnosis, obesity, and inadequate anticoagulation during the first 3 months of DVT treatment.

Understanding Post Thrombotic Syndrome

The most important initial step in the evaluation of PTS after obtaining a history of DVT is obtaining a venous duplex ultrasound.  The key features of this evaluation include the degree of recanalization of the deep venous system, the location of the obstruction (proximal or distal), and the presence of both deep and superficial venous insufficiency.

Initial, conservative treatment options for PTS include appropriate anticoagulation for DVT, leg elevation, weight loss in overweight patients, and the use of elastic compression stockings for up to 2 years post DVT.4 In patients with ulceration development, appropriate wound care and compression bandages are indicated.  Also, in some patients, venous ablation in patients with significant superficial venous reflux may provide symptomatic relief.

In addition, from the American College of Chest Physician Evidence-Based Clinical Practice Guidelines in 2012, there is evidence to suggest that catheter directed thrombolysis (CDT) in the setting of acute DVT may reduce PTS and improve quality of life without being associated with an unacceptable increase in bleeding.  The patients who experience the best results are those who have ileofemoral DVT for less than 14 days.5  CDT involves taking the patient to an angiography suite and infusing thrombolytic therapy, typically tissue plasminogen activator (TPA), directly into the thrombus.  The dissolution of thrombus can prevent the subsequent inflammation of obstruction which occurs secondary to the thrombus and can preserve long term deep venous function.

Lastly, in patients with established PTS, some have shown that venous balloon dilation and stent therapy can be effective treatments for chronic ileofemoral thrombosis.6  With this minimally invasive approach which can be safely and easily accomplished in an angiography suite, patients with PTS can get quick symptomatic relief with minimal morbidity and good patency of the venous system after stenting.    We have had several patients with ulcerations in the setting of PTS who have gone onto complete resolution of this pathology.

In summary, PTS can be a significant source of morbidity in patient with DVT, however with the proper evaluation and treatment selection by a venous specialist, PTS can be either prevented or treated to provide patients with an excellent quality of life.

By Robert C. Kiser, DO, MSPH

Phlebology is a rapidly advancing branch of medicine. It has been Just over 10 years that thermal closure techniques such as radiofrequency and laser ablation were invented, and now they are the standard of care for ablation of superficial venous insufficiency. Thermal closure is extremely effective and safe. It is far less time consuming and has much less down time and associated expense compared with ligation and stripping. Thermal closure has much more reproducible results and is also much more consistently effective in the long term as compared to sclerotherapy alone. However, endovenous thermal closure does have its own requirements, such as disposable catheters, laser fibers, and because it uses heat within the vein it requires the use of tumescent anesthesia around the vein to act as a heat-sink. For the phlebologist, requirements add expense and time to the procedure. For the patient, the more body is penetrated with needles, infused with fluids, or otherwise invaded, the less comfortable the procedure. Newer phlebology treatments focus on providing highly effective treatment methods (>90% success over multiple years) with less bodily invasion, less time and fewer or equal risks.

Supergluing Veins: Sapheon

phlebology

Cyanoacrylate has been used in medicine for many years, primarily to close skin wounds. It also has been  used to close arterio-venous malformations, incompetent ovarian veins and duodenal varicose veins. Cyanoacrylate for saphenous vein closure is not yet available in the United States, although phase 3 trials are underway in the US and the UK. The technique is as follows: A long glue-installation catheter is placed within the vein, much as one would place a thermal catheter. Glue is injected under ultrasound-guidance, starting at 5cm from the saphenofemoral junction. The ultrasound probe compresses the glued vein for 3 minutes. The remaining length of incompetent vein is then glued in a proximal to distal fashion. The effect is a sort of “spot welding” of the vein. The cyanoacrylate causes an acute inflammatory reaction, at the endothelium, that results in fibrotic closure of the vein.

I had the good fortune to speak with Tristan Lane, surgeon  and clinical research fellow at the ImperialCollege, London. Mr. Lane has had the experience of performing more than 100 of these procedures during phase 3 trials. He states he has seen no embolization of glue, no skin pigmentation, no DVT or PE. He did report one case of asymptomatic thrombus extension, which did not recur after changing the starting placement from 3cm to 5cm from the SFJ.  A similar threadlike thrombus extension was noted after Jose Almeida’s series of 38 patients which also resolved spontaneously and asymptomatically.

The major difficulties to consider when using cyanoacrylate intravascularly are the control of viscosity and curing time. If the mixture is not viscous enough, or takes too long to cure, then the glue can migrate to unwanted areas. If the glue cures too quickly then the delivery catheter can become adhered to the vessel walls. The delivery system includes an especially mixed, proprietary blend of cyanoacrylate with additives that affect polymerization. The glue, along with the delivery catheter is made and distributed in a disposable kit by Sapheon, Inc. The entire process is carried out through a single incision, with no tumescent, only a single dot of anesthesia, and no machinery required save for the ultrasound machine. Post-operative care does not mandate compression for this technique.

A New Twist on an Old Therapy: Clarivein Sclerotherapy. 

clariven sclerotherapy treatment

Sclerotherapy for varicose veins has been around for several hundred years. The method has been refined and evolved by many individuals and “schools” of sclerotherapeutic technique. Currently the most widely used and FDA-approved sclerosants are sodium tetradecyl sulfate and polidocanol. These being detergent sclerosants, they are frequently used as a foamed preparation to displace intraluminal blood and increase contact time with the vein wall, thus improving fibrous closure and reducing the amount of retained blood. In the best of hands, sclerotherapy can produce excellent results that yield short and even long-term closure. However, the percentage of veins that reopen some years after sclerotherapy is estimated to be as high as 40% in some studies. This is in likely due to varying techniques, which can lead to inadequate destruction of endothelium and subsequent, inadequate fibrotic closure. Clarivein uses both chemical sclerosant (generally sodium tetradecyl sulfate in the United States) and mechanical agitation of the vein wall. The device is inserted into the vein to be treated (great or small saphenous vein or other straight vein), and positioned below the saphenofemoral junction. The catheter has a thin stainless steel mechanical agitator that runs the length of the catheter to a motor at the hub. An infusion port connects to the lumen surrounding the agitator, and allows the instillation of a sclerosant. Once the agitator is deployed and the motor engaged, the agitator oscillates at 3,500 repetitions per minute in a to-fro motion. This traumatizes the endothelium and causes the vein to spasm. At the same time, the infused sclerosant travels to the tip of the agitator, contacting the traumatized endothelium. This allows for more effective sclerosis of the vein and more robust fibrosis of the lumen.

Because no heat is used, no tumescent anesthesia is needed. Once again, the entire procedure can be done through one small incision, requiring only a dot of anesthesia. Compression is recommended after the procedure, using either compression stocking or bandaging. This is because, unlike the glue method, sclerotherapy does not obstruct the proximal point of reflux, but rather induces an immediate spasm, which then relaxes and allows the admittance of blood into the lumen. Compression is used to reduce the amount of retained blood, which improves the ability of the vein lumen to fibrose and eventually become a fibrous cord.

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Over the course of the last few years, the world of venous care has evolved at a staggering pace. There are more phlebology practices now than ever before, and unfortunately there is significant variance in the quality of vein care provided by the various practitioners. This may be due to the great variability of training or the broad range of treatment modalities.   For this reason, it is more important than ever to examine each practice’s quality related processes and outcomes.

As every field in medicine gets analyzed more closely for over utilization, effectiveness, and patient outcomes, the field of phlebology will also be in the cross hairs.1It is important that everyone who practices venous insufficiency treatment takes on the responsibility of providing the best care available. This can be achieved by establishing medical protocols, continuous evaluation and grading of providers, clinical audits on complication rates, regular reviews of evidence-based treatment plans, and compliance reports.

Evidence-based treatment protocols ensure the most appropriate patient care and are becoming more and more important in every medical field. Because of the wide variation in treatment options in phlebology, medical protocols are necessary. They are a set of predetermined criteria that defines appropriate interventions that articulate or describe situations in which the provider makes judgments relative to a course of action for effective management of the venous patient.     The daily use of protocols has proven to yield better results than in practices that do not utilize them2

Regular evaluation and grading of providers using a “score card system”, which includes criteria such as post-procedure venous closure rates, improvement in Venous Clinical Severity Score (VCSS), as well as physician evaluation skills should be included as part of a continuous evaluation of all providers. This ensures that the quality of care is at or above national standards.   This “score care system” also gives providers and practices a chance to objectively improve on the quality of care, thus always advancing the field.

By Robert C. Kiser, DO, MSPH

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Varicose veins occur when veins become distensible, leading to valve dysfunction and venous insufficiency. In the previous Venous Review newsletter we learned that it is primarily humans who suffer from varicose veins of the lower extremities. This article looks at why varicose veins and venous insufficiency occur and persist in humans from an evolutionary perspective.

The field of Darwinian Medicine or Evolutionary Medicine was pioneered by University of Michigan psychiatrist Randolph Nesse and Stony Brook University biologist George C. Williams. In Dr. Nesse’s words:

“All biological traits need two kinds of explanation, both proximate and evolutionary. The proximate explanation for a disease describes what is wrong in the bodily mechanism of individuals affected by it. An evolutionary explanation is completely different. Instead of explaining why people are different, it explains why we are all the same in ways that leave us vulnerable to disease. Why do we all have wisdom teeth, an appendix, and cells that can divide out of control? “

 

Varicose veins occur because of both inherited and environmental factors. A specific gene has not yet been definitively identified as causing the predisposition to varicose veins, although the FOXC2 gene on 16q24 has shown evidence of linkage in one study. The evidence that varicose veins are inherited comes from studies showing that varicosities occur more commonly in those whose parents have varicose veins.

Ultimately, the cause of venous insufficiency and varicose veins is gravity. More proximately, the largest contributing factor is our upright posture. The first primate to have been bipedal is believed, at the time of this writing, to be Oreopithecus bambolii, a southern Italian ape whose feet and pelvic structure suggests an upright, bipedal gait. O. bambolii lived approximately 9 million years ago. It is believed that hominids developed a bipedal gait around 4.2-3.9 million years ago Bipedalism allows for many important evolutionary benefits, such as the ability to run and walk effectively and, in animals with hands, the ability to free the hands for other activities during ambulation. However, with an upright posture come certain disadvantages as well, such as the tendency to develop back pain, falling down, and the need to develop hemodynamic mechanisms to overcome the change in how gravitational forces interact with the previously quadrupedal physiology. On the arterial side this requires blood pressure be maintained to the head. In the venous system this requires that venous valves and vein walls maintain their structural integrity against the downward pressure of blood.

Why Varicose Veins Persist in the Human Genotype

Assuming that varicose veins have some probability of leading to end-stage signs and symptoms such as venous ulcers and varicose hemorrhage, shouldn’t natural selection tend to favor those whose genotype does not contain a tendency to cause venous insufficiency? There are several possible reasons why this has not occurred. First, varicose veins generally have their onset after reproductive age and rarely reach an end stage of venous ulcer or spontaneous varicose hemorrhage before reproduction. Therefore, the phenotypic expression of the underlying genetic predisposition does not occur until an age after which reproduction is common; there is little or no selection pressure to reduce the frequency of the genes predisposing to a varicose phenotype. An example of an analogous would be Huntington’s chorea, in which the debilitating and eventually fatal condition most commonly occurs between 35-44 and therefore after the common age for reproduction. Furthermore, the child of a person affected by Huntington’s has a 50% risk of inheriting the disease. An understanding of the genetics of the disease allows for genetic counseling and genetic testing. This creates a selection pressure against replication of this gene via the mechanism of knowledge and understanding of risks. People who undergo genetic testing understand that they have a chance to pass on the deadly gene. This allows them to choose not to have biological children, to abort an affected fetus, or otherwise avoid passing the gene.

More speculatively, varicose veins occur frequently in women after childbirth. Their frequency increases as the number of child births increase. Varicose veins in women, therefore may act as a marker of fertility, demonstrating that a woman bearing them is fertile and capable of conception and surviving childbirth. Varicosities could therefore have at some time been a sexual selection factor that positively increases its presence in the gene pool.

It is also possible that the tendency to varicose veins is associated with other characteristics which have selective advantages at least in some circumstances. For instance, varicose veins are noted to be associated with lighter skin tones, which may have some selective advantage in extreme Northern climates (due to increased vitamin D production at lower light levels). So the tendency to develop varicose veins may aggregate with other genes that have are favored due to natural selection or sexual selection.

Conclusion

As Dr. Nesse tells us, we clinicians can benefit from having a more global view of disease – both the proximate and evolutionary causes. Understanding that humans as a species are on some level predisposed to developing venous insufficiency can help physicians reshape their thinking when it comes to prevention, diagnosis, treatment, and ultimately compassion for their patients and the difficulties this condition can bring.

 

CVR TV Ads Aim to Educate Consumers

January 28th, 2013 | Posted by CenterForVein in vein-center - (Comments Off)

Have you seen us on TV? As part of our commitment to educate the public about venous disease and treatment options, we’ve launched a series of TV ads in the Washington- Baltimore region. The spots were created with the help of agency DMW Direct. One ad gives examples of complaints we’ve received from real patients to highlight the symptoms and the personal cost of varicose veins: “My legs hurt all the time,” “I’m tired of leg cramps that keep me up all night,” “I’m embarrassed to wear shorts,” “I don’t like hospitals,” and so on. To illustrate the problem, the text of the complaints forms what looks like varicose veins on a patient’s leg. Then, a voiceover cautions the audience not to let symptoms linger and offers free consultations. The second ad features a CVR Patient Services consultant taking calls from the public, again highlighting common questions we receive, detailing symptoms and offering free screenings. You can view the ads on our Web site or on YouTube or Facebook; just search under “Center for Vein Restoration.”

CVR Attends, Exhibits at ACP Congress

January 28th, 2013 | Posted by CenterForVein in CME-Events - (Comments Off)

CVR Attends, Exhibits at ACP Congress

 

Center for Vein Restoration was out in force at the Nov. 15-18 American College of Phlebology Annual Congress in Hollywood, Florida. Our physicians attended several educational sessions, while we also for the first time exhibited, giving us more opportunity to meet colleagues from around the country. Among the things we discussed were CVR’s expansion plans and our continuing need to recruit talented physicians, vascular technicians, nurses, surgical assistants and management
professionals.

CVR Goes on the Speaking Trail

January 28th, 2013 | Posted by CenterForVein in CME-Events | vein-center - (Comments Off)

CVR Goes on the Speaking TrailCenter for Vein Restoration physicians were proud to address a pair of recent medical groups:

  • CVR sponsored the Asian American Medical Society meeting on October 18, 2012 in Arlington, VA. Our doctors Khan Nguyen, DO, Richard Nguyen, MD, Arun Chowla, MD and Sean Stewart, MS, MD led a discussion on venous insufficiency and presented a check to the organization for $3,500 to help support world health in East Asian countries.
  • Our physicians also were pleased to present at the Oct. 27 Washington D.C. Dermatological Society’s Clinical Conference at Inova Fairfax Hospital. About 70 dermatologists attended the event, which included our participation in a Live Case presentation and discussing management of Inferior Vena Cava Occlusion in a patient with thrombophilia and leg ulceration. The presentation given by CVR’s Dr. Arun Chowla, also included a live ultrasound demonstration by our expert Vascular Tech Melissa Muto and an overview of CVR by our Director of Growth and Development Bob Howell. CVR was a sponsor of the conference.

Dr John PietropaoliNo, although many patients may have multiple areas of venous reflux involving multiple viens, once a single vein is treated the efficacy of that treatment is over 95%. In other words, once a vein is ablated, that vein will stay closed permanently. Ablation is a very durable solution. Other veins, may, however require additional treatments including ablation or other therapeutic modalities such as sclerotherapy or phlebectomy depending on the size and location of the offending veins.

Dr John PietropaoliNo, foot ulcers can have various etiologies, several of which have to do with the circulatory system in general, such as – arterial insufficiency, diabetes, venous insufficiency and/or a combination of any or all of the above. At Center for Vein Restoration, we can evaluate the patient and his or her specific wound at any of our centers. Those ulcers that are from a source such as diabetes and/or arterial insufficiency can be cared for at our sister practice “The Center for Vascular Medicine,” which specializes in these types of patient care issues. Wounds that are from a venous etiology can be cared for and definitively treated at a CVR office.

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