Cosmetic and Medical Approaches to the Patient with Leg Varicosities SERENA MRAZ, MD, FAAD, FACP

DERMATOLOGIST AND PHLEBOLOGIST

SOLANO DERMATOLOGY ASSOCIATES

Disclosures

u   None related to topic

u   Phlebology practice at Solano Dermatology Associates, Vallejo, CA

Evaluate Patient Prior to Treatment

u   History u   length and progression of signs and symptoms

u   Pt comorbitidies/meds

u   Associated Symptoms u   Itching, aching, leg swelling, heavy/tired legs, leg cramps, restless legs, rashes

u   Family History

u   Pregnancy history and future for female patients

u   Lifestyle factors (Job requirements, Activities/hobbies, Daily demands)

u   Pt goals for seeking treatment

u   Physical exam

Venous Anatomy

CEAP Classification

Who should receive further evaluation (u/s) prior to treatment

u   C1 disease if in distribution suggestive of saphenous vein reflux and all C2-C6

u   Etiology if Congenital or Secondary (always) and Primary if indicated

u   Anatomy: duplex u/s with maneuvers; further eval, esp if iliac/vena cava or complicated (consider referal to vasc surgeon)

u   Pathophysiology: u/s for reflux, if obstructive component consider further eval

Why Evaluate Prior to Treating?

u   Good Medicine

u   Reduce risk of complications

u   Treat the source of reflux prior to secondary/visible varicosities

u   Improve likelihood of successful tx

Goals of Duplex u/s with maneuvers

u   Determine all sources of reflux

u   Document incompetent vessels, lumen diam, highest & lowest pts of reflux, perforator involvement

u   Dx anatomic variants

Vein QOL Questionnaire helpful in assessing impact of treatment on QOL

Greater Saphenous Reflux Common Source

u   Clinical symptoms

u   Bulging or clusters of smaller vv’s in mid leg

u   Corona phlebectasia (mid ankle vvs)

u   Ant shin vv’s and/or discoloration

Indications of GSV Reflux

Extensive vv’s on shins/med low legs

Scar changes/LDS lower leg

Common Visible Signs Suggestive of Advance Vein Reflux

u   Red or purple veins on the mid ankle/instep of foot

u   Ropy or green vv’s on the mid calf &/or thigh

u   Low leg and ankle swelling

u   Recurrent or persistent rash on the low legs

u   Discoloration of the low legs

u   Difficulty healing on the low legs

u   Hardening/sclerosis of low leg skin

u   Current or healed ulcers on the low leg or ankle

u   Mult SCC on low legs

Common symptoms suggesting saphenous and/or perforator vein reflux

u  Heaviness of legs u  Aching u  Restless legs u  Throbbing sensation in legs u  Leg cramps (often at night) u   Itching on low legs u  Sensation of burning or heat

u  Ulcer on med ankle

Indications of GSV Reflux

VV’s on mid ankle Extensive Corona phlebectasia

Indications of GSV Reflux

Hemosiderin pigmentation & swelling R GSV diam 8 mm

U/S Criteria of Reflux

u   Superficial vein criteria (GSV/SSV/tributaries/perforators)

u   Normal reflux times <0.5 sec

u   Normal vein diameter <4 mm

Indications of GSV reflux

Atrophe Blanche mid ankle Eruptive SCC in setting of venous insuff

Short Saphenous reflux

u   Clinical symptoms

u   Pain

u   Restless legs

u   Cramping

u   Clinical signs

u   Discoloration

u   Swelling

u   VV’s on back of leg and/or lat ankle

u   Ulceration (late)

Perforator Reflux

u   Clin signs/symptoms

u   LDS

u   Nonhealing ulcer

u   Tenderness with indentation under refluxing perforator

Treatment options for Saphenous Reflux

u   Endovenous Laser Ablation

u   Radiofrequency Ablation

u   VenaSealTM (glue)

u   Foam Sclerotherapy

u   Traditional Vein stripping

Treatment Options for Tributary and Other Large Varicosities

u   Microphlebectomy

u   Foam Sclerotherapy

u   Sclerotherapy

Indications for Sclerotherapy

u   Treatment of spider veins or other skin “blemishes” (e.g. venous lake)

u   Treatment of reticular veins or small vv’s(1-3mm) when no major reflux

u   Treatment of veins <3mm that remain after surgery or larger veins 3-4 mm that are not due to underlying perforating veins

u   Treatment of bleeding vv’s

u   Treatment of large vv’s hidden below a venous ulcer

Contraindications for sclerotherapy American Venous Forum

u   Pregnancy (except in cases of bleeding vv)

u   Age >75 y/o (relative)

u   Very sedentary/immobilized pts at risk for DVT

u   Sig med probs: kidney, liver, lung, heart dz, cancer, uncontrolled diabetes

u   Severe allergic reactions and/or asthma

u   Fever or active illness

u   Recent or acute phlebitis, superficial or deep vein thrombosis

u   Treatment of veins that are tributaries off refluxing saphenous veins

u   Current use of NSAIDs or anticoagulants (d/c if possible prior to tx)

Treatment for Small Varicosities/telangiectasias

u   Sclerotherapy

u   Laser

u   Radiofrequency needling (VeinGoghTM)

Sclerotherapy Agents

u   Detergents – act on vein endothelium via interference with cell membrane lipids. May be foamed. u   Polidocanol

u   1%-3% for large vv’s and retic veins

u   0.25% - 0.75% for telangiectasias

u   Sodium tetradecyl sulphate

u   0.5%-3%-large veins

u   0.25%-0.5%-reticular veins

u   0.1%-0.2% for telangiectasias

u   Sodium morrhuate

u   Ethanolamine Oleate

u   Osmotic Agent u   Hypertonic Saline (11.7% - 23.4%)

u   High risk of complications – hemosiderin staining, ulceration, painful

u   Dilutes in vein quickly and loses effect downstream

u   Diffusion through vein wall results in irritation of adventitial nerves causing post-injection pain and muscle cramping

u   Chemical irritants u   Chromated glycerin (72%)

u   Polyiodinated iodine

Comparison of Common Sclerosants

Agent Advantages Disadvantages Comments

STS More potent on large veins than other agents

Rare incidence of anaphylaxis

1st FDA approved sclero agent in US (1946)

Polidocanol Least painful, low risk of AEs

$$$ 2nd FDA approved sclero agent in US (2010) Foaming increases efficacy in larger veins

Hypertonic Saline inexpensive Highest risk of ulceration and other complications & AEs; Painful

Chromated glycerin Lowest risk of matting, hemosiderin dep,

Not FDA approved in US Must be compounded; painful

My treatment of choice for small vvs; may be mixed with lido

Post Vein treatment Requirements

u   Fitted compression stockings (20-30 mm Hg) or compression ACE wrap following treatment (1-3 wks)

u   Ambulation and low impact activity following treatment

u   Leg elevation

Expected Reaction to Sclerotherapy Urticaria

u   Red, raised itchy areas at site of injection

u   Expected reaction to sclerosant, NOT an allergic reaction

u   Self limiting

u   No tx needed

u   May use top steroid

u   Advise pt in advance of tx with expectation to resolve within 24 hrs

Complication of Sclerotherapy Intravascular Coagulum

u   Liquified thrombus trapped in treated vein

u   Nonblanching darken vein(s) post tx

u   Tx with microthrombectomy 2-3 wks after tx

u   Coagulum will likely cause hemosiderin “tattoo” at these sites if not treated

Complications of Sclerotherapy Hyperpigmentation

u   Incidence est 10-30% u   Occurrence within 4-6 wks u   60% resolve within 6 mos u   90% resolve within 1 yr

u   Risk Factors u   Soln too aggressive for vein u   Admin too rapid u   Intravascular Coagulum u   Darker skin type (Fitzpatrick IV-VI) u   Sun exposure before or after tx u   Noncompliance with post tx

compression u   History of high iron stores u   Taking minocycline

Sclerotherapy Complications Telangiectatic Matting

u   Fine, red blood vessels occurring adjacent to tx site

u   Angiogenic reaction to insult/injury

u   May occur with sclerotherapy, laser, surgery/microphlebectomy, EVLA/RFA

u   Est incidence 10-30% with sclero

u   Common areas are med and lat thighs, med and lat calves, Med ankles

u   Assoc with females, obesity/high estrogen states

u   May spontaneously resolve

Sclerotherapy complications Ulceration

u   Ischemic necrosis due to the arterial occlusion or extravasation of sclerosant into extravascular space

u   Often see prolonged blanching with “porcelain-white” appearance immed after injection

u   Immed or delayed pain

u   Dermis may get dusky appearance

u   Dermal sloughing and ulceration may occur 1-3 days following

Sclerotherapy complication Cutaneous Necrosis: An emergency

u   An ounce of prevention worth a pound of cure

u   Use lowest concentration of sclerosant/most appropriate agent

u   Inject slowly and d/c immed if atyp blanching or duskiness

u   Use u/s guidance for larger veins with foam if needed

u   Vigorously massage

u   Inject normal saline or Hyaluronidase 75 un in saline immed to dilute area

u   May apply Nitroglycerin

u   Treat and follow wound with debridement and occlusive dressings/compression if a wound occurs

Sclerotherapy Complications Systemic effects

u   Alllergic reaction/anaphylaxis

u   1/700 for STS

u   <0.01% for polidocanol

u   Bradycardia (Polidocanol)

u   Limit to 10 ml per session

u   Hematuria (glycerin)

Differential of Venous Insufficiency Low leg cellulitis

Venous stasis Cellulitis

Differential of Venous insufficiency Lymphedema

u   Risk factors for Secondary

u   Obesity

u   Venous insufficiency

u   Cancer

u   Surgery

u   Positive Stemmer’s sign

Differential dx of Venous insuff Lipedema

u   Fat deposition which does not respond to weight loss

u   Etiology unk, genetics likely plays role

u   May have assoc venous insuff

u   Often leads to lymphatic obstruction->lipolymphedema

u   Tx with liposuction at specialized centers

Conclusions

u   Varicose veins are often more than a cosmetic nuisance

u   Proper evaluation and treatment are critical for proper treatment and outcome

u   Proper management of varicose veins can be life changing for the patient