On Vein Problems of the Leg

     Over the last decade, there have been major advances in the minimally invasive approach to vein problems. The key to proper treatment is the correct diagnosis of the root cause of the vein problems of the leg. We start with a careful history and physical examination to identify risk factors along with the signs and symptoms of venous disorders. The next step is the use of noninvasive ultrasound diagnostics to create a road-map of the venous system to identify and locate valve dysfunction. Only then can an appropriate treatment plan be developed. If ultrasound evaluation identifies that the valves of the saphenous vein or perforator veins are not functioning normally, a minimally invasive catheter based treatment can be used. Radiofrequency ablation, the Venefit procedure, is the technique of choice for the NJ VeinCare to treat valve dysfunction resulting in reflux of the long and short saphenous veins along with the perforator veins. This treatment is covered by most health insurance plans!

     Venefit™ is a clinically proven, minimally invasive procedure that treats varicose veins and their underlying cause, venous reflux, with little or no pain. Venefit patients can walk away from the vein procedure and be back to everyday activities – either at home or at work – typically within a day.

     The Venefit procedure is the treatment for venous reflux and varicose veins patients seek when they want a minimally invasive treatment alternative with less pain and less bruising when compared to traditional vein stripping surgery and laser treatment. Using the Venefit system, physicians close the diseased veins by inserting the Venefit catheter and heating the vein wall using temperature-controlled RF energy. Heating the vein wall causes collagen in the wall to shrink and the vein to scar close. After the vein is sealed shut, blood then naturally reroutes to healthy veins with normal valves.

     The Venefit procedure does not involve pulling the diseased vein from the thigh as with vein stripping surgery, or using 700° C laser energy which boils blood to occlude a vein as with endovenous laser (EVL).4   In the RECOVERY Trial, a multi-center head-to-head comparative randomized trial comparing Venefit with EVL, the Venefit procedure was found to have less patient pain and less patient bruising than EVL for the best patient recovery experience available from a minimally invasive vein treatment.2  Additionally, in other randomized comparative studies have shown that patients receiving the Venefit procedure return to normal activity and work significantly faster than those receiving vein stripping.1

     The ClosureFast catheter, which represents the latest advancement in the Venefit procedure, has been shown in a multi-center study to have a 97.4 efficacy rate at one-year.3This shows that the treatment is highly effective.

     Venefit catheters are inserted into the vein via a tiny incision in the lower leg, eliminating the need for groin surgery and general anesthesia. The Venefit procedure is performed using local anesthesia in the office.

     Because treatment with Venefit is minimally invasive and is catheter-based, it results in little to no scarring.

     Venefit can be used for the long and short saphenous veins. In addition, incompetent perforator veins can be treated with excellent success using the Venefit technique. Dr. Nackman presented one of the first series of patients at a national meeting treated with Venefit for perforator disease.5

1. Lurie, F, et al.Prospective randomized study of endovenous radiofrequency obliteration (Venefit procedure) versus ligation and stripping in a selected patient population (EVOLVeS Study), J Vasc Surg 2003; 38(2):207-14.
2. RECOVERY Trial – Data on File – Venefit Medical Technologies, Inc.
3. Dietzek A, Two-Year Follow-Up Data From A Prospective, Multicenter Study Of The Efficacy Of The ClosureFast Catheter, 35th Annual Veith Symposium. Symposium. November 19, 2008. New York.
4. Weiss RA, et al. Comparison of Endovenous Radiofrequency Versus 10nm Diode Laser Occlusion of Large Veins in an Animal Model. Dermotol Surgery 2002; 28: 56-61.
5. Nackman GB, et al. Radiofrequency Ablation of Incompetent Perforator Veins. Presented at the 19th Annual Meeting of the American Venous Forum. Feb. 2007. San Diego, CA.

Looking for a last minute Valentine's Day Special? Call for an appointment and say "Valentine" for a 50% off special on any Cosmetic office treatment. May not be combined with other offers. One per patient.

On Competency

     What does it mean to be competent at something?  Competency may be defined as the ability to do something successfully or efficiently.  When it comes to determining if a physician is competent in his profession, no one, board, no organization, no government, no residency training program or hospital actually will state that an individual is competent.  There are significant legal ramifications to declaring someone as competent to practice medicine, and a mal-occurence  happens.  Would the organization that states a physician is competent become legally responsible?

     In medical school, residency and fellowship programs, trainees need to demonstrate proficiency in core competencies specific to medicine.  The ability to gather information, interpret the information and form a management strategy along with the ability to perform a variety of interventional tasks are inherent to the role of being a physician.  Medical students must pass national subject exams, national board exams, mock patient interview and physical exams.  Residents and fellow must pass annual inservice exams for advancement and board exams regulated by the American Board of Medical Examiners to become "Board Certified".  To take the board exams, one's residency director certifies that the trainee has completed and met the requirements of the training program. 

     The State mandates that physicians are licensed to practice medicine. One's application includes diplomas from medical schools and residency programs, and a certificate of completion from the national board of medical examiners.  One then is licensed to practice "medicine and surgery".  Most physicians practice beyond the four walls of their office and may have admitting and or operating privileges at a hospital or surgical center.  The assumption is that licensure and having one's "Boards" is a measure of competency, and for the most part it serves well.  

    In 1989, New York State enacted the 405 regulation, limiting resident work hours, as the result of a commission evaluating the causes of the death of the daughter of a prominent journalist at NY Hospital.  The commission blamed resident work hours and poor supervision for the death. This was a controversial finding with little data to support such sweeping changes. I was a junior resident at St. Luke's/Roosevelt Hospital center at the time, and we were very concerned about the impact on our training as surgeons.  A surgeon has to know a lot and do a lot.  Less hours in the hospital meant fewer chances to perform surgery and follow patients.  We worried that  when "on call" were covering far more patients than we normally did. Patients that we did not normally cover , so we were at a disadvantage in providing care.  We used to joke that "405" meant the 4th or 5th yr resident now did all the work, while the intern and junior residents went home.  The choice was between having a tired doctor that knew you vs. a less tired doctor that had never seen you before.

    In 2003, the Accreditation Council for Graduate Medical Education made the cap of an 80 hr work week mandatory nationally. Length of shifts were limited. Time off between overnight shifts required.  In a surgical residency, what had been a full time duty, had become shift work with penalties to the training institution for violation.  As a faculty member of a University, I was concerned that we were making a major change to how we train physicians without first defining how competent our current "product" was and not knowing if the decreased "time on topic" would result in less competent trainees.

     In a recent article in the New England Journal of Medicine (N Engl J Med. 2016 Feb 2), the end points of patient mortality and complications along with resident satisfaction were compared between surgical training programs that adhered to the work hour mandates vs. more flexible policies that waved the rules on maximum shift length and time off between shifts.  The results were that there was no difference in patient outcomes among the groups.  No mention or measurement standard was applied towards assessing resident competency.  Shouldn't the competency of residents be the subject in a training program?

Rosacea Facts

 Rosacea is a chronic inflammatory condition of the skin that effects millions of Americans. It may start as a general redness of the cheeks and nose. It may progress to bumps and thickening of the skin. It may be confused as "Adult Acne". It most commonly develops in people with fair skin in the 30-50 age group. The exact trigger for Rosacea is unclear. Rosacea can cause emotional distress and lack of self-confidence. There are treatments for Rosacea, but no cures. The redness and prominent visual veins of Rosacea may be effectively reduced with Intense Pulsed Light treatments. IPL is safe and effective in improving the appearance of Rosacea. Contact NJ VeinCare and Aesthetics Center for a free consult: 973-778-2222

Are You at Risk?

You just got home from vacation last night. You spent 6 hours on an airplane traveling back from some exotic location. In the morning you wake up with a painfully swollen left calf. Should you be worried? The answer is a resounding yes!

What is a DVT?

DVT or deep vein thrombosis is a life threatening medical condition with serious consequences that affects 2 million Americans each year. A blood clot forms in a deep vein within the leg or in some cases an arm. The most common presentation of a DVT is a painful, swollen leg. The clot can travel to your lung causing a PE or pulmonary embolism, which kills over 300,000 people in the US per year. That is over 7x the number of people that are killed annually in automobile accidents.

What is the postthrombotic syndrome?

DVT can also cause something known as the postthrombotic syndrome in the years following the event. This condition includes a painful swollen leg, itching, and difficult to heal leg ulcers near the ankle. It is caused by continued blockage of the veins or destruction of the valves in your veins that normally prevent blood from pooling down by the ankle. To avoid this condition, proper medical care is needed. Patients with DVT should be seen by a Vascular Surgeon to avoid this difficult to treat chronic illness. The best way of avoiding this condition is to use doctor prescribed compression stockings or socks following the DVT. Should you develop a leg ulcer following a DVT, there are new treatments that we employ to help heal the wounds in far less time than in the past.

What is your risk for DVT?

The best way of finding out your risk for DVT is to talk with your doctor. I have spent over 20 years taking care of patients with DVT. Sometimes the only risk factor is a long car or airplane ride during which the patient was immobile for many hours. There are known risk factors for DVT, and you should be aware of them. The greatest risk is recent hip or knee replacement surgery, serious trauma with a broken leg or pelvis bones, and spinal cord injury. Other important factors are a prior blood clot in you or a family member, a family history of clotting disorders, and age over 75. There are other less obvious health problems that also put you at risk for DVT: cancer, recent surgery, being in a cast, bed rest, being over age 60, the use of birth control pills, hormone replacement therapy, inflammatory bowel disease, being overweight, heart disease, lung disease, and even just garden variety varicose veins.

How is DVT diagnosed?

If you suspect you may have a DVT, it is important to immediately contact your doctor or go to an emergency room. Sometimes a blood test, known as d-dimer is done to see if you have a blood clot. It is considered a good, but not perfect screening test. A positive result in a patient whom the doctor expects has a DVT is a strong indication that a clot is present. However, a negative test in a patient that the doctor has a strong suspicion of DVT is not enough to rule out that diagnosis. The best test to determine if a DVT is present is a venous ultrasound. Venous ultrasound, sometimes know as a venous duplex, looks at the blood flow and appearance of the veins. If blood flow is blocked, a clot exists. Venous duplex is over 95% accurate in the detection of DVT.

Recently, I had a patient come to see me in my office for a same day, urgent appointment. She had been having leg pain and swelling for ten days. I performed an ultrasound in my office and was able to diagnose a DVT in under 15 minutes with this non-invasive technique. I was able to talk with her primary care doctor and coordinate her treatment. She was lucky that she sought medical attention, before she experienced a life threatening pulmonary embolus, or PE.

How is DVT treated?

The standard treatment for DVT is anticoagulation (thinning of the blood in layman’s terms) with the use of a drug called heparin. Heparin prevents the blood clot from getting larger, but it does not destroy the clot that is there. In the past, all patients were admitted to the hospital and heparin was given through an intravenous catheter for about one week. There are new forms of heparin that patients can take just once or twice a day as an injection just under the skin, very much like insulin, allowing treatment as an outpatient. Following heparin therapy, a pill called warfarin or other newer non-vitamin K dependent anticoagulants is started, to further prevent the spread of the clot. Treatments last typically for 6 months to 1 year. For patients with very extensive DVT, clot-busting drugs similar to what is used for a heart attack or brain attack can be used to destroy the clot. This would be followed by anticoagulation with heparin and warfarin.  Sometimes, patients have medical conditions that prevent them from being anticoagulated with drugs. In those situations, a medical device called a vena cava filter can be placed in the inferior vena cava (the large vein in the abdomen that collects the blood from your legs) to trap a blood clot travelling.

Rarely, surgery by a Vascular Surgeon is required to save a leg that DVT has threatened. In 15 yrs, I have only had to perform limb saving surgery 3x for DVT. In those situations, the blood clot had spread throughout all the major veins of the leg, and blood could not get back to the heart. There was no room in the leg for new blood to enter by the arteries. In surgery, the clot was removed with catheters allowing blood to return to the heart and supply the leg.

How is DVT prevented?

Ask your doctor to assess your risk at your annual check-up. For some patients, preventative blood thinners are needed. For others, just wearing compression stockings or socks is enough. If you had a DVT in the past, it is important for your doctor to try to find out why the DVT happened in the first place, and see if your risk factors can be modified to make it less likely to happen again.

New Guidelines for DVT Management

Interesting new guidelines for treatment of patients with Deep Vein Thrombosis:
-Goodbye to Warfarin
-Goodbye to compression stocking recommendations

I agree with the first, but the second is kind of silly. Warfarin was difficult to manage and newer oral anticoagulants have been shown to be as effective or better with similar or safer safety profiles. I don't understand the second recommendation or new recommendation not to offer compression stockings post DVT. The stockings don't prevent the post thrombotic syndrome but due decrease acute and chronic pain.  Acutely, they decrease pain and swelling. Chronically, they aid to prevent ulcers.

Hand Rejuvenation

Here is another interesting article about hand rejuvenation.  http://www.nytimes.com/2012/03/15/fashion/Skin-Deep-Treating-Hands-for-Signs-of-Aging.html?_r=1

 Unfortunately as we age, our hands make us look older than we really are! We spend most of our time focusing on our face and body – with expensive creams and cosmetic treatments. Our hands usually do not get the same care. Hands are exposed to the weather and sun, and as we age, the skin on the back of the hand becomes thin, looses elasticity, wrinkles and reveals the underlying tendons and veins. Age spots and sun damage also develop. For total hand rejuvenation, three elements need to be addressed:

Prominent Veins:  Treat with Sclerotherapy

As we age, the veins of the hand become more prominent. Why does this happen? For some people, the veins enlarge. One method of improving the appearance is to perform sclerotherapy. Using a tiny needle an FDA approved drug is injected into the veins on the back of the hand. Asclera is the sclerosant of choice at NJ VeinCare for the injection of hand veins.  A compression glove is applied and the veins will reduce in size and ultimately disappear. Treatment is almost painless and results are typically obtained with one or two treatments.

Loss of Volume Under the Skin: Restore Volume with Radiesse

Another approach is aimed at increasing the amount of tissue under the skin to hide the unsightly veins and tendons. This is called injecting a “filler”.  Radiesse and other fillers have been FDA approved for use for adding volume to many locations on the body, and are considered safe and effective when properly used.

Skin Rejuvenation: Remove Pigment Spots with Light Therapy

We offer light treatments – photorejuvenation – to reduce age spots and sunspots. The same treatment may be used on the face– IPL PhotoFacials™ – can be used for the same conditions on the back of the hands. Using the most advanced laser technology – the Palomar Icon – the intense pulse light seeks out specific pigment colors in the deep layers of skin on the back of the hand. The laser penetrates deep to treat the “problems” deep at their source.

I had an article published on a well known blog: http://www.kevinmd.com/blog/2015/08/why-this-physician-still-loves-medicine.html

What I Still Love About Medicine?

From every direction, the practice of medicine in the U.S. is under attack. If one were to believe the headlines, the American healthcare system is populated by insensitive, selfie shooting, medicare-medicaid cheating, inefficient, and ineffective physicians grappling with an over regulating government, predatory insurance companies more concerned about profits than the health of their customers, and a legal system that more often confuses a bad medical outcome with actual malpractice.  Morale in medicine may never have been lower among physicians than it is currently. Studies have demonstrated that few physicians are positive about the future of their profession, and the majority do not recommend medicine as a career choice for young people or their children. 

I have always wanted to be a physician. It has always seemed that it was the “family business”.  With a Grandparent, uncles, cousins and a father in healthcare, did I exercise “free will” when I accepted admission to a 6-yr medical program at the age of 18?  One could argue, maybe not!  However, on the eve of starting medical school I affirmed for myself that it was what I wanted to pursue.  I have never looked back on that choice with regret despite the ups and downs of this noble profession.  To answer my self-imposed question, what I love about medicine are the unique opportunities it has given me. Caring for others, educating trainees, a collegial bond, and the intellectual challenges have sustained me through difficult times.

As a physician we have a unique responsibility and a privilege. It is called the “doctor-patient relationship.”   I have always viewed this privilege as earned through years of hard work. Inherent in our profession is the acknowledgment that those we care for are suffering. The Latin root “patiens,” from “patior,” is to suffer or bear. I can’t stand it when some try to use the term client in its place.  My automobile mechanic has clients. I have patients. We share an intimacy of information and emotion with patients that few other professions allow. Other than maybe members of the clergy, no one else is privy to the closely held secrets, pains and distress of our patients.  We often have the ability and need to heal not just the body but also the spirit of our patients.  At the end of the day, it is just one doctor-one patient linked together in a sacred relationship. I don’t think any other field would provide the same opportunity. The more we give, the more we get.

Sadly, the pressures on physicians are increasing while economic reimbursement is decreasing.  The amount of debt accrued by medical students is astounding. In as study by the AAMC, it was noted that the median educational debt of all students was $180,000. Including interest payments, the total repayment could approach half a million dollars. Considering the length of time in post graduate training as a resident or fellow varying from 3 to 7 yrs. earning a modest income while working long hours, the “opportunity cost” of not being able to earn a higher income and start saving for retirement is a real economic hardship.  Medicine has attracted the “best and the brightest” historically. Given falling reimbursements, increased debt and outside pressures, people contemplating a career in medicine may not make the equation that the personal rewards that a medical career can give balance against the decreased economic benefits.  That will be a regrettable day that is probably already here.  To “save” medicine, society will have to absorb the cost of medical education in some manner as it did the cost of postgraduate training with Medicare.  Those that choose the profession in the future may actually be more dedicated and value the non-monetary reimbursements more than the financial.  Hopefully they will be just as capable.

Gary B. Nackman, M.D.

Owner, NJ VeinCare, LLC

Clifton, NJ

Clinical Associate Professor

Dept. of Surgery

Rutgers-Robert Wood Johnson Medical School

New Brunswick, NJ

     Here is an interesting article discussing the interaction between the venous and the lymphatic system. Chronic venous insufficiency can lead to not only the pain, aching, heaviness and restless legs but also swelling.  The tissue fluid can overload the lymphatic system causing edema.

http://www.lymphedemablog.com/2013/07/03/chronic-venous-insufficiency-and-the-effects-on-the-lymphatic-system/

     This is a touching story about how doctors and patients can touch each other's lives in unanticipated ways. It is about the magic of the doctor-patient relationship.
http://www.kevinmd.com/blog/2015/08/doctors-arent-allowed-to-cry-but-maybe-they-should-be.html

Individuality in Medicine?

http://www.kevinmd.com/blog/2015/08/embracing-individuality-will-save-medicine-heres-how.html#comment-2173724348

    This is an interesting article by a physician early in their career. I have been out of residency and fellowship for close to 20 yrs and have a bit of a different take than the author. Sadly, the author's view reflects an element of being trapped in a field that the author would not recommend to others. I have always viewed being a physician as a privilege that was earned through years of hard work. I have spent most of my career as a full time academic surgeon/educator at a major university hospital until 6 yrs ago when I started a private practice. The author seems to feel that the subjective evaluation of his faculty is somehow unfairly inhibiting individuality and that the societal forces of medicine are pushing against the individuality of the physician practice. It is true that medical students and residents are evaluated by both subjective and objective methods, but education research has demonstrated the validity of the subjective observations of trained observers. The issue of when individual expression becomes a question of "professionalism" is a good one. The societal forces impacting medicine with increased regulation, governmental and corporate interference with the doctor patient relationship is a real issue. However, at the end of the day, the physician is granted a unique experience and responsibility in the doctor patient relationship, which is why medicine still offers exceptional opportunities to intervene in the suffering of others.

Phlebitis

     Many people have questions about a medical condition called phlebitis. Phlebitis means inflammation of a vein. Most of the time this is a "sterile" inflammation, which occurs in the absence of an actual infection (an exception might be after having an intravenous catheter that becomes infected).  The inflammation of the vein may be associated with a blood clot, a condition known as thrombophlebitis. The superficial veins, such as varicose veins of the leg or arm may be involved or even the deeper veins found near the muscles.   A blood clot of a deep vein, a DVT, can have life threatening consequences.

     Most episodes of superficial phlebitis respond to elevation of the extremity, warm soaks, anti-inflammatory medication such as non-steroidal anti-inflammatory dugs such as ibuprofen or aspirin.  Sometimes, a superficial clot can spread to a deep vein so it is very important to see a physician if you have a painful vein.

    For an excellent review, see this article on WebMD: http://www.webmd.com/a-to-z-guides/phlebitis

27 years ago I started my surgical internship at St. Luke's/Roosevelt Hospital Center at the St. Luke's site.  Hard to believe how time flys! There have been so many changes in technology, procedures, training and how health care is delivered.  In my specialty of Vascular Surgery, the greatest changes have been in the area of endovascular procedures which treats the abnormality of a blood vessel remotely using a catheter of some sort. In the world of vein care, the management of patients with varicose veins and chronic venous insufficiency has dramatically improved. There has been an increase in the understanding of the role of the venous valves of not only the deep veins of the leg but also the superficial and perforator veins in the causation of pain, swelling and even ulceration of the leg.   27 yrs ago, a patient was admitted the night before a painful stripping of the veins of the leg under general anesthesia through incisions from 1/4 of an inch to 3 inches and remained in the hospital overnight afterwards. People were often 6 weeks before they returned to normal function. Today, we achieve better results with an office based procedure in under 1 hr with local anesthesia and practically no pain. Patients return to work in a day or two. This procedure, known as the Venefit procedure has radically improved the quality of life of millions of patients around the world since its inception.

     Some people say that the appearance of one's hands tells a story of our lives! That is because of the environmental exposure our hands receive. Sun can cause significant skin damage and our hands are almost always exposed to the elements.  A good sunscreen can prevent cosmetic problems and even skin cancer.  Sun related aging once it has occurred, can be addressed by aesthetic procedures. Intense pulsed light therapy can reduce the appearance of years of damage.  Age related thinning of the skin over the back of the hand reveals prominent veins and tendons. There are injectables that can restore plumpness.  Call today and ask about our hand rejuvenation specials! 973-778-2222

Here is an interesting link with a lot of information about varicose veins. It is well written and answers many common questions! http://www.medicalnewstoday.com/articles/240129.php

If you suffer from varicose veins, you don't need to. Treatment is far better and less painful than in the past. Minimal discomfort with great cosmetic results are the norm!