A Q&A on Treatment of Symptomatic Varicosities of the Left Lower Extremity with Image Guided Surgery Associates’ Robert L. Worthington-Kirsch, MD

What type of venous disease did your patient have?
The patient is a 33-year-old male who has symptomatic varicosities of the left lower extremity. Varicose vein disease is more properly known as superficial venous insufficiency (SVI). The disease may be attributed to either malformation of a valve that controls the direction of blood flow in the veins of the legs, or an abnormality of vein wall formation, which make the veins more elastic than usual. A patient is most likely born with the problem, or a susceptibility to developing SVI later in life.

SVI is quite common. Around the age of 40, as many as 25% of men and 40% of women will have some evidence of SVI. The percentage will be even higher in older populations. In addition to being nearly twice as common in women as in men, the disease tends to be hereditary. At least 75% of my patients have a parent, grandparent, and/or sibling with similar problems. Obesity and repeated pregnancies can aggravate SVI, making the findings and symptoms worse. These issues, however, do not cause the problem.

What was your patient's history with the disease?
The patient has had varicose veins since early in his teens. He has no other health problems. The varicose veins have increased in size over the years. The patient has a sensation of heaviness and discomfort in his leg. He experiences these maladies at all times, except when he lies down and elevates his leg. His symptoms are relatively mild in the morning, but steadily worsen over the course of the day. The patient claims he can barely get through a day's work because of the discomfort. He maintains that the pain interferes with his job performance, which could result in a serious problem should the discomfort worsen.

The patient was seen by a vascular surgeon, who conducted a visual examination, but no ultrasound. His recommendation was to have the visible varicosities removed surgically.

Physical examinations indicate some mild swelling of the ankle and large varicosities on the anterior and medial aspects of the lower leg (IT Pre Lat.jpg and IT Pre Ant.jpg).

Ultrasound examination indicated the great saphenous vein (GSV) measuring 13 mm at the groin—normal size is up to 6-7mm (IT Uls1.jpg). There was bidirectional flow in the GSV, indicating that the valves did not function (IT Uls2.jpg). The GSV branches into the visible and palpable varicose veins just below the level of the knee (IT Uls3.jpg).

What treatments did you use?
After fitting the patient with appropriate compression hose, I performed endovenous ablation of the left GSV. The procedure, performed in the office under local anesthesia, took approximately 35 minutes. The patient went home after a 15-minute recovery period. He returned to work the next morning.

Two months after the endovenous ablation, the patient had 80% reduction in symptoms. In addition, the tributary varicosities were decreased by at least 50%. The residual visible varicosities were treated by a combination of ambulatory phlebectomy and injection sclerotherapy.

What were the results of your treatments?
The patient is now one year post-treatment. During his most recent visit, he stated that he has no symptoms. He is not only able to perform his regular duties, but he feels comfortable volunteering to work longer shifts. He has no visible residual varicosities (IT Post Ant.jpg and IT Post Lat.jpg).

What type of prevention do you recommend for this disease?
If the valve at the saphenofemoral junction was the only abnormal valve, the treatment I rendered should be permanently curative. I recommend annual or bi-annual visits for survey follow-up, though I would certainly want to see him if he develops any new or recurrent symptoms.

Robert L Worthington-Kirsch is Board Certified in Diagnostic Radiology with Subspecialty Certification in Vascular & Interventional Radiology. Dr. Worthington-Kirsch practices at Image Guided Surgery Associates, PC in Philadelphia, PA.