Pelvic and Leg Pain?

It could be vein disease.

Jill no longer has to worry about the bump behind her knee showing when she wears shorts.

Colorado native Jill B.*, 39, relocated to Florida ten years ago to get away from the snow and cold, but prior to moving to the Sunshine State, Jill resided for a short time in the Bluegrass State.

“I moved to Kentucky because I wanted to live somewhere other than Colorado,” Jill shares. “Nobody in my family ever left Colorado, but a few members of my partner’s family live in Kentucky, so that’s where I went.

“I loved living in Kentucky. Everybody there is genuinely nice and goes out of their way to help you out. They practice real Southern hospitality. The only problem is, it snows there and I wanted to get away from snow, so I moved to Florida.”

For fun, Jill loves going to the Keys. She enjoys visiting local breweries and sampling their craft beers. When she has time, she visits family and friends in Colorado and Kentucky. Jill likes sports as well, and roots for the University of Kentucky basketball team and the Denver Broncos of the National Football League.

What Jill doesn’t like are her unsightly varicose veins. Her mother had them, and she remembers they were so bad that they altered the shape of her mother’s legs.

“I grew up seeing her legs and thinking, I hope that doesn’t happen to me,” Jill recalls. “But when I lived in Kentucky, I worked on cars for Toyota and was on my feet all day. Eventually, varicose veins appeared on my left leg and became progressively worse over the years.

“There was a vein that bulged behind my left knee. It was quite large, about the size of a marble. It was gross. I wouldn’t wear shorts that left it exposed because I was embarrassed by it. I had cramping and itching in my leg as well. My upper thigh itched terribly over the varicose veins. It was extremely annoying.”

Jill was determined not to let the varicose veins on her leg become as ugly as her mother’s, so she went to her primary care physician for help. The doctor referred her to Joseph G. Magnant, MD, a board-certified vascular surgeon who specializes in treating vein disorders.

Dr. Magnant’s practice, Vein Specialists, has offices in Fort Myers and Bonita Springs, and is dedicated to the modern evaluation and minimally invasive treatment of leg vein disorders.

“A couple of people in my office knew of Dr. Magnant as well,” Jill notes. “When I met him, I thought he was very nice. He’s really down-to-earth and low-key. I like that.”

Endovenous Ablation

To begin the evaluation, Dr. Magnant and his advanced providers ordered an ultrasound exam on Jill’s leg. The results showed she had a disorder affecting the one-way valves in her leg veins called venous insufficiency.

Venous insufficiency occurs when leg veins, which are the blood vessels that return deoxygenated blood to the heart and lungs, have weak valves that allow blood to flow backward in the legs. Dr. Magnant explains the problem further.

“On the inside of the leg veins there are one-way check valves that assist blood flow back toward the heart against gravity,” he describes. “Venous insufficiency occurs when these valves fail, resulting in pressure that builds up in the leg veins, leading to varicose veins and other presentations of venous insufficiency.

“This leads to signs and symptoms such as varicose veins, swelling, heaviness, achiness or cramping, discoloration, restless legs and frequent nighttime urination. If left untreated, venous insufficiency can progress further and cause more serious complications such as a breakdown of the skin and venous ulcers.”

To correct the problem in Jill’s leg, Dr. Magnant chose a procedure called endovenous ablation. This procedure is minimally invasive and is performed through a small IV placed in the vein through the skin.

During endovenous ablation, Dr. Magnant uses ultrasound imaging to place the small IV in the abnormal vein under local anesthesia. A catheter is advanced into the problem vein through the IV. Using either heat (radiofrequency or LASER energy) or medical adhesive, Dr. Magnant gently seals the walls of the diseased veins. In Jill’s case, he used heat to collapse the veins.

Over time, the sealed veins are absorbed by the body. Blood flow from the closed veins is rerouted through healthy veins, and venous pressure is reduced back to normal levels.

“Parts of the procedure were a little uncomfortable, but it wasn’t painful. It was really no big deal,” Jill relates. “After the procedure, I drove myself home. I didn’t need someone to pick me up. To reduce my risk of getting blood clots, I walked a lot for the first week. I didn’t sit down for more than fifteen minutes.

“I went to work the day after the procedure. It wasn’t like I had to stay home to recuperate. I was surprised by that.”

Critical Discovery

Anna*, 66, has multiple degrees in languages and linguistics. While teaching foreign languages, she decided to concentrate on disordered language, an impairment that causes someone to struggle to find the right words to form clear sentences.

She later became a speech pathologist specializing in voice and swallowing disorders. Now, Anna is the only board-certified swallowing disorders specialist south of Tampa.

“I work for a large physician group that has hundreds of providers and specialists, mostly in southwest Florida,” she states. “I’ve been with this physician group for five years and with the facility where I’m working for close to twenty years.

A few years ago, Anna experienced achiness and discomfort in her legs. Some neuropathy symptoms, such as numbness and tingling, were present as well. There were no bulging varicose veins visible on her legs, but there were spider veins. Anna’s sister, who suffered with venous insufficiency as well, recommended Dr. Magnant.

“What brought me to Dr. Magnant is the fact that he trains other physicians,” Anna notes. “He’s also topnotch with regard to current practice research, and he’s ahead of the crowd. The way he worked on me was super fantastic. He did an initial assessment, including a detailed venous ultrasound, then treated the underlying venous insufficiency.”

After treatment, Anna’s legs were fine for a few years. But last year, while attending a meeting in Boston, Anna’s left leg suddenly started swelling. She feared the problem was a blood clot, so she sought immediate attention.

“I went to the emergency room at Tufts Medical Center in Boston,” Anna recounts. “I was relieved to have a clot ruled out, but they couldn’t find anything else wrong.

“My left leg swelled for no apparent reason. Whenever I went to the gym to work out, both legs swelled. Even my personal trainer said there’s something happening there. I wasn’t overdoing it, but the swelling occurred anyway, so I was concerned about that. I was on my feet all day, which didn’t help.

“There was discomfort in my legs as well. I had to put them up every night on a large cushion. My legs were getting tired and heavy, and I was starting to see a little discoloration of the skin.”

Anna’s symptoms interfered with some of her favorite activities as well, including biking. She struggled to ride her bike when her legs were swollen and achy.

“I couldn’t ride very far around my neighborhood,” she confirms. “I could maybe go a block or two, but that was it. Finally, I decided to go back to Dr. Magnant.”

Advanced Procedures

Since he already successfully treated Anna’s lower extremity venous insufficiency, Dr. Magnant suspected her symptoms were coming from another vein condition called iliac vein compression syndrome and ordered a pelvic vein ultrasound. This test was positive for May Thurner Syndrome, a type of iliac vein compression on the left side where the left pelvic vein is pinched between the crossing iliac artery and the spine.

Dr. Magnant recommended an intravascular ultrasound, or IVUS, which is a catheter-based probe used to examine veins from the inside. In using IVUS to evaluate Anna’s pelvic veins, Dr. Magnant confirmed she had a severe left common iliac vein blockage, which was the underlying cause of her pelvic congestion syndrome.

“This syndrome occurs when the right iliac artery compresses the left common iliac vein,” Dr. Magnant explains. “This blocks blood flow through the left iliac vein and results in symptoms of venous congestion in the pelvis, buttocks and legs.

After identifying the compression, Dr. Magnant performed an angioplasty and stent placement during which he first stretches the narrow spot with a balloon and then inserts a stent inside the area of compression. The stent procedure opens the compressed vein and restores normal venous blood flow.

“I didn’t think my problem was that bad, but then Dr. Magnant showed me the blockage,” Anna notes. “I said, No wonder I had to stop when I exercised. Because of that blockage, I wasn’t getting the return of blood I needed, and it was taking a toll on my physical activity.

“The IVUS and stent procedure seemed very easy. There was minimal discomfort. I watched the whole thing on a screen. Dr. Magnant explained everything to me beforehand in easy-to-understand terms, and it was a very pleasant procedure area.”

In treating Anna, Dr. Magnant used a stent that was brand-new on the market at the time made of Nitinol, a combination of nickel and titanium. She was the first person in southwest Florida to receive that particular type of stent for pelvic congestion syndrome.

Disease Origins

Jill B

Both Jill and Anna suffered with vein disease and uncomfortable leg symptoms, but their problems differed in their origins,”
Dr. Magnant notes. “Jill’s vein disease was an inflow problem. Anna’s was an outflow problem.

“When we talk about inflow disease, we are referring to vein disorders that occur from the groin to the ankle, or below the belt. Outflow disease is vein disease occurring above the groin, or above the belt. Inflow disease is much more common. More than ninety-five percent of my patients have inflow disease.”

People with inflow disease typically have venous insufficiency and experience its symptoms in the form of swelling, heaviness, achiness, cramping and restlessness in the legs or signs such as varicose veins, swelling and skin changes. Outflow disease can cause similar symptoms in the legs but also pain in the buttocks and pelvis, menstrual pain, pain when bending at the waist and pain during or after intercourse.

Treatment for inflow disease is different from that for outflow disease.

“The treatment for vein conditions below the belt, or inflow disease, is to seal the veins with heat or medical adhesive,” Dr. Magnant observes. “Treatment for vein disease above the belt, or outflow disease, is typically opening the blockage with balloon angioplasty and placing a stent inside the vein to keep that blockage from recurring.”

Historically, when women with pelvic pain have been found to have varicose veins in the pelvic area, the first line treatment offered by many interventional radiologists has been to close off (embolize) these pelvic varicose veins with coils and sclerosants. These veins often developed over time to compensate for the iliac vein narrowing, and closing them off often worsens the problem.

With IVUS technology, vein specialists such as Dr. Magnant now understand that this approach may not be the right path of treatment for many patients. At Vein Specialists, Dr. Magnant treats blocked iliac veins as the first line of treatment for patients with pelvic congestion syndrome by using IVUS-directed stenting, which allows the pelvic varicose veins to decompress and improves the patient’s symptoms.

The pelvic congestion syndrome that afflicted Anna is a common outflow disease, Dr. Magnant reports. The angioplasty and stent placement he performed on Anna relieved what Dr. Magnant refers to as a “bottleneck” caused by the hourglass-shaped narrowing of her iliac vein.

“I like to use the analogy of a five-lane highway that gets closed down to one lane,” Dr. Magnant recounts. “When that happens, there is a significant backup of traffic downstream. As soon as that blockage is cleared and those four lanes are reopened, traffic is able to resume. But it may take a little time to clear the backed-up traffic.

“In the same way, the results of angioplasty and stent placement are not necessarily immediate. They may be realized within a week of the procedure or two to three weeks afterward. When they are realized, patients typically note significant improvement in the symptoms they presented with. That was true with Anna.”

The venous insufficiency, or inflow disease, that affected Jill’s left leg is typical of what Dr. Magnant sees in the majority of his patients. “We start investigating patients with leg swelling or aching in their feet as their primary complaint,” he informs.

“With Jill, we performed a standard ultrasound of the leg and discovered significant venous insufficiency, which caused her uncomfortable leg symptoms. We performed an endovenous ablation to seal her leaky veins, which eliminated her symptoms.”

The primary issue with vein disease, both inflow and outflow, is venous hypertension, Dr. Magnant points out. High venous pressure is what causes all of the signs and symptoms of the disease.

“The pressure can be high because of leaky valves in inflow disease, or it could be high because of obstructed veins in the pelvis in outflow disease,” the doctor reports.

“Due to high pressure in the thin-walled veins of the legs, the components of blood can leak out. These components include water, proteins and eventually red and white blood cells. This causes the swelling, heaviness and achiness, as well as skin changes such as oozing of fluid through water blisters and can cause bleeding or eventually ulceration.

“The same things can occur with outflow disease. The only caveat to that is that patients who have this type of vein disease often present with buttock pain, pelvic pain, pain with intercourse or really painful menstruation. Those are symptoms specific to a higher location disease, or an outflow problem.”

“Top Dog”

Following her endovenous ablation at Vein Specialists, Jill achieved significant, positive gains toward eliminating the signs and symptoms of her venous insufficiency.

“My legs are much better now,” she enthuses. “There’s a little bit of discoloration, but it’s very light, and Dr. Magnant says it’ll go away in a few months. But the bump on the back of my left knee is gone. You can’t see it at all, and that’s great.”

Anna responded positively to her treatment as well.

“Dr. Magnant’s angioplasty and stent placement resolved my compression problem. My legs feel great now,” she raves. “I’m able to stand for ten, twelve, fourteen hours without having any issues. There’s no swelling whatsoever, and the heaviness and tired feeling in my legs is gone. I can walk, bike and do everything else with ease. I have no limits.”

Jill and Anna suffered with vein disease that had different origins. Fortunately, Dr. Magnant had treatments for both conditions, and they were highly effective for his patients.

“The ablation procedure Dr. Magnant performed on my left leg was definitely successful,” Jill states. “When I show my before and after pictures to people, they say, Oh my gosh. I have to get that done. They’re surprised by how much better my legs look in the after pictures. I recommend this procedure and Dr. Magnant to perform it.”

“The angioplasty and stent were very successful for me,” Anna echoes. “I’ve mentioned it to all seven of my brothers and sisters, and one has already been evaluated. There are eight of us kids total, and we probably all have iliac vein compression. Dr. Magnant is great. He’s top dog as far as I’m concerned. I won’t go to anyone else.”

*The patients’ names were changed to protect their privacy.
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    • Vein Specialists

      Vein Specialists is 100 percent dedicated to identifying and treating vein disorders. Led by Dr. Joseph G. Magnant, they understand that the venous system varies between patients and consists of both deep and superficial venous systems and a net... Read More

    • Joseph G. Magnant, MD, FACS, RPVI

      Joseph G. Magnant, MD, FACS, RPVI, is a Fellow of the American College of Surgeons and is board certified by the American Board of Surgery in vascular surgery. He earned his medical degree from Medical College of Virginia. He completed a g... Read More