restless leg syndrome and venous insufficiency sean stewart, ms, md regional medical director...

Restless Leg Syndrome and Venous Insufficiency

Sean Stewart, MS, MDRegional Medical Director

Director of Sclerotherapy

Center for Vein Restoration

Outline

• Restless Leg Syndrome (RLS)• Chronic Venous Insufficeincy (CVI)• Center for Vein Restoration

Restless Leg Syndrome

• Neurological Disorder• Insomnia• Daytime fatigue• 5-15% of the general population of the United States• Onset can occur at any age• Women affected twice as much as men• African Americans < Caucasians• Hereditary component in up to 50% of cases

Symptoms

• Unpleasant sensation of leg with constant tingling and pulling

• Creepy, crawling feeling• Itching, aching, nighttime twitching• Burning• Pain• Sensation of electricity

Diagnostic Criteria

• International Classification of Sleep Disorders, 2nd Edition (ICSD-2) 2012– Urge to move the legs– Worsens during periods of rest or inactivity– Partially or totally relieved by movement– Worse or only occurs in the evening or night

• American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) adds:– Symptoms occur at least 3 times per week and have persisted

for at least 3 months

RLS Primary vs. Secondary

• Primary– idiopathic central nervous system disorder– the most widely accepted mechanism involves a genetic

component, along with abnormalities in the central subcortical dopamine pathways

• Secondary– iron deficiency– peripheral neuropathy

RLS Primary vs. Secondary

• Secondary cont.– Folate or magnesium deficiency– Amyloidosis– Sjogren syndrome– Lumbosacral radiculopathy– Lyme disease– Monoclonal gammopathy of undetermined significance– Rheumatoid arthritis– Diabetes – Uremia– Vitamin B-12 deficiency– Frequent blood donation– Pregnancy– ESRD and Hemodialysis

– Antidopaminergic medications (eg, neuroleptics)– Diphenhydramine– Tricyclic antidepressants (TCAs)– Selective serotonin reuptake inhibitors (SSRIs)– Serotonin-norepinepherine reuptake inhibitors (SNRIs)– Alcohol– Caffeine– Lithium– Beta blockers

Exacerbating Factors

Differential Diagnosis

• Akathisia– an inner urge to move all or part of the body– does not correlate with rest – usually results from medications such as selective serotonin

reuptake inhibitors (SSRIs), neuroleptics, or other dopamine-blocking agents

• Neuropathy• Nocturnal leg cramps• Painful legs and moving toes• Vascular disease• Radiculopathy• Osteoarthritis• Venous Disease

Restless Leg Syndrome

• AKA– Willis-Ekbom disease

• 1672- first known medical description of RLS was by Sir Thomas Willis

• 1945- Karl-Axel Ekbom provided a detailed and comprehensive report of this condition in his doctoral thesis, Restless legs: clinical study of hitherto overlooked disease.

Restless legs: clinical study of hitherto overlooked disease

Dr. Ekbom observations/explanations:

–Many of his patients had “course varicose veins”

–Hypothesized that “accumulation of metabolites” in refluxing varicosities may play a role

Ekbom, KA. Asthenia Crurum Parasthetica Acta Medica Scand. 1944;118:197-198

Varicose Vein Disease

• Venous hypertension• Incompetent valves• 15% men, 25% women• 30% men, 50% women > age 50• Heavy, fatigue, throbbing, frank pain• Nocturnal cramping, restless legs• 20% develop advance disease

Restless Leg Syndrome and Chronic Venous Insufficiency

Symptoms of RLS Symptoms of CVI

Develop at rest Develop at rest

Better with movement Relieved with movement

Worsens with age Worsens with age

More common in women More common in women

Journal Dermatologic Surgery

• 22% of patients with RLS also have venous insufficiency• Study assessed effect of sclerotherapy on RLS• Sclerotherapy performed on 113 RLS patients• 98% of patients reported initial relief with recurrence rate 8% at 1

year• RLS sufferers should be considered for phlebological evaluation

and treatment

Kanter, et al. Dermatol Surg. 1995 Apr, 21(4):328-332

Phlebology Study

• 35 patients with moderate to severe RLS and duplex-proven CVI• Patients separated into operative and non-operative cohorts• Operative cohort had endovenous laser closure of diseased

refluxing axial veins followed by US-guided sclerotherapy of refluxing tributaries

Hayes CA, et al, Phlebology 2008 (3) :122-7

Phlebology Study

• Patients completed IRLS (International RLS rating scale) questionnaire before and after treatment– Treated patients had decrease in IRLS score

from 26.9 to 5.5, corresponding to average of 80% improvement in symptoms

– 89% of patients had decrease in IRLS score of 15 points or greater

– 31% of patients had follow-up score of 0

Phlebology Study

Conclusions– 98% of patients experienced relief from RLS

symptoms by treating their venous insufficiency– 80% had long-term relief– Thermal ablation of refluxing axial veins

followed by ultrasound-guided foam sclerotherapy of associated varicosities alleviates RLS symptoms in subset of patients with CVI and moderate to severe RLS

Take Home

– RLS like CVI is under-recognized and underdiagnosed

– Symptoms are interchangeable– CVI should be ruled out in RLS patients

before initiation of drug therapy• Non invasive sonogram• Cost covered by insurance

Treatment of CVI

• Minimally invasive• Office based, outpatient treatment• Local anesthesia• No cutting, no stitches• Instant recovery• Covered by insurance

Thank You