1. Restless Leg Syndrome and Venous Insufficiency Sean Stewart, MS, MD Regional Medical Director Director of Sclerotherapy Center for Vein Restoration

2. Outline Restless Leg Syndrome (RLS) Chronic Venous Insufficeincy (CVI) Center for Vein Restoration

3. 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

4. Symptoms Unpleasant sensation of leg with constant tingling and pulling Creepy, crawling feeling Itching, aching, nighttime twitching Burning Pain Sensation of electricity

5. Diagnostic Criteria International Classification of Sleep Disorders, 2 nd 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

6. 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

7. 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

8. – 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

9. 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

10. 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.

11. 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

12. 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

13. Restless Leg Syndrome and Chronic Venous Insufficiency Symptoms of RLSSymptoms of CVI Develop at rest Better with movementRelieved with movement Worsens with age More common in women

14. 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

15. 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

16. 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

17. 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

18. 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

19. Treatment of CVI Minimally invasive Office based, outpatient treatment Local anesthesia No cutting, no stitches Instant recovery Covered by insurance

20. Thank You