Variety of treatments available for problem veins

Host Amber Smith: From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Superficial venous diseases are a broad group of venous vascular disease that predominantly affect the body's lower extremities.

I'll go over the most serious of these manifestations with Dr. Anderson Anuforo. He's a chief resident in internal medicine at Upstate Medical University.

Welcome to "HealthLink on Air," Dr. Anuforo.

Anderson Anuforo, MD: Thank you so much for having me, Amber. It's my pleasure to be here.

Host Amber Smith: When we talk about superficial venous diseases, what does that include?

Anderson Anuforo, MD: So there are a couple conditions that are classified. There's a classification system that's from C1 to C6, and every one of those conditions are classified under superficial venous diseases.

So the way it progresses typically would be, it would start out something like, they call it a ... the medical name is not really important, but it's a very small vein, the smallest vessels, kind of like a star, and it all spreads out from the center, and that's the C-1.

And then it goes on to become a varicose vein. And that is commonly seen, it's deep blue, you see it under the skin, it's bulging, a little tortuous, kind of like veins clumping together. So that's kind of the next stage.

And after that, the leg gets a little bit more swollen. That's what they call venous edema. So it's basically leg swelling, and then it begins to get a little more discolored, darker.

And after that, if nothing is done at that point, it goes on to get some ulceration. And that's kind of like the last stage.

And sometimes it can get really bad. Thrombosis, that's a blood clot basically in the superficial veins. The common thromboses we tend to talk about are what we call deep vein (DVT, or deep vein thrombosis). The ones in the deep veins, like after long (airplane) flights, stuff like that. In these ones they have blood clots in the very superficial veins overlying the skin.

And that's another category of conditions that are classified within superficial venous disease.

Host Amber Smith: Varicose veins -- I've heard of that. Is that what you just described?

Anderson Anuforo, MD: Varicose veins are the ones in which the veins just under the skin. Typically, you would just see, like, a dark line, long dark line.

In this case, varicose veins are more serpentine and swollen and then distended, and it's more on the lower extremities, the legs and the thighs, because of the pressure. So people who stand upright for a long time tend to have it more from all that pressure of blood having to go against gravity.

Host Amber Smith: And I've also heard of something called chronic venous insufficiency.

Does that get dealt with as a superficial venous disease?

Anderson Anuforo, MD: It definitely is. It definitely is. So, if the pressure in the venous system is very high, over time, because veins have valves which help to ensure that blood flows in just one direction, from the body to the heart, unfortunately, due to certain conditions, a bunch of things could make that happen. The veins become incompetent, so they don't work as they should. And so there's a reflux. Blood flow goes backwards. Instead of going forward towards the heart, it goes backwards again due to the high pressure. And that's what chronic venous insufficiency basically is, that incompetence of the valves.

Host Amber Smith: As you're describing this, it sounds to me like some of these conditions can be serious. Is that right?

Anderson Anuforo, MD: Oh, yes. Yes, at the early stages, not as serious. But if nothing is done for some people, if there's a need for intervention, and nothing is done, it can get quite serious and can affect people's quality of life significantly.

Host Amber Smith: So at the earlier stages, is it considered a cosmetic thing, and if you just take care of it, it won't get worse, necessarily? Or is it a condition that isn't cosmetic, but it does need to be treated?

Anderson Anuforo, MD: At the early stage, actually, it is more cosmetic than anything. But there are some questions that you would ask patients or individuals who find this, like, do they have any of the risk factors for the progression of the disease?

And if they do have those risk factors, then some of them might need to be treated sooner rather than later.

It's very, very prevalent, actually. Millions of people have it all over the country, and not everyone needs to be treated for it. But if they do have risk factors for progression, then there might be a need for intervention.

Host Amber Smith: So who is at risk for a superficial venous disease?

Anderson Anuforo, MD: So I tend to classify this into those with modifiable risk factors and those with non-modifiable risk factors.

The non-modifiable ones, I'll start with that, is age. We cannot turn back the hands of time. Female sex tends to be a slightly higher risk. Family history is something you can't change; sometimes we've seen that people who have family history of these varicose veins and venous issues tend to have it appearing in their children. There are some genetic conditions; the names are not important. There are a bunch of names I could start reeling out now, but basically these names, they affect the structural integrity of the superficial veins, and that increases the risk of people that have those diseases having superficial venous diseases.

But thankfully, there are a number of modifiable ones that people can do things about, things like smoking, prolonged standing, prolonged sitting. If they have certain heart conditions like heart failure, situations like that, treating those underlying issues will also help. Deep venous thrombosis is also modifiable because there's treatment for that. And if you're able to treat that, it might help improve the superficial venous disease. It's also found to be more common in pregnancy, so that's another risk factor.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith.

I'm talking with Dr. Anderson Anuforo about superficial venous diseases. He's a chief resident in internal medicine at Upstate.

So how are these diseases diagnosed, or how are they recognized? Is it usually a primary care provider that notices it, or do patients experience some symptoms that bring them to a doctor's office?

Anderson Anuforo, MD: That's a great question. There are symptoms associated with it, things like leg swelling, the leg pain. Sometimes you can visibly see the abnormal veins, or you can actually feel it. In cases of, like, blood clots in the superficial veins, you can feel it when you touch it, that this is hard, it's not like a regular vein that collapses.

Some people might also have increased pain in their legs, and then they might complain of that to their primary care provider. So I think a good number of these cases are picked up by primary care providers.

However, in the more advanced stages, then a couple different subspecialties start getting more involved, like vascular surgery, wound care and some portion of interventional cardiology. Some people do superficial interventions, so there is that overlap. So it's multidisciplinary, but primary care does see a significant number of these.

Host Amber Smith: Is there any testing that goes into diagnosing?

Anderson Anuforo, MD: Oh, yes. Oh, yes. So first-line tests would be an ultrasound, basically just a basic ultrasound of the superficial veins, and then checking to see how the blood flow is between the superficial veins and the deep veins, which typically they're connected by what they call the perforator veins. Just imagine a superficial one, a deep one, and then something -- a bridge -- between both of them.

And these are evaluated using ultrasound. And on the ultrasound, you can also check to see flow, and so you can also diagnose something like the chronic venous insufficiency based on the reflux in the veins.

So that's first line. There are some more advanced things (tests) like MRIs and CTs. There's a procedure called plethysmography, which you measure the pressure within the vein. It's more advanced, but first line would be an ultrasound.

Host Amber Smith: Well, let's talk about what treatments are available and how effective they are.

Is there a gradation? Do you start with a certain thing and see if that works and then move on?

Anderson Anuforo, MD: It kind of depends on which of the superficial venous diseases that we're dealing with.

So, like I said, the CEAP, that's the common "clinical, etiological, anatomic and pathophysiology," that's the name of the classification -- based off of that, if it's a varicose vein or a reticular vein (visible but smaller than varicose veins), the more milder, superficial ones, a lot of times topical creams. There are a bunch of creams, azelaic acid, metronidazole cream. There are a couple of creams that work, and you might not need to do any medications or any interventions for that.

From varicose veins onwards, where you have, like, leg ulcers and all of that, there are other treatment options. Some are systemic: We take it like drugs, medications. So if it's like leg swelling, in that case, a water pill that helps people pee can help the swelling resolve.

There are some other, they call it medical foods; the trade name is Vasculera. It contains a flavonoid, which is some kind of chemical that helps improve the structure and the integrity of the vessels. And it can be used primarily or as an adjunct.

And then in patients who have the blood clots in those veins, for those who are at high risk of the blood clot going on to become a deep venous thrombus, a blood clot in the deep veins, or dislodging and going to the lungs, for those patients, there's also a role for using a blood thinner for a short period of time.

So those are a couple of the treatment options, pharmacologically. There are a bunch of newer interventions that are usually within the field of vascular surgery or wound care or interventional cardiology, as well.

Host Amber Smith: Do compression stockings offer any assistance?

Anderson Anuforo, MD: Oh, they definitely do. That's one of the first-line things, in addition to lifestyle modification, so trying to minimize prolonged standing, prolonged sitting, compression stockings are among the first line of things that help with swelling, varicose veins, even, like, venous ulcers. Even at pretty much the last stage, compression stockings are still first-line treatment for a bunch of patients.

Host Amber Smith: Can any of the conditions that we've talked about be reversed with diligent treatment?

Anderson Anuforo, MD: Oh, yes. Oh, yes, especially if it's found earlier. There are a good number of these situations with lifestyle modifications and treatment, you're able to significantly reverse the trend and help prevent newer ones from forming. Because just because it's on one leg doesn't mean it cannot appear on the other one. And so with lifestyle modifications and things like that, compression stockings and adhering to whatever treatment regimen is provided by the providers, that might also help reverse the trend.

Host Amber Smith: So that's encouraging.

Anderson Anuforo, MD: Yes.

Host Amber Smith: You had a paper on this subject published in the Annals of Vascular Surgery Journal, and you mentioned a growing clinical and financial burden of superficial venous diseases. What did you mean by that?

Anderson Anuforo, MD: Not really surprisingly, a good number of these cases are actually undiagnosed, because some people see it on their body, and they never bring it up with their primary care provider, so it's significantly underdiagnosed.

However, for example, like varicose veins, about 150,000 new cases of these are diagnosed every year, and health care costs are close to $500 million every year. And that's just for that.

If we go on to talk about chronic venous insufficiency, like the incompetent veins and how much more it runs into millions and millions of hundreds of millions of dollars, and possibly even into billions of dollars, if we begin to factor in how these diseases affect the lifestyle and the productivity of these individuals.

It can have significant, far-reaching effects.

Host Amber Smith: Do health insurers typically cover care? I mean, if we talk about varicose veins, for instance, is a health insurer going to pay to have someone's veins taken care of?

Anderson Anuforo, MD: So for most of the creams and the medications, oral medications, a good number of that is covered by insurance.

However, when we start getting to the interventional things, a lot of fancy names -- so there are thermal interventions and there are non-thermal.

So thermal, basically they use heat to burn up the veins and then close it up, and then that way it's almost like it gets squished, and it doesn't open up anymore, so blood is forced to go through the veins that work and not through the ones that are incompetent. So endovenous laser ablations, microwave, radio frequency, steam are thermal options. Some of these are not covered, especially by Medicare, so that can be a challenge for the patients.

There are other sclerotherapies where we don't use heat. They use different chemicals that also cause the same, pretty much the same, effect.

And it kind of depends. But there are some of them that are covered by insurance and some are not.

Host Amber Smith: It sounds like there's a lot of options out there and that patients really need someone like yourself to kind of guide them to what would help in their situation.

Anderson Anuforo, MD: Oh, yes. There are a lot of options out there, and thankfully, there's a lot beyond myself; there are a lot more providers, and it's multidisciplinary. A lot of different specialties get to see different people at different stages. like for example, the wound care team also sees some people with advanced ulcers. And there are artificial skin graft substances that are also used in caring for patients with superficial venous diseases.

But there are definitely options and providers out there, unified, willing to help and provide hope to these patients.

Host Amber Smith: Dr. Anuforo, I appreciate you making time for this interview.

Anderson Anuforo, MD: It was my pleasure.

Host Amber Smith: My guest has been Dr. Anderson Anuforo. He's a chief resident in internal medicine at Upstate Medical University.

I'm Amber Smith for Upstate's "HealthLink on Air."

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