Restless Leg Syndrome and Venous Insufficiency

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Restless Leg Syndrome and Venous
Insufficiency
Sean Stewart, MS, MD
Regional 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
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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
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International Classification of Sleep Disorders, 2nd Edition (ICSD2) 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
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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
Exacerbating Factors
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Antidopaminergic medications (eg, neuroleptics)
Diphenhydramine
Tricyclic antidepressants (TCAs)
Selective serotonin reuptake inhibitors (SSRIs)
Serotonin-norepinepherine reuptake inhibitors (SNRIs)
Alcohol
Caffeine
Lithium
Beta blockers
Differential Diagnosis
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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 dopamineblocking 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
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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
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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
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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
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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
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Minimally invasive
Office based, outpatient treatment
Local anesthesia
No cutting, no stitches
Instant recovery
Covered by insurance
Thank You

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