Caveat Emptor / Buyer Beware!

images-4 copy This is a case presentation about a doctor’s deliberate misrepresentation of existing medical facts for excessive financial gains in a field of medicine I have dedicated myself for exactly 30 years: vein conditions, varicose veins included, treatable in an office setting. I assume full responsibility in exposing this case, as it is probably just the tip of the iceberg with many more identical cases happening all over the country ever since the start of American “vein revolution” some 10-15 years ago. (See below.)

The Latin idiom/phrase “caveat emptor” warns buyers to be on the lookout in getting incomplete even false information about the goods or services they intend to buy. Defects in the goods or misrepresentations of services are deliberately hidden/withheld from the buyer for clear financial gains.  In plain English and in a more popular term, this could be considered deliberate cheating  which in medical field is clearly unethical and in total conflict with the Hippocratic oath and of course punishable by law.

PhotoA: Right Leg in clockwise rotation  with calf varicose veins.

Photo 1: Right Leg with calf varicose veins, in clockwise rotation. (Double click to enlarge)

THE patient is a healthy 43 year old non-smoker male. He has been referred to my office (December 2013) by a cousin of his I have successfully rid her varicose veins some time ago. The patient, for years, has on his right leg the same asymptomatic varicose veins (his father had too) and he was interested treating them for basically cosmetic reasons. The examination of the patient was performed in standing position, as it should be in all cases of varicose veins, as the blood (helped by gravity) flows in them downward, making them distend even bulge, even palpable with naked eyes. As one can see, the Right leg (Photos 1&2) displayed only mild to moderate calf varicose veins. The clinical as well as Ultrasound (US) examination revealed reversal of blood flow (medically, reflux) starting behind the knee, at the Junction between the superficial (so called) short  Saphenous vein with the deep Popliteal vein (abr.SPJ). The  gravitational reversed/downhill blood flow pattern was

RT calf  varicosities enlarged

Photo 2: same Right calf (inner and posterior aspect (close-up)
(Double click to enlarge further)

detectable by US up to middle of the calf from where blood “spilled” into multiple visible distended (varicose) venous branches or tributaries of his short saphenous vein. Ultrasound interrogation of the groin disclosed a normal/competent Junction between the superficial ( this time called ) long Saphenous vein with the deep Femoral vein, ( abr.SFJ). No reversal of flow was present along the entire length of the long saphenous being considered totally normal.

The reader has to understand that in normal i.e. physiologic conditions the blood flow in our leg veins, even in a standing position, is always uphill, back towards the heart. This literally anti-gravity uphill flow is enabled by multiple unidirectional valves (like “gates”) we all have in both deep and superficial leg veins; however, varicose veins can occur only along the superficial venous system. Heredity,standing jobs, meager support (skin and subcutaneous fat), gender (female hormones/pregnancies), sedentary life style, obesity may all

contribute in distending the superficial leg veins triggering secondary valvular failure/incompetence that will result in an abnormal reversed gravitational downhill flow or, reflux in medical terminology. The origin of this abnormal pattern of flow usually starts at the site of the two above-mentioned junctions: SFJ in the groin or SPJ behind the knee, causing either long respectively short saphenous varicose veins. (Please note that in some writings “long” or “short” saphenous veins can be used interchangeably used with “great” or “small” saphenous veins.) Detecting these two escape points (as the two junctions are also called), is imperative when choosing and offering a long lasting therapeutic modality. In order to better comprehend this point, please imagine a dripping faucet responsible for a puddle in the yard. Siphoning / suctioning only the water, without fixing the leaking faucet will end up being an exercise in futility as the puddle would surely re-accumulate. In case of varicose vein, the palpable and visibly distended veins are the the puddle equivalents, while the feeding / leaking “faucet” is either in the groin at the SFJ (in case of long saphenous)  or behind the knee at the SPJ (in case of short saphenous vein varicosities). While, in the standing position, the distended veins  –  (as”puddles”)  – are clearly visible even palpable with closed

The normal and abnormal venous circulation

The normal and abnormal venous circulation

eyes (!!),  the two above-mentioned junctions – (as faucets) – are NOT!!  Even a thorough clinical examination could be inaccurate and misleading, therefore, a non-invasive  ultrasound (US) test/interrogation of the groin or behind the knee area, becomes imperative in order to detect and localized the leaking junction(s). This will enable to individually tailor the procedure for each case, and also assure the longest lasting results possible. Indeed, we can fix the existing varicose condition but NOT the tendency to possibly create new recurrent veins. Missing to diagnose a junction or NOT treating it properly will surely assure varicose vein recurrences. This is the case with injection sclerotherapy and with both thermal ablation methods that shy away from the true junctions since a blood clot in that area could dislodge and find its way, through the deep veins, to the lungs with dire consequences ( pulmonary emboli).  The US examination preferably should be done by the practitioner, or at least in his/her presences as he/her will be responsible for offered procedure’s performance and outcome.  (Additional information)

Left leg ( four sides in clockwise rotation) No varicose veins present!

Photo 3. Left leg ( four sides in clockwise rotation) No varicose veins present!

LEFT leg (Photo 3) displayed NO varicose veins at all and the ultrasound interrogation of SFJ in the groin as well as SPJ behind the knee disclosed a normal/competent junctions over both: i.e. normal uphill flow i.e. reversed flow (reflux) was non-existent. Both legs displayed minimal and scattered spider veins.  

Exhibit A: Fees for endovascular ablation

Exhibit A: Fees for endovascular ablation

After the examination I have informed the patient I can help him and described him that I intend to do the same procedure I have performed in the last 20 plus years for more than 3500 times: a tamed, minimally invasive surgical approach (well described on this website), performed in simple local anesthesia and in an office setting that will not incapacitate him. Indeed, he was told he will be able to drive away from my office and immediately resume normal daily activities, sporting activities included, except swimming and the light dressing covered by a surgical stocking should not interfere with his quality of life. I also informed him, based on my vast experience, that I am expecting no complications worthy of mentioning. In addition I also informed him that any  necessary post-operative follow-up examinations certainly are  included in the quoted fee of $2300. The patient agreed and was relieved as my fees were  reasonable, as the reader will se below…

Exhibit B: Fees for sclerotherapy

Exhibit B: Fees for sclerotherapy

Please note that  together with Prof. Dr. Albert Yellin from the Department of Surgery USC, I have authored  and published several publications on the tamed, minimally invasive surgical approach for varicose vein that were all a first in the American surgical literature. (see bibliography 1-4

At this stage the patient disclosed me that basically he came to me for a second opinion. Indeed he was seen in August of 2013 by a local  “vein doctor” and showed me the documents he had on himself regarding  the intentions and fees for the two  options given to him, one for endovenous heat ablation totaling, a whopping $9,300 (Exhibit A), and one for injection sclerotherapy totaling $4.950 (Exhibit B). Since he was in my office, and upon my request, he signed an information release document that was immediately faxed demanding release of pertinent medical information. We promptly received by return fax, the ultrasound examination  (Exibit C)…  good enough to conclude that something smells fishy…terrible fishy to say the least. I am not here to argue about fee issues. This is a free market country and for some doctors – especially those in  cosmetic specialties – skies  could be the limit! Nor do I intend to start a public debate what is or what should be the best treatment option for varicose veins: foam ultrasound guided injection sclerotherapy, endovenous thermal ablation by radio-frequency current (VENUS) or by laser (EVLT),  or the tamed minimally invasive local anesthesia in-office surgery, of course I certainly prefer. I am here however, to shed light about a deliberate fraudulent practice I believe is happening all over the country when using the high tech treatment options for the varicose veins. The issue , the main issue in this case, is the deliberate and purposely misleading incorrect diagnosis for the sake of the all mighty dollar…

Exhibit D - the ultrasound examination with the 3 outlined paragraphs.

Exhibit C – the ultrasound
examination with the 3 outlined paragraphs.

The patient was examined correctly, standing, in both setups, as it indeed should be as varicose veins become obvious when blood, under gravitational “down-flow” (reflux), makes them bulge/protrude from the surface of skin. As mentioned just above, varicose veins can be clinically diagnosed even with closed eyes, by simple leg palpation in this position, and only in this position! I have no idea who in the BH office did the ultrasound test  (in my setup I do it) but the BH doctor signed to it electronically and he would also be performing one of the proposed therapeutic procedures, thus responsibility is his. The patient complained of ONLY of right leg (calf) varicose veins (Photo 1&2). Reading the BH executed ultrasound report, it seems that we both agree with the clinical as well as ultrasound examination which concluded that the right superficial long saphenous vein is normal and that its corresponding junction, the SFJ is competent thus normal too. We both also agreed that  the right calf varicose veins belong only to the territory of superficial short saphenous vein and that, as expected, its corresponding junction, the SPJ, was found incompetent or leaking. Photo A depicts the four sides (front, inner, posterior, lateral aspects) of the right leg in clockwise rotation showing existing  calf varicose veins. Photo depicts the same right calf varicosities  in close up photography. The left leg  (Photo 3) is the leg I have the problem with as the two superficial long and short saphenous veins were wrongly diagnosed  ( in the BH office) as faulty, with both SFJ and SPJ leaking that my clinical as well as ultrasound examination revealed as completely NORMAL. Please read the Exhibit C paragraph 1:  “ Severe valvular incompetence is identified from the sapheno-femoral junction (SFJ) and through the saphenous vein to the level of the knee” and later in the same paragraph “ Severe valvular incompetence is identified in the short saphenous vein” Moreover, Exhibit C paragraph 2 reads: “Multiple tortuous varicosities of the left GSV (Greater Saphenous Vein …” finding that were NOT visible during my examination. But let the pictures speak for themselves. Please look well, Photo C, displays the four positions of the disputed LT leg, photographed again in clockwise rotation, and NO varicose veins could be detected. (Please double click on the Photos and Exhibits to enlarge them). While still on Exhibit C paragraph 3, one can clearly read: “This patient DOES meet the qualifications for venous ablation of the left  (?) great saphenous vein and both right and LEFT (?) small saphenous veins. (Procedure code 36475, need Autho(rization) for 3 times) (?). Wow!!! And indeed in the fee chart given to the patient (Exhibit A),  $2200 is multiplied by 3 for a total of $6.600 out which $4400 are fraudulent fees. I permit myself to also comment on the follow up visits as well. The general rule myself follow and abide by,  is that for the first 60 days, the follow up “fees” are included in the original fee. And while I do agree that after any form of thermal endovenous ablation, RF current or laser, the possibility of an unwanted deep vein thrombosis/clot is there, ultrasound follow up of the deep vein is indeed needed, yet the quoted six times are, maybe, just a little too …  generous. Indeed, a blood clot in the deep venous system once discovered, will need anticoagulant treatment to prevent the dreaded pulmonary emboli that could be fatal. All these potentially severe complication for  basically a cosmetic procedure, most varicose veins  basically are!! Therefore, endovenous ablation will never be my preferred treatment modality, not to speak about many other annoying complications,  none seen with the minimally invasive surgical approach I prefer. The fees for sclerotherapy (Exhibit B)  takes in consideration again 3 treatable varicose systems, out of which two on the disputed left leg do not exist.

Discussion. Varicose  veins (VV) are the most common manifestation of lower extremity vascular pathology in general and venous pathology in particular. Due to condition’s high prevalence/penetration, (mainly in the cosmetically driven female population), the demand  for consultation and treatment is significant. Traditionally, the treatment  was in surgical hands. Unfortunately, the over 100 year old classic stripping surgery had to be performed in general anesthesia, hospital setting and was dreaded by patients because of excessive operative trauma, lengthy convalescence, frequent unaesthetic skin scarring  and occasional nerve damage as well. As time passed, newer and much less traumatic procedures were slowly introduced. Two innovations revolutionized varicose veins surgery and both by Swiss colleagues. The dermatologist Robert Muller introduced in the mid sixties the hook removal of varicose branches via millimetric skin openings cutting down on trauma and also much improving the cosmetic appearance and the vascular surgeon, Andreas Oesch who finally tamed the traumatic stripping of the main saphenous vein trunks by introducing the invaginated PIN (peel-out) stripping. Personally, I have adopted these minimally invasive approaches and together uniquely performed them in an office setting (not hospital) and only plain local (not general) anesthesia. So far in twenty years this tamed procedure  was used  by me 3500 times with utmost patient satisfaction.

More or less the same time I started using the minimally invasive surgical approach in early nineties, non-surgical novel and also minimally invasive methods of treatment were introduced as well: ultrasound guided foam sclerotherapy and thermal endovenous ablation procedures (first CLOSURE by RF current followed by laser or EVLT ) for which surgical skills were basically not needed. Moreover, as manufactures of the hardware managed to convince insurance carriers, Medicare included, to honor quite excessive reimbursement fees, the floodgates opened for basically all non-surgical specialties feeling the drop/pinch in their insurance reimbursable incomes in their respective specialties. Indeed, attracted by prospects of higher and even reimbursable fees, many, many of these diverse specialists jumped on the opportunity and became, over the night – well, over a weekend course, – “vein specialist”. Yes, the “vein revolution” , already mentioned above, was started and it still goes on…

In 2009, it was the last time I was targeted and enticed by VNUS Co. (the hardware manufacturer for CLOSURE by RF current – radio-frequency – thermal endovenous ablation), to join the “club”, which of course, I did not do. (My patients treated with the minimally invasive surgical approach were satisfied, so was I and as they say, “if ain’t broke don’t fix it”. Moreover, I was a “fee for service” physician thus never depending on insurance reimbursement. My fees were and are reasonable and whatever the insurance reimbursed, the patient got it.)

Exhibit D depicts Medicare reimbursement fees, procedural codes, and approximated intra-operative times. When seeing the document in 2009, first, I could not believe my eyes: for a life threatening Abdominal Aortic Aneurism (AAA) an extremely difficult procedure needing extraordinary technical skills  and for which the operating time was correctly estimated for 3:30 hours, the Medicare’s doctor reimbursement fee was $1.858. For a similarly technically challenging cleanup of the carotid artery, a stroke and life preventing procedure (Carotid Endarterectomy), the fee was $1.608 and time allocated 2.4 hours.  Yet, for the endovascular  – by CLOSURE – ablation, (CPT code 36457) needed for a condition that is in most cases a cosmetic nuisance,  the reimbursement fee is the highest on the entire list: $2.493 !! while the allocated time to complete the procedure: a measly one hour!!!! So, for  3:30 grueling hours spent on one of the most technically challenging and risky procedures existing in the surgery to the a human being

Medicare payment fees, CPT codes and times (Double click to enlarge)

Exhibit D: Medicare payment fees, CPT codes and times
(Double click to enlarge)

the surgeon, who trained for six years in general surgery and additional 1-2 years in a vascular surgery fellowship, is paid LESS  than a dermatologist, family practitioner, radiologist, etc. who spent a weekend in a workshop learning the thermal ablation technique, (workshop usually organized by the hardware manufacturer), yet he will be reimbursed BETTER that the vascular surgeon. INCREDIBLE!!! Please note that the Medicare fee charts guide most insurance companies, meaning that they usually follow Medicare’s fee fluctuations and copy it. As previously already mentioned, considering that in the last 15-20 years overall  physician’s reimbursement dropped significantly for most specialties, anything new that does not need special skills yet is better reimbursed became very attractive indeed. Personally, I have nothing against all this provided that the standard of care is maintained: procedure being patient appropriate, should be well performed, does not have potential severe complications, assures good results and that the  patient is not fooled or taken advantage of, as in this case almost was. I have to “commend” the hardware companies as they did a “great” job: first by assuring exaggeratedly high reimbursement fees and by advertised these high income opportunities to all medical specialties: dermatologists, gynecologist, internists, radiologist, family practitioners, cardiologists etc. etc. and of course surgeons as well, who all bought into the gold rush… By the way, from the same Exhibit D one can read that Vein Stripping surgery -procedural CPT code 37722 – is being reimbursed for a measly $465! No wander surgeons, mostly depending on insurance reimbursement, embarked on the bandwagon too!  Unfortunately, greed joined into the fray as well. Indeed, greed driven physicians, like in this case, are easily able to talk into a naïve, cosmetically motivated patient to undergo thermal ablation by stressing that is a simple procedure of 45 minutes, performed in an office setting and not like the dreaded stripping surgery that needs hospital setting (the minimally invasive surgical alternative is not even mentioned existing), and  stressing that if the patient has insurance it will not cost him/her much… regardless if the procedure is or not warranted… Click here to see the full VNUS physician recruiting pages guaranteeing $655,653.60 in additional revenues per year for coming on board with them…)

The patient in this case informed me that the BH “specialist” told him that he has indeed visible varicose veins on the right leg – the patient was aware and consulted him for – but he told him too that he has them on the left leg as well, below the skin, therefore non visible to the naked eye…but they need medical attention. This is how a single procedure, fully indicated for the right leg, swell, (with two unneeded ones for the left leg), into three procedures… although the two additional proposed ones, had no medical nor cosmetic reasons: they simply did not exist (see for yourself Photo 3).  There is only one single explanation for the two additional suggested procedures – for the non-existing left leg veins – namely financial gains, or plain English, greed. The patient believed the doctor blindly, especially as both have the same ethnic background and speak the same mother tongue and psychologically, few consumers/buyers will suspect a “tribesman” to be dishonest! I was told that the BH doctor advertises in the ethnic newspaper, a good source for generating additional naive patients and fraudulent income.

Once the patient is convinced that the procedures are needed and agrees to their performance, the following needed step is to convince insurance carriers to pay the bill. To get insurance carrier approval for the procedure is not easy but if a good supportive ultrasound examination test exist, it makes it easier. In our case the ultrasound test, was – as we have seen- falsified to justify the claim.  It was shamelessly and daringly put on paper as no insurance company would come to the doctors office (audit) and examine the patient and check the accuracy of the ultrasound test. Doctors could argue about interpretation and meaning of any test, but one can’t fool anybody when the obvious naked eye evidence, which should be there and visible to ALL, is simply missing… (see Photo 3)  This patient never had and does not have varicose veins on the left leg of any kind: neither long not short saphenous. THEY WERE SIMPLY INVENTED TO JUSTIFY FINANCIAL GAINS. PERIOD. The best analogy I could come up with is to convince a hernia patient, having a legitimate and visible / painful ONE SIDED inguinal hernia, that he has one on the OTHER SIDE  as well, not yet painful and not yet visible as it is still under the… skin.  I am aware of cases in which unnecessary ultrasound tests were/are performed routinely for simple spider veins; cases in which long saphenous veins were closed i.e. ablated, while the patient is told that without the (well reimbursed) procedure the spider veins will never go away. Apparently, greed overrides ethics, morals and shame.

Unfortunately, I take issue with a second misconduct regarding this case, namely the malpractice one. A normal long saphenous vein is an excellent vascular conduit used in bypassing coronary artery occlusion as well as obstructive arterial disease of the legs. Ablating, closing, destroying or removing a normal saphenous vein for financial gains in my humble opinion is medically criminal and in total contradiction with our Hippocratic Oath. This patient was lucky as he escaped the trap put in front of him…

Bibliography:

1. Goren, G., Yellin, A.E. Surgery for truncal varicose veins: the ambulatory stab avulsion phlebectomy. Am J Surg 1991; 162:166-74

2. Goren, G., Yellin, A.E. Invaginated axial saphenectomy by a semirigid stripper: PIN stripping. J Vasc Surg 1994; 20:970-77

3. Goren, G., Yellin A.E. Invaginated axial stripping and stab avulsion phlebectomy: a definite outpatient procedure for varicose veins. Amb. Surg 1994; 1: 27-35

4. Goren, G., Yellin, A.E. Minimally invasive surgery for primary varicose veins: limited invaginated axial stripping and tributary (hook) stab avulsion. Ann Vasc Surg 1995; 9:401-14 (also translated to French and Spanish)

 

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Swelling of Leg(s)

 Swelling of Leg(s) .

Swelling  (edema) of the lower limb is a frequent symptom of many people of any ages. The excess of fluid will accumulate due to gravity at the lowest part of the body namely the legs and feet. The first criteria is to ask yourself is the swelling on both legs or just on a single leg. Second criteria, is the swelling visible all the time or, mainly worse in the evenings. Third criteria, is the specific localization of the swelling. Mostly it is around the lower part of the leg manifested by puffiness of the ankle and calf. Rarely the swelling starts at the toe level and  foot, and even more rarely it will  engulf the thigh as well. Other criteria to follow are the color and temperature of the skin/limb, body temperature, are any other parts of the body swollen such as abdomen, is there shortness of breath, chest pain, recent weight gain, jaundice, etc. etc.

I. A bilateral leg edema usually points to a systemic problem and not a local one the most important being:

  1. Diseases of the heart  (such as congestive heart failure of CHF)
  2. Diseases of the liver  (liver failure)
  3. Diseases of the kidney  (renal failure)
  4. Obstruction of the abdominal vena cava (blood clot, tumors)
  5. Conditions responsible for a low blood albumin level, etc. etc.

Other bilateral conditions :

  1. Pregnancy
  2. Prolonged sitting or standing ( usually the swelling gone in the morning)
  3. Menstrual periods with fluid retention-PMS,
  4. Excess slat intake (Chinese food),
  5. Medications: birth control pills, steroids (cortisone), etc.
  6. Constrictive clothing (garters), etc. etc.
  7. Obesity

II. An unilateral leg edema points to a local condition, the most important being:

  1. Infection  (red hot skin, high body temperature),
  2. Arthritis of the knee and ankle,
  3. Trauma
  4. Varicose veins (superficial venous insufficiency,
  5. Deep vein clot /thrombosis, DVT; post phlebitic leg
  6. Lymphedema (swollen toes and feet) congenital or acquired.

In case of bilateral edema a clinical examination with additional tests will clarify the cause and once the cause is known adequate treatment will follow. Prompt medical attention is warranted in case of associated shortness of breast, chest pain, swelling of the abdomen, redness and warmth of the leg and high body temperature, reduced urine output, or jaundiced skin and eyes. In a unilateral leg edema it is best to see a vascular surgeon who will supplement his/her clinical examination with a Doppler ultrasound/duplex imaging . If the reason is superficial disease this is relatively easy to treat and basically can be cured. Deep vein disease it is a complex problem that is manageable bur rarely curable  especially if an acute deep vein clot (DVT) was not caught in time or nor properly treated.  Acute leg (calf) pain with ankle and calf swelling is suspicious for an acute DVT and immediate medical attention is required.

Besides the specific approaches briefly mentioned above, the general measures to treat edema of the lower limb(s) are :

1. Compression (elastic or non-elastic) usually to knee level. In pregnancy maternity panty hose are highly suggested for the last trimester,
2. Leg elevation, when just possible, ankle to be positioned higher than the level of the heart for a good gravitational drainage,
3. Ambulation, walking as it lowers the pressure and congestion in both superficial and deep veins,
4. Salt restriction.

 

 

 

 

The Pelvic Congestion syndrome

This condition is encountered exclusively in women during and after pregnancies. Normally, the blood from lower abdomen and pelvis is drained back to the heart by veins that are branches of pelvic veins such as the internal iliac vein and the ovarian veins. The uterus is not far from these veins. During late stages of any pregnancy, due to the compression of these veins by the growing and heavier uterus, all veins in the area are exposed to increased venous pressures resulting in excessive blood congestion. Transmitted to the anatomically lower vein branches of the vulva and vagina and inner aspect of the upper thigh, the veins in the area may bulge, and cause discomfort and pain. Occasionally hemorrhoids will be present as well for the same reasons. Fortunately, however, in most cases after delivery, most of these painful bulging veins could disappear. It is, however, possible that after subsequent pregnancies these veins will be permanently present and will cause discomfort and pain while standing and mainly around the monthly periods. Many women may also complain of lower abdominal pain and some will complain of pain during sexual relations. While the syndrome is rare, it is unfortunate that is not easily recognized by the gynecologist and these women will go from physician to physician for help.

Once the condition is diagnosed or suspected the patient is be referred to an interventional radiologist. A simple trans-vaginal ultra sound examination could verify the suspicion.  The radiologist will correctly diagnose the problem by injecting a dye through a catheter inserted in the main vein of the leg in the groin. After positively diagnosing the offending and leaking vein, the radiologist will use, through the same catheter, either foam or special coils to close off the vein through which blood was flowing downhill filling up the veins of the vulva, vagina and upper inner aspect of the thigh. Occasionally, foam injection sclerotherapy or hook extraction of the externally visible veins will be indicated as well.

Varicose veins and pregnancy

Screen Shot 2013-09-08 at 2.58.40 PMThere is no secret that women have more varicose veins than man. Certainly a family tendency is found in most of cases, man women alike, but pregnancy and especially multiple ones, predispose women to well surpass the number of man affected with the condition.

During pregnancy there are several factors that can aggravate either the tendency to have the condition or the already existing varicose veins. The reasons are:

1. High level of the female hormone of pregnancy that relaxes the smooth muscles existing in the vein walls making the veins dilate and and by this rendering the existing valves incompetent;

2. Increased blood volume existing during pregnancy and

3. Increased abdominal pressure due to the greater size of the pregnant uterus, mainly evident in the last trimester of pregnancy (7-8-9 months).

4. Excessive weight gain exceeding the permitted 30 lbs. for a single pregnancy.

All these factors will just increase the venous pressure in the varicosities clinically resulting in itching, discomfort/pain and ankle swelling. The followings are suggested to ease the possible symptoms and also prevent further aggravation of existing varicose veins:
1. Use of surgical elastic stockings during the day for the whole period of pregnancy; knee level first 2 trimesters, maternity pantyhose in the last trimester. These are fitted items that should be prescribed by a physician.           2. Gravitational drainage by leg elevation several times a day for at least 5-10 minutes while the foot/ankle should be higher than the level of the heart.
3. Walking with the elastic surgical stockings the more the better and wearing laced up shoes to possibly prevent ankle and foot swelling.
4. Shower/bath should be taken in the evening rather than morning; hot water just further distends the veins in the morning causing early daytime pain and discomfort.
5. Avoidance of salty foods will reduce the water retention tendency.

Usually, veins that came upon during the first pregnancy will disappear after breast-feeding when the hormonal levels and the monthly cycle have returned to normal. Should the veins persist 2-3 months after delivery one should consult a physician for possible radical treatment.

As a general rule the best time to take care of the varicosities in women in childbearing age would be after she is done with all the pregnancies. However, if the patient had a miserable pregnancy due to already existing varicosities they should be treated after the termination of that pregnancy regardless whether the patient desires to have more children. The reason being that with advancement of another pregnancy the quality of life could be much affected  with pain, swelling, vein thrombosis etc.  demanding bed rest for most part of the third trimester of pregnancy.

Tendency to clot – Thrombophilia

Blood is of prime importance in the normal physiologic function of our entire body. In order to be effective, blood must be in a liquid state to be able to carry oxygen, carbon dioxide, nutrients, body’s defense mechanisms (such as white cells, antibodies, etc.) to our tissues and organs. This is part of homeostasis i.e.  maintaining the normal functions of the human body.

Another important function of blood is to maintain the integrity of the circulatory system following trauma. The process by which blood is maintained fluid within the blood vessels and the ability to clot, thus prevent excessive blood loss following an injury, is called hemostasis.

The balance between the forces that cause blood to solidify (clot) or to remain fluid is very delicate and involves several, and not easy to comprehend, interacting systems, basically a cascade of events in the center of which there is a protein, synthesized by the liver, Prothrombin, that when activated by other factors, becomes Thrombin. Acting as an enzyme/catalyst, Thrombin, transforms an other liver protein, Fibrinogen into Fibrin, which will now stabilize the initial (white) platelet plug/clot by forming a solid mesh that will now also incorporate red cells as well, forming the final red clot. A disbalance between clotting on one hand, and dissipation (lysis) of the clot on the other hand, will either cause a tendency to clot or a tendency to bleed.

Thrombophilia, or hypercoagulopaty is a tendency to clot and is present in approximately 50% of patients presenting with venous thrombosis. It is imperative that the possible existence of thrombophilia should be considered especially in recurrent deep vein thrombosis (DVT) without any obvious venous pathology. Suspicion should be high in case of a family history of vein thrombosis especially in an affected young persons without precipitating factors such as surgeries, debilitating diseases with long bed rest, cancer, etc. All these should suggest the possibility of an inherited disorder of the clotting mechanism.
This is rather a complicated subject and I advise the reader to print out these lines and possibly show it to the family physician who may also not be aware of the possibility.

One should differentiate between existing two main groups:

1. Hereditary

  1. Antithrombin III deficiency
  2. Protein C and S deficiency
  3. Activated protein C resistance
  4. Factor V Leiden abnormality
  5. Hyperhomocysteinemia ( n 10-15)
  6. Prothrombin G20210A gene mutation
  7. Fibrinolytic defects (delayed fibrinolysis)

The practical implications: persons having the hereditary form of thrombophilia have to be anticoagulated for life.

 

2. Acquired

1. Antiphospholipid syndromes such as: lupus anticoagulant and anti – cardiolipin antibody  ( antibodies against cell membrane constituents) existing with LE disease,

2. Heparin induced thrombocytopenia (HIT) with thrombosis/clotting. A strange condition when somebody receiving therapeutic Heparin, a blood thinner, has the contrary effect…

3. Myeloproliferative disorders such as Polycythemia Vera

4. Sickle cell anemia, a form of anemia seen mainly in African-American

5. Thrombocytosis , to much platelets

6. Pregnancy,

7. Oral Contraceptives , hormone replacement therapy (HRT)

8. Malignancy (cancer) especially metastatic

9. Paroxysmal nocturnal hemoglobinuria (PNH)

Conservative and Preventive Measures for Chronic Vein Diseases.

People with symptoms who have  chronic superficial or deep vein problems (CVI)  such as severe varicose veins and/or  post phlebitic  leg (after a deep vein thrombosis) should follow these simple common sense rules known to me as the “Rivlin’s Rules” since they were suggested to his patients by the late Mr. Stanley Rivlin of London,  the surgeon who among others also operated PM Mrs. Thatcher’s varicose veins. He  gave me his permission to use these original drawings – done by a patient of his – in which he is depicted in the role of the instructor. Needless to say those who knew him will easily recognize him… I paid him a visit in 1991, he being among the first surgeons to use minimal skin openings/incisions to remove leg varicosities (with ophtalmic instruments…) in order to reduce the excessive trauma associated with the traditional stripping. He operated only in a private hospital having only private patients. When I mentioned to him the I operate in an office setting and LOCAL anesthesia he looked at me, elevated his bushy eyebrows and said: “What, do I have to also entertain the patient?”…

 

 Rule 1

Fig.1

Reason: In standing position the blood in your diseased veins will pool , the pressure will increase and fluid (water) will accumulate in the soft tissues of the foot, ankle and lower calf inducing symptoms.

Rule 2

fig 2

Reason: Staying active will set in motion your calf muscle pump; blood will be pushed uphill toward the heart and the pressure in your veins should drop. Accumulated fluid is reabsorbed from the soft tissues. Distention and pain should improve.

Rule 3

Fig 3

Reason: Wearing laced-up shoes (and for that matter support stockings) will minimize the fluid retention in the soft tissues of your foot and ankle that in turn will reduce the distension, discomfort and pain.This is a very important rule in long distance (over 5 hours) travel by car or plane. Don’t remove shoes, as will be difficult to put on at the end destination.

 

Rule 4

Fig 4

Reason: Calf muscle pump inactivity will induce swelling and discomfort. (See Rule 1)

Rule 5

Fig 5

Reason: This will activate the muscle pump as well with the same beneficial effect mentioned in Rule 2. ( Nails are thrown to make the patient move his feet…)

Rule 6

Shot 3

Reason: Calf pump inactivity with local heat, which dilates veins, will further increase fluid retention and discomfort.

Rule 7

Fig 7

Reasons: At night, during sleep in the horizontal position, even bad veins can regain a more narrow shape as blood is easily returning to the heart. Heat in early hours of the morning will immediately distend these veins that will promote fluid retention quite early in the day with the accompanying discomfort and pain. This is especially the case if one has a sitting job…

Rule 8

Fig 8

Reason: Gravitational drainage of the blood will reduce elevated venous pressure and will ease the discomfort. Note: people with congestive heart failure, emphysema and obese people may have breathing problems and should possibly refrain from doing this. So should people with hiatal (diaphragmatic) hernia in whom this position may induce reflux of stomach contents into the lungs. Elevating the legs three to four times a day for 5-10 minutes with ankle above the level of the heart could be beneficial as well for the same reasons. BTW. 7 inches is good enough…

Venous Stasis Ulceration and Post Phlebitic Syndrome.

Chronic Venous Insufficiency:

Venous Stasis Ulceration; Post Phlebitic Syndrome.

Stasis ulceration (SU) can be a serious debilitating and challenging condition for life.  The reason for developing  SU is that blood, that the heart pumped down the legs via the arteries, is not returning properly back to the heart via the leg veins. The backed up leg’s venous blood will lead to increased venous pressure (venous hypertension) in the limb – rarely, very rarely in both limbs – and with passage of time the already indurated skin mostly in the swollen and pigmented ankle area will break down in a form of an ulcer/wound. The aim of any treatment is to lower this elevated venous pressure.  One can cure, yes CURE any venous stasis ulcer by TOTAL bed rest and continuous leg elevation, however this is not practical as we would need weeks possibly months to achieve results. The moment the patient cured leaves the bad what happens then? Without additional care the ulcer will reoccur! Moreover, the inactivity will make the patient gain weight which is detrimental to say the least. The patient with the condition, if being under the care of a knowledgeable practitioner, has been thoroughly examined and must find out if the disease originates in the superficial or deep veins.

Figure 6 - Varicose Veins

Fig.1 Typical Chronic Venous Insufficiency, in this case due to superficial disease. Patient had the surgery that prevented further deterioration; the deep pigmentation is for life.

If the condition is caused by superficial vein disease namely varicose veins one can offer total cure of the condition  if caught in time and certainly with proper treatment. As already previously stated on these website pages,  our preferred form of treatment would be surgery in its minimally invasive form that we uniquely perform in local anesthesia, office setting, one single session for the entire leg and which does not require convalescence. If, however, caught late, further deterioration can be stopped, however, existed discoloration of skin and the left behind (healed) ulcer’s scar, will remain visible possible for life.

If however it is found that the deep veins are diseased the situation is far more complex.  Excluding very rare congenital conditions – not presently discussed – the deep vein disease and the associated venous hypertension (with or without SU) is caused by a previous deep vein thrombosis (DVT) namely blood clot.  This is why the condition’s accurate name in this situation is “post phlebitic syndrome” (PPS) and stasis ulceration is basically the most extreme presentation of PPS. (“phleba” in Greek is “vein”) A physician treating a person with a deep vein clot, especially if the clot is localized in the larger veins of the thigh possibly even beyond, has to do everything to prevent PPS to occur. The reader has to know that a blood clot in the deep veins besides obstructing the flow back to the heart (already difficult in normal physiologic conditions because of the uphill – against gravity – direction of flow!) will in addition destroy the existing valves in the deep veins and compound an already bad situation. Indeed destruction of valves in a later stage will simply reverse the blood flow in the deep veins (from above-down rather down-above) thus further overloading and aggravating the already elevated venous pressure.  Therefore, a DVT of the larger veins of the thigh and beyond has to be diagnosed EARLY and properly treated by clot busters followed by anticoagulation and lengthy and efficient compression. Indeed “an ounce of prevention is worth a pound of cure”. A late diagnosis or wrong/incomplete treatment could, with passage of time (months, years), induce PPS that may lead to tissue breakdown including stasis ulceration.

The treatment’s aim should be lowering the elevated venous pressure. This is achievable by conservative means such as elevation of the limb and compression in its two major forms: elastic (usually surgical stocking at least 30-40 mmHg gradient pressure) or inelastic such as the Circ-Aid legging. If the person is capable of an active form of life I would use for daytime elastic stockings and suggest walking as much possible as simply walking reduces by itself the venous pressure. Indeed the calf muscles act as a “peripheral heart/pump” pushing blood uphill in the deep veins.  If the person has a sedentary way of life (mainly do to obesity) one should use the inelastic form of compression. In both cases elevation of leg whenever possible is highly indicated. The efficient elevation has the ankle(s) higher than the level of the heart for a proper gravitational drainage. One should elevate all times while sitting for reading or watching TV. I would also elevate (at foot level) during the night with a foam wedge beneath the mattress. Elevating the leg on simple pillows are inefficient as the leg rolls off it during sleep.

Fig 2. Chronic Venous Insufficiency: venous ulcer

Fig 2. Chronic Venous Insufficiency: venous ulcer

If one already the skin broke down and stasis ulceration set, the wound should be kept clean simply by applying a jet of tapped water – while sitting in the tub – for several good minutes directly on the ulcer for several days. A saline wet dressing should be applied over the ulcer. Removing it after it dried will pick up the accumulated secretions which will help clean the wound. One should do this several times a day. One could use, once the secretions are gone, a colloid dressing such as Duoderm patch that can stay on the leg for several days. One should NOT apply on the ulcer any form of antibiotic creams. If the ulcer is infected and bacterial cultures are positive one should of course use oral antibiotics. Weigh loss is imperative, as it permits an active, mobile way of life. One more thing, compression to the knee is sufficient in most cases and no compression of any kind is need during the night. However, it should be applied first thing in the morning. If the compression protocol used are stockings please shower in the evening to avoid struggling in reapplying the stocking, on a still damp leg, every morning. Use of rubber kitchen gloves for better gripping is highly advised.

Of course if the deep thigh or pelvic veins are found occluded/incompetent there are today invasive procedure that may help in case the above briefly mentioned conservative measures have failed. I am referring to venous by-pass procedures as well as stenting. These are however performed only by handful of physicians in a handful of hospitals in the country.

Please remember, this is a lifetime preoccupation and one should make the best of it as if one is a couch potato the weight will just creep uphill making the situation much worse as time goes by. I have seen patients not willing to help themselves and preferring to play the role of the “victim” making life miserable to everybody around too. Of course the condition can also affect the financial situation of the patient.

Certainly other associated condition such as overweight, diabetes, congestive heart failure, sedentary life style are all additional aggravating factors that will need to be addressed as well.

PS. A concomitant condition that could be present too is when, due to the increased venous pressure in the deep veins, blood will be “pushed” out into the superficial venous system through veins that bridge the two systems. As they perforate several layers of different tissues they are called the perforator veins. Normally, they drain blood from the superficial system into the deep. In case of PPS the flow is reversed, from the deep to the superficial. Closing them with injection sclerotherapy under ultrasound guidance or by surgery will be beneficial to improve the circulation of the skin and subcutaneous tissues to try to heal and also prevent further deterioration.

Leg veins blood clots after long-haul flights. The economy/coach class syndrome and their prevention.

 

EconomyClassSyndromeLeg Veins blood clots after long-haul flights:

The “Economy/coach Class Syndrome”.

Blood clot formation

Blood clot formation

In the last decade there has been a lot of scientific and media interest on the risks of deep leg vein blood clots (thrombosis and venous thrombo-embolism) following long-haul flights of 5-6 hours or more. Most cases are caused by the imposed long time sitting mainly, in the limited space available in the crowded economy/coach class.It is  therefore that the condition was coined as “economy (coach) class syndrome”. Indeed prolonged sitting is associated with venous congestion (stasis) in the lower leg veins, which predisposes blood to clot. Rare case have been also reported with long haul car travel, and the first known cases did  occur in citizens of London sitting for hours, even days, in air-raid shelters during the German Blitz of World War II. Predisposing factors are: advanced age, women on birth control or hormone replacement therapy, presence of varicose veins, recent surgery for cancer, recent chemotherapy, previous history of blood clots (DVT), congestive heart faillure, gout, obesity, heavy smokers, etc. etc.

Air travel, however, additionally, predisposes the formation of blood clots because of several unique and specific conditions.

1. Hemoconcentration (or “thickened” blood) is the result of possible decreased fluid intake and excessive insensible water loss (unfelt perspiration) due to the low humidity atmosphere of the cabin (20%) as recycled air is very dry. The possible diuretic effect of alcohol and coffee consumption could further aggravate the hemoconcentration.

2. Lastly, the relatively low cabin air pressure (equivalent to a 6-7000 feet mountain and not 30000 feet plus cruising altitude) and the corresponding low oxygen concentration (20-25% less than at sea level) is also favoring clotting in a sitting individual.

Your should walk on these long haul flights; you do not want to get a deep veins thrombosis...

Your should walk on these long haul flights; you do not want to get a deep veins thrombosis…

Combination of all these factors could be occasionally, a recipe for disaster as once a blood clot is formed in the leg vein, there is an imminent danger that the clot may dislodge, travel with the venous circulation to the lungs and cause pulmonary emboli which, if massive, can also be fatal. The clinical signs of blood clots in the leg (DVT) as well as pulmonary emboli (PE) are not specific and could be completely absent as well. However, calf pain, unilateral swelling of an ankle or calf should be taken seriously. Similarly, sudden chest pain, shortness of breath, apprehension, and sweating, irregular pulse etc. should alert to the possibility of these dreadful yet preventable complications of, mainly, air travel. These symptoms can occur days even weeks after the flight. Treatment with clot busters and /or blood thinners has to follow a positive diagnosis established by blood tests and venous ultrasound imaging in a hospital setting early as possible.

In conclusion, the condition described is potentially very serious, but preventable.  The incidence of the condition is very, very low, if one takes into consideration the millions of travelers using air transport each day.

Easy sitting exercise

Easy sitting exercise

PREVENTION: WHAT TO DO:

1. Stretch and walk the aisles 3-4 minutes every 11/2- 2 hours. If sitting near the window ( the highest incidence of cases!)  or a center seat, do NOT be too considerate toward your neighbors. Get up and walk!

2. While sitting, periodically, either tap your foot up and down (heels on the ground) as if beating time to music or simply move heels up and down; curl your toes in your shoes.  Activating calf muscles pump will lower the blood congestion in your leg veins.

Compression3. Keep no baggage in the space under your legs so that you can perform the described sitting foot exercises.

4. Use comfortable non-constricting clothes and laced shoes to prevent foot swelling, not high-hills or flip-flops . Do not take shoes off, it may be difficult to put them back at the end of the flight.

5. Drink a lot of fluids (water, juice, soda pop) but abstain from excessive alcoholic beverages and coffee as they are diuretics.

6. Compression stocking is one of the best preventions modalities. A knee level surgical stockings can be pick up in any drug store (see pictured item). If  however, someone is in the high risk group I would prefer a stronger compression that may need a doctor’s prescription.   A baby Aspirin (81mg) useful in preventing strokes and heart attacks apparently have no major protective effect on the venous circulation, however at such minimal dose it can not be harmful.

If at known risk for clotting (see above), please talk to your doctor about your travel plans as well.