NCMA Healthy Insights

The Forgotten Circulation: The Treatment and Diagnosis of Venous Disease

by Allen W.Cortez, MD
Acute and chronic venous disease, including thromboembolism, affects 20 percent of American adults, kills more than 100,000 Americans each year and is the third leading cause of death in hospitalized patients. Fortunately, early diagnosis and treatment can prevent the long-term effects.

Weakness in vein walls One-way valves in the veins keep blood flowing in the right direction: toward the heart. When the valves become weakened or damaged, varicose veins develop. Weakness in vein walls stretches them, causing valve flaps to separate. Blood flows backward through the valves, filling the vein and causing it to become swollen and often twisted. The result? Decreased forward flow and increased venous pressure (venous hypertension), which, if prolonged, causes tissue edema, inflammation and hypoxia. Examination may reveal varicose veins, hyperpigmentation, stasis dermatitis, venous eczema, and skin thickening (lipodermatosclerosis) on the lower legs and at the ankles, with or without ulceration.

Assessment and treatment options

Color flow duplex ultrasonography is considered the gold standard for noninvasive assessment of venous reflux. It allows direct visualization of the veins and identification of blood flow through the vein valves. This information is useful in treatment selection and as a guide for minimally invasive procedures or surgery, and can also identify and assess deep venous thrombosis (DVT).

There are two general treatment options: conservative measures, such as compression stockings, andcorrective measures, such as sclerotherapy, surgery, and light source/laser treatment. In some cases, a combination of treatment methods is needed.

In sclerotherapy, a minimally invasive treatment for spider veins and medium size (reticular) veins, a tiny needle injects a solution (sclerosant) into the veins, irritating the lining and causing them to collapse and be reabsorbed.

Endovenous treatment are minimally invasive, in-office procedures that include laser treatment, radio frequency ablation, and ultrasound-guided sclerotherapy. Endovenous laser treatment delivers pulses of laser light inside the vein, causing it to collapse and seal. In endovenous radio frequency ablation (Closure® procedure), a radio frequency catheter is inserted into the damaged vein, causing it to collapse and seal. In ultrasound-guided sclerotherapy (echo-sclerotherapy), a sclerosant is injected into the vein under direct ultrasound guidance to destroy the lining of the blood vessel and seal it. Following these procedures, a bandage or compression hose is used.

Surgical intervention

Surgery is generally used to treat large varicose veins. Perforate Invaginate (PIN) stripping is an updated method of vein stripping in which small incision is made in the leg and the “PIN stripper” is inserted and advanced through the vein. The tip of the PIN stripper is sewn to the end of the vein, and as it is removed, the vein is pulled in on itself and is “stripped” out.

Ambulatory phlebectomy is an office-based procedure involving surgical removal of surface varicose veins. The area surrounding the varicose vein clusters is flooded with anesthetic fluid and a puncture is made next to the varicose vein. A small hook is inserted and the varicose vein is grasped and removed.

Read Dr. Cortez’s Article in NCMA Healthy Insights Magazine (pdf)

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