By Robert Kiser, DO, MSPH

Vulvar varicosities are a source of embarrassment and pain for many women but they are often reluctant to discuss their condition or symptoms with their doctors. These varicosities can easily be missed in casual examination, as they are less obvious in the supine position and may not be seen until the patient stands or assumes an upright sitting or squatting position.

When evaluating lower extremity varicose veins, varicosities in the proximal inner thigh should prompt the physician to consider a pudendal origin. The question, ―Do you have any varicose veins of the vulva or labia? should be asked as well as questions about pelvic congestion symptoms. There are a variety of treatments that can help to improve or eliminate these symptoms.

Vulvar varicosities may occur as isolated tributary varicosities or may be a sign of underlying pelvic venous insufficiency. They can also be associated with PCS

Background and Epidemiology

Vulvar varicosities occur in an estimated 4% of women1 and 15.8-23% of those with lower extremity varicose veins. Most occur during pregnancy and resolve within a few months. When they do not resolve they may cause symptoms of pain, itching, burning, dysparunia, and are perceived by some women as a cosmetic nuisance.

Vulvar varicosities may occur as isolated tributary varicosities or may be a sign of underlying pelvic venous insufficiency. They can also be associated with Pelvic Congestion Syndrome (PCS). PCS results from venous insufficiency (reflux) of the ovarian veins. This important but under-diagnosed condition is associated with symptoms of dysparunia, chronic pelvic pain, feeling of pelvic fullness and discomfort

When signs or symptoms of PCS are reported, a diagnostic transvaginal ultrasound both supine and standing, with and without Valsalva may be ordered to quantify pelvic vein reflux. Magnetic resonance venography is also extremely sensitive to finding dilated gonadal veins and provides an abundance of anatomic information5. Consultation with an interventional radiologist or vascular surgeon for venography and possible coil embolization or fluoroscopy-guided sclerotherapy is warranted when found.

Compression Therapy

Any patient with symptomatic vulvar varicosities (pregnant or not) should be encouraged to try compression therapy. The company, Prenatal Cradle, makes the V-2 Supporter for the pregnant or non-pregnant woman with vulvar varicosities. This device is similar in appearance to a male athletic supporter, but is contoured to provide compressive support for the vulva, thus preventing the pooling of blood in the labial veins.

Non-surgical and Minimally Invasive Techniques

For vulvar varicosities in the non-pregnant patient, remarkable improvement can be achieved with sclerotherapy. The visible varicosities are injected with a quantity of liquid or foam sclerosant, and the area is then compressed with a pad and the V-2 supporter or similar compression garment7. A few treatments can provide lasting relief and cosmetic improvement in vulvar varicosities. To minimize the risk of complications, the injecting physician should have extensive experience with vein sclerosis and a strong working anatomy of the pelvic venous system.

Persistent Pelvic Congestion Syndrome

Under fluoroscopy guidance, patients with PCS can be embolized by endovenous insertion of a metallic coil

For some patients, treatment of vulvar varicosities with a V-2 compression trial followed by compression sclerotherapy affords symptomatic improvement8. Patients with PCS who are not responding to compression should be evaluated by an interventional radiologist or vascular surgeon for possible coil embolization. Under fluoroscopy guidance, the refluxing ovarian veins can be embolized by endovenous insertion of a metallic coil.

After the pelvic venous insufficiency has been treated, if not previously addressed, the vulvar varicosities may be re-evaluated by a phlebologist who practices sclerotherapy to determine whether the varicosities and their associated symptoms have adequately resolved. If not, sclerotherapy of the visible varicosities may be provided if the patient wishes.

Help is available for your patients suffering with Pelvic Venous Syndromes. For more information, call 1-800-FIX-LEGS.

The term Chronic Venous Insufficiency (CVI) describes a condition that affects the venous system of the lower extremities with venous hypertension causing various pathologies including pain, swelling, edema, skin changes, and ulcerations.

Although the term CVI is often used to exclude uncomplicated varicose veins, varicose veins have incompetent valves with increased venous pressure leading to progressive dilation and twisting. We use the term CVI to represent the full spectrum of manifestations of chronic venous disease.

The Venous Ultrasound Exam

Venous Ultrasound

At the Center for Vein Restoration, the diagnosis of Chronic Venous Insufficiency is made via patient history and a physical examination with the assistance of noninvasive testing. A portion of the physical exam entails inspection and palpation of the surface of the skin to detect irregularities or bulges. The calf muscle is consistently assessed and measured for indications of fullness or increased girth due to long-standing edema.

Palpation may also reveal tenderness of the dilated veins. Active or healed ulcers are seen with more advanced disease.

There is a broad differential for the common presenting complaint with CVI. As a result, noninvasive ultrasound imaging plays an important role in diagnosing and guiding CVI treatment. Ultrasound imaging, also called ultrasound scanning or sonography, involves exposing part of a patient’s body to high-frequency sound waves to produce pictures of the inside of the body. Unlike x-rays, ultrasound exams do not use ionizing radiation.

Ultrasound imaging helps us to diagnose and treat medical conditions because they can show the structure and movement of the body’s internal organs, as well as blood flowing through blood vessels. A venous ultrasound provides us with pictures of the veins throughout the body that carry blood back to the heart.

This painless noninvasive exam measures the function of the vein valves that are critical to venous function, and can also identify vein blockages. In fact, compared to venography, which requires injecting contrast material into a vein, venous ultrasound is nearly as accurate for detecting blood clots in the calf and almost fully as accurate in finding clots in veins of the thigh.

A Doppler ultrasound may also be part of a venous ultrasound examination. This special ultrasound technique evaluates blood as it flows through a blood vessel, including the major arteries and veins, and the images can help us to see and evaluate blockages to blood flow, such as clots, or the narrowing of blood vessels.

While many patients present with large, clinically obvious bulging varicose veins, other individuals may have significant “silent” reflux (abnormal direction of blood flow) in diseased veins, which can only be detected by Doppler vein mapping a more detailed ultrasound evaluation of the abnormal veins of the legs which illustrates the path of the blood flowing through the abnormal veins and where the trouble begins.

Careful mapping of the lower extremity venous system aids us in determining the optimal treatment plan to meet each patient’s specific needs.

Doppler ultrasound

Venous disease ranges in severity from the unsightly, such as spider and varicose veins, to the life-altering, such as chronic venous insuffi-ciency (CVI). In CVI, failing valves in leg veins can’t do their job of pushing blood up against the forces of gravity toward the heart. As a result, blood pools in the lower legs and over time may cause pain, swelling, skin discol-oration and even limb threatening ulcers.
For many years, patients with venous diseases had few options other than supportive treatment such as special boots and stockings or inva-sive vein stripping surgery. Today, CVI is treatable through an in-office, minimally invasive and pain-free procedure known as The VNUS® Closure procedure.

We perform this procedure by using ultra-sound to position the Closure catheter into the diseased vein through small needle sticks. The tiny catheter delivers radio frequency (RF) energy to the vein wall, and as the RF energy is delivered and the catheter is withdrawn, the vein wall is heated. This causes the colla-gen in the wall to shrink and the vein to close. Once the diseased vein is closed, blood is re-routed to other healthy veins.

Patients resume regular activities the same day, but the ultimate goal of this treatment is to minimize further pain or disability. Typically, CVI does not pose a serious threat to life or limb, but early treatment is crucial to prevent further pro-gression and the complications that can result from chronic venous stasis which can be disabling.

As the holiday season approaches many travelers will soon clog highways and airports. No matter what the mode of transportation, sitting motionless for long periods may put some travelers at increased risk for deep vein thrombosis (DVT), a blood clot in a vein deep within the muscles, usually in the calf or thigh. But people can reduce their risk of getting DVT by taking some simple precautions on long trips.

About one out of every 1,000 Americans develops DVT each year. Symptoms include a swollen, painful leg, usually in the calf but DVTs can be silent, producing no noticeable signs. In certain cases when a piece of thrombus (blood clot) breaks off and goes into the lungs the consequences can be deadly. This complication of DVT, known as pulmonary embolism, was brought to public attention in 2003 when it caused the death of 39 year old NBC reporter David Bloom. Bloom had spent long hours reporting the war in Iraq from the cramped quarters of a military vehicle. Earlier this year, vice president Dick Cheney also was also diagnosed with a DVT but was fortunate not to have serious complications.

Any long period of immobility – such as being bedridden from illness, recovering from surgery, or sitting for extended periods while traveling – is a risk factor for DVT and pulmonary embolism. DVT can also develop in other instances when the blood flow in the legs is restricted and slows down. Restricted flow may occur with certain types of cancer and cancer treatment, obesity, inherited clotting disorders, pregnancy, and damage to the veins following injury.

DVT has been known as economy-class syndrome, because of the lack of legroom in economy class airline seating. But it can happen to passengers in any seating class of an aircraft. It can also happen to people on long rides in cars, trains, or buses. In instances where you will be immobile for periods of time you need to take precautions. A one-hour flight wouldn’t be a problem but a 10-hour flight could be a big problem if a person sits inactive the entire time. It is important to get up and walk during the flight. When you walk, the muscles of the legs squeeze the veins and move blood to the heart.

Another way to help move blood to the heart is to wear compression stockings, which put gentle pressure on the leg muscles. Studies in healthy people have shown that wearing compression stockings minimizes the risk of developing DVT. These stockings are available at medical supply stores.

Other precautions are avoiding regular socks with very tight elastic bands at the top and sitting with your legs crossed for long periods of time, which constricts the veins. Also travelers should walk around frequently to exercise their legs by curling or pressing the toes down, during connections, which causes the muscles to contract and squeeze on the leg veins, helping to pump the blood along. Drinking plenty of fluids to prevent dehydration can help. Dehydration causes blood vessels to narrow and blood to thicken, increasing the risk for DVT. Reducing alcohol and coffee consumption, which both contribute to dehydration, is also recommended. When traveling by car or train the same prevention methods apply.

The symptoms of venous insufficiency are closely related to those of DVT. If you have pain and swelling during long periods of sitting or standing or swelling at the end of the day, it is more likely that you have venous insufficiency, which is an issue with the valves in your leg not working properly. If left untreated, venous insufficiency can lead to serious issues such as leg ulcers or blood clots. It  is important to see a vein specialist to determine if you are suffering from a DVT or venous insufficiency. Have a safe, happy and healthy holiday season!

Center for Vein Restoration cordially invites you to a CME Event: Chronic Venous Insufficiency
3.0 Category One CME Credits

It’s a problem affecting 10-20 percent of all adults, including patients in your practice: chronic venous insufficiency, the often undiagnosed medical condition behind varicose veins and spider veins (telangliectasia). Venous insufficiency affects a broad range of people. Common causes include heredity, age, sex, weight, history of DVT, pregnancy, inactivity and prolonged sitting or standing. Certain groups, such as expectant moms, have extra difficulty – studies show that varicose veins get worse with each subsequent pregnancy.

In this informative and relevant 3-hour session, our physician presenters will describe causes, symptoms, diagnosis and treatment of venous insufficiency. Participants will learn about the staging/classification of venous insufficiency, how duplex ultrasonography is used to evaluate patients and how modern, outpatient treatments including radiofrequency and laser ablation, and foam and cosmetic sclerotherapy can make addressing varicose and spider veins quick and relatively painless so your patients can return to normal activity with short recovery times.

Thursday, March 15, 2012

Bravo Restaurant & Café
5402 Portage Road
Kalamazoo, MI 49002

Reception & Registration: 6:30 p.m.
Dinner & Presentation: 7:00 p.m.

RSVP by Thursday, March 8
To Kristin Rekucki, Physician Liaison at (269) 512-5036 or
kristin.rekucki@centerforvein.com

http://www.facebook.com/events/190907691013151/

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Thursday, March 22, 2012

Imperial Hotel
208 High St
Chestertown, MD 21620

Reception & Registration: 6:30 p.m.
Dinner & Presentation: 7:00 p.m.
RSVP by Wednesday, March 14

To Kristin Rekucki, Physician Liaison at (269) 512-5036 or
kristin.rekucki@centerforvein.com

http://www.facebook.com/events/281224851950072/

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Wednesday, March 28, 2012

Sir Walter Raleigh Inn
6323 Greenbelt Road
Berwyn Heights, MD 20740

Reception & Registration: 6:30 p.m.
Dinner & Presentation: 7:00 p.m.
RSVP by Tuesday, March 20

To Bob Howell, Physician Liaison at (301) 908-7142 or
bob.howell@centerforvein.com

http://www.facebook.com/events/194272844010852/

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This questionnaire is a helpful tool to assess whether you have chronic venous insufficiency (CVI), also known as venous reflux disease. This disease is one of the most undertreated and under diagnosed diseases in the United States with more 24 million Americans affected. Many of these individuals are unaware of the specific cause of their pain, swelling or tired legs. This questionnaire is the first step to assessing whether you may be suffering from this treatable condition.

• Does anyone in your family have a history of varicose veins, leg ulcers or swollen legs?
• Do you experience any of the following in your legs:

1. Aching/Pain
2. Heaviness
3. Tiredness/Fatigue
4. Itching/Burning
5. Swollen Ankles
6. Leg Cramps
7. Restless Legs
8. Throbbing

• Do you experience these problems in one or both legs?
• Do you have any ulcers or skin color changes on your legs or ankle area?
• Do you have pain or swelling in your legs at the end of day or after periods of standing?

If you have answered “yes” to one or more of the leg health questions you may be one of the millions of Americans whom suffer from chronic venous insufficiency. This condition is characterized by insufficient circulation of the blood by your veins in your legs. Typically valves in your legs, which should open and close just like the valves in your heart, are not closing properly. This is what leads to many of the symptoms mentioned in the questionnaire.

The good news is that this condition is easily treated once it is properly diagnosed. It is important to see a specialist in this area for the correct diagnosis. A specialist can determine whether you are suffering from a life threatening blood clot or “DVT” or simply CVI. Many people with these symptoms have been checked for a blood clot and their results have been negative. However in most, they have never been checked for CVI and as a result their symptoms have persisted and progressed over the years. For some this progression has led to devastating leg ulcers.

Once a specialist has properly diagnosed you with chronic venous insufficiency, new technology exists to treat this condition with an in office procedure that is covered by most insurance companies. This new technology has led to a new laser and radio frequency approach that can be performed in less than one hour and have you back on your feet and back to your activity and/or work on the same day.  CVI can be treated, but like many conditions, proper and early diagnosis is the best medicine.

Leg swelling, or edema, as it is called in the medical profession is a common condition that plagues many of our community members. Edema can afflict both men and woman and adults of all ages. Edema can be caused by many different factors so it is crucial to work with your primary care doctor and the right specialist to alleviate your issue. Once identified and treated your quality of life can be greatly improved.

Edema is swelling of both legs from a buildup of extra fluid. Edema has many possible causes:

1. Prolonged standing or sitting, especially in hot weather, can cause excess fluid to accumulate in the feet, ankles and lower legs.
2.  Tiny valves inside the veins of the legs can become weakened, causing a common problem called venous insufficiency. This problem makes it more difficult for the veins to pump blood back to the heart, and leads to varicose veins and buildup of fluid.
3. Severe chronic (long-term) lung diseases, including emphysema and chronic bronchitis, increase pressure in the blood vessels that lead from the heart to the lungs. This pressure backs up in the heart. The higher pressure causes swelling in the legs and feet.
4. Congestive heart failure, a condition in which the heart can no longer pump efficiently, causes fluid buildup in the lungs and other parts of the body. Swelling is often most visible in the feet and ankles.
5. Pregnancy can cause edema in the legs as the uterus puts pressure on the vena cava. Fluid retention during pregnancy also can be caused by a more serious condition called preeclampsia.
6. Low protein levels in the blood caused by malnutrition, kidney and liver disease can cause edema. The proteins help to hold salt and water inside the blood vessels so fluid does not leak out into the tissues. If a blood protein, called albumin, gets too low, fluid is retained and edema occurs, especially in the feet, ankles and lower legs.

Symptoms vary according to the type of edema and its location. In general, the skin above the swollen area will be stretched and shiny. You should see a doctor to determine the cause of leg swelling. If both legs are swollen, your doctor will ask about other symptoms and will examine you. A urine test will show if you are losing protein from the kidneys. Blood tests, a chest x-ray and an electrocardiogram (EKG) also may be done.  Arterial or venous ultrasound tests may be done to look for blockages in your leg arteries or bad valves in your leg veins.

Treatment of edema focuses on correcting the cause of the fluid accumulation. A low-salt diet usually helps. You also should avoid drinking too much fluid. If you are not short of breath, elevate your legs above the level of your heart to keep swelling down. Your doctor might suggest that you take a low dose of a diuretic (water pill).

For swollen ankles and feet caused by pregnancy, elevate your legs and avoid lying on your back to help improve blood flow and decrease swelling.

If you have leg edema caused by venous insufficiency, elevate your legs periodically and wear support (compression) stockings. However, to permanently fix this issue a simple in office medical procedure (called endovenous ablation) covered by most insurance plans is needed to improve the flow of blood through the leg veins.

No matter what the cause of edema, any swollen area of the body should be protected from pressure, injury and extreme temperatures. The skin over swollen legs becomes more fragile over time. Cuts, scrapes and burns in areas that have edema take much longer to heal and are more likely to get infected.

The outlook for edema of the legs depends on the cause. For most people with edema, the prognosis is excellent as long as you don’t ignore the problem and talk to your doctor.

James's Testimonial - Baltimore, Maryland

Fortunately, treatment no longer means a hospital stay or a long, uncomfortable recovery. Minimally invasive techniques allow varicose veins or its cause venous insufficiency to be dealt with by a specialist in a physician’s office with minimal discomfort and within one hour.
Self-help measures such as exercising, losing weight, using compression stockings and avoiding long periods of standing or sitting – can ease pain and prevent varicose veins from getting worse. Varicose veins that develop during pregnancy may improve without medical treatment within three months after delivery.
If you don’t respond to self-help or if you are one of the 60 million Americans whose condition is more severe, your doctor may advise one of these varicose vein treatments:
• Sclerotherapy. In this procedure, your doctor injects small and medium sized varicose veins with a solution that closes those veins. In a few weeks, treated varicose veins should fade. Although the same vein may need to be injected more than once, sclerotherapy is effective if done correctly. Sclerotherapy doesn’t require anesthesia and can be done in your doctor’s office.
• Skin Laser procedures. Doctors are using new technology in laser treatments to close off smaller varicose veins and spider veins. Laser works by sending strong bursts of light onto the vein, which makes the vein slowly fade and disappear. No incisions or needles are used.
• Catheter-assisted procedures. In one of these treatments, your doctor inserts a thin tube (catheter) into an enlarged vein and heats the tip of the catheter. As the catheter is pulled out, the heat (laser or radio-frequency) destroys the vein by causing it to collapse and seal shut. This procedure is usually done for larger varicose veins.
• Vein stripping. Because of the advent of more sophisticated technologies, this procedure is rarely performed anymore.
• Ambulatory phlebectomy (flush-BEK-to-me). Your doctor removes smaller varicose veins through a series of tiny skin punctures. Local anesthesia is used in this outpatient procedure. Scarring is minimal.
Be a cautious consumer
When it comes to treatment options for varicose veins, it pays to be a cautious health consumer. Advertisements claiming “unique,” “permanent,” or “painless” methods to remove varicose veins may be appealing, but they may not actually measure up to those claims. Before undergoing any procedure, ask your doctor about any health risks and possible side effects.
Varicose veins are a presentation of underlying venous insufficiency. Treatment of venous insufficiency is covered by almost all insurance plans.  The medical community realizes that the treatment of venous insufficiency is not a luxury but a necessity.
Symptoms associated with venous insufficiency such as achiness of the legs, easy fatigability etc. can be quite frustrating. Current treatments for varicose veins and spider veins are highly successful, so it is possible to love your legs again.
However it is important to realize that venous insufficiency is a “chronic” condition in which post procedure follow-up is mandatory for optimal long-term results.

Sklerosis: from the Greek, a hardening or induration of a tissue or part.

Therapeia: from the Greek, treatment of disease or disorder as by some remedial or restorative process

Sclerotherapy is a somewhat broad-based term to describe the medical technique of introducing medication into a vein for the purpose of shutting down and eliminating it. Typically this is done to alleviate concomitant symptoms, such as pain, heaviness, aching, cramps, itching or burning, or alternately purely for cosmetic purposes. Sometimes referred to as injection sclerotherapy or compression sclerotherapy, this technique was originally developed for the treatment of varicose veins but later evolved into the treatment of choice for “spider veins ” or telangiectasia. More recently the value of this technique in the treatment of the larger varicose veins has been recognized anew.

While varicose veins have almost certainly existed since man initially stood up, the first historical documentation thereof dates to the writings on papyrus scrolls by the ancient physician Ebers in the year 1550 BC. Since that time several major discoveries or inventions have led to the many refinements that bring us to the present day techniques.

Certainly, sclerotherapy has at times been used as an alternative to surgery which was initially very primitive and later simply not as effective as one would have hoped. Presently, sclerotherapy and surgery coexist as complimentary modes of treating the total vein problem.

The first documented treatment of venous disease was found in the historical annals around 400 BC in the form of offerings to the gods as supplication seeking relief. Hippocrates, around 460 BC, wrote of introducing “a slender instrument of iron” through multiple punctures into the veins to induce thrombosis. This concept of inserting a foreign substance into the vein was most likely the precursor to sclerotherapy itself.

Great things evolved from these unlikely beginnings. Events that changed the procedure dramatically include the first injection of distilled plantain water via an enema syringe into a branch of the crural vein by Sigismund Eisholtz in the mid-1600′s.

The introduction of a lachrymal syringe by Anel in 1713 led to the development of the hypodermic syringe by Rynd in 1845 and its subsequent modification by Pravaz. At this point experimentation with many varied types of medication resulted, including absolute alcohol (1840), ferric chloride (1851), iodine (1906), mercury (1920), sodium morrhuate (1930), sodium tetradecyl sulfate (1946), polidocanol (1966).

Compression therapy was recognized early on as an important adjunct starting first with Hippocrates, then the use of leather straps by Roman soldiers, plaster bandages and ultimately the mechanically-engineered graduated-pressure compression stockings of today.

The 1970′s saw the refinement of ultrasound as a medical tool that gave rise to applications in the treatment of venous disease. The use of duplex ultrasound in conjunction with the development of thick foam-like medications (some now the consistency of toothpaste) allowed the skilled physician to place by injection, with great precision, measured doses of sclerosant medications directly into the incompetent or refluxing vein.

Sclerotherapy has, in many ways, evolved enormously yet in other ways has changed little. Today it is unquestionably the treatment of choice for “spider veins” in the legs. It is also used to treat veins in the face, arms, back, breasts and other areas. And recently, the use of ultrasound and foam has opened up fantastic possibilities in the treatment of varicose veins, perforator veins and in some cases even the great saphenous vein.

Venous insufficiency most commonly presents as recurrent aching and unreasonable tiredness of the legs. This disease entity may also present with leg swelling. All too often these symptoms develop surreptitiously over years, so most patients may just take their presence as an integral part of aging. Commonly women and men first notice only the cosmetic presentations of venous insufficiency (spider veins or even large ropey worm like veins know as varicose veins).

Varicose veins are a medical condition that affects 55-65% of women and 25-30% of men in the United States.

Varicose veins and spider veins are caused when the valves of the veins are weakened. Veins, which work against gravity as they carry blood back to the heart, contain one-way valves to prevent the blood from flowing backwards. When the valves weaken, blood collects in the vein. Pooled blood enlarges the vein. This increased pressure in the venous system leads initially to spider veins and subsequently varicose veins. The plasma from this blood pooling exudes out of the veins into the surrounding tissues making the skin look hyper pigmented (darker), ultimately leading to the formation of painful non-healing ulcers.

Early treatment is crucial to prevent the further progression and complications. Hence giving credence to the fact that the treatment of venous insufficiency (varicose and spider veins) is a necessity and not a luxury. Most insurance companies recognize this necessity and now include the treatment of large varicose veins and venous insufficiency as a covered benefit.

Varicose veins are now treated with a minimally invasive in office procedure. It takes about an hour of the patient’s time, and in most cases the patient can go back to work (if they so desire) the same day. This procedure can be performed using either radiofrequency ablation or the laser ablation of diseased varicose veins.  This procedure is a welcome change from the painful vein stripping procedure which would need to be done in the hospital and would require weeks of recovery.

It is possible to love your legs again but one must take action to make this a reality. If you suffer from leg pain, swelling or varicose veins talk to your primary care doctor for a referral to a vein specialist for the proper treatment.