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Melanie Cole, MS (Host): Welcome to UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole. And today, we're offering you an update on venous health and disease. Joining me is Dr. Benjamin Jacobs. He's an Assistant Professor in the University of Florida Division of Vascular Surgery and Endovascular Therapy, and he practices at UF Health Shands Hospital.

Dr. Jacobs, it's a pleasure to have you join us. Just tell us a little bit about venous health and disease and how it has such a detrimental effect on quality of life. How prevalent is it and what risk factors would predispose a person to poor venous health?

Benjamin Jacobs, MD: Good morning. Thanks for having me. Venous disease is one of the most common diseases that we see here. And the important thing to recognize about venous disease is it actually impacts people through sort of all stages of life, so young people, elderly people. And while the incidence does increase as people get older, a lot of our patients are younger and working. And so, a lot of the impact of it is on, you know, people who are trying to make a living and they are limited in some way or trying to raise their kids and they are limited in some way.

The venous disease ranges from asymptomatic to very severe venous disease, which can cause ulcers, wounds, and can actually threaten limb loss. The pathophysiology of venous disease is a little complicated, I imagine we'll talk about it. But, you know, generally speaking, the risk factors for venous disease are there's a hereditary predisposition. So many of our patients who have venous disease, they'll say, "Oh yeah, my mom or my grandma or my uncle has legs that look just like mine."

Another common risk factor is an occupation that has you standing or sitting for extended periods. So, a lot of our patients are nurses or machinists or anybody who sort of spends their whole workday for a long time standing upright with gravity kind of pulling down on them.

So, the next common risk factor is obesity. And we do see that venous disease is more common in overweight and obese patients. Having four or more children similarly is a risk factor. And you know that when you think about that sort of the common thing is that blood comes down to the feet and the arteries and comes back to the heart in the veins. And all those risk factors that I described to you are either a process of pushing down or pulling down on the blood in the veins that's coming back to the heart.

Melanie Cole, MS: Dr. Jacobs, for providers that may not see this as often as you do, tell us a little bit about the clinical presentation of a chronic venous insufficiency. What are they looking for?

Benjamin Jacobs, MD: Probably the most common thing that a family doctor is going to see is a patient either with the presence of varicose veins, which would be these sort of enlarged veins, may be the size of your thumb or bigger just underneath the skin. And in patients with varicose veins, those can present either entirely asymptomatically or they can present with symptoms associated with them. The symptoms are usually aching, pain, tingling or paresthesia. Some people will complain of burning pain or itching. Some patients will have nothing at all. They'll just have varicose veins that are there on their legs and they don't bother them in any way.

The next most common presentation is edema or swelling in the legs. That can be associated with pain or, again, it can be asymptomatic. Skin changes are common, and skin changes really come in a few sort of different common findings that we find, but they all kind of tend to be in that gaiter distribution around the ankle and lower calf. We'll see what we call brawny induration, which is that sort of bronze discoloration of the skin, resulting from hemosiderin deposition there. Corona phlebectactica, which are those tiny sort of blue or black veins that we see in folks just around the ankle or on the medial part of the foot, that's what we call corona phlebectactica. Stasis dermatitis, would be a more severe manifestation of skin changes where we get a scaly, raised up, heaped up kind of appearance of the skin in that same gaiter distribution. And ulcers, patients can present with ulcers in that gaiter distribution as well, usually above or near the medial malleolus of the leg.

Melanie Cole, MS: So then, tell us a little bit about the difference of chronic venous insufficiency from the other causes of leg pain and leg swelling. How is this differential diagnosis made? Because there are a few things, and as you've mentioned, the symptoms and the risk factors, the many risk factors that can cause this type of venous insufficiency, how are we determining difference from edema and things that might be caused by arterial or other causes?

Benjamin Jacobs, MD: That's a really good question. So, I think the first important distinction to make is between varicose veins and what we call spider veins or telangiectasias. Spider veins or telangiectasias are not usually raised and they're a millimeter or two or sometimes even less than that when we're talking about what we call a spider vein. Spider veins are always asymptomatic. They don't ever bother folks and they don't cause leg pain. Some people find them unsightly. But other than that, they're not hurting you. Though we sort of commonly misconstrue the one is the other, really the size and the physical appearance are the most sort of the key determinants of distinguishing those two things. Spider veins or telangiectasias don't necessarily require treatment because they are asymptomatic and varicose veins may require treatment.

Edema is a tough one because there are a lot of things, as you say, that can cause swelling in the legs. The most common one that we see, or well one of the more common ones I should say, is lymphedema. Lymphedema comes in two sort of flavors, either primary or secondary. Secondary would be lymphedema caused by something. I think the most common thing that most providers are familiar with is lymphedema in the arm caused by a breast operation in a woman. But lymphedema can happen in the legs and can happen from surgery, can happen from orthopedic surgery or groin surgery. And secondary lymphedema can be a cause of swelling in the legs. Primary lymphedema is not caused by anything, it just sort of is. I sometimes even hesitate to really think of primary lymphedema as a disease. I mean, primary lymphedema comes in three subtypes, congenital, which would be, you know, babies; lymphedema praecox, which would be in girls most commonly around the time of puberty; and lymphedema tarda, which is most commonly in women around the time of menopause. So, those primary lymphedema syndromes can be causes of leg swelling. And so usually, if somebody sends me a 16-year-old-female for a question of venous disease, I can be pretty sure before I even see her that it's probably going to be lymphedema praecox rather than true venous disease.

So, you know, heart problems, congestive heart failure obviously can cause swelling in the legs. And this is the toughest one, the last one, which is just like sometimes your legs are swollen. And there's no real good explanation for it. It doesn't sort of rise to the severity that we would expect from lymphedema. But as we get older, everybody just tends to have just a little bit of swelling in the legs. If it's asymptomatic, there's nothing to do about it.

The pain in the legs that would be different from arterial pain in the legs is usually easy to distinguish because arterial pain in the legs is due to a mismatch between oxygen delivery and metabolic need. So, we have patients with arterial disease, are going to present with either claudication or rest pain when they have pain in the legs. Claudication would be pain in the legs with walking, and it's very regular. They walk a certain distance, the metabolic requirement exceeds the oxygen delivery. And then, they develop pain, usually pain in the calves, and that pain goes away with rest. More severe arterial disease will cause pain unremitting, never goes away, pain in the feet. Usually, it is what we think of as nocturnal metatarsalgia, which is pain right over the metatarsal heads, more common at night, really suggestive of arterial disease rather than venous disease.

The pain of venous disease tends to be very vague. One of the things that's actually suggestive of vein disease is if a patient has a hard time describing it. And they say, you know, "Doc, I don't know, it's just my legs feel wrong or they feel achy. But they can't really put their finger on it,|" much more suggestive of a venous cause of pain rather than an arterial cause of pain.

Patient's risk factors are also going to be suggestive of which diagnosis you're working with. So namely, like I said about lymphedema, age, things like that. Smoking history would be suggestive of arterial problem rather than venous problem, or those other atherosclerotic risk factors.

The last thing I should say about lymphedema is that one of the causes of secondary lymphedema is indeed venous disease, which makes that diagnosis more complicated when we're thinking about lymphedema because lymphedema can be caused by longstanding venous disease.

Melanie Cole, MS: Well then, which patients would require referral to vascular surgery, Dr. Jacobs? Speak about that.

Benjamin Jacobs, MD: Let me say first which patients don't. Patients who have asymptomatic edema that is otherwise not very bothersome and not very severe. So, people who have just a little bit of swelling in their ankles and otherwise are not bothered by their legs in any way, they probably don't require a referral. And the reason being that even if they had a venous problem, I'm probably not going to do anything about it. And I'll explain that in a second.

Telangiectasias are spider veins in an asymptomatic patient, you don't require referral to vascular surgery because, again, the procedures that we offer don't treat that problem and that problem is usually asymptomatic. If the patient has really convincing symptoms and also has some telangiectasia, you have to kind of question whether there's something else going on because it's, as I said, very unusual for telangiectasia to cause pain in the legs.

The reason that that is true is because the treatment of venous disease is predicated entirely upon its impact upon the patient's quality of life. So if the patient is feeling fine, doing good, not limited in any way, no reason to treat them. And so consequently, probably no reason to refer them. Patients who absolutely I would suggest need a referral to vascular surgery are patients with the skin changes. And patients with ulcers should probably see a vascular surgeon because they have, stigmata of more advanced venous disease. Patients with edema alone, it all depends on their level of symptoms; patients with varicose veins alone depends on their level of symptoms, which is to say if a patient is feeling fine, we often don't need to see them just to make sure everything's good. If they feel fine, everything's good.

Melanie Cole, MS: Well then, speak little bit about the treatments that you might use and what are you doing for them?

Benjamin Jacobs, MD: That's a great question. So when we think about the treatments, we have to think about sort of what we're treating and sort of separate it into two different things. Because the two problems that I described, you know, I spoke about venous varicosities, right? And I mentioned varicosities and all these things that I mentioned so far are clinical signs and symptoms, but the treatment actually is related to the underlying pathology and so what's going on underneath. And so in order to know what's going on and how we're going to treat it, we need an ultrasound.

You remember I, you know, mentioned that oxygenated blood comes down in the arteries and comes back in the veins. Well, the way that that works is there are valves in the veins, one-way valves that let the blood move up but not back down. So as the patient moves their calves, moves their thighs, the muscles squeeze the veins, the veins get squeezed and the blood gets pushed up and the valves close behind. In some people, those valves become weak. They sag open. And when that happens, when those valves don't close all the way, then gravity pulls that blood backward down into the legs and the blood pools there. That's what we call venous reflux or venous insufficiency. And so if we identified a patient with symptoms or signs suggestive of venous disease, we would then order an ultrasound to determine whether they had venous insufficiency or bad valves in the veins.

If they have bad valves in the veins, then that is treated with an ablation procedure. So for example, if a patient had bad valves or evidence of venous reflux in the great saphenous vein, what we would do is a great saphenous vein ablation. There are two ways to do that that I use. One would be radiofrequency ablation. Radiofrequency ablation uses an endoluminal catheter that has radiofrequency, gets real hot, and it burns or cauterizes the vein shut. So, we enter the vein sort of in the high calf with a needle. And using the Seldinger technique, we put a wire in, we put the catheter over the wire, and we advance that catheter up to the junction of the saphenous vein with the common femoral vein, and then we burn it close sequentially.

The other technique that I use is to close the vein down with cyanoacrylate, which is like Dermabond or any other surgical glue. It's super glue. And it just clogs that vein up. We do the same technique. We enter the vein with a needle, we put a wire in, and we advance that catheter. And then, we just fill the saphenous vein with glue. So again, if the problem is that those valves are bad and that blood is being pulled backward in the vein. Both of those modalities close the vein down and so the blood can no longer be pulled backward. And consequently, the blood is forced to find other healthier routes out of the leg, thus relieving the patient's symptoms.

The treatment for varicose veins, which is those prominent, bulging, painful veins that are just under the skin is what we call ambulatory phlebectomy or stab phlebectomy. What that is, is that we just make small incisions right over each one of those varicosities and we use a little hook and we pull them out. And once we pull them out, the blood finds other healthier ways out of the leg. Patient symptoms are usually significantly relieved. Both of these are outpatient procedures. Patient comes in, leaves the same day. Depending on what we do, sometimes we do them under general anesthesia, sometimes we do them under local. Recovery is usually a couple of days.

Melanie Cole, MS: Dr. Jacobs, this is such an informative podcast. You are an excellent educator. And as you specialize in complex, minimally invasive endovascular therapies for arterial and venous peripheral disease, tell us a little bit about your unique practice in the reopening of occluded venous stents that may have been unable to be reopened elsewhere. What's interesting to note about the unique pathophysiology of post-thrombotic syndrome?

Benjamin Jacobs, MD: So, post-thrombotic syndrome is a sort of a subset of what we see in venous patients. And so, a lot of what I said earlier applies to these patients. Namely, they'll have some of the same presenting complaints and their physical exam will be similar. But these are specifically patients in whom damage to the valves or the veins has happened because of a prior blood clot.

The treatment for that is often the placement of stents. These stents don't last forever, and sometimes these stents will re-thrombose, particularly in patients who have prothrombotic disease like factor V Leiden or something like that. When these stents thrombose, they can be very, very difficult to reopen. And so, those patients will develop severe debilitating symptoms of post-thrombotic syndrome, swelling of the leg, skin changes, stasis dermatitis and ulcers. We have developed some techniques to reopen these stents, and we've had a significant amount of success. These are complex endovenous reconstructions where we have the patient under general anesthesia. We will access the veins at several places in the neck and both thighs or both groins, whichever one we have to do. And we can use radiofrequency or heat to burn our way through these occluded stents, if you can believe that. We can find ways to go through stents and break them open and put new stents in. And all with the goal of reopening these occluded vessels to relieve that obstructive pathology.

The important difference to recognize in these post-thrombotic patients and then your sort of primary venous patients is that the primary venous patient is going to have a valve problem or a varicose vein problem. The post-thrombotic patients have both valve problems, varicose vein problems, But then on top of that, they have obstructive problems or narrowings or blockages in the veins, and that's what we have developed, a pretty good technique, pretty good amount of success in doing. These patients often get stented at other hospitals. And then, a couple years later, they'll come to us with those stents that were working well for a while are now blocked up. And we have been able to have a lot of success in reopening those block stents here to treat that post-thrombotic process.

Melanie Cole, MS: This has been an absolutely fascinating episode, Dr. Jacobs. Thank you so much for joining us today. To learn more about this and other healthcare topics at UF Health Shands Hospital, please visit innovation.ufhealth.org. And to listen to more podcasts from our experts, you can always visit ufhealth.org/medmatters.

That concludes today's episode of UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole. Thanks so much for joining us today.