Case of the Month

Venous Insufficiency & Ulceration:  A 68 year old female with a long standing history of BLE leg swelling, leg cramping and nocturnal restless legs presented for wound care evaluation after developing a leg ulcer 2 years earlier.  She had been seen and treated without success at several local wound care clinics. On her initial visit to AZH Wound Center, diagnostic arterial and venous Duplex studies were obtained. No significant arterial compromise was identified, but the patient did demonstrate severe venous hypertension with insufficiency of bilateral great and lesser saphenous systems.  Vessel diameters greater than 9mm (normal <5mm) and reflux of greater than 3400ms (normal 500ms) was measured. The patient was treated with multi-layer compression and underwent endovenous ablation therapy. The photos demonstrate pre and post ablation findings. The patient showed rapid healing after her ablation treatments. Follow up visits were remarkable for no ulcer recurrence.

Services & Technologies

CVI & Venous Ablation

Venous Insufficiency is venous pathology whereby venous blood escapes from its normal antegrade path of flow and refluxes backward down the veins into an already congested leg. Venous insufficiency syndromes are most commonly caused by valvular incompetence in the low-pressure superficial venous system.  Untreated venous insufficiency in the deep or superficial system causes a progressive syndrome, Chronic Venous Insufficiency (CVI). CVI is a significant public health problem in the United States. It has been estimated that 2-5% of all Americans have some changes associated with CVI. Published estimates of the prevalence of varicosities range from 7% to 60% in the adult population, with most studies demonstrating clinical varicose reflux in about 40% of the population. Venous stasis ulcers affect approximately 500,000 people and the estimated annual expenditures dedicated to the management of venous ulcer disease exceeds $1 billion.  The incidence of CVI rises substantially with age. A history of DVT, which renders venous valves incompetent and thereby causes backflow and increased venous pressure, is a risk factor. Other risk factors include a sedentary lifestyle, vocations that involve standing for long periods and heredity. CVI occurs more frequently in women who are obese or those with multiple pregnancies.

Common symptoms may include burning, swelling, cramping, aching, heaviness, restless legs and leg fatigue. Varicose veins serve as indicators of venous hypertension.  Pain caused by venous insufficiency is the opposite of that of the pain caused by arterial insufficiency. The pain of arterial insufficiency usually is worse with walking and worse when the legs are elevated.  The pain of venous obstruction is worse with walking or warmth but better with elevation of the legs. Compression stockings usually improve the pain of venous obstruction. With nontreatment CVI typically demonstrates a progressive deterioration. Skin changes of lipodermatosclerosis in the lower extremities include capillary proliferation, fat necrosis, and fibrosis of skin and subcutaneous tissues or reddish-brown discoloration because of the deposition of hemosiderin from red blood cells. Nonhealing ulcers are often noted around the medial malleolus, where venous pressure is maximal because of the presence of large perforating veins.

Duplex ultrasonography is the study of choice for the evaluation of venous insufficiency syndromes and is both sensitive and specific.  Ultrasonographic reflux mapping is essential for the evaluation of peripheral venous insufficiency syndromes and measurements of vessel diameter (normal <5mm) and reflux (normal <500ms) confirm the diagnosis.   Intravascular ultrasonography has been gaining acceptance in the management of venous disease. This test uses a catheter-based ultrasound probe to visualize periluminal vascular anatomy in order to assess for obstructive or stenotic disease of the venous system. Venography with magnetic resonance (MRV) is the most sensitive and specific test for the assessment of deep and superficial venous disease in the lower legs and pelvis, areas not accessible by means of other modalities. MRV is particularly useful because it can help detect previously unsuspected nonvascular causes of leg pain and edema when the clinical presentation erroneously suggests venous insufficiency or venous obstruction.

Management of patients with CVI and ulcerations are typically treated with wound care regimens that include compression.  The standard approach has been to use gradient compression wraps or stockings that provide 30-40 or 40-50 mmHg of compression at the ankle, with gradually decreasing compression at more proximal levels of the leg. This amount of graduated compression is sufficient to restore normal venous flow patterns in many or most patients with superficial venous reflux and to improve venous flow, even in patients with severe deep venous incompetence.  Consultation with a phlebologist (vascular interventionalist specializing in venous diseases) often yields new options for patients with chronic and seemingly refractory disease. Venous insufficiency syndromes can be diagnosed and treated by means of a variety of specialized techniques with which a generalist may not be familiar.

The endovenous treatment of patients with CVI can achieve spectacular clinical results and may involve both superficial insufficiency as well as deep central venous disease. Venoablation is reserved for those with discomfort or ulcers refractory to medical management. The primary goal of endovenous approaches is to correct venous insufficiency by removing the major reflux pathways. Techniques for venoablation include the following: Radiofrequency ablation (RFA), Endovenous laser therapy (EVLT), Non-thermal medical adhesive (Venaseal), Sclerotherapy and Micro-phlebectomy. Sclerotherapy is performed by injecting or infusing a sclerosing substance into the refluxing vessel to produce endothelial destruction and fibrosis of the treated vessel. RFA is performed by passing a special radiofrequency (RF) catheter from the knee to the groin and then carrying out controlled and preset heating of the targeted vessel until thermal injury causes shrinkage. The process is repeated every 7 cm along the course of the vein. Initial thermal injury is followed by fibrosis of the treated vessel. EVLT is performed by passing a laser fiber from the knee to the groin and then delivering laser energy along the entire course of the vein. Destruction of the vascular wall is followed by fibrosis of the treated vessel. Venaseal uses a proprietary medical adhesive to close the diseased vein.  Ablation therapy has been shown to yield excellent long-term (>5 years) results and a low rate of complications.

AZH Vascular Center provides a comprehensive diagnostic and therapeutic program to care for patient’s suffering from CVI.  AZH was the first center in the Milwaukee to offer Venaseal and Dr. Siddique has performed more venous interventions than any other venous center in Wisconsin.  

Super Star

Awais Siddique, MD:  Dr. Awais Siddique has joined the AZH Team as the Medical Director of the AZH Vascular Center.  In this capacity Dr. Siddique will be providing care to patients with arterial and venous disease to treat their pain and ulcers.  Dr. Siddique is a Board Certified Fellowship trained Interventional Radiologist (University of Michigan Health Care System). With 16 years of experience, he has extensive knowledge in the treatment of complex vascular and non-vascular disease, performing over 15,000 endovenous procedures.  Dr. Siddique has a special interest in the treatment of patients suffering from venous and arterial disease, including ulcerations. He provides treatment to patients with symptomatic venous disease, including venous ablations, sclerotherapy, and deep venous system reconstructions and interventions.  In addition to providing care to venous patients, he also provides treatment for arterial disease, including lower extremity angioplasty and stenting. As an Interventional Radiologist, Dr. Siddique has expanded his expertise into the treatment of compression fractures, performing thousands of successful Kyphoplasty procedures, alleviating pain induced by the fractures.  Dr. Siddique specializes in embolization procedures to treat tumors, aneurysms, gonadal veins, varicocele, and uterine fibroids. In providing embolization as a treatment option, Dr. Siddique offers a less invasive alternative for patients, avoiding painful surgical procedures, including women facing hysterectomy. In addition, Dr. Siddique will be involved in the AZH Regenerative Medicine program, which offers pain relief and a non-surgical management options to patients with osteoarthritis and other joint ailments utilizing amniotic stem cell therapy.  Dr. Siddique has a strong commitment to his community and has served the patients of Sheboygan and the neighboring communities for the past 15 years. He made the decision to transition from hospital care to an independent practice after recognizing the need to provide more personalized care while achieving efficiencies and cost savings that cannot be provided in the hospital. Dr. Siddique is married to Lori and they have two children Alya and Nadya.

IPN Insider

ACO Distributes Profit Sharing:  This is the first of a series of videos in which the State of the (IPN) Union is presented by the IPN CEO, Mike Repka.   Mike discusses another successful year of IPN participation in the ACO Medicare Shared Savings Program. He encourages all IPN physicians to work together to decrease the cost associated with referrals to hospital based programs, physicians and services.  By keeping ACO patients within the IPN physician referral network cost of care can be controlled and the savings realized will benefit our patients, the ACO and member physicians.


Video Vignette

Near Infrared Spectroscopy (NIRS):  NIRS is a new technology that measure and compares saturated and unsaturated hemoglobin in the tissues.  AZH has been utilizing NIRS to evaluate tissue perfusion and compromise. We are finding that this technology can complement and enhance clinical decision making in a variety of settings, including arterial and venous interventions and responses to hyperbaric oxygen therapy.  A recent video entitled “What Lies Beneath… Spooky or Spectacular?” produced at AZH Centers went viral.  We hope you enjoy as the Wound Care Window  looks under the dermis with Near Infrared Spectroscopy to monitor HBOT success!