From diagnosis to treatment of leg veins, avoiding pitfalls requires attention to detail, according to an expert.
New York - From diagnosis to treatment of leg veins, avoiding pitfalls requires attention to detail, according to an expert.
For starters, says Todd V. Cartee, M.D., “History and physical are critical when evaluating any of your patients with leg vein disease.” He is assistant professor of dermatology at Penn State Hershey Medical Center, Hershey, Pa.
Commonly, he says, patients present seeking cosmetic treatment of spider veins. In such cases, Dr. Cartee says it’s critical to establish whether their problem is purely cosmetic or deeper. In this regard, “You can be fooled and wind up treating the symptom of a much more significant disease.”
To help determine which patients require referrals for vascular studies, Dr. Cartee offers the BEDPANS mnemonic: look for Bulging varicosities, Edema/stasis dermatitis, DVT (history of), Prior sclerotherapy (unsuccessful), Ankle telangiectasias, Nature (family history) and Symptoms.
“Spider veins localized around the medial ankle are a reliable indicator of great saphenous reflux,” he says. Similarly, if everyone in a 35-year-old patient’s family has varicose veins after age 60, “She’s probably on that trajectory; the spider veins are just the beginning.”
Such patients often already have some underlying saphenous vein leakage, he says. “If you don’t address that and just go after the spider veins, patients are unlikely to get a durable response.”
For spider veins and reticular veins of the leg, Dr. Cartee says, visual sclerotherapy represents the gold standard - but only for patients who have no underlying saphenous vein insufficiency (failure of valves within the vein that allows retrograde blood flow away from the heart). Correct technique includes treating feeding reticular veins before spider veins, he says. Agents approved by the Food and Drug Administration for this indication include sodium tetradecyl sulfate and polidocanol.
“Both are very effective and can be used as foams, which offer additional advantages for treating larger vessels,” although the foam technique is an off-label use, Dr. Cartee says.
Because foamed sclerosants do not mix with blood, they push blood out of the way, increasing the time that the sclerosant is in contact with the endothelium, according to Dr. Cartee. This effectively doubles their sclerosing power compared to the liquid form; however, he says, foam may be too potent for fine telangiectasias, causing transparietal burns, extravasation of blood, and untoward side effects.
Foam sclerotherapy, while in general very safe, has been associated with rare adverse neurologic events. A recent comprehensive review showed that foam sclerotherapy can produce temporary visual disturbances in 0.9 to two percent of patients (Willenberg T, Smith PC, Shepherd A, Davies AH. Phlebology. 2013;28(3):123-131). Experts previously blamed gas emboli for this side effect, Dr. Cartee says, but this review noted an additional, more satisfying explanation: systemic spread of locally induced vasoactive mediators, especially endothelin, which can trigger a migraine with aura in susceptible patients. No patients in the review experienced any lasting visual or neurologic effects.
For patients with underlying saphenous vein insufficiency, he says, dermatologists can refer them to a phlebologist or, with proper training, treat this problem themselves. Dr. Cartee performs endovenous laser ablation, which seals up faulty veins from the inside and forces the body to reroute blood to healthy veins.
In this regard, he says that various lasers operating between 810 and 1,470 nm all have proven effective.
“Emerging evidence suggests that the water-selective lasers with wavelengths of 1,320 to 1,470 nm may produce less postoperative pain and quicker recovery,” Dr. Cartee says.
Other effective techniques include radiofrequency ablation and ultrasound guided foam sclerotherapy.
“Recently, a foam sclerotherapy product became the first such agent to garner approval by the Food and Drug Administration. Varithena (injectable polidocanol foam, BTG) is now approved for the treatment of great saphenous incompetence and associated varicose veins,” he says.
In phase 3 clinical trials, Varithena produced an ultrasound-confirmed closure rate of 88 percent, and a 64 percent reduction in symptoms (Todd KL 3rd, Wright D; for the VANISH-2 Investigator Group. Phlebology. 2013 Jul 17. [Epub ahead of print]).
“Presently, we have no data on long-term outcomes. But it appears to be effective in early results,” Dr. Cartee says. “It offers the advantages of lower cost and near-painless administration, potentially without even using full sterile technique. This could make it faster and more user-friendly than the endovenous technologies currently used.”
Overall, Dr. Cartee says he looks forward to the arrival of new technologies, “But the techniques we have now are wonderful.” They have supplanted surgical vein stripping, he says, largely because they are one-hour ambulatory procedures that are easier on patients.
In all patients with symptomatic venous insufficiency, Dr. Cartee says, “We recommend graduated compression stockings.” Donning two pairs of light (15 mm HG to 20 mm Hg) compression stockings doubles the compression, he notes, which can be a useful trick to achieve therapeutic compression levels (30 mm Hg to 40 mm Hg) in elderly patients.
Dr. Cartee says, however, that patients should avoid thromboembolic deterrent (TED) stockings, which they may have on hand from a prior surgery. These stockings are designed to prevent embolisms - in patients on operating tables and hospital beds. “In ambulatory patients, they can make vein disease worse. It’s one of the most common mistakes I see from primary care physicians.”
Disclosures: Dr. Cartee reports no relevant financial interests.