Venous reflux disease – a condition in which blood can’t sufficiently be pumped from your legs to your heart – is more common than heart disease, peripheral arterial disease and congestive heart failure. Heredity and gender put people at higher risk. Family history is a risk factor and women, particularly those who’ve had children, are more susceptible.
“There are factors we have some control over: being overweight and sedentary behavior make it worse,” said Dr. J. Dana Dunleavy, director of interventional radiology at Windsong Radiology Group.
Dunleavy and a team of seven other health professionals recently opened the Windsong Interventional Radiology Clinic in Amherst. They treat a variety of conditions that once required invasive surgery, including venous reflux disease. The group performs what is considered the gold standard of treatment, radiofrequency ablation, and several weeks ago became the first in Western New York to also use the VenaSeal procedure, a more convenient but costly option.
“We don’t treat people with varicose veins. It’s once you have chronic venous insufficiency, so you have pain or swelling related to that,” said Dunleavy, 37, a New Hampshire native who attended University of Vermont Medical School and did his residency and fellowship work at Johns Hopkins. He and his wife Sarah, a Utica native, were both accomplished skiers during their college years. They live in Clarence Center with their daughters, Ella, 5 and Callie, 3.
Q. Why Buffalo?
It was a nice combination for our family of having the city with the ability to be out in the country so quickly, and it’s close to family. We can be out skiing or biking or hiking, and we can be downtown shortly. That’s been great for us and our kids. We live on 13 acres, which we enjoy, even when it’s just going for walks.
Q. What is interventional radiology?
A procedure guided by imaging. That could be X-rays or CT or ultrasound. The easiest to understand is a coronary angiogram, where you go into the artery in the groin and you can do all your imaging by just having a catheter in a blood vessel. The simpler things that we do are vascular access, meaning a mediport. If someone needs medications through a vein permanently, we’ll place catheters into veins. The same goes for a patient that needs dialysis. We’ll place catheters for that. We do a lot of image-guided biopsies. One of the areas that some practices do is treating benign growth in the uterus by cutting off the blood supply to fibroids. In our setting, we’re doing something different, too, by treating varicose veins in the pelvis by going into the blood vessel in the groin using flouroscopy images to prevent backup of blood into the pelvis.
Q. How has the specialty changed just over the last decade?
That is one of the things that drew me to the field. It is a dynamic area of medicine, continually changing. The interesting areas of change have included oncology. You can put a catheter directly into a tumor as opposed to IV chemotherapy that treats the whole body, and by directing the medicine to the tumor you have less side-effects. That’s been the largest area of growth for our speciality. One of the things I have been involved with is migraine treatment. By putting a catheter into the nostril under image guidance, I can deliver medication right to the pain center in the back of the nose where those ganglia live. It’s a very interesting treatment because people used to stick a needle straight through your face to get to those nerves, which worked well but was more dangerous. Now, you can go into the nostril and you don’t puncture the mucosa, you don’t make any incisions.
The reason that interventional radiology has traditionally been based in the hospital is because the equipment is expensive. But almost all the procedures we do, the patient goes home afterward. If you’re coming for a vein treatment, or a pelvic vein treatment or some cancer treatments – getting a mediport before you start chemotherapy – you don’t have to go to an operating room.
Q. How does your caseload break down at Windsong?
Here we have chosen some of the things that make the most sense for a non-hospital practice that do not require hospital observation or a hospital stay. Things like varicose vein treatments in the legs, varicose vein treatment in the pelvis, migraine treatments. We treat compression fractures in the spine – that’s where we use flouroscopy to guide a needle into the spine and put cement in to stabilize that fracture. That tends to happen ... in the middle back but can happen anywhere. Similar to the other things we’ve talked about, it prevents or avoids an operation. You leave with a Band-Aid. Obviously, there are some things that require surgery but we are choosing the things appropriate for us to do as less invasive as possible, where people can come in, get their procedure and go home very easily. We do biopsies every day. We do central lines, too. Fifty percent is the varicose veins in the legs and smaller percentages of the top three are the varicose veins in the pelvis and the migraines.
In terms of the leg treatments, it fits very well with the skill set for an interventional radiologist because everything is an ultrasound probe in one hand and a needle in the other hand. So having that hand-eye coordination of precision within the blood vessel is very helpful.
Q. Has the skiing helped with the precision and hand-eye coordination.
Maybe. I certainly think it’s an area of interest. You know how people get injured and you want to help get them back to their normal state of functioning. It’s true that it is an athletic career in some respects. If you have precise skills, you’ll have better outcomes. It’s one of those things where most cases are easy and some cases are difficult and if you have the combination of coordination and experience, you don’t have any bad outcomes with those.
Q. Talk about the Interventional Radiology clinic’s VenaSeal closure system procedure for venous reflux and varicose veins.
We initially scan the vein with ultrasound and map out the anatomy. Then we prep the leg so it’s sterile, numb the skin at the chosen spot to access the vein. It is usually in the lower calf. The reason you can do that is because there’s no heat and you won’t injure any nerves by treating all the way down into the calf versus with thermal ablation, where we access the upper calf. We numb the calf, put a very small catheter into the vein and that travels all the way up to the groin without the patient feeling anything all the way up. Then we make some measurements. You want to be very precise with your adhesive. We initially go up to the groin, so that catheter is extending the entire length of the leg and we pull back to give a safety margin so the glue is only within the vein we treat. The adhesive is very viscous, or thick, so it shouldn’t go anywhere you didn’t intend. At that point you have a new delivery system – basically a fancy gun – that delivers .1 ccs at a time ... so you deliver the exact quantity you intend.
Q. So you look for the trouble area and seal it off at that spot?
Correct. It could be that the entire vein is diseased once you get to this stage, so the longer the segment of vein that you treat, the better the outcome. This is not a cosmetic problem. You’re treating a medical problem where blood, as opposed to traveling to the heart, goes backwards. So the varicose veins improve but we’re not going into those for the treatment. We’re going into the vein that caused all that pressure and caused the varicose veins. I look at the most critical part as not the treatment but the evaluation and determining what caused this problem. We call this the “mapping exam.”
Q. How many veins are there in your leg?
More than you can imagine. You can’t always identify them and only some of them have names. That brings up a common question: If you close down this vein, how do you get blood up to your heart? The simplest way to understand that is you have many normal veins that aren’t diseased and that we aren’t seeing that do all of that work – and the vein we’re treating is not helping you get blood back up to your heart.
This treatment is most common for the greater saphenous vein. It’s the longest superficial vein that goes from your ankle to your groin and it is the most common superficial vein. That’s the one that’s closed. The process of venous insufficiency is that as you are standing and your veins are not closing, it builds up pressure. Because of that, that pressure backs up to those veins that were normal near your skin and they become diseased, or varicosed. That’s why treating what you see doesn’t fix the problems.
Q. How does the VenaSeal adhesive do it’s job? Is there anything you can compare it to?
It is very comparable to super glue. It’s obviously sterile. When we put it into the vein, it immediately seals the vein. One of the exciting and rewarding benefits to the patient is that at the end of the procedure they feel better. It doesn’t take weeks or months to notice improvement. Normally patients wear compression stockings to keep that vein treated after treatment. Because VenaSeal is an immediate vein closure, you don’t need to wear compression stockings afterward. That seems like a silly, little thing but some people hate compression stockings.
As we moved away from vein stripping to ablations, that recovery period has been dramatically improved. Even with thermal ablation, you’re up walking the same day. A lot of people go back to work the same day. There’s still a recovery period. We encourage people not to do heavy lifting. It takes time to decrease in size. Since the adhesive immediately closes that vein, you can go back to your activity the same day.
Thermal ablation is so great I don’t want to sound like there’s a problem with it. The biggest thing about this new treatment is that for people who are needle-phobic, VenaSeal is an option for them.
Both techniques have extremely high closure rates, clinical outcomes. The major difference is how many needle sticks.
Q. What is the cost of the VenaSeal and radiofrequency ablation?
The radiofrequency ablation is about $2,000 per vein treatment versus about $3,500 for VenaSeal. The cost of ablation is different across insurance carriers, which all have a different system. There is a co-pay or deductible, so that cost is going to vary. We’re trying to keep VenaSeal as low as possible, given that the supplies – particularly the adhesive, which is proprietary, and making it safe to administer – are so expensive. Hopefully that cost will come down and will be covered by insurance. I think both of those things will happen but don’t know how long it will take. ... At this point, there are still two great options: the radiofrequency ablations and VenaSeal. The major reasons people choose VenaSeal is because of the lack of needles – one versus as many as six needle pricks – faster recovery, not having to wear compression stockings, the lack of a waiting period for insurance approval ... and a lot of people have very high deductible plans that you have to pay yourself.
Q. Are you working with local insurers to one day cover the procedure and, if so, how long might that take?
Yes, we are working with the carriers but at this point there is no established code to even give to an insurance company. A later stage would be negotiating the appropriateness and value of reimbursement.
Q. When considering those options, what do you suggest people consider? I supposed you can do nothing.
What we always try first are conservative measures: wearing compression stockings, taking anti-inflammatory medications, walking, and elevating your legs. If you feel well with those things, you don’t need any of the things that we do. That is one of the reasons insurance companies have a waiting period for approval. In many cases, people have a long history of these problems.
Those concerned they may have venous reflux disease are encouraged to check with their primary care doctor or schedule a consultation with Windsong Radiology’s Interventional Radiology Clinic by calling 929-9484.