New Modes Of Treatment Save Pain, Legs And Lives
Leg veins are incredible, gravity-defying structures. With every step, as the calf contracts, these hard-working vascular conduits return blood from the lower body to the heart.
When they fail, as the great saphenous vein too often tends to do when time and heredity take their toll, the result can be pain, swelling and ulcers that resist healing and can leave patients having to choose between their leg and their life.
For almost a hundred years, from 1904 to 1999, the standard treatment of stripping veins could be quite painful and leave patients unable to return to work for up to four weeks. New procedures can have them walking out to their car the same day.
Though diabetics are at greater risk of developing foot and leg ulcers, venous insufficiency is a problem eventually experienced by a much broader segment of the population.
“Heredity is one of the strongest influences,” James Isobe, MD, of the Baptist Vein Center in Hoover, said. “If one parent has the problem, you are at greater risk. If both parents have a history, the odds increase significantly. Obesity, pregnancy and anything that increases abdominal pressure can have an effect. Each pregnancy adds to the risk. Relaxin, the hormone that softens the pelvis, also affects the veins. The veins should return to normal after pregnancy, but sometimes that doesn’t happen.”
Too much standing or sitting, as well as the effects of aging, can also play a role. According to Isobe, if we live long enough, eventually about 80 percent of us will experience at least some degree of venous insufficiency. What are the signs that problems are developing?
“Some will present with ulcers, but leg pain and swelling are likely to be earlier signals that a patient’s circulation should be evaluated,” Isobe said. “In diagnosing the cause of the symptoms, we get a lot of crossover. It’s important to determine exactly what is going on to choose the right course of treatment. For example, compression can be helpful in some cases and harmful in others.
“Venous ulcers tend to occur on the inside of the leg, just above the ankle. Arterial ulcers are usually lateral and distal. In diabetics, you have to watch the pressure areas of the feet. The architecture of the foot tends to change, and the nerves that regulate moisture become weaker. Where there is pressure and dryness, a callous may develop that a diabetic may not notice until it becomes a sore. Wherever there’s neuropathy, a wound may be overlooked. Diabetics can have multiple types of problems happening at the same time.”
A careful exam provides clues to confirm the diagnosis and suggest which approaches to treatment are likely to be successful.
“The patient’s blood pressure in the arm and the leg should be the same. When the pressure is lower in the leg, it suggests a circulation problem. We do an ultrasound on the veins to look for leakage and we check for clots in the deep vein system. The ultrasound color is red and blue. When the calf squeezes, then releases, if there’s insufficiency, you see the color reverse where the blood flows back.”
Venous ulcers account for more than 70 percent of leg ulcer cases. When leaflets in the vein fail and allow blood to accumulate, problems ranging from aching legs to varicose veins to leg ulcers can occur. Exactly why the effects on surrounding tissue are so destructive isn’t completely understood. There is some thought that proteins leaking into surrounding tissue cause damage or that molecules that would normally assist healing are blocked. A buildup of white cells could be triggering inflammation.
What is known, however, is that a venous ulcer left untreated can develop cellulitis or even gangrene, which can mean the loss of a foot or leg. If the venous insufficiency isn’t addressed, ulcers tend to recur.
Fortunately, in recent years, new modes of treatment offer a simpler way to correct venous problems that typically arise along the great saphenous vein.
“Now we can do endovenous ablation using heat sources such as lasers that target hemoglobin. Another device uses heated water vapor which seems to minimize discomfort. Radio frequency ablation is a third option,” Isobe said
“It’s an outpatient procedure guided by ultrasound. We begin with local anesthesia and then use a heat probe that we place just below the sapheno-femoral junction. Since the saphenous vein is superficial, the leg can do quite well without it, so we eliminate the source of the problem” Isobe said. “If there are varicosities, we can encircle them with a small hook to remove them.
“Then we can clear up spider veins with sclerotherapy. In the past we used a 28 percent saline solution. Now we have a better solution that is more comfortable to use and we can inject it with a small needle.
“Around 90 percent of patients are awake and talking through the procedure, though we sedate a few,” Isobe said. “We apply a dressing, and patients are able to walk out the door the same day.”
