We now know that cancer cells give off unique chemicals that tend to make the blood sticky.  Separately, the treatment of a particular cancer with either radiation, chemotherapy, hormones or surgery can all increase the body’s propensity to form a blood clot in a vein.  Doctors are well aware of this issue and may prescribe blood thinners that require a daily injection similar to the way diabetics give themselves insulin.  He or she will recommend against becoming dehydrated, to exercise as much as possible and to wear leg compression hose or socks during the day to improve the circulation of blood back to the heart.

If a blood clot does form in a vein, patients that have cancer are treated nowadays with self administered injections rather than the old standby pill, warfarin.  The injected medications reduce that chance of internal bleeding and work as good if not better than warfarin in preventing future clots from forming.  This type of treatment is surprisingly well tolerated and usually does not require multiple blood tests with the frequent readjustment of drug dose.

In summary, we have developed a better understanding of how and why blood clots form in the veins of cancer patients.  In addition, patients who have cancer and are undergoing therapy, will be carefully observed for the development of blood clots in their veins.  We are now more aware of the relationship between cancer cells and blood clots.   Thankfully, the prevention and therapy against these types of blood clots is effective and safer than ever before.

As a vascular surgery resident in training in 1984, I examined a patient in his early 20’s that developed a blood clot in a major vein in his leg for no apparent reason.  It surprised me how few answers we had for this young man except to recommend blood thinner pills.  Over time, I evaluated similar patients and only recently did I learn that we now have some insights into “hyperclotting” conditions that can impact prevention and treatment of deep vein thrombosis (blood clots in major veins).

A person who is predisposed to developing  a blood clot in their veins can be that way because of an INHERITED defect in their blood.  While there are several of these blood conditions, most involve a defect in the way our body manufactures some of the blood chemicals used in the normal process of  blood clotting.  The result is that in some people with these defects (1 in 20-40 people)  their blood  clots too easily.  These chemical defects can be now tested for but are usually only checked after someone has their first blood clot or if a blood clot event occurs in a major vein of a close family member.

ACQUIRED (not inherited) reasons for an increased risk of forming blood clots in veins can involve the use of either oral contraceptives or hormonal replacement therapy.  They both have a weak but measurable blood clotting effect which is secondary to the estrogen hormone in these medications.  These medications have been rigorously tested and while they definitely increase the risk of clots in veins, the risks are miniscule compared to pregnancy itself which results in a greater risk of women getting blood clots in their veins compared to taking the medications.

Other acquired or non-inherited conditions that increase the risk of forming blood clots in veins are major trauma, and abdominal, pelvic or leg surgery.  We normally give all patients blood thinner medication during and for a period of time after these procedures.  Finally, there are a handful of diseases that are not inherited but increase the risk of a blood clots forming in a vein without a provocation.  These are Lupus and Antiphospholipid Syndrome.  Many of these patients who have had their first blood clot stay on blood thinners for life.

Finally, perhaps the most important point that needs to be made in this discussion , is that it is often found that more than one clotting defect or risk factor exists in a patient who develops an unexpected blood clot in a major vein.  Time and again, research into these episodes reinforces to doctors that a second condition or multiple blood clotting defects may be discovered as contributors to the development of an unexpected blood clot in a vein.  Accordingly, doctors will look for and often find more than one condition or risk factor that contributes to the development of an unexpected blood clot.

After 60 years of using warfarin without an alternative, the past 24 months has brought FDA approval of several new blood thinners. These tablet drugs do not require blood testing, do not interact with diet, rarely interact with other medications, are not toxic, and are usually prescribed as a single daily dose. They even seem to be modestly better than warfarin in reducing the formation of blood clots in both arteries and veins. Unfortunately, they still can cause bleeding like warfarin and what is more, they have no antidote….yet.

Still, this is progress. These new blood thinners do their job a bit better than warfarin and with less hassle. They allow elimination of hospitalization for a few medical conditions but more commonly, they can reduce days spent hospitalized. Ironically, it will be years before these drugs replace warfarin use in those possessing artificial heart valves. Unfortunately, large and expensive studies will need to be performed before the FDA will approve a medication switch in this group of heart patients.

The monthly cost of these new medications named: dabigatran, rivaroxaban, apixaban exceed the combined monthly expense of warfarin and regular blood testing. Accordingly, all medical insurers will review the cost/benefit ratio when asked to pay for these new medications. It is likely that insurance payment decisions will result in many patients having to stay on warfarin despite the fact that these new drugs will be a better choice for some, but not all, patients. Your physician will rapidly become familiar with the nuances of these new blood thinners and others likely to be approved in the next 5 years. He or she will know when to recommend one of these drugs to you over warfarin both from a medical and economic standpoint.

Overall, this is positive news for some warfarin users. Do we have safer blood thinners? We’re getting closer.

In 1996, the New England Journal of Medicine published an important article concluding that there was equal safety in treating patients with deep vein thrombosis (DVT) of the leg at home after a brief hospitalization compared to full hospital confinement (5-7days).

Since then, the widespread use of self injection blood thinners along with finger prick blood testing have resulted in many if not most patients with leg blood clots being safely managed without hospitalization. Exceptions to this community standard include patients with DVT complicated by clots in the lungs, malignancy concerns, pain or infectious issues of the limb, other heart and lung diseases or contraindications to the blood thinner medication. The wide availability of home health services has expanded enthusiasm for outpatient treatment of illnesses that have been historically managed with hospitalization. The recent FDA approval of new oral blood thinners that require no blood testing has further contributed to this practice.

Pulmonary Embolism or blood clots in the lung is a different story….

The standard treatment for pulmonary embolism in the U. S. is immediate inpatient hospitalization. However, we now have access to the “Pulmonary Embolism Severity Index” that categorizes patients into four risk classes. The lowest two patient risk classes have been studied for possible home treatment of pulmonary embolus.

A recent high quality, multicenter international study using the above noted Index reported results of 344 “low risk” patients with pulmonary embolism. The result was that in these low-risk patients with pulmonary embolism, outpatient (home) care after emergency room evaluation resulted in no increase in major early bleeding, recurrent blood clots or death. Of course, of the patients surveyed, most favored being at home over hospitalization.

A patient with acute pulmonary embolism in the Tampa Bay medical community is not commonly treated as an outpatient. However, we may soon have confirmatory studies that support treating “low risk” pulmonary embolism patients at home. Additionally, the new oral blood thinner rivaroxaban, has recently been shown to be as effective and safe when compared to current drug therapies for both deep vein clots of the legs and pulmonary embolism. FDA approval is eminent and NO blood testing is needed when taking this drug.

There is increasing evidence that we can tailor blood thinning medication treatment for an individual patient who has had a blood clot in their vein. The American College of Chest Physicians (ACCP) has just updated its 9th edition of the guidelines for Antithrombotic Therapy and Prevention of Thrombosis. The above referenced guidelines allow your doctor to use several new recommendations so as to develop an anticoagulation management plan for you.

Deep venous thrombosis (DVT), whether manifest in an extremity or in the lungs, now should be viewed as either an “unprovoked”or a “secondary” event. An unprovoked episode generally occurs in a healthy individual without increased risk factors for forming blood clots. If this is the case, your doctor will order blood tests and occasionally x-rays to determine if an underlying cause for your blood clots can be found.

A secondary blood clot event is associated with conditions that range from post trauma, stroke, major orthopedic, abdominal, pelvic, and neurosurgical procedures to medical states that are expected to eventually resolve or abate. (eg. pregnancy, inflammatory bowel disease, active malignancy, intravenous lines, major pneumonia). These conditions are all well known risk factors which predispose an individual to develop blood clots in their veins. To that end, if we divide blood clot events into these two categories we can make a clear recommendation of anticoagulation duration for our patients.

A patient thought to have an unprovoked DVT should be investigated for having an acquired or inherited predisposition to developing clots in veins. If one of these predisposing conditions is discovered by your doctor, a recommendation for prolonged use of ablood thinner medication is likely.

However, if nothing is found as to cause, after 3 months of anticoagulation, an ultrasound (sound wave) exam of the extremity should be performed. If the ultrasound is now normal,you can be taken off of blood thinners. Four weeks later, a blood test (“D-dimer”) should be analyzed to help determine the risk ofblood clot recurrence. An elevated D-dimer suggests you would benefit from continuation of anticoagulation (blood thinners)…at least for another 3 months. Even if all indicators are found negative, the unprovoked DVT patient has a known increased risk of recurrent blood clots in veins due to factors that as of yet we doctors have not been able to identify. A recommendation for life long blood thinners in this group is a tough call. We usually do not recommend this after the first episode. A second blood clot episodewould trigger a life-long anticoagulation recommendation.

In secondary DVT, after three months of blood thinners, an ultrasound should also be performed. If this ultrasound shows a persistent vein blockage from old clot (at least 40% narrowing), a higher risk of blood clot recurrence exists compared to an ultrasound without any residual vein blockage. It is usually not recommended to stop anticoagulation if a blockage is seen on ultrasound except if a patient is at a high risk for internal bleeding (eg. history of stomach ulcers). In fact, a vein blockage of greater than 50% may warrant placement of a metal stent into the vein to open it up. Generally, a normal ultrasound after 3 months of treatment with resolution of any precipitating/provoking risk factors predicts a small chance for blood clot recurrence. If the ultrasound is indeed now normal and those risk factors for forming blood clots have passed, anticoagulation can be stopped. Blood tests are also frequently ordered four weeks later.

Patients with DVT and under treatment for cancer are a difficult group to advise as to duration of anticoagulation. Usually, upon completion of cancer treatment and in the presence of cancer remission is when anticoagulation can be stopped.

In summary, anticoagulation can be concluded after 3-6 months in most patients with a first DVT. Ultrasound tests, the D-dimer blood test and the medical history surrounding the patient should be used to help your doctor decide when to stop blood thinner therapy.

I hope this summary helps. Please feel free to contact our practice for questions.

Gary Dworkin, MD

• Pervious blood clot in an artery or vein
• Malignancy
• Hypertension
• Type I Diabetes Mellitus
• Inflammatory bowel Disease (Crohn’s or Ulcerative Colitis)
• Rheumatoid Diseases
• Lupus
• Predisposition to forming blood clots (“Hypercoagulable” disease either inherited or acquired, eg. Factor V Leiden Mutation).

In conclusion, oral combined hormonal contraceptive medications double the risk of blood clots in women’s veins. The newer drugs containing updated types of progesterone along with estrogen further increase this risk of forming spontaneous blood clots in veins. The risk of forming blood clots in an artery causing a stroke or a heart attack is slightly increased but only in women over age 35 who take drugs with the newer progesterone substitutes. Finally, there are a number of medical conditions in which use of combined hormonal drug therapy should be avoided.

Vein Specialists of Tampa is a medical practice exclusively dedicated to helping patients with a variety of vein conditions.

These phrases are increasingly recognized by the world’s traveler but can be misleading and are not new ideas.
In fact, an association of blood clots forming in leg veins and air travel was first reported in 1954 by often
quoted Boston surgeon John Homans, MD (1).

It is now nearly 60 years since Dr. Homans published the report of his patient, also a physician, who developed a deep venous
thrombosis (blood clot in a leg vein) while on a transcontinental flight. Since that initial account, a better understanding
has developed between the relationship of travel and the development of leg vein blood clots.

Blood clots occur in legs due to a variety of reasons and situations. However, three basic factors identified about 150 years
ago seem to be essential ingredients for clots to develop in veins:

1. Alterations (stasis) in normal blood flow.
   
   Regardless of the cause, any slowing of blood flow in the veins as they work to return blood to the heart is called
   “stasis”. There are numerous causes for this in humans. Standing in one place or sitting for long periods are the simplest
   examples.

2. Injury to the inner lining (endothelium) of the vein wall.
   
   This injury does not have to be the result of a typical trauma. It can occur as a result of an increase in blood pressure within
   the vein itself, a chemical, infectious, or drug injury to the inner lining of the vein or an injury due to unusual turbulence
   of blood flowing through enlarged or varicose veins.

3. Blood becomes sticky or “hypercoagulable”.
   
   Conditions that create this change in blood are: dehydration, recent major surgery, typical trauma, tobacco use, birth control
   or other hormonal replacement medications, most malignancies and obesity. Even pregnancy and delivery has been discovered to
   possess a normal and welcomed, albeit temporary, hypercoagulable state.

   This triad of slower blood flow, injury to the lining of a vein and increased stickiness of blood are still believed to be the local conditional changes that need to exist for a blood clot to develop in a vein.

   There is a medical explanation that must be understood at this point before we go any further discussing a possible link between travel and venous thromboembolism.

   Venous thromboembolism (clot in a vein) consists of two related conditions:

   1. Deep Vein Thrombosis (DVT) is a clot forming in a major vein of the leg or rarely the arm.

   2. Pulmonary Embolism (PE) is a venous blood clot that travels from its vein origin to the lungs.

   DVT results in a partial or complete blockage of a deep vein by a blood clot, most commonly in the legs. This clot may mature and fuse into the wall of a vein becoming immobile or it can fragment and travel through the remaining venous system to the lungs. Both scenarios are considered serious and emergent medical issues. Pulmonary embolism can have a high and occasionally sudden fatality rate.

   Symptoms of deep venous thrombosis (DVT) include swelling of the effected leg, subtle redness or warmth of the skin, pain or tenderness of the calf, thigh, and occasionally the groin. If a clot has migrated to the lung (PE), then chest, mid-back, low back or flank pain is usual, often made worse by taking a deep breath. Breathlessness at rest, the sensation of not being able to take a deep breath or not being able to catch one’s breath often ensues. Even more severe signs that can evolve quickly are dizziness, fainting, or collapse. Anxiety as well as low grade fever and malaise can be early or late signs. Rarely do just one of these symptoms present. A skilled clinician can usually make the diagnosis and quickly begin treatment. I have seen all of these symptoms with PE, individually and in combination.

   Unfortunately, DVT and PE can occur in the absence of overt signs of a leg blood clot, somewhat like other medical problems which have been known to occur without classic signs and symptoms. An experienced and conscientious physician can occasionally be fooled into missing the diagnosis of DVT or PE. For that reason, understanding prevention and risk reduction have become serious educational subjects for doctors in Western countries.

   General risk factors for DVT presumably increase the risk of a traveler acquiring DVT and PE. These accepted medical risk factors include but are not limited to:

   Recent major surgery—abdominal, pelvic, orthopedic, neurological, and cardiothoracic

   Paralytic spinal cord injury

   Multiple trauma injury

   Malignancy

   Congestive heart failure

   Respiratory failure—end stage lung disease

   Hormonal replacement therapy—including oral contraceptives

   Previous episode of DVT or PE

   Inherited hypercoaguable condition

   Acquired hypercoaguable condition

   Pregnancy and recent delivery

   Obesity

   The rapid acceleration of the number of people in our world who travel by train, automobile, bus and aircraft has heightened the awareness of physicians to a possible link between travel and blood clots in the legs. Physician researchers have begun to understand that a traveler’s degree of immobility during the transportation process may contribute to one if not all three of the basic vein/blood conditional changes discussed previously (2,3).

   Commercial air travel has become a popular focus for DVT medical research. The goal of these investigations is to discover if a link between deep venous thrombosis and flying exists. Traveling in a commercial aircraft is probably the most confining of all commercial travel modalities and results in the severest restrictions on physical activity when compared to train, bus and even automobile travel. In addition, physical immobility when flying commercially has been further exacerbated by the necessity of airlines to accommodate more passengers per flight so as to improve economic efficiencies, thereby reducing space per seat.

   Airlines cannow also accommodate passengers with significant chronic medical illnesses, and more travelers are able to afford flights of greater than 4 hours duration creating additional circumstances that could predispose to DVT and PE.

   Studies of flying passengers as well as travelers using other modes of ground transportation have focused on examining extended periods of space confinement. These reports have begun to sift out conditions that seem to increase the risk of DVT and eliminate factors that do not contribute to the risk.

   A large Dutch study (4) of adults being treated for their first episode of DVT discovered that confined space travel doubled the risk of acquiring a DVT compared to those without a history of travel. This risk of acquiring a deep vein clot was preserved for at least a week after travel and was slightly elevated up to two months after a trip. Immobility or confinement of at least four hours was required before this doubling of DVT risk was appreciated.

   Travel by aircraft in this Dutch study (4) increased the risk of DVT to the same extent as travel by bus, train or car. This suggests that prolonged immobility and not necessarily the method of travel is responsible for creating the needed changes in the body’s systems that increase venous blood clot risk. In fact, a recent British study (5) probably has ruled out aircraft cabin environmental factors alone such as low humidity and cabin pressure as direct contributors to DVT risk.

   The British study (5) also reported that individual passenger medical factors indeed added to the risk conferred by prolonged immobility. For example, women using oral contraceptives, passengers with body mass index greater than 30kg/m2, or height equal or above 6’ 3”, increased their risk for developing a DVT beyond the risk associated with confinement alone. A combination of these additional risk factors created a “synergistic” risk. In other words, when the risks were added together, the total risk was higher than predicted.

   A third study (6) analyzing 8755 employees of several international organizations confirmed the above report findings. The risk of travel related DVT was higher in women using oral contraceptives, as well as when body mass index was increased and when height was greater than 6’ 1”. Risk of travel related DVT was found to be higher with increasing travel duration and with the number of times the employee flew within an 8 week period. The risk of DVT tripled (over non-travelers) in employees taking 5 or more long haul (>4 hours) flights. Each extra flight increased the risk of DVT 1.4 fold. The risk of DVT was highest in the first two weeks after a long haul flight and gradually decreased to pre-travel risk after 8 weeks.

   In a study (7) of healthy Dutch (mostly male) pilots, the rate of DVT was not different from that in the general Dutch population. In this unique investigation there was no association between the number of hours flown and development of DVT. It is conceivable that this “exceedingly healthy group” had few if any of the above medical risks, were trained to exercise in their seats, and commanded a number of flights less then 4 hours long.

   Diagnosis:
   As alluded to in the above discussion, diagnosis of a DVT can often be obtained swiftly, non-invasively and inexpensively. An ultrasound examination of the legs performed by a Registered Vascular Technician and interpreted by a Vascular Specialist or Radiologist can make the diagnosis of DVT within 30 minutes. Ultrasound technology is now portable and can be brought to virtually any location. CAT scans, MRI, and nuclear scans are used to diagnose pulmonary embolism (PE) but can also be utilized if an ultrasound exam is indeterminate for DVT.

   Treatment:

   Urgent hospitalization and swift treatment are indicated in most instances of DVT or PE. Blood thinner and/or clot busting medications are prescribed as well as bed rest for several days followed by ambulation, usually with compression stockings. In the last two years, invasive and unique catheters that mechanically break up and chemically dissolve clots near and above the groin have been used effectively to remove freshly formed DVT. This technology has not been applied for clots in the lung, but variations of this catheter may eventually be used for such a purpose. All patients who can tolerate blood thinners are usually kept on these medications for at least three months after a clot is diagnosed regardless of the initial treatment method. In some instances, these medications are recommended for extended periods, occasionally for life. When these medications cannot be safely given to a patient because of other medical issues, surgically implanted clot filters are often prescribed.

   There are instances when patients diagnosed with DVT limited to the knee or calf can be managed outside of a hospital only with medications. This treatment is safe and common but does require serial ultrasound exams of the clot location during the first 4 weeks of treatment. It must be determined that the clot is not extending up the leg despite taking the medications as prescribed.

   Preventative Measures:

   There have been a number of preventative measures for DVT and PE studied both retrospectively and prospectively. Surprisingly, the only preventative measure shown to reduce the risk of traveler’s thrombosis is graded compressive stockings, ideally with 15-30mmHg circumferential pressure at the ankle. Despite the availability of a host of clot prevention medications, ranging from aspirin to powerful blood thinners, no other measure has been shown to so profoundly reduce the risk of DVT when traveling than graded compression stockings (8). Avoiding dehydration, eliminating alcohol and reducing other diuretic beverages is also prudent. Simple leg exercises every 15 minutes while awake are encouraged.

   Graded compression stockings obtained with a prescription from a Vascular Specialist’s office are your best prevention strategy. These stockings should be worn during any travel where you will be in a confined space for > 4 hours. There is some evidence that they should be worn for an additional week after such trips since the risk of traveler’s venous thrombosis lingers for reasons which are not yet clear.

   The Art of Medicine:

   Your doctor may recommend to you more than stockings to prevent a blood clot in your veins when traveling. There are legitimate reasons for a physician to prescribe for you more than just compression stockings as a preventative measure. This flexibility is what I personally enjoy about the practice of medicine.

   Doctors routinely weigh the risks and benefits of a treatment. We couple this exercise with our knowledge and opinion (critical review) of published studies; studies that are often performed on otherwise healthy people. Finally, we consider a patient’s unique medical and social condition and reflect on our own professional experience. What culminates is a recommendation. This recommendation may go beyond or occasionally fall short of medical evidence-based treatment guidelines. Recommendations often vary from patient to patient but should always consider the presence of additional risk factors which may contribute to that patient’s chance of developing traveler’s vein thrombosis. This balance of medical knowledge, experience and in-depth understanding of a patient’s condition is how a physician provides outstanding medical care.

1. Homans, J. “Thrombosis of the Leg Veins due to Prolonged Sitting.” New England Journal of Medicine. 1954, 250: 148-149.

2. Nielsen, H.K. “Pathophysiology of Venous Thromboembolism.” Seminars in Thrombosis and Hemostasis. 1991, Suppl 3: 250-253.

3. Geroulokos, G. “The Risk of Venous Thromboembolism from Air Travel.” British Medical Journal. 2001, 322 (7280): 188.

4. Cannegieter, S.C., Doggen, C.J., Van Houwelingen, H.C., Rosendaal, F.R. “Travel-Related Venous Thrombosis: Results from a Large Population-Based Case Control Study.” (MEGA Study). PLoS Med., 2006; 3:e307.

5. Toff, W.D., Jones, C.I., Ford, I. Pearse, R.J., Watson, H.G., Watt, S.J., Ross, J.A.S., Gradwell, D.P., Batchelor, A.J., Abrams, K.R., Meijers, J.C.M., Goodall, A.H., Greaves, M. “Effect of Hypobaric Hypoxia, Simulating Conditions during Long-Haul Air Travel on Coagulation, Fibrinolysis, Platlet Function, and Endothelial Activation.” Journal of the American Medical Association. 2006; 295: 2251-61.

6. Kuipers, S., Connegieter, S.C., Middeldorp, S. et.al. “The Absolute Risk of Venous Thrombosis after Air Travel: A Cohort Study of 8,755 Employees of International Organizations.” PLos Med. 2007; 4(9): e290.

7. Kuipers, S., Schreijer, A.J.M., Cannegieter, S.C., Middeldorp , S., Buller, H.R., Rosendaal, F.R. “Incidence of Venous Thromboembolism Among Dutch Airline Pilots.” Journal of Thrombosis and Haemostasis. 2005; 35: P2256.

8. Hopewell, S., Juszczak, E., Eisinga, A., Kjeldstrom, M. “Compression Stockings for Preventing Deep Vein Thrombosis in Airline Passengers.” Cochrane Database System Review 2006, CD 00400

In the United States, over half of the RLS patients are treated with several classes of neurologically directed medications with variable results and of course, occasional side effects.  However, the evidence in support of a purely neurological cause of Restless Legs Syndrome is still not compelling.

I wanted to share with you several  recent and well done studies that reinforce
not only the strong presence of documented chronic venous disease in patients
with criteria established Restless Legs Syndrome (RLS) but also a surprisingly
effective treatment for RLS when venous insufficiency is found  in these patients.

The new information is that many, (perhaps nearly 50%) of RLS patients have been found to have quantifiable and substantial chronic venous disease.   Treating this venous insufficiency with the newer and effective minimally invasive techniques ( Laser/EVLT), is now a reasonable and medically safe approach to the RLS patient.

The first medical study, (McDonagh, B., et. al., Vol.22,No.4,PHLEBOLOGY,2007) documents the surprisingly close association between patients who meet the International  RLS Study Group criteria for RLS AND are found to have ultrasound documented chronic venous disease. The second study,  (Hayes,C.A., et. al.,Vol.23, pg. 112-117, PHLEBOLOGY,2008) takes this information and actually studies the effect of treating established RLS  patients with laser endovenous ablation.  The results are quite good in eliminating or greatly diminishing RLS symptoms.  Dr. McDonagh’s and Dr. Hayes’ research groups have been instrumental in developing both diagnostic and treatment recommendations for RLS.  We owe these physicians a great deal of admiration and respect for continuing their efforts on behalf of patients with RLS.

The RLS patient is often difficult to diagnose let alone treat.  However, there are a number of medical history similarities between RLS  patients and those with symptomatic chronic
venous disease.  RLS may be a syndrome still in search of an cause, but there is evidence that there exists a disproportionate number of RLS patients who also have documented chronic  venous disease.  It is becoming apparent that the two diseases are so intertwined, that the cause, perhaps of both, may be realized soon. The data that endovenous laser ablation of venous insufficiency in the RLS patient is effective in eliminating RLS symptoms is good news for our patients.

At Vein Specialists of Tampa, our treatment of RLS patients who have venous insufficiency has been quite successful.  I am no longer a skeptic.  Finally, we can offer a treatment for the RLS patient that requires no chronic medication and is effective and safe.

Typical symptoms occur exclusively in premenopausal women. The pain is described as a dull ache in the pelvis and is a similar to the dull aching pain experienced by people with varicosities in the legs. The pain reported is predominantly on one side, but some patients report that the pain occasionally moves to the other side. The pain is made worse by prolonged standing or lifting. Although the pain exists throughout the menstrual cycle, occasionally it is worse just before the onset of menstruation. Dull pain after intercourse that lasts 2-4 hours is also typical.

For many years, the above complaints of female pelvic discomfort without an identifiable cause were unfortunately given the name of Pelvic Congestion Syndrome, signifying that this was a “syndrome” not well understood by physicians. In recent years, more thorough evaluations of these women correlated their physical findings of varicose veins of the vulva, perineum, buttock and high thighs with ultrasound exam findings of enlarged veins within the pelvis, usually located near the left ovary.

Previously, this type of pelvic pain was attributed to irritable bowel syndrome, endometriosis, adhesions from previous surgery or caesarian section. It was even reported that there was a psychological origin to these complaints! We now believe that this type of chronic pelvic pain is secondary to sluggish return of blood through the pelvic veins leading to congestion of pelvic organs and appearance of varicose veins in areas just external to the pelvis that are not the usual sites for varicose veins (see below).

The evaluation of all pelvic pain should start with a thorough gynecologic exam that may include an abdominal and intravaginal ultrasound. These two studies are safe, low risk exams that can tell much about the veins near the ovaries and uterus. Often, enlarging varicose veins are noticed by the presenting patient or her gynecologist that involve the vulva, buttock, upper inner thighs, and occasionally extending down the leg. An evaluation by a vein surgical specialist may be warranted to help narrow the diagnosis by evaluating the veins of the legs themselves.

After careful non-invasive studies that support the diagnosis of PCS, options are to perform an MRI study to further look at the pelvic veins or directly proceed to a venogram. The latter is an invasive exam with contrast dye but often treatment of PCS can be done simultaneously during the venogram.

Traditional treatment for PCS had been surgical closure of the culprit pelvic veins, usually on the left. While effective in reducing or eliminating pain, the procedure itself required a night or two in the hospital, general anesthesia and did leave a small flank scar. Today, the same results can be obtained by placing a catheter in the enlarged veins (after the venogram) and actually sending small metal coils along with medication down these malfunctioning veins in order to close them off. This procedure is done in a radiology suite with fluoroscopy. Studies have now shown this technique, in experienced hands, is as effective as surgery but without the need for an overnight hospital stay or scars. Discomfort is minimal and improvement in PCS pain should be appreciated within 4 weeks. Longer term, some patients have a recurrence of symptoms and require repeat investigation. Thankfully, this is an unusual event.

In summary, Pelvic Congestion Syndrome is now a well recognized medical condition in women which is related to malfunction of the pelvic veins. PCS pain affects the ability to live fully and can be the source of a number of disagreeable symptoms. PCS diagnosis and treatment is much better established and the results of minimally invasive treatment are favorable, safe and durable.