Southwest Florida's Health and Wellness Magazine Health and Wellness Articles
Attention anyone who has had a previous vein stripping, vein ablation or varicose vein removal, and has not received the desired results. This article is also addressed to those of you who have been suffering with swollen legs for months to years without a definitive diagnosis. There may have been trauma to the extremity or perhaps a joint replacement and you have been plagued with a swollen leg since then without a definitive diagnosis. Perhaps you have been to the emergency room for an ultrasound which was considered “normal”, meaning that there was no blood clot identified. Perhaps you have had more than one “normal” ultrasound in the past 6 months and still are bothered by the thigh and leg swelling. I am writing this article for the group of patients out there who have been watching their lower leg skin discoloration progress over the last few years, and have been frustrated by the repeated suggestion “not to worry about it and just wear compression hose” without being given any diagnosis. Some of you may have waited patiently for an answer, only to progress to the point of further skin thickening or eventual ulceration. You may have been languishing in a wound care center, returning for weekly wraps or hyperbaric oxygen therapy sessions, without noticing any significant improvement in the appearance of your leg wound. It is for all of you I have written this article, with the sincere hope that this information will educate and benefit you by giving you the knowledge, hope and direction to seek appropriate attention and be further evaluated for treatable venous disease.
First, let me go back in time 17 years. The year was 2000. I was practicing as an arterial vascular surgeon, in my 14th year out of my fellowship. The bulk of my practice focused on arterial disease, fixing abdominal aneurysms, cleaning out carotid arteries and saving legs from amputations. Vein treatments were very rare, primarily because the only treatment we had at the time was a somewhat barbaric procedure known as the VEIN STRIPPING procedure. Thankfully, the endovenous closure procedure was introduced in 2000 and was a vast improvement over vein stripping. As is the case with new technology, endovenous closure was initially met with a tepid response by most vascular surgeons. However, I adopted it into our practice and soon realized there were many patients with significant venous disease who had been largely ignored or expectantly observed, as I liked to say, because we previously lacked a reliable, scientifically directed, minimally invasive and well tolerated procedure to treat their abnormal veins. The introduction of endovenous ablation techniques resulted in a significant paradigm shift in our treatment approach for the care of patients with vein disease including not just those with varicose veins, but also patients with swollen achy legs, stasis dermatitis, venous ulceration and other less common presentations. I left my position as an established vascular surgeon in Georgia in 2006 to move to Southwest Florida to open Vein Specialists and dedicate 100% of my attention to the modern evaluation and treatment of patients with venous insufficiency. Since then, I have continued to expand my knowledge and experience in the care of patients with venous disease. Through caring for thousands of patients over the last 11 years, I have developed an approach to help us in the decision making of which patients are most likely to benefit from our interventional efforts. Fortunately, most of the patients we see in our practice have superficial vein disease, that is, weakness or leakiness in the valves of the veins from the groin crease inferiorly. This group of patients often has very good clinical outcomes from the procedures we have offered. Radiofrequency and laser thermal endovenous ablation have served them well as has the newer chemical adhesive methods of sealing veins (VenaSeal).
Unfortunately, 10-15% of our patients may not realize as much relief from their signs or symptoms of venous insufficiency as either they or we would have hoped for or expected. Additionally, 10% of our new patients may have had previous vein procedures such as vein stripping or endovenous vein closures when they present to our practice for second opinion. Ultrasound evaluation of these patients often reveals only short segments of leaking veins which are not significant enough to account for their persistent or recurrent vein related symptoms or clinical signs. A potential cause of recurrent vein problems after previous procedures which has received much attention in the vein specialty world is iliac vein compression syndrome (IVCS). IVCS may occur as the result of arterial compression of one of the main outflow (iliac) veins, leading to increased pelvic and lower extremity venous pressure. This increased pressure can lead to failure of previous vein treatments such as vein stripping or the more current endovenous ablation techniques. Since the iliac veins are deep in the pelvis, they are not easily examined with traditional techniques such as transcutaneous pelvic ultrasound, CT scan or Magnetic Resonance Imaging. However, intravascular ultrasound (IVUS), a minimally invasive, catheter based ultrasound technique, allows direct examination of the more proximal pelvic veins from within the actual blood vessels. Precise identification of the presence, location and severity of iliac vein compression is possible with the use of IVUS as a diagnostic test. IVUS is an outpatient procedure performed under local anesthesia, through a small IV inserted under ultrasound guidance. Based on the results of the IVUS, individualized plans of therapy can be established based on the severity of narrowing, and if appropriate, stenting of the compressed segments may be performed at a later date to restore normal pelvic venous outflow and return of blood from the legs. This is analogous to removing the barriers to a closed interstate and restoring 4 lanes of traffic. Although placing stents in arteries has been performed for 30 years or more, and IVUS has been used in clinical practice on arteries for the last 10 years, the application of these two technologies, in concert, to evaluate and treat iliac vein compression syndrome and pelvic vein congestion is the most recent and important advance in the field of phlebology. IVUS has changed our approach for treating our patients with either first time or recurrent venous insufficiency whose lower extremity venous insufficiency ultrasounds may not match their clinical severity. It is this group of patients who are most likely to benefit from further assessment with intravascular ultrasound and be possible candidates for iliac vein stent placement.
So for those of you I called attention to in the introduction, there may be hope for you yet! Although vein problems may fall into one of three broad categories: venous insufficiency (VI), deep vein thrombosis (DVT) and iliac vein compression syndrome (IVCS), we have been focused on the first 2 categories for many years and have just begun including IVCS and IVUS in our vein assessments and diagnostic evaluations. I have been encouraged with the results of IVUS and the accuracy of the information it has provided and predict that many patients who have not had the desired results from previous vein therapy will be helped as a result of this new application of IVUS and intravascular stent placement. If this article has resonated with how you have been feeling please consider further evaluation for possible iliac vein compression syndrome and see if you may be a candidate for IVUS.
Leaders in Vein Treatment
Joseph G. Magnant, MD, FACS, RPVI and Patrick A. Nero, MD, FACS are both fellows of the American College of Surgeons and are board certified by the American Board of Surgery.
Dr. Magnant earned his medical degree from Medical College of Virginia. He completed a general surgery residency at Medical College of Virginia Hospitals and a fellowship in vascular surgery at Dartmouth Hitchcock Medical Center, Lebanon, NH. Dr. Magnant of Vein Specialists focuses exclusively on vein evaluation and modern treatments in a dedicated, outpatient, vein-centered facility. Dr. Magnant is an active member of the American College of Phlebology, Society for Vascular Surgery and Society of Vascular Ultrasound.
Dr. Nero earned his Bachelor of Science degree in Pre-Medicine from the University of Dayton in Ohio and his medical degree summa cum laude from The Ohio State University College of Medicine. He completed a residency in general surgery through the Phoenix Integrated Surgical Residency program. Dr. Nero is a diplomate of the American Board of Surgery and a member of the American College of Phlebology and the Society for Vascular US. He joined Dr. Magnant and staff at Vein Specialists earlier in 2016.
They can be contact either by calling 239-694-8346 or through the website, www.weknowveins.com, where patients can submit their request for an appointment.
1510 Royal Palm Square Blvd., Suite 101, Fort Myers, Florida | 3359 Woods Edge Circle, Suite 102, Bonita Springs, Florida
