Ep. 26 - LiveWell Talk On...Varicose Veins
Host: Dr. Dustin Arnold, chief medical officer, UnityPoint Health - St. Luke's Hospital
Guest: Dr. Richard Kettelkamp, cardiologist, UnityPoint Health - St. Luke's Cardiology
Dr. Arnold: This is LiveWell Talk On…Varicose Veins. I'm Dr. Dustin Arnold, chief medical officer at UnityPoint Health - St. Luke's Hospital. Varicose veins on one or both legs can be extremely painful, limit activity, not to mention unsightly. Joining me to talk more about this is cardiologist Dr. Richard Kettelkamp from UnityPoint Health - Cedar Rapids Heart and Vascular Institute as well as St. Luke's Cardiology. Thanks for taking the time to talk today about this topic.
Dr. Kettelkamp: Sure, Dustin. It's nice to be here.
Dr. Arnold: What sets someone up to have varicose veins?
Dr. Kettelkamp: It's typically genetic and it can also be an occupational hazard. So statistically if one parent has varicose veins, you have about a 50% chance or likelihood of getting them yourself. And then if both parents have varicose veins, you have about a 90% chance of having them kind of, regardless of the occupational hazard. Which you know, segues into the other risk factor and people who are in a dependent position for long periods of time. So they're working on a factory line there working in retail. Perhaps they're a barber cosmetologist and they're on their legs for long periods of time. Nursing is another risk factor. That can lead to congestion and varicose veins.
Dr. Arnold: You hear the term spider veins. Is that a varicose vein? I mean, is that the same thing? It's a venous pressure.
Dr. Kettelkamp: For all intents and purposes, it's a sign of venous insufficiency. A Smaller vein than a varicose vein, but it is a sign of passive congestion and it's an engorgement of blood that causes these little, smaller veins to become bigger and they look like little spiderwebs.
Dr. Arnold: But now patients can have venous insufficiency with swelling in their legs without varicosities, correct?
Dr. Kettelkamp: Right. So there's a lot of different presentations. Edema and swelling is one of them. Discoloration of the gaiter region of the leg, which is the area of the leg from the knee joint to just above the ankle. And people can get this ruddy purple red complexion, thickening of the skin. That's a sign of longstanding passive congestion of the legs from venous insufficiency. Of course you can get the edema, which is typical where you push your fingers into the in front of the tibia and you'll see a indentation. Then of course there's the large, big lumpy veins and spiders.
Dr. Arnold: And I think people you might not even know this statistic, but your five-year mortality, five year chance of death with a venous ulcer is higher than a heart attack.
Dr. Kettelkamp: I believe that. Well and as with your wound experience and expertise, a lot of vascular wounds, the vast majority of vascular wounds are venous in origin, correct?
Dr. Arnold: Correct.
Dr. Kettelkamp: Very few of them are were actually arterial in origin. Most of them are venous and those, that's the most dreaded and the worst form of complication related to venous insufficiency.
Dr. Arnold: And I think that it's hard for patients because, and I'm going to ask you next about how to treat these, is compression is the primary treatment for that.
Dr. Kettelkamp: For wounds? Yeah, absolutely.
Dr. Arnold: I tell patients that, you know running water doesn't freeze. And if you have this kind of chronic high blood pressure in that vena system, it's oozing across that wound, it's never going to close. And that we need to put that pressure on that. So along this pressure mentality, so you have this back pressure in the legs from standing. There are medical conditions, we're going to get into some of those, but how do you treat varicose veins?
Dr. Kettelkamp: So there's conservative treatments and there's invasive treatments. The conservative treatments are what we start with. Considering that varicose veins primarily are a gravity problem. Most people, you know, if you lead in your bed all day, you wouldn't have an issue with passive congestion and varicose veins.
Dr. Arnold: You'd pick up some other health problems.
Dr. Kettelkamp: There'd be other issues, cubitus ulcers and you know, a variety of others. Preconditioning might be one of them. So gravity will help. So if you can get your legs up whenever you're reading a book, watching television, put your legs up, try to get your ankle above your knee, knee above your hip, and let gravity help. So that's important to keep in mind. Trying to avoid those things that cause passive congestion, sitting at a desk for long periods of time. If you're stuck at a desk job, get up several times every hour and just make a lap that keeps blood moving.
Dr. Arnold: So let's stop right there. So you know, I've come to learn after almost 25 years in practice, patients love specifics. So every 20 to 30 minutes, every get up every 20 to 30 minute, is that your recommendation? Reasonable?
Dr. Kettelkamp: Yep. And as long as your boss doesn't wonder where you're off to, you know, make a bathroom break, make a coffee break, but get up and move and it doesn't have to be very far and very long. Just, you know, a couple of minutes, a lap around your cubicles is probably enough. So elevation. Walking is important. And so aside from just walking a little bit at work but half hour everyday would be great. And a half hour of moderate exercise is great for everybody for a number of reasons, but it's good for the varicose veins as well. You mentioned compression stockings, that's kind of the mainstay of treatment. There are sort of universally hated but they work and so the struggle is getting them on and getting them off. But the intent is to put them on first thing in the morning when your legs are skinny and then take them off in the evenings when you can get your legs up and relax for the night. And that really helps. People will notice their legs are less congested, less heavy, less tired and fatigued at the end of the day if they wear stockings. Smoking is an important risk factor too. So quitting smoking, like for everything is better for you, but it does lead to varicose veins, and insufficiency. So those are the mainstays of noninvasive therapies.
Dr. Arnold: Okay. Then what if I've failed that or I have persistent symptoms? What's the next step?
Dr. Kettelkamp: First is kind of mapping the veins, looking at the veins and finding out what the culprit is. You know, what is it? Is it a superficial vein? Is it the varicose vein? Sometimes we have these large the varicose veins themselves are the problem. And so the focus for treatment is that sometimes some of the deeper veins the saphenous veins are what they're called, can be insufficient, not work and lead to varicose veins and swelling and edema and wounds. And so we do an ultrasound to assess that. We do a venous insufficiency study. That takes roughly half hour, 45 minutes per leg to do. But it's a fairly complete study and looks at how well the veins carry blood back to the heart against gravity. And then we get a sense of what vein is involved. And then there's a number of invasive treatments that we can do. We can ablate a vein that's insufficient. So back in the day when mom and dad had varicose veins, they potentially had vein stripping, which was done in the surgical suite. That was a big procedure that honestly wasn't that effective.
Dr. Arnold: No. You see the people decades later and it's the same problem.
Dr. Kettelkamp: Yeah. And that's because the, a little bit technical, but the venous sheath was still intact. And so this fascial connective tissue that held the vein in place was still there and then it just sort of took over as the vein. And so that's why varicose veins just, it was about 50% effective at one year, so they weren't that effective. But ablation works the same idea, the same ideas to ablate or get rid of the vein. That's the culprit.
Dr. Arnold: And how do you do that?
Dr. Kettelkamp: So it is a small little catheter that's placed in the vein, kind of down by the ankle. We will place a catheter up towards the top of the leg, right up in the upper thigh. And then either the vein is glued shut with the surgical glue called a venous seal. Or it could be used with heat energy. So either a laser or radio frequency, heat is administered to the vein after we place a little bit of a tumescent and an anesthetic around the vein, that causes the vein to collapse on top of the catheter. Both are very effective. They ablate or collapse the vein and the vein remains collapsed. The success rate is about 98% at five years. So it's very successful. It works really well. It's an office based procedure. It takes roughly half hour to 45 minutes or so to so it's easy.
Dr. Arnold: First question that would come up. What's the recovery time?
Dr. Kettelkamp: Not much for recovery. We have you wear the stockings day and night for two days, but we do want you to get up and walk. Just do your normal activities. Probably don't go out and play full court basketball the first day or two. But just your normal modest, moderate activity shouldn't hold you up at all.
Dr. Arnold: And can you have both legs done if that's required on the same day?
Dr. Kettelkamp: Potentially. It depends on what procedure, how it's done. If it's done with glue, then typically we can do it on in one day with both legs. If it's a patient that we feel that ablation is a better form of treatment, the limiting factor is how much lidocaine we can give. And so if a person, they're very tall, it may take too much lidocaine to do two saphenous veins in one session. So that's sort of the limiting factor. But we often do that and we often will couple of ablation with something called phlebectomy. And phlebectomy is a procedure where the vein is actually removed with a tiny incision in the skin. We put a numbing solution underneath those large, lumpy varicose veins, make a tiny little two millimeter incision and use a surgical hook and pull the vein out. And that is very effective at removing the very large varicose veins. And so we often will combine an ablation procedure with phlebotomy and that's very successful.
Dr. Arnold: So the ablation prevents blood from traveling down that vein in a back pressure sort of fashion?
Dr. Kettelkamp: Right. So, so it seems sort of counterintuitive to me that you remove a vein because your veins don't work well. But the problem is actually the vein. So if you think about it, the vein is supposed to act like a river. It's supposed to carry blood back to the heart. The problem is, is the vein that's big and dilated and not functioning normally. It's more like a reservoir. Blood is just pooling in that vein all day long. And it's the problem. That's what's causing the edema, the swelling, the pressure, the congestion that varicose veins. And so if you can drain the reservoir, you can solve the problem. And people always wonder. So how does the blood get back to the heart? Well, it already is. It's already found a detour, right? That blood is just stuck there all day long. It's not moving. So that blood is harbored inside that vein. That vein isn't contributing to the blood return at all. So what happens is your deep vein in the leg, even without the saphenous veins, does about 90% of the draining of the blood. It easily takes over. So the blood gets back to the heart. And so that's not a concern, but again, it seems sort of counterintuitive.
Dr. Arnold: Okay. Yeah, it does. And so when patients, they used to donate their saphenous vein for bypass surgery. Not as common anymore, but used to be. That leg would typically swell compared to others. How's that different from the varicose treatment?
Dr. Kettelkamp: Because over time, so they won't harvest a saphenous vein that's not working properly for bypass surgery because those veins aren't good conduits. They're big and dilated and they don't move blood very rapidly, but they'll take a competent saphenous vein. And so if you remove a competent or a functioning saphenous vein from a leg that contributes roughly 10% of the draining of the leg. And although the deep system will compensate, it hasn't had time to develop that, just like collaterals develop in the heart. It takes a while for the deep system to compensate for it. But if you do it, just like that, it has an added chance to develop a competency.
Dr. Arnold: I would say it's a significant minority of saphenous vein harvest for bypass these days. Right? And most it's radial artery.
Dr. Kettelkamp: A lot of times it's radial artery. To some degree, you know, fluctuates surgical preference. I would say almost all bypass surgeries still involve some saphenous vein harvest. The interesting thing is they just use short segments now. Instead of harvesting the whole thing. Back in the day, we'd have these post bypass patients who had a scar from their upper side down to their ankle where they harvested the saphenous vein. Now it's a tiny little incision and they may take a little four centimeter segment and that's all they need.
Dr. Arnold: Okay. Alright. Wow. Different topic, but good answer.
Dr. Kettelkamp: Yeah. But it doesn't lead to as much edema.
Dr. Arnold: So when is varicose veins not being insufficiency ulcers, just lumpy bumps. When is that a sign of significant disease? Meaning, let me clarify that Dr. Kettelkamp. I have varicose veins. Let's say but I feel fine. I mean, is there a time when I say, you know, I have these varicose veins and this could be a harbinger for something else. I should talk to my physician? What's your answer to that question?
Dr. Kettelkamp: So varicose veins, as you know, as we alluded to at the beginning, it can just be a genetic thing. You know, you inherited it from mom and dad and, and it doesn't necessarily mean that there's anything else dangerous or looming. You know, you may think about, okay, well I should probably quit smoking. And that's a great idea for lots of reasons, but it could also contribute to the varicose veins, but as a sign or a marker of other more dangerous things looming, unlikely. So varicose veins can just happen and they're an occupational hazard and a genetic predisposition. And I remind patients, varicose veins themselves aren't dangerous. If they're painful, if your legs get heavy, tired, fatigued, they burn, they itch, uncomfortable in some way. Typically towards the end of the day as you've been on your feet all day. Well that's symptomatic venous insufficiency or it could be. And that warrants treatment, but asymptomatic varicose veins, they don't bother you. It's not necessarily something to worry about. But that said, if you're in a particular job that's a hazard for development of varicose veins, you probably ought to think about treating them, you know, compression, stockings, elevation and exercise.
Dr. Arnold: Good advice. You know, I can't remember the details so I probably shouldn't even bring it up, but I will. Over in the quad cities, maybe 10 years ago, they had this elderly couple came home and there was blood all over and they thought they were investigating it as like a possible murder scene or satanic rituals. And it has turned out that the, the elderly woman in the couple had a varicose vein that was painlessly bleeding and you know, she just walked around the house and just spurting venous blood everywhere.
Dr. Kettelkamp: Well that's a good point. Now that's considered symptomatic though, that's legit. And so women who shave their legs, if you have this particular varicose mean that you typically, you'll cut when you shave your legs. That's enough to say, let's do something about it. Sometimes varicose veins, they don't necessarily hurt, but they're just an annoyance because they're right at the elastic area of your underwear or whatever. You know, there's a number of reasons why varicose veins can be a problem. Once in awhile, varicose vein leads directly to an ulcer.
Dr. Arnold: Yeah. I mean, I see that over in the wound clinic. Right. I would from wound clinic experience. I would probably recommend to patients that if you have varicose veins or swelling in a singular leg compared to the other without an explanation that probably should be investigated.
Dr. Kettelkamp: That's a good point. No, you're absolutely right. Because that could be, it could be trauma, but it could be a history of a deep vein thrombosis or you know, a number of things. Even genetic or something like that.
Dr. Arnold: Like a may-thurner, where they have the anomalies of the iliac. I've seen patients that recurrent DVTs in the left, treated, recur, chronic Coumadin and all they needed was a peripheral intervention to get that. Because I think they need to stop and think about that. Well Dr. Kettelkamp, really great information today. Thank you so much for taking time out of your busy schedule to discuss this. Again, this was Dr. Richard Kettelkamp, a cardiologist from UnityPoint Health - St. Luke's Cardiology and the Heart and Vascular Institute. If you have a topic you'd like to suggest for our talk on podcast, shoot us an email at email@example.com. Let me encourage you, tell your family, friends, neighbors, strangers about our podcast. Until next time, be well.