Michael R. Anderson, MD (Host): Hello, everybody, and welcome to this episode of The Fortcast, the official vodcast of Fort HealthCare. I am your host, Dr. Michael Anderson, President and CEO of Fort HealthCare. And I have with us today a very special guest, somebody I've worked alongside with for over 20 years now, and that is Dr. Bill Kontny.

So Dr. Kontny, thank you very, very much for joining me, today on this episode of The Fortcast. It is wonderful to have you here.

Bill Kontny, MD: Well, I appreciate that, Mike. And we've been here for 33 years, I have been. And it's been a pleasure working with you during this entire time and being part of this wonderful organization. And I'm happy today to talk about varicose veins.

Host: Yeah, I got to tell you, Dr. Kontny, what you have done for our patients and community has just been extraordinary over the decades of your dedicated service here to Fort Healthcare, and I just want to say thank you. And I know we're going to be talking about varicose veins today.

So Dr. Kontny, varicose veins, it's a pretty big topic. We hear a lot about it. It's fairly common, but what exactly is a varicose vein?

Bill Kontny, MD: Sure. As you mentioned, it's fairly common. Forty million people in the United States have varicose veins. One in four people essentially will have varicose vein issues. And by the time you reach the age of fifty, half the people will have varicose vein issues.

What are issues? Well, first of all, you asked what are varicose veins. Varicose veins are basically the veins in our system. Our arteries are the system that takes blood from our heart to our structures. All our structures, all our cells, all our tissues need oxygen. And the arteries take the blood to the cells and provide oxygen. Well, the veins take the blood back once it's gone through the process of getting through the cell and taking that oxygen out, and then the veins will take the blood back to the heart in order to keep that process going.

So, the veins that we're talking about, the varicose veins, are in our lower extremities, typically. You can have them in our upper extremities too, but most likely and most commonly, they're in the lower extremities. Varicose veins are dilated veins, veins that you can see kind of bulging on your legs, and that is because our veins have valves in them. In order to take the blood back to our heart, we don't have a pump. The heart pumps blood to everything, but we don't have a pump to take it back. So, what we have is our muscle structure that squeezes veins, pushes the blood up back to the heart. And if we didn't have valves in our veins, then the blood would just pool backwards into our lower extremities because of gravity.

So, the varicose veins occur because somewhere along the line, those valves are damaged, typically from genetics. A lot of times it's also from other issues like standing too long. Pregnancy is a big reason because of the back pressure from the baby in the uterus pushing on our main veins, pushing the pressure back into our legs, causing those veins to get more dilated.

And if you don't have valves, the valves are broken, so then the blood pools backwards and gravity keeps the blood in the veins, causing them to bulge. And that's what you see on your legs when you notice, "Why do I have these bulgy veins on my legs?" It's for that reason.

Host: Okay. So if I could just summarize, so varicose veins are basically when there becomes too much blood in the vein, and the vein just expands significantly, and you can physically see it mostly in the lower extremities. It can happen in the upper extremities, but most of the time it's a lower extremity phenomena. Would you say that's accurate?

Bill Kontny, MD: Absolutely accurate. That's exactly what happens. Gravity makes the issue in the legs more prominent

Host: Gotcha. So when somebody does have varicose veins, are there symptoms of varicose veins, or is it just a physical finding that people see in their legs? Are there some symptoms that go along with it?

Bill Kontny, MD: Yeah. Symptoms typically are very common. I very commonly hear "My legs ache," "My legs are throbbing," "I feel pins and needles," "I feel a heaviness in my legs," "I feel like I'm carrying around some water bottles in my legs because I just feel that they're heavy, especially at the end of the day," and that makes sense because of gravity, right?

If we're up on our feet all day, over time, the blood's pooling more in our legs as the day goes on, causing some fluid to be retained into our skin, and it causes our legs and both of our lower extremities to feel heavy. So, heaviness is a big one. Achiness, throbbiness, those are very common symptoms that people feel.

Host: So when somebody is experiencing that and they feel that they have varicose veins, do they typically go to their primary care physician or provider to be evaluated?

Bill Kontny, MD: Yeah, I typically think many people just deal with it, right? They just assume that's just normal, and they don't get that, "Hey, I could probably get some help for this." But typically, I will get people that have seen their primary physician who also understands varicose vein issues and will then send them along to me for evaluation to determine if there is anything we can do to treat it.

Typically, the first thing that we would start and recommend to treat is support stockings. Support stockings are very common. We use pressure gradients on the stockings that overcome the back pressure of the veins, which makes sense, so that you keep compression on those veins so they don't dilate, keeping the blood going forward back to the heart. And we commonly try to treat people with support stockings first in order to see if we can get improvement before getting onto surgical procedures.

Host: So, the support stocking is like a super sock, right? It's a really tight sock that's meant to cinch down on the leg and help the leg return the blood that's pooling back to the heart.

Bill Kontny, MD: Exactly. That's exactly how it works. And they're stretchy, and they're usually gradient, and they're tighter from the foot and then get less as you go up in order to have that natural vein action of getting the blood back.

Host: So when somebody uses a, a support stocking, I'm assuming that probably helps a fair number of people. But, Dr. Kontny, when do you start to consider further treatment for varicose veins?

Bill Kontny, MD: Yeah. I will typically, for a first time patient, okay—and there's exceptions and we can talk about that as well—but for a first time patient who comes in and they talk about these symptoms and they clearly have varicose veins, I'll typically get an ultrasound of their lower extremities to see which veins are involved with valve damage because that's important with our treatment we'll discuss later.

The next step would be then to say, "Okay, you have this varicose vein problem. You don't have any significant complications from it. So, let's just try treating you with support stockings first. And we'll get you measured for proper stockings, send you off to where you can get them, and then start wearing them. And then in three months later, I would have you come back and see how you're doing." And then, at that point, some people will—I think it's very few—but it's some that will say, "Hey, my legs feel great. I'm just going to continue wearing these stockings. I don't really need to do anything else." Most people, however, are like, "Well, it did help for a while, but I still have the problem. I still have aching, I still have throbbing. And as time goes on, it's getting worse." And at that point, we would then discuss our particular surgical procedures that we could do.

Host: Okay. So, I want to circle back on a couple things you said. So when you see somebody for varicose veins, you still have to evaluate those veins, and it sounds like you do that with ultrasound, which is essentially a non-invasive radiologic diagnostic procedure they go through where they put a probe on the leg and evaluate the veins. And is that typically done in radiology, Dr. Kontny?

Bill Kontny, MD: Yeah, we send people to radiology to get the ultrasound, and it's exactly what you said. It's a probe that goes onto the leg. And while you're laying down, they will examine your veins with the probe. And then, they'll have you stand up and examine your veins with the probe. And they have fancy dials on their ultrasound machine to determine the velocities in your vein.

So when you stand up, if your velocity is a lot higher than it should be, it would indicate that your valves are damaged in certain areas of your veins, and that's what they're evaluating. That procedure will take 15 to 20 minutes typically, and it's painless. It's just a probe that it's like a magic wand they're putting over your legs just to evaluate this process and where these valves are damaged.

Host: Right. And who doesn't like a little bit of magic?

Bill Kontny, MD: Exactly. Exactly.

Host: So once you've had the ultrasound done and patients haven't responded to as much as they would like to with the compression stockings, so now you start to develop a little bit of a conversation about further treatments. Take us through that, if the stockings don't help the patient as much as they would like.

Bill Kontny, MD: When that patient comes back in and clearly they're having trouble the treatment's not responding to the compression as well as we'd like, then at that point I would offer them a few options. One of them is I would look at the ultrasound and see where the valves are damaged. And if they're a candidate for having what's called a radiofrequency RF ablation of that vein, then we would then take them to the surgery as an outpatient and take us about 20 minutes to do this procedure, which closes the saphenous vein. It's just a catheter. It's got a little heater probe on the end of it. With ultrasound, we just make a little nick in the skin. We pass the catheter into the vein. We pass it up to the proper location, up towards the upper area in the upper thigh. And then, once we get it in the proper location with ultrasound, we then turn the machine on, and it heats up that vein after we inject local anesthetic around the vein to keep it safe. We pull that vein catheter back. It heats the vein up and closes it. We pull the catheter out. We put one little stitch in that little spot with a Band-Aid. Patient then wakes up, has a wrap on their leg, and goes home. It's quite painless. There is really no significant or any real pain. We don't even need pain meds.

Host: And what's the success rate of that, Dr. Kontny?

Bill Kontny, MD: Yeah, it's about 90% to 95% successful, especially if you have the proper ultrasound findings. If you do, it's going to be very successful with getting rid of your symptoms, and it also prevents recurrence of varicose veins in the long term. It's a very good treatment. You can also use laser. We just choose radiofrequency ablation. They both work the same way.

Along with the radiofrequency ablation, we also typically do what's called stab phlebectomy. So, those big grape-like veins that are on your legs that you may be feeling that feel all that heaviness, those veins are now so dilated they're not going to get better with this treatment. This treatment is to prevent the back pressure, which gets rid of your symptoms and also prevents further issues in the future.

If there's any veins that don't recede, we would then make tiny little nicks in the skin where those veins are and we go in with like basically like a crochet hook and just pull those veins out through a tiny little opening, and we just put little Steri-Tapes on, no stitches. And that would be done at the same time if the patient wishes. And again, after two days, the dressing wrap comes off, and they go about their business. some soreness, some bruising. But usually, people are up and around moving quite well.

Host: So just to confirm, that's an outpatient procedure?

Bill Kontny, MD: It's an outpatient procedure, yes?

Host: And do people just get sedation for that?

Bill Kontny, MD: Most people get sedation. You can have general anesthesia if it's significant veins that we're going to be working on. But most of the time, it's sedation. Yeah. And then, you basically are just put in a sleep state and you wake up and go home right away afterwards.

Host: So it sounds pretty patient-friendly, especially if somebody's dealing with this. It sounds like it's a really good alternative.

Bill Kontny, MD: Yeah. It's a good alternative for treatment. It works really well. Once people get to this step, I find that people are extremely happy after their procedures.

Host: So Dr. Kontny, now you mentioned, about 90%, 95% percent success rate, which is really, really strong. What happens if it doesn't help?

Bill Kontny, MD: Well, if it doesn't help, it may be a separate issue, and there might be separate issues involved. A person may have what we call lymphedema, which also is something we can't gauge with ultrasound or identify with any test. We're pretty good at guessing which one it is. But in that case, it may be something that requires long-term compression treatment, and we would send people to a specific specialist that deals with chronic long-term issues with swollen legs. And they do very well with that treatment too.

Host: Well, I mean, it sounds like there's a lot of options for people, especially with how common varicose veins are. I'm sure you get an opportunity to really improve people's quality of life with the procedures that you can offer for the treatment.

Bill Kontny, MD: Oh, absolutely. And I would also like to discuss with people what happens with varicose veins. Because some people who have varicose veins just feel like, "I got varicose veins, it's not a big deal." And in reality, some people, it is not a big deal, and you can just go along with your varicose veins if you choose. But if you are having continued issues over time, if you start getting a brownish discoloration in your lower leg, that's a very common sign that your venous issue is really getting progressed.

And there are a smaller group, 1% to 2% of those people that have varicose veins can develop ulcers, and that can be a very chronic, difficult issue to deal with. So at that point, if you do develop ulcers and you do get that brownish discoloration, varicose vein treatment is really essential at that point. That's something that you really need to do. And we will have people sent to us from like people who are seeing wound issues. The wound clinic we have here at our facility will send people to us and say, "Hey, this looks like a venous problem. We can't really heal it without your help." And then, we would proceed with these, especially the ablation procedures.

There's also another procedure we do, which is called Varithena foam treatment. That's a procedure we also do. We use two different treatments, and I base those treatments based on where the problem with the valves are. And a Varithena foam treatment is something we do right in the office, and it's just a matter of numbing a spot in the lower leg, injecting a, a certain amount of foam, which is a chemical that irritates the vein, kind of like the heat does, causing it to close in the same way as the heat does. And that's a simple procedure with no sedation you do in the office, and people don't have any pain from that either. We get really good results, especially with ulcer patients with that.

Host: Well, that sounds like another good option. Yeah, it's so important to be aware of those warning signs like skin discoloration, ulcers that can kind of accelerate the process. But, Dr. Kontny, I can't thank you enough for coming on this episode of The Forecast and educating us. I always learn something when I talk to you. Educating us on varicose veins, we really appreciate it

Bill Kontny, MD: Oh, it's my pleasure. Thanks for having me and, appreciate you doing these podcasts to get the information out to those who need it.

Host: Well, thank you. Yeah, it's so important for our community members, our patients to have some resources. Maybe they want to learn a little bit more. Maybe they have varicose veins, maybe a loved one of theirs has varicose veins. So, it's always nice to watch a video, and then they get to know you a little bit too, before they make that appointment with you.

Bill Kontny, MD: Yeah. I think it's very common that people really don't think they're, you know, or don't really know some of these treatments. And, you know, some of the treatments we used to do in the past were a little more rough on people by stripping veins and all that kind of thing that some people still probably remember, but we don't do that anymore. And the vein treatments has gotten so advanced, and we're doing very well with it. So, thank you again.

Host: Well, it sounds like it. You got some great options.

Bill Kontny, MD: Thank you for having me.

Host: All right. Thank you, Dr. Kontny, and thank you for tuning in to this episode of The Fortcast. Please share us on your social media channels. For now, this is Dr. Michael Anderson saying thank you again, and have a great day. So long.