MGR featuring Dr. Michael Yacob – Venous Disease
Emmanuel Fagbola, MSc Candidate (Translational Medicine)
Last week we had the pleasure of hearing from Dr. Michael Yacob during our Medical Grand Rounds on venous disease, where he elucidated a myriad of venous irregularities that prevent the body’s veins from providing adequate blood flow back to the heart. Tenacious, progressive, and frequently underestimated, venous disease affects a significant portion of the population1-3 and has large socioeconomic, physical, and psychological implications4, 5.
To kick off the lecture, Dr. Yacob pointed out that veins and arteries are mirror images of each other, with the point of difference being the saphenous veins in the legs and the cephalic and basilic veins in the arms acting as vital backup systems for venous blood flow. Highlighting the necessity of this complex system, he introduced the concept of deep vein thrombosis (DVT), which is when a clot develops in the deep veins causing overreliance on blood flow through the superficial venous system. Furthermore, these cases have absolute contraindications to superficial vein surgical interventions as superficial system damage will completely compromise limb venous outflow leading to limb loss6. Interestingly, peripherally inserted central catheter (PICC) lines were highlighted as a risk factor for upper extremity DVTs as ~10% of PICCs lead to upper extremity DVTs.
Analogous to PICCs, patients with peripheral lines commonly develop superficial venous thrombosis (SVT)7 but rarely develop superficial suppurative venous thrombosis (SSVT). Although both diagnoses involve clots that compromise superficial venous return, SSVT consists of an additional infection component. The standard of care consists of line removal, cold compress, and Tylenol. Moreover, concerns arise when SVT affects the primary superficial system or propagates to the deep venous system8. Consequently, an ultrasound is conducted to confirm diagnosis and anticoagulation is considered if a DVT is suspected9. Lastly, ascending lymphangitis, a bacteria-induced inflammation of the lymphatic vessels from SSVT, was presented as an example where surgical intervention can occur.
Dr. Yacob then discussed the most common venous disease which is varicose veins. Veins are constantly working against gravity; therefore, muscle contraction squeezes the deep and superficial venous systems to assist blood propagation back to the heart. Venous insufficiency can result from the dilation of venous walls preventing valve components from making contact and causing leakage10. Chronic DVTs can cause varicose veins via saphenous vein dilation resulting in bi-directional blood flow11. Additionally, venous ulcers can occur when stagnant blood exits the venules and move into the skin, causing inflammation-induced breakdown11. Venixxa is a drug that inhibits chronic dermal inflammation and helps with ulcer-related symptoms; however, the side effects and inability to reverse disease take away from its widespread use as an effective therapeutic. Primary varicose veins result from inherent weakness in superficial veins. Common risk factors such as old age, obesity, and constant standing result in 23% of the population suffering from this disease with >75% being women11. Varicose vein prophylaxis includes regular use of compression socks.
The gold standard for effectively diagnosing these venous diseases is ultrasound 12. This diagnostic tool describes the anatomical findings of the superficial, deep, and perforator venous systems. It functions well in elucidating the venous system's hemodynamic activity, a vital aspect of venous insufficiency diagnosis. Finally, ultrasound can provide relevant timelines which includes differentiating acute from chronic thrombosis.
Finally, Dr. Yacob discussed one of the most severe forms of venous disease which is an acute iliofemoral DVT. This is different from a traditional DVT as it involves clot-mediated occlusion of the common femoral and iliac veins, resulting in complete obstruction of venous outflow as both backup and main pathways converge at this location13. Furthermore, limb-threatening ischemia from venous outflow obstruction is clinically diagnosed as phlegmasia cerulea dolens. Management of this disease involves emergency thrombolytics. Conversely, non-limb threatening iliofemoral DVT is controversial; however, evidence suggests that thrombolytics help avoid post-thrombotic syndrome.
After Rounds, the TMED801 class had the opportunity to discuss venous disease and career pathways with Dr. Yacob. We first delved into surgical treatment of varicose veins in the form of vein stripping and ablation. We discussed how the latter measure is more effective, safer, and conducive to quicker recovery; however, this procedure is not well covered in Canada, forcing many patients to choose the former option. Next, we discussed how vascular surgery is portrayed as a cosmetic surgical intervention in the press resulting in limited service coverage and lack of awareness of venous disease prevalence and severity. Finally, Dr. Yacob outlined his training, including an undergraduate education at the University of Ottawa, medical education in Ireland, and vascular surgery residency back in Ottawa. He also talked about his additional certifications and interests and how they benefit his current practice. In the end, Dr. Yacob encouraged TMED students that having a graduate degree is a great asset to future medical students and practitioners.
As translational medicine graduate students at Queen’s University, our research focuses on patients and their diseases through lenses like epidemiology, basic sciences, and artificial intelligence. With the limited translation of leading risk factors of venous disease to the public, inequitable access to optimal venous surgical interventions, and the shift toward valuing research experience as an asset to learners and professionals, it is clear that translational research and implementation is crucial to improving patient outcomes in the field of vascular surgery.
On behalf of the TMED 801 class, I would like to extend a big thank you to Dr. Yacob for his time, honest insights, and tireless contribution to patient care in the field of vascular surgery.
1. Rabe E, Guex JJ, Puskas A, Scuderi A, Fernandez Quesada F, Coordinators VCP. Epidemiology of chronic venous disorders in geographically diverse populations: Results from the vein consult program. Int Angiol. 2012;31:105-115
2. Rabe E, Régnier C, Goron F, Salmat G, Pannier F. The prevalence, disease characteristics and treatment of chronic venous disease: An international web-based survey. Journal of Comparative Effectiveness Research. 2020;9:1205-1218
3. Zolotukhin IA, Seliverstov EI, Shevtsov YN, Avakiants IP, Nikishkov AS, Tatarintsev AM, et al. Prevalence and risk factors for chronic venous disease in the general russian population. European Journal of Vascular and Endovascular Surgery. 2017;54:752-758
13. Vedantham S, Thorpe PE, Cardella JF, Grassi CJ, Patel NH, Ferral H, et al. Quality improvement guidelines for the treatment of lower extremity deep vein thrombosis with use of endovascular thrombus removal. Journal of Vascular and Interventional Radiology. 2009;20:S227-S239