In this episode of PodMD, specialist phlebologist and qualified general practitioner Dr Farshid Niknam will be discussing the topic of chronic venous disease, including what chronic venous disease is, the risks of the disease, warning signs that patients can look out for, when to refer and more.
Please note this is a machine generated transcription and may contain some errors.
*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMD studio Dr Farshid Niknam
Dr Farshid Niknam is a Specialist Phlebologist and qualified General Practitioner providing care in Perth and the surrounding areas.
Dr Niknam started his specialist training for Vascular and vein surgery in Sydney since 2016 and continued in Perth. He completed his fellowship of the Royal Australian College of General Practitioners as well as an Advanced Diploma of Phlebology at the Australian College of Phlebology. Dr Niknam has also had specialist training in Vascular Ultrasound and Ultrasound guided procedures.
Dr Niknam has a wealth of experience and has practiced at Wollongong Hospital and St George Hospital for over five years. He has trained generally in Vascular Surgery and has had extensive training and experience in the specialist area of Venous Disease.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.
Farshid, thanks for talking with us on PodMD today.
Farshid: Thank you for having me.
The topic of today’s discussion is chronic venous disease. Farshid, Can you describe for our listeners what chronic venous disease is?
Farshid: Chronic venous disease, as the name explains, is a long term problem in the venous system. Venous system is the blood vessels that takes blood flow from the limbs and extremities up to the heart. The venous system has two different level, deep system and superficial system and they are connected to each other and they work together and they help the blood flows up to side to the heart and is a unilateral circulation system.
The problem starts when this uni-directed blood flow doesn’t go properly and it starts basically what we say reverse flow. There is a few reasons for that. One of them is the valves that are normally in the venous system superficial and deep, they start not to work properly and they basically blood flows backward as a reverse flow. What it happens it’s basically increase the pressure in the vein system, and that vein is pressure in the venous systems from the deep systems comes up to the superficial system, and that’s where the problem starts.
And this is basically it’s a, it’s a spectrum. It starts from the minor symptoms like a very tiny capillary vessels gets visible under the skin or starts getting a little bit of bulging veins. That what we say varicose veins or starts causing some symptoms, like a crampy leg and heaviness on the legs or itching. And if it’s progress during the time, it can cause some skin changes like, you know, pigmentation of the skin and causing some thickening of the skin that we say [inaudible]. And if it progresses more and more and nothing to basically down for that it can end up with an ulcer in the limbs.
And the other reason for the Venus chronic venous disease is having some sort of blockage in the system. It can be deep or superficial, but mainly deep system blockage creates the pressure back to the superficial system that shouldn’t happen in normal patient. Blockage can be just a deep vein thrombosis or it can be because of any sort of pressure on the deep system like having mass or having any sort of lymph node on the deep system.
How would a patient with chronic venous disease typically present?
Farshid: Chronic venous disease, as I explained earlier is a spectrum of the symptoms. And the patient, the first thing that the patients noticed by themselves, they see a little bit tiny capillary vessels under the skin, that what we say spider vein, that can be red or purplish colour or they feel some sort of bulging vessels under the skin that mean it’s a varicose vein, that’s well known. And usually people say varicose vein.
This other symptoms that is very important to consider by the patients and the GP’s are the heaviness on the leg, having some sort of crampy pain, itchiness on the lower limbs and restless leg. And as I said in the long period of time they can cause some skin changes like pigmentation of or brownish colour of the lower limbs or thickening of the skin, that was we say like the lipodermatosclerosis. And end of the spectrum is having ulcer, and basically non healing ulcer, that’s is a big problem if goes to that level.
What are the risks of chronic venous disease?
Farshid: Depends to the level of the progress of the disease. As I said, the first few symptoms like spider and varicose vein till all set at the end of the spectrum. The risk will be having clot in that bulging veins that because the blood hangs there and doesn’t flow as normal and it has a tendency to get clot. And that club from the superficial system can progress to the deep system, and that’s what we say deep vein thrombosis or DVT. That clot, if it’s basically progress, it can end up to having a clot in the lung and it can be life threatening.
It starts from the superficial system, but it’s there is almost 5 to 10% chance to end up to the big life-threatening situation like pulmonary embolism or PE. That’s the one of the main risk factors. Uh, sorry risks and the other risk is having some sort of bleeding from the veins because they are very fragile and superficial with any minimum trauma they can get damaged and they bleed badly and a lot. And the other problem can be having ulcer on the leg and and losing the healthy condition of the skin during the time and end up having some sort of starts from the changing of the skin like eczema type that what we say venous eczema and progress to the having a ulcer. These are the risk if you don’t treat the venous condition on time.
What are the treatment options?
Farshid: Treatment options are divided in two category. One of them is a conservative, and that’s for the people who have just starting having some symptoms, minor symptoms like a spider vein or having some crampy or itchy leg end of the day. Lifestyle modification is the key. Having some regular exercise to do and losing a little bit of weight if someone is overweight and using some compression stocking that helps basically during the day if they wear it. Even below knee is enough for most of the patients. These are the conservative management.
There is some medications that none of them basically is covered by PBS in Australia, but in other countries as they get used, like [inaudible]. It’s not very commonly used in Australia anyway, and there isn’t a big evidence behind that, but the other side is intervention. Intervention from the old system that was surgery, now days it happens maybe less than 10% of the cases. That’s the just surgery ligation and stripping of the vein for the patient. That’s the hospital based operation that takes sometimes 24 hours to 48 hours admission to hospital. But the new modern intervention is what we say minimally invasive intervention that are again categorised in a few different level.
The best and the most used one is the thermal ablation of the veins that is with the laser. And abbreviation is VLA or using radio frequency to basically bend the vein internally and basically it’s a minimally invasive, on the local in the treatment room, doesn’t need admission, usually takes less than one hour. And most of the times patient can go back to normal activity next day.
And the other options, that is less get used, but they are getting progressing, is using a medical glue. Again, it’s a minimally invasive just using with the needle that helps for the some cases not for every case. And using type of medications that we say [inaudible], that’s the chemical medication that basically bands again or chemical band for the vein from the inside and all of the non-invasive treatments, the vein stays inside the body. Nothing comes off and the body looks after the damage vein and slowly, slowly basically absorbs the vein. That’s the what at this stage is available as a treatment for the varicose vein.
Have there been any developments in treatment in the last years or are there any in trials or development now?
Farshid: The development mostly is on laser technology and RFA technology, but laser is taking over most of the cases these days because the technology is progressing in that level higher and the outcome is marginally better than the radio frequency. It’s over 95% success in treatment in for five years. Basically, what we do, one of the follow up system that we have, we just see in next few years usually five years is the standard time after the intervention to see what’s the outcome and what’s the progress of the disease.
Laser taking over most of the other interventions. And there is a new technology on the laser, it is getting better, smaller size of the basically fibre and they have a technology changed and it’s getting more closer to the where exactly we want to start lasering with the different laser fibres, that’s what we say [inaudible]. Laser is the main one and the other trial that’s recently is happening in last maybe 24 months is creating a new valve for people who has a valve damage that’s on the just the start of the trial, not many as far as I known in last months I had a look, less than 20 of them has been done in Australia and it’s very basically early stage to say how it will go and usually takes a few years to come to the outcome that is going to be successful or no and if it is, it takes a little bit longer to be more commonly done in the most of the hospitals in Australia.
Are there any warning signs a GP or their patient can look out for?
Farshid: The warning signs are the early-stage signs, as I said earlier, having some sort of heaviness on the leg, having pain or itchiness or skin changes on the mainly lower limbs and legs. The other signs that they can look it for having some sort of clot under superficial vein, mainly having some sort of redness pain. That means possibly there is a clot on the superficial system that, as I said, it can extend to the deep system.
The other important signs that usually gets missed by the patients is having for the ladies mainly having some sort of heaviness on the pelvis. And they usually they look for the different reasons like a gynaecological variance system or some sort of bowel disease. But there is a percentage of these patients have this heaviness and pain on the pelvis. That’s basically because of again, venous disease, that insufficiency of the ovarian vein that needs to be looked after as well, that they can end up to create some sort of again varicose veins on the lower limbs.
Or it can cause some heavy abdominal pain that just sometimes end ups to some sort of unnecessary operations like laparoscopy and things. Having early basically investigation for pelvic congestion syndrome. That’s heaviness of the lower limb, heaviness of the pelvis, is one of the, I think key points that can help for patients and the for the GP to find the answer for that problem.
What is the likelihood of recurrence of the condition?
Farshid: Unfortunately, chronic venous disease is a progressive disease. You treat it to prevent to go to the progress to the end of the spectrum. But even if you treat it successfully with the most, uh developed technology these days, is still there is a chance to recur, but most of the time recurrence is not from the where you have treated. Recurrence happens from the other branches that because there is a pressure internally and the pressure wants to basically escape from one point.
You have treated part of them that you have at the time, but still it doesn’t mean that that pressure is not going to cause further varicose vein or any sort of symptoms. Yes, there is a recurrence chance, but again, having the basically treating as disease progress is the key. Sometimes it can happen every few years, sometimes it can happens every few months, but usually as I said, the new technology, and particularly with the laser and RFA is a good success for 90-95% of the cases to control the problem, at least for five years
When should a GP refer?
Farshid: Referring a patient for assessment and treatment for venous disease, the short messages earlier is better. The reason is that when the referred early treatment is much simpler and less costly for the patient. And the patient can learn about how to prevent further complications. Plus, if they refer patients early, the patient will have very simple sometimes treatments and they get the most benefit of that, like progressive preventive type of intervention. Sometimes if referral gets late, the damage has been done, and reversing the damage is not as easy and is not as quick. It takes time to get reverse all the damage has been done. So earlier is better.
What role does the GP play in the treatment of the condition?
Farshid: I believe GPs has two main fundamental role in this condition. First of all, is diagnosing that that’s the problem is venous condition. And the second part is basically intervention as a basically lifestyle modification, like encouraging patient to lose weight if patient is overweight, encouraging patient to do some daily regular exercise, that’s all of them helps for the patient to prevent or at least prevent the progress of the disease. And then with the early symptoms that the patient develops, GP has a major role in referring patient to the right people or vein specialist to see the patient and start doing basic intervention early.
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on chronic venous disease and varicose veins?
Farshid: Sure. The first point is chronic venous disease is very common in the community, more than 50% of the people in one stage of their life will have some sort of venous disease. It can be very mild or it can be very advanced level. But it mainly happens in the ladies. That’s one thing that patients and doctors need to keep in mind.
The second thing is that part of the venous disease management is changing just the simple things like lifestyle modification like exercise, losing some weight and preventing the complication of the venous disease early stage with the minimum intervention.
The third one is that the venous disease is treatable and it there is a good the technology these days and a lot of knowledge to treat venous disease with the minimal invasive procedures, and they can access that with the referring patients on time and to the right person who have been trained to look after the vein disease.
Thanks for your time and the insights you’ve provided.
Farshid: Thank you