By Joseph Magnant, MD, FACS, RPVI
I think it’s time to stop thinking about venous disease as limited to varicose veins. Of all the patients I see in my office, only about fifty percent of them have varicose veins, and the remainder have symptoms (what you feel) or signs (what you can see externally) of venous insufficiency other than varicose veins. These may include swollen and achy legs, restless legs, night time leg symptoms of cramps or frequent urination, or more severe stages of venous disease such as skin discoloration, vein bleeding and ulceration. Greater than ninety percent of the patients seen in our practice may have treatable superficial venous insufficiency.
There are many manifestations of venous insufficiency. Some of our patients experience restless legs. Other patients may have ankles so swollen that the calf and ankle appear to have merged as one, sometimes referred to as “cankles”. Other patients may experience extreme frequency of urination at night, while others have swollen, achy legs or bulging varicose veins. Rather than wait for complications of venous disease to consider evaluation, modern diagnostic and minimally invasive, catheter-based procedures have allowed vein specialists to take a more proactive, investigative approach to patients with suspected venous disease. We think of venous disease similar to how an internist thinks about high blood pressure or high cholesterol. Once we identify these medical problems in our patients, it is our responsibility to actively investigate and manage the medical problems to reduce the long term risk of complications. For the internist managing their patients, they are trying to reduce heart attacks, strokes and death. For the Vein Specialist, we seek to reduce the risks of developing intractable swelling, skin discoloration and thickening, vein bleeding or clotting and eventual ulceration and infections.
When it comes to patients with symptoms of restless legs syndrome(RLS), they may not have much in the way of external signs of venous insufficiency. In fact their legs may look “normal”.
When speaking to patients with RLS, I make a point of discussing the marked similarity of symptoms of RLS and those of patients with venous insufficiency. Since RLS is basically a diagnosis of exclusion, without any definitive tests to cinch the diagnosis, I generally recommend that before patients start taking prescription medication for RLS, they undergo ultrasound evaluation for venous insufficiency.
There is no downside to getting an ultrasound; there is no radiation involved, no needles, no pain, and it is a physiologic test which reveals which veins are leaking and how much they are leaking. If there is significant venous insufficiency identified by ultrasound the next step is begin a trial of compression hose therapy. If the patient experiences significant relief or improvement of their RLS symptoms, they should consider treatment of their venous insufficiency. Using this algorithm, we have found the majority of patients with RLS symptoms and venous insufficiency who undergo vein treatment benefit significantly.
Lisa, a 45 year old athletic nurse, was suffering with throbbing pain and fatigue in her legs.
“I just kept wondering why my legs were killing me. Wearing heels every day and constantly getting in and out of my car, I thought perhaps I needed to be wearing flats, that maybe there wasn’t anything else really wrong.”
She had researched RLS on the internet and seemed to have all the symptoms of RLS. According to the RLS Foundation, in order for patients to be officially diagnosed with RLS, they must meet the criteria described as follows:
1. irresistible urge to move one’s legs especially in bed at night
2. relief with walking or exercising the calf muscles
3. improvement of symptoms by the morning
4. worsening of symptoms during the 3rd trimester of pregnancy and improvement within 6-8 weeks post delivery.
Her primary care physician said that perhaps she did have Restless Leg Syndrome. Since she had visible varicose veins Lisa decided to see Dr. Magnant at Vein Specialists for further evaluation. She underwent venous insufficiency ultrasound examination which revealed significant leakiness in her veins. A trial of compression hose resulted in significant improvement of her leg symptoms including those of RLS. She then underwent staged treatment of her leg veins with endovenous radiofrequency ablation 2 weeks apart. Her response was almost immediate with relief of most of her leg symptoms within just a few days.
Although there are other factors thought to influence RLS there are no specific tests to confirm the diagnosis, which is why it is termed a “syndrome” rather than a “disease”. RLS medications are directed at treating the restlessness symptoms and often result in dulling of the senses and drowsinesss. Since there are symptoms of RLS are also seen in cases of venous insufficiency which can be definitively diagnosed with modern ultrasound techniques, we encourage patients to consider venous insufficiency as a potential contributing factor to their symptoms and consider a formal venous insufficiency evaluation by an experienced vein specialist prior to initiating medication therapy for RLS. We encourage patients who have already been taking medication for RLS to consider vein evaluation.
Dr. Magnant and Dr. Nero are board certified surgeons who specialize in vein disease evaluation and treatment. Vein Specialists has offices in Fort Myers and Bonita Springs, and their providers are 100% dedicated to the modern evaluation and treatment of patients with signs and symptoms of leg vein disorders, including Restless legs syndrome. Vein Specialists is the leading outpatient vein center in Southwest Florida complete with an accredited vascular diagnostic laboratory. They are committed to excellence in vein care and to the ongoing
education of physicians and the general public regarding the various presentations of venous disease, modern objective ultrasound evaluation and the latest available treatments. For more information about vein disease and Vein Specialists, please visit WeKnowVeins.com or call 239.694.8346.
Leaders in Vein Treatment
Joseph G. Magnant, MD, FACS, RPVI and Patrick A. Nero, MD, FACS, RPVI are both fellows of the American College of Surgeons and are board certified by the American Board of Surgery.
Dr. Magnant earned his medical degree from Medical College of Virginia. He completed a general surgery residency at Medical College of Virginia Hospitals and a fellowship in vascular surgery at Dartmouth Hitchcock Medical Center, Lebanon, NH. Dr. Magnant of Vein Specialists focuses exclusively on vein evaluation and modern treatments in a dedicated, outpatient, vein-centered facility. Dr. Magnant is an active member of the American College of Phlebology, Society for Vascular Surgery and Society of Vascular Ultrasound.
Dr. Nero earned his Bachelor of Science degree in Pre-Medicine from the University of Dayton in Ohio and his medical degree summa cum laude from The Ohio State University College of Medicine. He completed a residency in general surgery through the Phoenix Integrated Surgical Residency program.
Dr. Nero is a diplomate of the American Board of Surgery and a member of the American College of Phlebology and the Society for Vascular US. Dr. Nero joined Vein Specialists in 2016.
1500 Royal Palm Square Blvd., Suite 105, Fort Myers, Florida | 3359 Woods Edge Circle, Suite 102, Bonita Springs, Florida