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Melanie Cole: Welcome to the show. Our topic today is minimally invasive treatments for venous disease and my guest is Dr. Marc Passman. He's a vascular surgeon, professional of surgery and the director of the UAB Vein program. Explain a little bit about venous disease. Who is at risk and tell us about the different types of venous insufficiency that we’ll be talking about today.

Marc Passman, MD: There are generally two categories of venous disease problems. There's the blockage or thrombotic category and then there are the venous flow issues. The blockage or thrombotic category generally involved venous thromboembolism, deep vein thrombosis and the risk for pulmonary embolism. In general, the risk profile of those patients includes individual risk factors such as age greater than 70, personal history of clotting issues, family history of clotting issues and then other associations like smoking and obesity, which can be amplified in high risk situations, period of immobility, injury, server illness and even travel. The other group of venous problems tends to fall into the category of venous insufficiency or venous reflux, essentially venous flow problems. These can range anywhere from common spider veins and varicose veins all the way up to complex venous skin changes and venous stasis ulcerations to other severe venous flow related congestion type problems. The general risk factors for venous flow issues can include patients who've had prior deep vein thrombosis where there's damage to the vein valves or it can be a primary problem where there is essentially wear and tear on the venous valves that lead to leakages and the ambulatory venous hypertension issues that can result.

Melanie: As far as clinical presentation, of course with superficial venous reflux or varicose veins and spider veins, sometimes you can see those, but with deep vein thrombosis, not necessarily. Tell us about some of the signs and symptoms that someone might have.

Dr. Passman: For deep vein thrombosis, the patient presents with unilateral leg pain or swelling. It should always be a concern for deep vein thrombosis until proven otherwise because certainly for acute deep vein thrombosis, that patient is at risk for pulmonary embolism until they're effectively anticoagulated. If you look at all patients who present with deep vein thrombosis, about 25% of those patients will have pain and/or swelling, but there can certainly be other subtle presentation type symptoms. For patients who have really severe vein thrombotic occlusion, they’ll present with the typical Phlegmasia type leg where there are a significant venous congestion and purple discoloration. What that gets at its most extreme, it can start compromising arterial end flow and perfusion to the extremities. Those that present with acute deep vein thrombosis, it’s usually a sudden onset of that type of presentation.

On the other hand, those that have had deep vein thrombosis in the past, it's very common to have post-thrombotic syndrome. It may be several weeks or months or years after their deep vein thrombosis acute episode, but they still have ongoing swelling and general congestion in the leg. With that, over time, they can start developing hyperpigmentation around the ankles, venous eczema, skin changes at the ankle that make the skin really fragile and eventually lead to venous ulceration. That’s more on the venous thrombotic side. For patients who have varicose veins and never had deep vein thrombosis before, they can have the spider veins and varicose veins which you can see. They’ll have complaints that can range from pain discomfort, throbbing in the leg, limb dependent swelling, having this itching and things like that. When you examine the leg, it’s hard to know if the spider veins or varicose veins are just the tip of the iceberg or is reflective of a bigger flow issue in the leg. That's where additional testing including venous ultrasound can better differentiate the flow pattern and whether or not there's more involvement of the bigger vein. Those with varicose veins and spider veins, about 4-6% will progress over time to the more advanced venous findings similar to those that have post-thrombotic syndrome where you can develop skin changes and eventually the ulcerations.

Although there are two different categories and two different pathways, the common pathway for both venous thrombotic issues and venous insufficiency issues is what's termed ambulatory venous hypertension. Effectively, the hypertension in the venous system, the congestion that you get, can lead to all those advance findings whether it starts as a deep vein thrombosis or a primary valve reflux issue.

Melanie: Once you’ve differentiated what the flow issue is, how has it been treated in the past? What's different now and are there some exogenous methods that you would recommend as a first line of defense before you would discuss a minimally invasive option?

Dr. Passman: Let's expand first on how you can differentiate the venous disease with diagnostic testing because that will help dictate the appropriate therapy. The cornerstone of any venous evaluation from an imaging standpoint is venous duplex ultrasound. There are different types of venous ultrasound testing that's available. The most common type is just to look for deep vein thrombosis as part of an evaluation for a clot and that’s usually to screen the veins in the presence or absence of a clot. That’s usually the routine ultrasound, but the more extended, comprehensive ultrasound also will test the venous valve function in what's called venous valve closure time. A refluxing vein valve will have backward flow and anything greater than a second or so of backward flow in the deep vein is usually consistent with venous reflux as opposed to a venous valve that will close crisply and such and that would be a normal valve. Typically, if it’s a venous thrombotic problem, we’re just looking for DVT with a venous ulcer, but if it’s a venous flow issue, we’re actually mapping where the venous valve dysfunction occurs, which veins they occur in, because that will help dictate what that patient needs. In addition to venous ultrasound testing, there are some patients who need some advanced imaging and that can include CT venography, MR venography, diagnostic contrast venography and intravascular ultrasound. There may be specific instances where we will do more extended imaging along those lines. Depending on what the imaging shows and what the actual problem is, we’ll come up with a treatment plan for that particular patient.

For patients who have deep vein thrombosis, the standard evidence-based guideline is that all those patients should be on some form of anticoagulation. Those guidelines are very well published, American College of Physicians provides information and evidence-based ratings for those recommendations. In addition, patients who have deep vein thrombosis traditionally are also treated with compression therapy. Once they're on the anticoagulation, that will help with a lot of symptoms and swelling and post-thrombotic tendencies that they can develop later on. Aside from that, there are some minimally invasive treatments for deep vein thrombosis that are also supported by evidence-based guidelines that use catheter technology to move the clot. Whether that's with catheter-directed thrombolysis or various aspiration type catheters we have or combinations of that, for patients who have a clot that’s less than a few weeks old, may have significant compromise extending up into their iliac femoral vein. Those that have a reasonable life expectancy greater than a year, those patients that have good functional capacity, those patients may be candidates for those advanced minimally invasive catheter clot removal options and should be evaluated at a center that can provide those services.

For patients who have chronic clots and significant post-thrombotic issues, there may still be some options later on for recanalizing those chronically occluded vein segments with catheters using balloons and stents to try and reopen those veins, so there may be some roles even for chronic clot issues later on where they might be some benefit of treatment. That's different than the traditional treatments for clots which operatively involve venous thrombectomy or surgically removing those clots. That's an operation we still do occasionally, but with all these advanced catheter-based therapies, we don't need to do those as often, nor do we have to do the complex venous reconstructions that we used to do a lot more of. Still, there may be candidates where you just can't open them with a catheter that you might need to consider those open traditional operative options. For varicose vein problems and venous reflux problems, the traditional operations used to be venous stripping where you make a couple of incisions in the legs and strip out the long saphenous veins in the leg, phlebectomy where you make incisions and avulse or remove the varicose veins directly. That used to be the traditional approach. What's really happened and evolved in the last 10-15 years, instead of making incisions, now the minimally invasive options include things like endogenous ablation where you can use a laser catheter or a radiofrequency catheter to close down the saphenous vein instead of stripping it. There are some newer technologies that also include using glue or foam sclerotherapy to glue those vessels. The techniques we use for the actual varicose veins now use much smaller incisions, gentle hook techniques. We also have scoping systems that allow us to make tiny incisions and use scopes to image all the veins and directly see the veins.

What we used to do with many more incisions and larger incisions, we can do with much smaller incisions these days and fewer incisions. That’s where the evolution from the traditional approach is both for clot and venous flow varicose vein problems have evolved to minimally invasive techniques.

Melanie: It’s such an interesting field that you're in. In summary, tell other physicians what you'd like them to know about minimally invasive treatments for venous disease and when you feel it’s really important that they refer to a specialist such as yourself.

Dr. Passman: The thing with venous problems, especially when it gets into patients who present to their physicians with all kinds of complaints, is sometimes they can be underappreciated by the patients, sometimes by the physicians, because there are so many other medical issues to take care of. A lot of times, the venous symptoms they have will develop over a long period of time and people are just too busy to worry about it. It’s not until it gets to a critical point where they start seeking medical attention and assistance. The reality of many of the venous problems, especially the varicose veins and venous flow issues, is that certainly from a quality of life standpoint, it can help impact patients with earlier evaluation. Those that are appropriate for treatment, early interventions can not only help their current quality of life but may change their natural history and progression over time. For venous clot issues, the most important part of that is awareness for patients that know the risk factors to know when they might be in a high-risk situation. For physicians to recognize patients that might be at risk and to do a venous risk assessment for a clot, because when they're exposed to those high-risk situations, they may not know they have high-risk individual factors, and whether they're in the hospital or undergoing a big operation or severely ill, the biggest advantage of prevention is that you can prevent all the sequelae of clots. Early identification using therapeutic anticoagulation or prophylactic anticoagulation as a prevention strategy for patients who are at risk, especially in the hospital, can have a significant impact on their future venous potentials.

Melanie: Thank you so much for being with us today and sharing your expertise on this topic. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. You're listening to UAB Medcast. For more information on resources available at UAB Medicine, you can go to uabmedicine.org/physician. That’s uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening.