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