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Winter 2007

Venous Disorders Widespread and Undertreated

Venous disorders are exceedingly common, with more than 50 percent of the population showing some manifestions of these disorders, such as varicose or spider veins, by age 65. Venous disorders are often simply unsightly, but in many cases can cause leg pain, swelling, phlebitis, nonhealing ulcers of the skin and other serious problems. In the case of deep vein thrombosis, clots that break away can lead to death from pulmonary embolism.

Despite the very widespread and sometimes serious nature of venous disorders, they are not aggressively diagnosed or treated, UCSF physicians say. "For various reasons, patients often don't get to treatment centers that have expertise and interest in treating venous disorders," says Associate Professor of Surgery and UCSF vascular laboratory director Rajabrata Sarkar, M.D., Ph.D.

Part of the problem is that venous reflux, the most common cause of venous problems, is poorly understood, Sarkar says. "Most health care professionals don't understand the pathophysiology of the disease, and that often results in delays in getting the proper treatment."

Venous reflux (also known as venous insufficiency) occurs when venous valves don't function adequately, leading to reversal of blood flow through the valves during standing or sitting. Venous reflux most commonly occurs when vein valves weaken due to genetic influences or multiple pregnancies, among other factors.

Venous reflux is often self-perpetuating, as the pooling of blood in veins distends them, which pulls apart the valve leaflets of the next, lower valve and causes reflux farther down the leg. As blood pools in lower extremities, veins further swell, leading to pain, pigmentation of the skin and clots in the varicose veins (phlebitis). The high venous pressure in some cases can lead to nonhealing of simple breaks in the skin, which is seen as a chronic skin ulcer, usually around the ankle.

In simple cases, treatment for venous reflux can range from making lifestyle changes to use of compression stockings. In more complex cases, surgery may be required to correct the venous reflux and halt the progression of disease in the leg. Traditionally, one of the most common surgical procedures has been vein stripping, in which a vein-stripping tool is pulled through the great saphenous vein, removing the vein from the leg. More recently, vein stripping has largely been replaced by other vein ablation techniques.

Minimally Invasive Approaches

UCSF vascular surgeons are utilizing the latest technology to apply minimally invasive approaches to the treatment of venous disease. They have had great success with radiofrequency (RF) vein ablation, a technique in which a catheter uses microwave radiation to seal veins that have reflux.

The UCSF venous center has been growing rapidly. "In the last three years, the volume of cases has increased tenfold," Sarkar says. "Part of the reason is our expertise with minimally invasive technology, such as radiofrequency ablation, and part of the reason is that everyone is recognizing that they now have a single center dedicated to the proper diagnosis and treatment of venous disease of all forms."

Radiofrequency ablation allows clinicians to eliminate venous reflux with a needle puncture that is covered with a Band-Aid. Other procedures require two painful incisions. Patients undergoing RF ablation are back to work in two days, rather than three to four weeks, Sarkar says.

"The important thing for referring physicians to know is that we at the venous center have the experience to evaluate and treat large numbers of patients with a variety of problems," Sarkar says. "We can help by quickly identifying who needs advanced treatment and who needs simple reassurance or just lifestyle adjustments."

The venous center is also set up to best accommodate those who can't make frequent trips to UCSF. "Half our patients are elderly with limited mobility, and have a hard time getting to the center, and the other half work full time and can't easily get away from work," Sarkar says. "We offer a one-stop appointment, in which we perform a clinical evaluation, confirm this with an ultrasound examination, talk about the diagnosis, come up with a treatment plan and get them on their way."

To contact Dr. Rajabrata Sarkar, call (415) 353-2357.

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