What is Peripheral Arterial Disease (PAD)?

Arteries carry blood rich in oxygen and nutrients from the heart to all parts of the body. When the arteries to the legs become blocked, the muscles are deprived of oxygen and cause significant symptoms. This condition is called Peripheral Arterial Disease or PAD.

What are the Risk Factors for Peripheral Arterial Disease (PAD)?

The risk factors for PAD are the same as those for all types of atherosclerosis:

• Smoking
• High Blood Pressure
• Diabetes
• High Cholesterol
• Family history of stroke, heart attack, or PAD
• Age (>65)
• Prior history of coronary heart disease or peripheral arterial disease (PAD)
• Obesity

What are the Symptoms of Peripheral Arterial Disease (PAD)?

In the early stages, patients with PAD may have no symptoms. The most common early symptom from PAD is intermittent claudication (IC). IC is characterized as pain in the buttocks or legs that occurs with walking and goes away with rest. It occurs more quickly with strenuous walking or walking up hills and stairs. Over time, the pain occurs at shorter and shorter distances. As the disease progresses, the legs do not get enough oxygen even at rest. This leads to pain in the legs even at rest. In severe PAD, called critical limb ischemia (CLI), ulcers and gangrene can develop, usually on the toes and feet.

How is Peripheral Arterial Disease Diagnosed?

First your doctor will ask questions to determine if you have symptoms consistent with PAD. On physical exam, your doctor will check your pulses and examine your feet and legs to determine if there are signs of PAD.An ankle-brachial index (ABI) is a test that compares the blood pressure in the legs to the blood pressure in the arms. This can give an early indication of PAD.

An arterial duplex ultrasound is the best initial test to diagnose the presence, location, and severity of PAD. The ultrasound images the arteries in the legs and measures blood flow in order to detect blockages. This exam is simple and painless, and is performed in the office of your vascular surgeon.

If the ultrasound is positive for PAD, the next test is usually an angiogram. This can be done using CT scan, MRI, or tradition catheterization through the groin arteries. Dye is injected into the arteries and precisely defines the degree and location of the blockage, and provides your surgeon with a road map to plan further intervention.

Is Peripheral Arterial Disease (PAD) Dangerous?

PAD in and of itself is dangerous in that it limits activity and can cause significant discomfort. People with PAD can become disabled and be unable to work. When it advances to a severe level, gangrene can occur and can lead to amputation. More importantly, however, is that PAD is a marker that the patient likely has blockages in the arteries in the heart and brain. This puts them at a significant risk for having a heart attack or a stroke.

Do I need treatment?

The decision as to whether you need treatment is determined by the severity of your symptoms. If no symptoms or mild symptoms are present, then only medical therapy is indicated. As your symptoms become more severe, and become lifestyle limiting, then minimally invasive techniques may be warranted. When critical limb ischemia occurs, as characterized by rest pain, ulcers, or gangrene, aggressive intervention is essential to prevent amputation.

How is Peripheral Arterial Disease (PAD) Treated?

Medical Therapy:

Medical therapy consists of lifestyle modifications, medications, and walking exercise.

Lifestyle Modifications:

• Quit smoking
• Control high blood pressure and diabetes
• Control high cholesterol
• Achieve and maintain a desirable weight

Medication:

• Aspirin is the most important medication, and should be taken every day. A baby aspirin is adequate, as no dose of aspirin has been proven to be superior.
• Plavix works in a similar fashion to aspirin, but is more powerful. It is often given in combination with aspirin in patients at especially high risk.
• Trental and Pletal are medications that can help improve blood flow to the peripheral blood vessels.

Walking Exercise:

Exercise and walking regularly, at least 30 continuous minutes three times per week, can help improve your symptoms by encouraging your body to form new, collateral blood vessels. With a structured walking program, many patients experience a dramatic increase in the distance they are able to walk without pain.

ENDOVASCULAR (Minimally invasive) THERAPY

In some cases, your doctor may recommend angioplasty and stenting. It is done in a specially equipped room, Specials Radiology, which is a combination X-ray room and operating room that is unique to Milford Hospital. The patient receives a local anesthetic and is awake for the procedure. Sometimes a light sedative is given. A blood vessel in the groin is accessed using a catheter, similar to the type used when you get an intravenous line. The catheter is guided through the arteries to the area of the blockage. Once in place, a special balloon (see picture at left), which is attached to the catheter, is inflated and deflated several times. The balloon pushes the plaque that makes up the blockage against the artery walls, widening the vessel. In some circumstances, the doctor may also place a mesh metal tube, called a stent, into the narrowed area to keep the blood vessel open (see pictures at right). The stent remains permanently in the artery.

A specialized stent graft that is lined with a non-stick plastic (Viabahn) can help keep the artery open long-term (see picture at left). Some of these are impregnated with a blood thinning medicine called Heparin.

It is not possible to predict which of these techniques will be used until the surgeon is well into the procedure, but it is important that he is familiar with and has access to all of these techniques. Both Dr. Esposito and Dr. Davis, who usually perform the procedures together, are expert in these techniques and have actually served as instructors to other physicians in the area.
There is no surgical incision, only a small pinhole in the groin. The procedure takes between 1 to 2 hours. The typical recovery involves an overnight stay in the hospital. Sometimes, if the procedure is straight-forward, same day discharge is possible. There is very little postoperative pain, and the patient is able to eat right away. After a few hours, the patient can get out of bed and ambulate. The patient is typically discharged home after breakfast the day after surgery, often less than 24 hours after the procedure. The patient can resume normal activities right away. The patient may experience some discomfort at the groin puncture site and some swelling of the leg from the increase in blood flow. These are normal occurrences and usually last only a few days. The patient’s symptoms usually improve dramatically within one week.
For more severe, longer blockages more advanced techniques may be used. An atherectomy catheter has a sharp blade that rotates very quickly and actually cuts and removes the plaque, like a roto-rooter.

After the procedure, the patient will continue with lifestyle modifications, aspirin and Plavix, and routine ultrasound surveillance at the Milford Vascular Institute.

SURGICAL THERAPY

Sometimes the blockages are so severe that surgery is the only option. The surgery, called a bypass, creates a detour for the blood around a narrowed or blocked section of a leg artery.

To create the bypass, the surgeon uses one of your own veins or a plastic blood vessel called a graft (see picture at right). The bypass is attached with stitches above and below the area of the blockage. This creates a new path for the blood to flow to the distal parts of the leg. This procedure is done in the operating room.

Depending on the severity of the blockage and the patient’s medical condition, general, spinal, or local anesthetics may be used. There are usually two separate incisions in the leg. If the patients own vein is being used, the incision will be longer in order to harvest the vein. The surgery usually last between 1 to 3 hours. The patient can expect to be in the hospital 3-5 days.

The recovery from surgery is longer, but bypass surgery is very durable, usually more durable than the other techniques described previously. Dr. Esposito is board certified in Vascular Surgery, and has performed hundreds of leg bypass surgeries with excellent results. After the surgery, the patient will continue with lifestyle modifications, aspirin and Plavix, and routine ultrasound surveillance at the Milford Vascular Institute.

What is Sclerotherapy?

Sclerotherapy is a medical procedure used to eliminate varicose veins and “spider veins.” Sclerotherapy involves an injection of a solution (such as sodium chloride, a salt solution, or sotradecol, a detergent) directly into the vein. The solution irritates the lining of the blood vessel, causing it to swell and stick together, and the blood to clot. Over time, the vessel turns into scar tissue that fades from view. Sclerotherapy is a well-proven procedure and has been in use since the 1930s.

How will I know if I am a candidate for sclerotherapy?

Prior to the procedure, you will have an initial consultation with a vascular medicine specialist who will advise you on your eligibility for sclerotherapy.

You are not eligible if you are pregnant or are bedridden. If you have had a blood clot in the past, your eligibility will be decided on an individual basis, and will depend on the overall health of the area needing treated as well as the reason for the clot.

Veins that are potentially usable for future surgical bypass procedures (i.e., use of the saphenous vein, a large vein in the leg used for coronary artery bypass graft surgery) will generally not be considered for sclerotherapy.

How is sclerotherapy done?

In most cases, the sclerosing solution is injected through a very fine needle directly into the vein.

At this point, you may experience mild discomfort and cramping for 1 to 2 minutes, especially when larger veins are injected. The procedure itself takes approximately 15 to 30 minutes. You should plan to wear shorts during the injection.

The number of veins injected in one session varies, and depends on the size and location of the veins, as well as the general medical condition of the patient.

Sclerotherapy is performed in the doctor’s office by a vascular medicine specialist and requires that you do not partake in any aerobic activity for two days after the procedure.

What do you need to do before the procedure?

Prior to vein injection, you should avoid certain medications. Tetracycline, an antibiotic, may possibly cause a staining of the skin if taken seven to ten days before or after sclerotherapy. If you need to take an antibiotic before sclerotherapy, contact your physician. No lotion should be applied to the legs before the procedure. Some physicians recommend avoiding aspirin, ibuprofen (i.e., ®Advil and ®Nuprin) or other anti-inflammatory medications for 48-72 hours before sclerotherapy to minimize bruising. Tylenol, however, should not affect this procedure.

Could sclerotherapy cause any side effects??

You may experience certain side effects after sclerotherapy. There are milder effects, such as itching, which can last for one or two days after the procedure. Also, you may experience raised, red areas at the injection site. These should disappear within a few days. Bruising may also occur around the injection side and can last several days or weeks.

Other side effects include:

• Larger veins that have been injected may become lumpy and hard and may require several months to dissolve and fade.
• Transient hyperpigmentation consisting of brown lines or spots may appear at the treatment vein sites. In most cases, they disappear within three to 12 months, but some pigmentation may take up to two years to fade.
• Neovascularization describes a temporary development of new, tiny blood vessels, also known as “flares,” “mats,” or “blushing.” These tiny veins can appear days or weeks after the procedure, but should fade within 3-12 months without further treatment. If mats persist, they may be treated with vascular lasers.

Should any of the following side effects occur, contact your physician immediately. These include:

• Inflammation within five inches of the groin
• A sudden onset of a swollen leg
• Formation of small ulcers at the injection site

Allergic reactions to the sclerosing agents may occur at the time of the injection and are rarely serious. If you have a history of allergies, you have a greater chance of experiencing an allergic reaction to the agents. A minor allergic reaction will cause itching and swelling. To avoid any serious complications, your doctor will test the agents on a small area before applying the solutions to a larger area if there is concern over a possible allergy to the agent. If you have any concerns or questions following this procedure, you should contact your doctor.

What happens after the treatment?

After the treatment you will be able to drive yourself home and resume your regular daily activities. Walking is encouraged. You will be instructed to wear medical grade support hosiery to “compress” the treated vessels. If you have compression hosiery from previous treatments, you are encouraged to bring them with you to be certain they still have adequate compression. Department store support stockings will not be adequate. Your doctor’s office can recommend where to purchase heavy compression stockings.

Following the injections, avoid aspirin, ibuprofen or other anti-inflammatory medications for at least 48 hours. Tylenol may be used if needed.

Also, you should avoid the following for 48 hours after treatment:

• Hot baths
• Hot compresses
• Whirlpools or saunas
• Direct exposure to sunlight

Showers are permitted, but the water should be lukewarm. The injection sites may be washed with a mild soap and tepid water.

How effective is sclerotherapy?

Studies have shown that as many as 50 percent to 80 percent of injected veins may be eliminated following a series of sclerotherapy sessions. Less than 10 percent of the people who have sclerotherapy do not respond to the injections at all. In these instances, different solutions can be tried. Although this procedure works for most patients, there are no guarantees for success.

In general, spider veins respond in three to six weeks, and larger veins respond in three to four months. If the veins respond to the treatment, they will not reappear. However, new veins may appear at the same rate as before. If needed, you may return for injections.

Will my insurance cover sclerotherapy?

Insurance coverage varies. If your varicose veins are causing medical problems such as pain or chronic swelling, your insurance may offer reimbursement. If you are pursuing sclerotherapy for cosmetic purposes only, your insurance carrier most likely will not provide coverage. You should discuss your concerns with your doctor. If you have questions, please call your insurance company. Your insurance company may request a letter from your physician concerning the nature of your treatment to determine medical necessity.

Vascular Imaging is an integral part of the diagnostic work up of arterial and venous disease. This may involve one or more of the following non-invasive tests. The Milford Vascular Institute has an on-site Vascular Laboratory with a dedicated, full-time registered Ultrasound Technologist available Monday through Friday. All of the exams are either performed at our office or arranged for you through our office.

ABI

The ankle-brachial index (ABI) is a simple, reliable means for diagnosing peripheral arterial disease (PAD). Blood pressure measurements are taken at the arms and ankles using a pencil shaped ultrasound device called a Doppler. A Doppler instrument produces sound waves (not x-rays) and is considered noninvasive because it does not require the use of needles or catheters. The ABI test is performed in our vascular laboratory.

Although the ABI is extremely reliable, this test may not be accurate in all patients. Some patients with long-standing diabetes, kidney disease, or some elderly patients, may have rigid blood vessels. These may be difficult to compress with the blood pressure cuff and, in these patients, the ABI reading may not be accurate

An ABI value greater than 0.80 is rarely associated with short-term leg problems such as foot wounds or amputation. Nevertheless, any evidence of PAD (where the ABI measurement is less than 1.00) is associated with future risk of heart attack and/or stroke.

An ABI value between 0.40 – 0.80 is moderately decreased and such patients often experience some symptoms such as pain in the legs. Attention to foot care is extremely important to prevent accidental injury or infection. Again, any evidence of PAD is associated with future risk of heart attack and/or stroke! Serious efforts to keep one’s risk factors under control are essential to keep PAD from getting worse.

An ABI value of less than 0.40 indicates severe PAD. Patients should be extremely careful to avoid any foot injuries. Proper foot care may prevent development of non-healing wounds, rest pain, or even gangrene. The physicians at Milford Vascular Institute will evaluate the risk and benefits to improve leg blood flow through endovascular methods or surgery.

Duplex Ultrasound

Duplex ultrasound combines Doppler flow information and conventional imaging information, sometimes called B-mode, to allow physicians to see the structure of your blood vessels. Duplex ultrasound shows how blood is flowing through your vessels and measures the speed of the flow of blood. It can also be useful to estimate the diameter of a blood vessel as well as the amount of obstruction, if any, in the blood vessel.

Conventional ultrasound uses painless sound waves higher than the human ear can detect that bounce off of blood vessels. A computer converts the sound waves into two-dimensional, black and white moving pictures called B-mode images.

Doppler ultrasound measures how sound waves reflect off of moving objects. A wand bounces short bursts of sound waves off of red blood cells and sends the information to a computer. Doppler ultrasound produces two-dimensional color images that show if blood flow is affected by problems in the blood vessels, such as cholesterol deposits.

When performing duplex ultrasound, your physician uses the two forms of ultrasound together. The conventional ultrasound shows the structure of your blood vessels and the Doppler ultrasound shows the movement of your red blood cells through the vessels. Duplex ultrasound produces images that can be color coded to show physicians where your blood flow is severely blocked as well as the speed and direction of blood flow.

The physicians at Milford Vascular Institute may recommend a duplex ultrasound to help diagnose and examine conditions that affect the blood vessels, such as Carotid Artery Disease, Abdominal Aortic Aneurysmal disease (AAA), Peripheral Arterial Disease (PAD), and venous disease (DVT, Varicose Veins, Chronic Venous Insufficiency).

CT Angiography (CTA)

Computerized tomographic angiography, also called CT angiography or CTA, is a test that combines the technology of a conventional CT scan with that of traditional angiography to create detailed images of the blood vessels in the body.

In a CT scan, x rays and computers create images that show cross-sections, or slices, of your body. Angiography involves the injection of contrast dye into a large blood vessel, usually in your leg, to help visualize the blood vessels and the blood flow within them. When the contrast dye is used to visualize your veins, the study is called a venogram, and when it is used to visualize your arteries, it is known as an arteriogram. CT angiography is similar to a CT scan, but the contrast dye is injected into one of your veins shortly before the X ray image is performed. Because the dye is injected into a vein rather than into an artery, as in traditional angiography, CT is considered less invasive.

Your physician may order CT angiography to help diagnose a narrowing or obstruction of the arteries, an aneurysm, deep vein thrombosis, pulmonary embolism, or another vascular condition.

During the study, you will lie down on a table, which passes through a donut-shaped device. Inside the device, a machine takes x rays in arcs around the area of your body being examined. Tissues of varying densities absorb these x rays in varying amounts. The computer assigns these densities different numerical values and then plots an image based on these values, in shades of gray. During the CT angiogram, a dose of contrast dye will be injected into one of your veins. As the dye flows through your circulatory system, it will highlight your blood vessels on the scan. A computer will produce 3-dimensional (3D) images of your blood vessels from the x ray images.

MRA

MRI (magnetic resonance imaging) uses magnetic fields and radio waves to produce two-dimensional or three-dimensional images of the structures inside your body, such as your heart, brain or blood vessels. When this scanning method is applied to the blood vessels, it is also sometimes referred to as MRA (magnetic resonance angiography). The MRA equipment consists of a table that slides in and out of a donut-shaped machine. A computer attached to the machine processes radio waves and magnetic fields to create two-dimensional or three-dimensional images.

MRA not only helps the physicians at Milford Vascular Institute diagnose your condition, it also helps them plan treatment. MRA also may, in some circumstances, have advantages that other tests do not. For instance, MRA does not require X-ray exposure to detect narrowing of arteries, unlike computed tomography (CT) scans or angiograms.

What is Deep Vein Thrombosis (DVT)?

Deep Vein Thrombosis, commonly referred to as “DVT”, occurs when a blood clot, or thrombus, develops in a deep vein. Most of the time, DVT presents itself in the legs or pelvis, but occasionally DVT can occur in the upper extremities. The deep veins differ from the superficial veins in that they are located deep in the body and can not be seen, and more importantly, because they have a direct connection to the heart and lungs. DVT affects approximately 2 million Americans per year.

What are the Risk Factors for DVT?

Generally, a DVT is caused by a combination of 2 or 3 of the following underlying conditions:

1. Slow or sluggish flow through the veins
2. A tendency for a person’s blood to clot quickly
3. Irritation or inflammation of the inner lining of the vein

There are a variety of situations in which these conditions can occur:

1. During or after major surgery
2. Prolonged travel
3. Trauma to the legs
4. A family history of blood clots or blood disorders
5. Cancer
6. Obesity
7. Pregnancy
8. Smoking
9. Varicose veins

To assess your risk for DVT, click on this link and complete the Risk Assessment Tool. You can print it out and bring it to our office to discuss your risk and what it means to your overall health.

What are the Symptoms of DVT?

Approximately 50% of patients with DVT have no symptoms. When symptoms are present they include:

1. Calf pain and tenderness
2. Leg swelling
3. Leg discoloration (blue or red)

How is DVT Diagnosed?

A suspicion of DVT is raised after a physician performs a detailed history and physical, and identifies associated risk factors. The most important test is a venous ultrasound. This test is quick, painless, and very accurate in making the diagnosis. It can identify thrombus within the deep veins, and is also used to follow the patient’s response to therapy. Usually, this is the only test that is needed. Occasionally, for more complex cases, a venogram may be needed. This test involves injecting dye into the veins to visualize them more precisely.

Is DVT Dangerous?

DVT in and of itself is not usually life threatening unless it completely blocks flow out of the legs. When this happens, a condition called “venous gangrene” can develop and this requires immediate medical attention. Luckily, it is very rare for this condition to occur. However, the real danger of DVT is that the clot can become dislodged and move (“embolize”) to the heart and lungs. This condition, called a pulmonary embolism (PE), is a very serious condition and is often fatal. For this reason, it is very important to diagnose DVT early and begin treatment to minimize the risk of PE.

Do I need treatment?

All patients with DVT require treatment. The treatment goals are:

1. Relieve symptoms
2. Prevent extension of DVT
3. Minimize risk of pulmonary embolism (PE)
4. Minimize risk of recurrence
5. Minimize the late effects of DVT

How is DVT treated?

Medical Therapy:

Medical therapy consists of:

1. Bed rest for 24-48 hours
2. Leg elevation
3. Compression stockings
4. Anticoagulation

Anticoagulation involves taking medicine that thins the blood. Thinning the blood prevents further growth of the blood clot, but does not dissolve the clot. Your body has natural chemicals in the blood that will dissolve the clot slowly over time, usually within 3 months.

Coumadin is the oral blood thinner that you will take. Unfortunately, Coumadin does not work right away, and can take a few days to reach a desired level in your blood. Therefore, a fast acting blood thinner is also given initially. Traditionally, an intravenous medication called Heparin was the only option, and the patient would have to be admitted to the hospital for several days until the Coumadin level was therapeutic. This is still done in many cases. In some uncomplicated cases of DVT, however, a medication called Lovenox can be used as an outpatient. The patient gives themselves a subcutaneous injection (similar to taking insulin) twice a day at home. Blood work will be done every few days until the Coumadin level is adequate. Once it is, the Heparin or Lovenox can be discontinued, and the patient is maintained on Coumadin for a minimum of 3 months.

Lifestyle Modifications:

1. Quit smoking
2. Control high blood pressure and diabetes
3. Achieve and maintain a desirable weight
4. Regular exercise

Venous Intervention:

In severe cases, your doctor may recommend thrombolysis, which is the use of intravenous medication to dissolve the clot. This procedure is done at Milford Hospital, in the Specials Radiology unit, under light sedation and local anesthesia. A plastic tube, called a catheter, is threaded through a vein in the back of the leg and into the clot. The clot dissolving drug is then infused into the clot through the catheter’s many side holes, like a soaker hose. Sometimes a special instrument that works like a vacuum cleaner is used to suck out the softened clot. Once the clot is removed, sometimes a balloon or stent may be needed to treat an underlying narrowing of the vein. This procedure immediately relieves the patient’s symptoms and swelling, and can dramatically reduce the long term consequences of severe DVT, such as chronic leg swelling and ulcers.

Inferior Vena Caval (IVC) Filters:

Some people are at such a high risk of DVT and subsequent embolism that anticoagulation alone is not considered sufficient protection. In addition, some people can not tolerate anticoagulation due to other underlying medical conditions. In these cases, the doctor may recommend placement of an inferior venal caval (IVC) filter. The inferior vena cava (IVC) is the large single vein that connects both legs to the heart and lungs. All blood from the legs must travel through the IVC to get back to the heart, and therefore it is the only way that a blood clot can get from the legs to the heart and lungs. A filter, which is like a mesh cage, can be placed in the IVC. It allows blood to pass easily, but blood clots will be caught in the filter before they can get to the heart and lungs and cause damage. Once in the filter, your body dissolves the clot naturally over time. These filters are placed during a simple procedure in the Specials radiology Department at Milford Hospital. The procedure is done with local anesthesia and light sedation, and takes less than 10 minutes. A small catheter is placed in the groin, and under X-ray guidance, the filter is placed into its position. The patient can go home immediately after the procedure without limitations. Most of the time, the filters remain in place for life. If necessary, they can be removed in a separate procedure through a vein in the neck. Back to top

What are the long term effects of DVT?

The long term consequences of DVT can persist even when short term therapy has been “successful”. This is because the presence of a blood clot can cause damage to the inner lining of the vein, resulting in chronic scar tissue that constricts the veins and valves that do not function properly. Over time, this leads to chronic venous insufficiency (CVI) and venous hypertension. The result is chronic leg swelling, skin discoloration with brown pigment, leg heaviness, varicose veins, and ulcerations. This condition is called post thrombotic syndrome (PTS) and can result in significant disability. Once PTS develops, there are few options for treatment, and lifelong compression therapy is needed. Therefore, it is of utmost importance to prevent PTS from developing in the first place. This is best accomplished by prompt diagnosis and treatment, early thrombolysis for larger DVT, and the early use of compression therapy. Therefore, if you have any concern that you may be developing a DVT, consult your vascular surgeon as soon as possible.

Can DVT be prevented?

Some risk factors for DVT can not be changed. There are some things, however, that can reduce the risk of developing a DVT:

1. Regular exercise
2. Stop smoking
3. Early activity after surgery
4. Low dose blood thinners, elastic stockings, and compression pumps may be used during long hospitalizations or after major surgery
5. Regular stretching and walking for people who sit all day
6. If traveling by car, stop regularly to stretch your legs
7. If traveling by plane, get up and stretch in the aisle every hour when possible
8. Stay well hydrated
9. If you feel you are at high risk, talk to your vascular surgeon about other ways to reduce your risk of DVT

What are varicose veins?

Varicose veins are abnormal veins that can occur in the legs. They can be small, thin purple-colored lines (called “spider veins”) that lie just below the surface, or they can appear as thick, bulging, or knotted veins. While many people think that varicose veins are simply a cosmetic issue, there is often an underlying medical problem that causes varicose veins. This medical condition is called venous insufficiency. Varicose veins are very common in the United States, affecting approximately 15% of men and 25% of women. Over 25 million people in the United States are affected.

What are the Risk Factors for Varicose Veins?

The risk factors for varicose veins are:

• Family History – there is a strong familial component to venous disease. If your parents or siblings have varicose veins, you have an increased risk.
• Female gender
• Multiple pregnancies
• Occupations or lifestyles where you stand for long periods of time or perform heavy lifting
• Obesity
• Previous DVT (Blood clots in your legs)

What are the Symptons of Varicose Veins?

Some people with varicose veins do not experience any discomfort from the condition. When signs and symptoms do occur, they may include:

What causes Varicose Veins?

Arteries bring blood from the heart to the legs. Veins then bring the blood from the legs back to the heart. Varicose veins result from problems in the veins. When you stand, gravity pulls the blood to the feet. In order to prevent the blood from rushing to your feet, the veins have one-way valves in them. When you stand, the valves close and do not let the blood move backwards to the feet. In some people, because of the reasons listed above, these valves become worn out. Over time, the blood backs up in the veins, and pressure builds up. This increased pressure leads to the heavy feeling you experience, and causes the veins to enlarge. The branching veins to the skin also become dilated, and these appear as the varicose veins.

How are Varicose Veins Diagnosed?

Your doctor will examine your legs while you are standing. He will also ask you about your symptoms. More importantly, an ultrasound examination will be done to look for the underlying cause of your condition. The ultrasound technologist will test the valves in your veins to see if they are leaking. Back to to

Do I need treatment?

If you are unhappy with the way your legs look, or if you are having significant symptoms, you should seek medical attention. Varicose veins can be a sign of an underlying condition, venous insufficiency that can lead to serious medical problems such as ulcers and blood clots.

How are Varicose Veins Treated?

Conservative Therapy

1. Support stockings – Wearing compression stockings is an important part of any vein treatment. They are worn from the time you get up in the morning to the time you go to bed. You should be measured and purchase stockings that are of the appropriate size. The staff at the Milford Vascular Institute can provide this service for you.
2. Anti-inflammatory medication. Medications like Ibuprofen (Motrin) can help alleviate your symptoms.
3. Exercise.
4. Watch your weight and diet. Shedding excess pounds can take pressure off your veins. Follow a low-salt, high-fiber diet to prevent the swelling that may result from water retention and constipation.
5. Elevate legs.

Venous Intervention

If conservative therapy fails, venous intervention is warranted. Many patients are nervous because they are familiar with a procedure called vein stripping surgery. This procedure was historically done in the operating room under general anesthesia. It involved multiple incisions, a long hospital stay, and a long post operative recovery. Thankfully, this procedure is now rarely done. Today’s interventions are minimally invasive, done in the doctor’s office, and have very little in the way of pain or recovery. The type of intervention is dependent on the type of veins and the presence of underlying venous insufficiency. It is common for a patient to require multiple types of interventions during the treatment period.

1.) Sclerotherapy:

SclerotherapyIn this procedure, your doctor injects small- and medium-sized varicose veins with a solution that scars and closes those veins. In a few weeks, treated varicose veins should fade. Although the same vein may need to be injected more than once, sclerotherapy is effective if done correctly. Sclerotherapy doesn’t require anesthesia and is done in the doctor’s office. Dr. Davis has performed hundreds of these procedures, with excellent results.

2.) Endovenous Laser Therapy (EVLT):

Endovenous Laser Therapy (EVLT)As mentioned above, the underlying cause for many patientsEndovenous Laser Therapy (EVLT) with varicose veins is venous insufficiency. In order to truly get a long term solution to your problems, these leaky valves must be fixed. By fixing these leaks, the venous pressure can return to normal, alleviating your symptoms, and allowing future procedures to have a chance for long term success. EVLT is how your doctor fixes these leaks.

EVLT is done in the doctor’s office. For anxious patients, a light sedative, Valium, is given. Your lower leg is numbed with a local anesthetic. Using ultrasound, your doctor finds the abnormal vein and punctures it with a small needle. A long plastic tube, called a catheter, is then passed through the vein up to the leaking valve, which is usually in the groin. Through the catheter, the laser is passed. The laser is activated and slowly pulled out of the vein, closing it down so it will no Before and After Endovenous Laser Therapy (EVLT)longer leak. This procedure lasts less than an hour, and other than the pinches from the local anesthetic, is relatively painless. After the procedure, the leg is wrapped and you will walk out of the office. You will need to wear a support stocking for at least 2 weeks. You can return to normal activities immediately. The main possible complication from this procedure is a blood clot, but fortunately this is exceedingly rare. Because of this, you will be instructed to return to the office in one week for examination and a quick ultrasound to ensure that a blood clot has not developed. Both Dr. Esposito and Dr. Davis have been performing this procedure since it was first introduced. They have performed hundreds of the procedures in the office with excellent results. They have also served as instructors, teaching the technique to physicians from Connecticut, Rhode Island, Massachusetts, New York, and New Jersey.

VIDEO: View a video that explains the Endovenous Laster Therapy Procedure

3.) Ambulatory Phlebectomy (AP):

Ambulatory PhlebectomySome veins are too large to be treated with sclerotherapy and need to be completely removed. Far different than traditional vein stripping, ambulatory phlebectomy (AP) is a minimally invasive procedure done in the doctor’s office. It is often done at the same time as Before and After Ambulatory Phlebectomy EVLT. For anxious patients, a light sedative, Valium, and/or a pain killer, Percocet is given. The doctor marks the veins on your legs while you are standing, and then places you on the exam table. The procedure is done under sterile conditions with a local anesthetic. Tiny stab incisions, less than 1/8 inch in size, are made near the enlarged veins. Using special instruments, the veins are removed completely through these incisions. There are no stitches. Once the veins are removed, the leg is wrapped with an Ace bandage. This bandage is left in place overnight. The next day, you can shower and begin wearing a compression stocking. The stocking will be worn for a minimum of 2 weeks. There is very little pain associated with this procedure, and normal activity can be resumed immediately. There is some bruising for the first week, but once the bruising resolves, the veins are gone. The incisions heal completely without any scarring.

4.) Transilluminated Power Phlebectomy:

Transilluminated Power PhlebectomyThis surgical procedure was popular a few years ago, but with the arrival of EVLT, it is now reserved for only the largest, more severe varicose veins. This procedure is done in the operating room, usually under general anesthesia. A small incision is made and a light is placed under the skin to transilluminate the abnormal veins. Through a second incision, a device with a rotating blade attaches to the vein and literally chews it up and removes it completely. Anesthetic solution is then infused into the area. The patient goes home after the surgery, wears a compression stocking for 2 weeks, and returns to normal activity right away.. This is a very well tolerated procedure, with excellent success rates. With the newer techniques that can be done in the doctor’s office, however, it has become a much less used procedure.

Will the Varicose Veins come back after treatment?

One of the biggest worries that patients have is that after the treatments, the veins will simply return. Everyone knows someone who has had “injections” into their veins, only to have them return within a few months. At Milford Vascular Institute, we pride ourselves on treating the underlying cause of the disease process. We aggressively investigate your veins initially with ultrasound to find out the underlying cause, use the most advanced techniques to treat the cause, and provide close, long term follow-up to catch any problems before they return. Because of this comprehensive approach to the treatment of varicose veins, we expect that varicose veins treated at the Milford Vascular Institute will rarely return.

Graduated Compression Stockings are an essential part in the treatment of venous disease. They are the first step in management of venous insufficiency, which is a condition that leads to leg heaviness, swelling, and varicose veins. They are also an important part of the post-procedural care after intervention for venous disease.

These stocking recreate the natural pressure gradient that allows proper blood flow out of the leg veins and back to the heart. They come in different strengths of compression, lengths, sizes, and colors. Your doctor will recommend the proper type of stocking, and you will be measured and fit for the appropriate size.

The proper fit is essential for proper function. The Milford Vascular Institute has a stocking specialist that will come to the office to provide this service for you, and also has a wide selection of stockings that you can purchase immediately. Often, your insurance company will reimburse you for the cost of these stockings. Contact our office to make arrangements for your fitting.

What is an Aneurysm An aneurysm is defined as a localized widening of a blood vessel. When a vessel grows to 1.5 times its normal size is it classified as an aneurysm. What is an Abdominal Aortic Aneursym (AAA)? The aorta is the main artery in the body. It comes off of the heart in the chest, then loops around and descends in the body to level of the belly button. There it branches, with a main artery going down each of the legs. It gives off the blood supply to all the major organs including the brain, intestines, and kidneys. Below the kidney arteries it is called the abdominal aorta. This is the most common site of an aneurysm. At this level, the normal size of the aorta is approximately 2 centimeters. Therefore, when it reaches 3 centimeters in size or greater, it is called an abdominal aortic aneurysm (AAA).

Why is AAA dangerous?

As the aorta increases in size, the pressure within it builds up. Like a balloon, the larger it gets, the more likely it is to burst (rupture). When the aorta, which is the main blood vessel in the body, ruptures, it is almost always fatal.

What are the Risk Factors for AAA?

The most common risk factor is atherosclerosis, and therefore the risk factors are the same as those for all types of atherosclerosis:

• Smoking
• High Blood Pressure
• Diabetes
• High Cholesterol
• Family history of stroke, heart attack, or PAD
• Age (>65)
• Prior history of coronary heart disease or peripheral vascular disease (PAD)
• Obesity

In addition, there are risk factors specific for AAA:

1. Smoking – not only increases the risk of developing an AAA, but also increases the risk of AAA rupture.
2. Genetics – there is a strong family tendency to developing AAA. Individuals with a family member having an AAA have a higher risk of developing an AAA than the general population. They also tend to develop aneurysms at an earlier age, and have a higher likelihood of rupture.
3. Connective tissue disease – patients with diseases such as Marfan’s syndrome and Ehlers-Danlos syndrome have a higher incidence of AAA
4. Post traumatic – after injury to the aorta
5. Infections – infections of the aorta from things such as drug abuse, heart surgery, etc, can lead to AAA

What are the Symptoms of AAA?

The majority of patients with AAA has no symptoms and is diagnosed by accident when a patient has X-ray tests of the abdomen for other conditions. However, when they do produce symptoms, the most common is pain. The pain typically has a deep quality as if it is boring into the person. It is felt most often in the lower abdomen and lower back. The patient may also notice a prominent abdominal pulsation. Sometimes, if the AAA is large, it can causes obstructive symptoms such as difficulty urinating or moving one’s bowels. If a person experiences any of these symptoms, it often represents rapid expansion of the aneurysm and impending rupture, and he must seek medical attention immediately. Immediate medical attention can save your life.

How is AAA Diagnosed?

Sometimes a doctor can feel an abnormally wide pulsation of the aorta during a physical exam. Abdominal ultrasound is safe, painless, and noninvasive. It has a close to 100% accuracy in measuring the size of the AAA, and is the best initial test. Unfortunately, it cannot accurately define the extent of the AAA and is inadequate for planning intervention. Therefore, once the diagnosis is made, further testing, usually with a CT scan, is necessary.
A CT Scan is the most accurate test to define the full extent of the AAA and is essential before a doctor can recommend further treatment options.

Do I need treatment?

The natural history of AAA depends on there size and rate of growth. AAA is one of the most well studied diseases in vascular medicine. Over the years, many studies have given doctors good evidence that have led to generally agreed upon recommendations for treatment. AAA less than 5 centimeters in size almost never rupture. Once they become larger than 5 centimeters, however, the risk of rupture rises dramatically. In addition, AAA that grow rapidly, more than 0.5 centimeters in one year, have a higher risk of rupture. Based on this data, AAA that are less than 5 centimeters should be treated medically with close ultrasound surveillance. AAA that are greater than 5 centimeters in size, or that increase greater than 0.5 centimeters in one year should be surgically repaired. Obviously, any symptomatic or ruptured AAA must be surgically repaired emergently.
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How is AAA Treated?

Medial Therapy: Medical therapy consists of lifestyle modifications and close surveillance. Lifestyle Modifications:

• Quit smoking
• Control high blood pressure and diabetes
• Control high cholesterol
• Regular exercise

Medication: There are no medications that can prevent AAA or slow its growth. Aspirin is usually recommended to help improve the patient’s overall cardiovascular health. Surveillance: Patients with a known AAA should have ultrasound examinations on a 6 month basis. If at any time during this surveillance the AAA reaches 5 centimeters or shows rapid growth of greater than 0.5 centimeters, surgical repair is indicated.

Surgical Intervention: Surgical intervention involves replacing the diseased, enlarged aorta with a plastic tube (graft). This eliminates the pressure with the aneurysm sac, and subsequently the risk of rupture. Historically, there had only been one way to do this; open surgical repair. In the last few years, a new way to fix AAA has emerged as a viable alterative to open surgical repair, This technique is called endovascular aneurysm repair (EVAR), and involves placing a stent graft within the AAA through the arteries in the groin.

Open Surgical Repair: Open surgical repair has a long history and is a very durable solution to AAA. It is a major surgical procedure, and is very stressful to the heart and lungs. It is done in the operating room under general anesthesia with a breathing tube in place. A large incision is made vertically over the entire abdomen. The AAA is located, and the aorta is clamped above and below the aneurysm sac. The AAA is then opened, and a plastic blood vessel, called a graft, is sewn into the normal aorta. This completely removes the AAA from the circulation and cures the problem. After the surgery, the patients remain in the intensive care unit for about 3 days, and are usually in the hospital for 7-10 days. There is significant post operative recovery required, and often physical rehabilitation is needed. The patient will be ambulatory during this time, but a full recovery to a normal lifestyle can take up to 3 months.

Because this is major surgery, complications can include bleeding requiring blood transfusion, heart attack, kidney failure, and infections, Fortunately, these complications are rare. The good news is that the surgery is relatively common, very durable and is almost always a lifetime cure.Dr. Esposito is a board certified vascular surgeon, and has performed hundreds of successful open surgical AAA repairs. These procedures are performed at
Milford Hospital. Endovascular Aneursym Repair (EVAR): EVAR is a combined surgical and endovascular procedure. This means that it is performed from the inside of the blood vessel, using catheters, balloons, and stents. It is done in a specially equipped room, Specials Radiology, which is a combination X-ray room and operating room that is unique to Milford Hospital. The patient receives a spinal anesthetic and is awake for the procedure. Sometimes a light sedative is given.

A small incision is made in each groin and the arteries in the groin are exposed. These arteries are then accessed using a catheter. Using X-ray guidance, a plastic tube reinforced by a metal skeleton, called a stent graft (see picture at right) is positioned above and below the aneurysm. This stent graft is custom made for the patient’s anatomy as defined by the preoperative CT scan. Special balloons expand the stent graft and secure it in the appropriate position. This completely removes the AAA from the circulation and cures the problem.

This procedure is remarkably well tolerated, even by elderly patients with multiple medical problems. The typical recovery involves an overnight stay in the hospital. There is very little postoperative pain, and the patient is able to eat right away. The patient is typically discharged home after breakfast the day after surgery, often less than 24 hours after being operated upon. The patient can resume normal activities right away. The main risk of the surgery is that the stent graft will be unable to be deployed, or that injury to the aorta can occur. This may lead to conversion to an open surgical repair. Fortunately, this is an exceedingly rare occurrence. After surgery, the patient will need routine surveillance of the stent graft by CT scan to ensure that the graft does not leak or move its position.

EVAR is a relatively new procedure that has only been approved for use in the United States since the late 1990’s. There is no conclusive evidence that it is superior to surgery. Everyone is not a candidate for EVAR, and this decision is made based on the anatomy of the AAA and the patient’s characteristics. It is usually reserved for older patients and those with serious medical conditions that would be at high risk for the open surgical repair. You should discuss these options thoroughly with your doctor before deciding on the most appropriate therapy for your AAA.

VIDEO: animated recreation of the EVAR technique