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    Avoiding pitfalls of venous disease requires deliberate approach


    New York — From diagnosis to treatment of leg veins, avoiding pitfalls requires attention to detail, according to an expert.

    For starters, says Todd V. Cartee, M.D., “History and physical are critical when evaluating any of your patients with leg vein disease.” He is assistant professor of dermatology at Penn State Hershey Medical Center, Hershey, Pa.

    Commonly, he says, patients present seeking cosmetic treatment of spider veins. In such cases, Dr. Cartee says it’s critical to establish whether their problem is purely cosmetic or deeper. In this regard, “You can be fooled and wind up treating the symptom of a much more significant disease.”

    To help determine which patients require referrals for vascular studies, Dr. Cartee offers the BEDPANS mnemonic: look for Bulging varicosities, Edema/stasis dermatitis, DVT (history of), Prior sclerotherapy (unsuccessful), Ankle telangiectasias, Nature (family history) and Symptoms.

    “Spider veins localized around the medial ankle are a reliable indicator of great saphenous reflux,” he says. Similarly, if everyone in a 35-year-old patient’s family has varicose veins after age 60, “She’s probably on that trajectory; the spider veins are just the beginning.”

    Such patients often already have some underlying saphenous vein leakage, he says. “If you don’t address that and just go after the spider veins, patients are unlikely to get a durable response.”

    Spider veins and reticular veins

    For spider veins and reticular veins of the leg, Dr. Cartee says, visual sclerotherapy represents the gold standard — but only for patients who have no underlying saphenous vein insufficiency (failure of valves within the vein that allows retrograde blood flow away from the heart). Correct technique includes treating feeding reticular veins before spider veins, he says. Agents approved by the Food and Drug Administration for this indication include sodium tetradecyl sulfate and polidocanol.

    “Both are very effective and can be used as foams, which offer additional advantages for treating larger vessels,” although the foam technique is an off-label use, Dr. Cartee says.

    Because foamed sclerosants do not mix with blood, they push blood out of the way, increasing the time that the sclerosant is in contact with the endothelium, according to Dr. Cartee. This effectively doubles their sclerosing power compared to the liquid form; however, he says, foam may be too potent for fine telangiectasias, causing transparietal burns, extravasation of blood, and untoward side effects.

    Foam sclerotherapy, while in general very safe, has been associated with rare adverse neurologic events. A recent comprehensive review showed that foam sclerotherapy can produce temporary visual disturbances in 0.9 to two percent of patients (Willenberg T, Smith PC, Shepherd A, Davies AH. Phlebology. 2013;28(3):123-131). Experts previously blamed gas emboli for this side effect, Dr. Cartee says, but this review noted an additional, more satisfying explanation: systemic spread of locally induced vasoactive mediators, especially endothelin, which can trigger a migraine with aura in susceptible patients. No patients in the review experienced any lasting visual or neurologic effects.


    John Jesitus
    John Jesitus is a medical writer based in Westminster, CO.


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