What If It’s Not IBS or Anxiety? A Vascular Surgeon Explains with Dr. Robert Hacker (Ep 178)

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Dr. Linda Bluestein: [00:00:00] I'm super excited to tell you about the Bendy Bodies boutique. I'm so proud of our fierce styles and flexible designs. These are created by Hypermobile artists. For Hypermobile shoppers. There are so many fun items from clothing, accessories, home goods, and my favorite are the bags. I especially love the Weaker Tote with one of the EDS tough designs.

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Dr. Robert Hacker: The most important part, and if you read the papers from the group in Seattle, they're trying to take the nerves, is drip the nerves off the artery.

It's more than just plucking a string. You have to what they call de innervate the artery so that the pain goes away. The problem is that's a surgical procedure and you can develop scar tissue and it can come back so there's no guarantees.[00:01:00] 

Dr. Linda Bluestein: Welcome back. Every bendy body to the Bendy Bodies podcast. I'm your host, Dr. Linda Bluestein, the Hypermobility md. A Mayo Clinic trained expert in Ehlers Danlos. Dedicated to helping you navigate connective tissue disorders and live your best life. Today's guest joins us to share expertise for those living with EDS and HSD.

Our conversation is unscripted and their views of their own, not those of me or the bendy bodies team. I'm so excited to chat with vascular surgeon, Dr. Robert Hacker today. We've talked a little bit in the past about compression syndromes like mals, median, arcuate ligament syndrome, mayner syndrome, pelvic venous congestion, and Nutcracker syndrome.

But today we'll be getting the perspective of a vascular surgeon. So I'm really excited to have this conversation. Dr. Robert Hacker is a double board certified general and vascular surgeon based in St. Louis, Missouri. He founded his private [00:02:00] practice in 2023 to broaden access to advanced vascular care.

His work spans complex arterial and venous conditions and has expanded to include pelvic venous disease, mals, neck cracker syndrome, and mayner syndrome. Dr. Hacker frequently treats patients with EDS, pots mast cell activation, and related disorders. He is known for his individualized approach, integrating advanced imaging and minimally invasive interventions to help patients improve function and quality of life.

I'm so excited to have this conversation because people so often suffer from these conditions, yet struggle to get properly diagnosed and treated. As always, this information is for educational purposes only and is not a substitute for personalized medical advice. Although we discuss healthcare topics, nothing on bendy bodies is personalized medical advice.

Always consult a qualified healthcare provider for your own personal care. Stick around until the very end, so don't miss any of our special hypermobility hacks. Due to the highly visual and complex nature of these topics, I would strongly recommend that you check out the YouTube video [00:03:00] if you possibly can.

Here we go.

I am so excited to be here with Dr. Hacker, vascular surgeon, who does lots and lots of work with patients, with EDS, HSD, pots, MCAS, et cetera, vascular compressions. Um, it's so great to have you here. How are you doing today? 

Dr. Robert Hacker: Oh, I'm very well and I'm excited and, uh, honored to be on the show. So thank you for the invitation.

Dr. Linda Bluestein: Of course, of course. Um, I'm super curious to to know how you got involved in EDS, uh, in the first place. 

Dr. Robert Hacker: So this is all basically an accident or luck if wanted to look at it this way. I used to be an academic surgeon for the last, uh, for the first nine years of my career and wanted to leave the academic environment and start my own private practice so that we could deliver, uh, more affordable care, faster care, different types of care than you can offer in the hospital.

And so part of that [00:04:00] was converting from a very heavy arterial practice where you do some of the big stuff like gunshot wounds and rupturing blood vessels to the more bread and butter daily stuff like varicose veins, swollen legs and wounds. So as the practice shift, we started, uh, identifying a lot of patients, mostly women.

Who had swollen veins, varicose veins of various ages, thirties, forties, fifties, sixties, seventies, eighties. And you start talking to them and some of them had this diagnosis of Mayer syndrome. Well, this is very well known in the vascular community. Rarely seen in the hospitals, but very frequent in our clinic.

So we started treating the Mayer syndromes. And it's interesting because they said, yeah, my leg feels better. And then you start to get the stories, Hey, did you know I've always felt this way since I was 20 years old, 30 years old, and now all my symptoms are gone. And some of these women were pelvic congestion syndrome patients.

Some of them [00:05:00] later on said, Hey, I had POTS disease. And they didn't really wanna tell the doctor because of the scrutiny and the, and the criticism that they get in the community. And we started getting 1, 2, 3 stories like this. And when we started getting 10, 12 stories, we said, there must be a correlation.

So we started really drilling down and I had hired a new partner into the group, uh, Dr. Shadi, and she has a very strong background in research and we started fracking our research and, uh, we ended up publishing a paper and doing some statistical analysis on quality of life. And it turned out that the PE patients that we were treating were having very statistically significant quality of life improvements after one or two treatments.

And now we're drilling down to what is really happening. And we've been working in the community with, uh, doctors who specialize in MCA and POTS to see if we can find some corollaries. [00:06:00] So it's all by luck. 

Dr. Linda Bluestein: Yes. Same with, same with me. This was not, uh, this was not an intentional thing really. Well, I guess it was intentional, but it wasn't part of my original plan, let's say.

Um, so, so why do people who have connective tissue disorders, pots mast cell activation, why are they so prone to these conditions? 

Dr. Robert Hacker: You know, I think that is gonna be the million dollar question, and I think that as the research progresses in the scientific community and the fact that now that we're seeing not just a medical component, but some kind of anatomic, correctable or surgical component, I think what we're gonna notice is that maybe we've been slightly misclassifying or not looking in all the corners, and I suspect in the end it's gonna end up in the nerve world, some kind of disautonomia, some kind of way that the nerves are functioning that is yet to be described.

I'm actually very fascinated where the next 10 years go with this. 

Dr. Linda Bluestein: Yeah, me too. Me too. So you talked about [00:07:00] people dealing with things for many years, which of course is, you know, the people, the patients that I see. Absolutely. This is such a common thing. What symptoms do you find are most often overlooked or misattributed, but are things that you can actually address?

Dr. Robert Hacker: Yeah. So actually I will tell you first off, 95 to 97% of our patients are women. 

Dr. Linda Bluestein: Mm. 

Dr. Robert Hacker: Uh, we've treated close to 185 common iliac vein stents or Mayer syndrome, and we're up in the 45 renal vein stents. Almost all of them are women except for about four or five men. So I think, uh, a lot of the symptoms that the women are presenting with the men have too, but they're more overlapping with gynecologic symptoms and pathology.

And so, because. They go through the normal gynecologic evaluations, the OBGYNs look at them and all their testing is negative. They end up going to the GI [00:08:00] doctor because it's a similar space. All that testing is negative. Um, no one has been looking at the vasculature. There hasn't been a lot of interest in it.

Uh, in the academic community and in the private practice world. The focuses have not been on venography or taking photos. So what you have is this basically anatomic area. Essentially the pelvis, which is poorly understood by medical doctors is not of interest to academic doctors, but it's been there the whole time.

And so we've actually uncovered a ton of pelvic congestion syndrome, completely un unrelated to EDS or MCA or pots. And a lot of the women are having a lot of the same symptoms. And so I think what we have is a gap in our medical knowledge and it's related around women's health, which. A common theme that we hear.

And I, and I'm really glad we found it because I think we're really changing lives. 

Dr. Linda Bluestein: Yeah. I, I'm actually married to a urologist, um, but [00:09:00] I've definitely, when I was having some problems, um, in my pelvis, you know, it was like the black box, you know, it seemed like so few, few people really understood and knew what things to, to look for.

So what kind of symptoms should primary care doctors or other clinicians, what kind of symptoms should draw their attention to, you know, I know we're talking today in, you know, in the interest of time, we could spend hours and hours talking about this, I'm sure, but we're gonna talk about, you know, Mayer or Nutcracker malls, you know, uh, various different things.

What kinds of symptoms should a person think, okay, maybe there is something going on in the, in the pelvis, maybe in the abdomen, and this could be, um, a compression syndrome, a venous problem, and then what kind of imaging should be done? And I understand that those are big questions. 

Dr. Robert Hacker: Oh yeah. So what I like to do is, um, medicine as you know, can be very, very complicated.

And a question like this, I'll start talking surgery jargon and I'll lose you in [00:10:00] three seconds, but this is what I would tell the patients. And when we ask them, I would say 75% of the patients all have the same core of problems and each has their own little unique characteristic to themselves. And I, those characteristics are where when you listen to the online boards or you listen to, that's where they deviate.

But the vast majority of the time, everyone has the exact same symptoms. And let me go down anatomically. If I was looking at you, because I'm looking at people like with x-ray vision, what would you complain of? Right. So in the malls patients, this is very rarely diagnosed. And I started picking onto this about five years ago when I had one very specific patient, and this is when it clicked for me last year, when I correlated with that.

MALS is the median arcuate ligament syndrome. It's very rare and it has to do with the way the embryology is around the artery. There is a nerve plexus around it and it creates pain, but the way the brain is innervated [00:11:00] it, the brain doesn't put a lot of onus into the abdominal organs on like a finger or a face or a nose.

So it just has vague pain Malls. Patients have a very specific pain in between their shoulder blades that bores through them, and it hurts, and it can come in and it can lead to ER visits. And here's the deal. You'd go to the er, they find nothing except if you are looking for it, you can get a certain cut or a side slice this way.

So I'm looking at you this way. You can see the angulation on CT scan and if it's been there for a long time, you'll even see what we call a post stenotic or post narrowing dilation or ballooning around this, which is pathognomonic for it. What you do with it is an entirely different discussion. How you treat it is an entirely different discussion, but if you think you have it, you just need to go find a vascular lab that can do very specific breathing in ultrasound and breathing out [00:12:00] ultrasound to reproduce it.

So that's how we find mals, but it's very rare. 

Dr. Linda Bluestein: Can, can I just ask, uh, sorry to interrupt you, but I just wanted to ask, is it very rare even in EDS patients? 

Dr. Robert Hacker: Yes, I have been paying attention to the EDS patients and some of the other connective tissue patients. Remember the EDS group of people, they have a connective tissue problem, but MALS goes back to when you're being formed as an embryo, how your cells migrate.

That migration is very much a function of growth and is very individualized. So you could have twins with EDS and one have malls and one does not. And this has to do with chemical signaling during embryology, which obviously you're gonna be familiar with, but the audience may not. And so it is, I would say, a bad luck attribute if you have mals.

And I bet you there's many people who have it where I think the EDS patients become more prevalent. If we were to look at why do you see so many? I think it goes back to the nerve issue. I think their nerves are [00:13:00] more sensitive and they may be more attuned to the sensation, even though there are probably many people who have it.

Dr. Linda Bluestein: Mm-hmm. Right. Okay. 

Dr. Robert Hacker: So moving down, that's the malls. So the next one would be the Nutcracker. Now the Nutcracker I find very fascinating. I almost need a chalkboard to draw all the things, but I want everyone to kind of close their eyes for a minute and remember from your heart. 'cause the next things all correlate together from your.

The blood goes into your kidney or it goes into your leg, and how does it get back? It gets back through the veins. 25% of our blood flow, and you can check it with urology husband, if I'm wrong, goes through our kidneys, which means your left kidney gets 12.5% of every heartbeat. This is a tremendous amount of blood.

So it goes into the kidney and if you look at the pictures, it comes back outta the kidney and goes back up to the heart. Now take that everybody, except for very few people are born with their superior [00:14:00] mesenteric artery going over and the renal vein going under this configuration. That changes as you grow.

So when you're young, there's a lot of space and if you happen to grow very quickly, you that angle can tighten. So we talk about the superior mesenteric artery angle. There's a vein under it. Well, if you're compressing the vein. And a lot of blood is going through it, the body will find a way for it to come out.

So how does it come out? It turns out that our left gonadal vein, which would go to the scrotum on a man on the left or the ovary of a woman on the left, happens to drain into that vein. And so many times we'll see that the valves, which are meant to drive the blood up or keep it going up into the left renal vein will break.

Or this is even more fascinating. We identified this with Dr. Ella, uh, with some of the POTS patients. They will develop a very large secondary [00:15:00] collateral or network off that vein and bypass it right into the spine. And we've identified that many patients who have that pattern suffer from the headaches.

And right now, I'd love to have a poll that you guys could show how many people said, oh, I have headaches and I had a blood patch and it was negative. If we were to do the venogram on them, they would probably have this pattern because the patients who do not have headaches traditionally have not had this drainage pattern.

And the ones who do do, so now you have the blood coming in, it wants to come out, and you have this compression. Well, around the superior mesenteric artery is another neural plexus. And what we've identified around this neuro plexus, this is responsible for gallbladder, pancreas, and gastrointestinal symptoms.

And what we've identified is in the population, the level of nutcracker is very low. If you look at the literature for academics, it's very [00:16:00] low in the population. In our cohort of patients who we've selected for and we're checking for because they're coming in with symptoms, 95% of them have compression of the renal vein.

The prevalence in the office is far greater than what it's reported in the national population. Now, why do EDS patients have it? Uh, I think it has to do with the way that you're growing and the way that your connective tissue is. And why are EDS patients, uh, and maybe patients with pelvic ingestion syndrome more symptomatic?

Well, if you have an inability to bring your stretched vessels back together because you have a connective tissue disease, you're more prone to venous dilation, collaterals, or those side branches. And where do they go? They go around your stomach. You get early satiety. They start irritating the plexus around your superior mesenteric artery.

You may have a pancreas attack, but your labs are normal or people out there will complain of, oh, my, I had gallbladder attacks, [00:17:00] cholecystitis. They took my gallbladder out and my symptoms never went away. We treated a woman two weeks ago. Gallbladder was out, was frequently in the emergency room, lots of pancreatitis diagnosis in the er.

We did her stent. All the symptoms went away. 

Dr. Linda Bluestein: Hmm. 

Dr. Robert Hacker: The society, the, the, the, the bloating. These nerves from the superior mesenteric arteries start traveling down onto the intestines and they're telling the body rest and relax or fight and flight. That's where the p parasympathetic neuro ganglion are, how they're being activated.

I am unsure, but I think because the artery is squishing the vein, we must be activating something. 'cause the stent seems to alleviate a lot of the symptoms. The left flank pain, the blood in the urine, the microscopic blood in the urine, the protein in the urine. These are all also signs of con congestion and uh, the body starts trying to reduce it so you don't have kidney problems.

A lot of those improve. [00:18:00] So if you follow the blood down the gonadal vein, it goes right into the pelvis, into the ad nexa, and we have venogram after venogram. On our Instagram page, we have a little anatomic picture that says, do you have nutcracker? Mayer syndrome, and if you swipe over, you can see a venogram of a patient who has all of these features.

The, the blood goes in, the kidney, goes down to gonadal vein, fills the pelvis, fills the spine. It was a really good example. So we see that. Why it works, I do not understand yet, and I think this is where research goes. But once we put the stent in, and I'll preface, we can have a stent conversation a little bit later.

For the, for the, uh, for the audience, because this seems to be a point of topic all the time, we do notice improvement in those gastrointestinal symptoms, upper epi, gastro symptoms, left pain symptoms. As we start traveling down, the next big compression is that [00:19:00] Mayner syndrome, which is also very poorly understood by the medical community.

If you ask your doctor, what's Mayner syndrome, most of them have never heard of it, and this is. We're all born this way. We're also all bored with our aorta or our big red blood vessel off our heart coming down the left side of our spine. And the big blue blood vessel or the inferior ven cava going up the right side of the spine.

But we have legs and so there's a natural crossing, right? And you can see where you're gonna have a compression. Well, it turns out unfortunately, that the soft vein, which is only meant to hold 1, 2, 3, 7 millimeters of mercury, of pressure, which is very, very light, is being compressed by a blood vessel that has a heartbeat pressure one 20 over 80.

What do you think wins the artery winds? So you get a compressive syndrome. And it's interesting, again, because when I've gone back and looked at CT scans, thousands of CT scans, most people, [00:20:00] the way that the veins and the arteries and where they cross in relation to the pelvis, there's a drop off like a cliff.

And so even though they're crossing, the crossing has no physiologic. In all of these patients, it's almost like everything has shifted up. And so we have, uh, a compression that is now causing symptoms. So now you have the blood in the left leg trying to get out because that compression is right in the upper pelvic brim.

Now, every woman experiences during pregnancy, 'cause they have a large uterus sitting on this, right? But, and if you listen to the stories often you'll hear that people got worse after their second or third pregnancy. So maybe they've compensated for a little bit, but they can't after time. So now I want you to take the two pieces we talked about focusing on the Nutcracker and they made Theyer, and we're gonna put 'em together now as one giant picture.

So now the blood comes down, it goes in the kidney, it caused to come out the kidney, it can't [00:21:00] because it's hitting the compression. So it says, Hey, I'm gonna open up this gonadal vein. It goes down the gona vein, it goes into the ovary or the aa, the Batman looking thing that you remembered from anatomy class.

It drains into the internal system of the pelvis. It starts trying to go back up the iliac system, and it hits a second compression. So what does the pressure do? Blood finds a way, so it just goes across the pelvis through the AA and the female pelvis has a tremendous amount of ability to develop collaterals.

Again, I think because of the open potential space and the people who have the connected tissue disease, I think are far more susceptible to, again, this venous dilation. People without connective tissue disease may experience this during a short period of pregnancy, but once they deliver, everything goes back to normal and it's fine.

But if you have EDS. [00:22:00] Or any other connective tissue disease, or you've had multiple pregnancies or multiple insults where you were born with higher grade compression than the rest of the population, right? This is persisting and it persists forever. So now what do you have? You have all these large open tortuous or bendy ropey veins, and they have blood in them.

And what does blood? Blood is? Water and proteins, and it's really heavy. And so what do you finally get? You start getting pressure, fullness, discomfort, right? Uh, women will complain of painful intercourse, heavy menstrual periods. We have some women who have had multiple miscarriages, late term, let's say 12 weeks, 15 weeks, 20 weeks.

They've had genetic analysis, no genetic abnormalities. So why? Well, if you have a high venous pressure, you lose what in medicine we call the the perfusion pressure. So if your artery is one level and your vein is very close, there's only a small gap that the oxygen. Can [00:23:00] travel through, you need a large gap.

And if you have high pressure, maybe, maybe, and this is a theory, maybe that placenta isn't getting enough oxygen and the baby is actually starving from this. And so you wonder, 'cause we see the pattern, is this starting to tie everything into a bow? Is there an actual reason why this is happening? It's very fascinating and I wish I had so many more answers, but I don't.

Dr. Linda Bluestein: Yeah, yeah. No, that's, that's really, really helpful. And you know, so many people struggle with a lot of the symptoms that you're, that you're describing. And of course, like you said, some of these are more pathognomonic and others are, you know. Quite common, but if you've ruled out a lot of the more common causes, it's really important for people to be able to hear this and hear, okay, these are the things that can cause that kind of a symptom picture.

So if you have possible mals, then you would want an inspiration expiration ultrasound of the abdomen is what it sounds like. Um, what imaging studies are most important for people to, to get, um, [00:24:00] and knowing that sometimes it's not so easy to get those ordered? 

Dr. Robert Hacker: Sure. So the, the first thing is the least invasive test you can get the least risk to you and the least costly is an ultrasound.

The limitation with the ultrasound, of course, is, um, and many people have seen these ultrasounds, is the technologist who does it. In our office, I had very experienced technologists and we still took us three months to learn the right protocol to do it well. It's just not baked into the institutional knowledge and people aren't spending time also.

Most places that have ultrasound techs, they're really looking for very protocolized things. So the celiac artery plexus, it's in the textbook. Most techs learned it in school, but a lot of hospitals don't offer it as an available study. And so in the ultrasound world, this is starting to fall into the, not unknown, but to the, to the rare and unique.

And you might not be able to get [00:25:00] one, but we can teach them. So, uh, and there's always discussions. If there are people out there that said, Hey, I have an ultrasound. They're not sure what to get, they could reach out to us and we could help guide them. But I would say you'd have to take the result with a grain of salt if you don't have an experienced team doing it.

Right. Uh, CT scan, many people have had CT scans for various ER visits. The CT angiogram, meaning they put the dye in your vein, is an excellent test for this. If, and there's a big if. The hospital did the right protocol because what people don't understand is when you go through the ultrasound tube, sorry, the CT tube, the study is protocolized or told to do it in a certain way where, think of it like a slice of bread.

Most of them are thick Texas toast bread. And what you need is like wafer thin bread. So when we talk about millimeters and often an abdominal CT scan is five millimeters, which is what, two point, [00:26:00] uh, like half an inch. What we're looking for is 0.7, you know, millimeters or less than a millimeter. It's tremendously more packed in the data.

And so when you're going through these areas, which the compression may only be two millimeters in size, and so a five millimeter scan may be skipping right over it or lacking what we would call the resolution, but it may be there. It, it's really hard to tell. Um, but it's a really great test, especially if it has.

The front view and the side view, and then the regular bread view, which a standard CT scan has. These would show both the renal compression, it would show the celiac compression and if you know how to interpret it does show the Mayer if it goes low enough. But what I've identified is the Mayer, we find the best test for it is ultrasound and then an angiogram with an in the blood vessel ultrasound.

That's how we diagnose everything before treatment. An actual ultrasound in your blood vessel. 

Dr. Linda Bluestein: I [00:27:00] actually went and observed somebody, uh, an an interventional radiologist who's in my community and they were doing that intravascular ultrasound and I had never seen it before because I've been out of the OR for a few years.

I don't know if I was, would've seen it, if I was still in the or or not. But anyway, um, it was really, really fascinating. So if there, we have a lot of clinicians who listen to this, uh, podcast and many who really want to help this population of people. So what about something like a venogram? Is that an appropriate thing to order?

So it, it sounds like, I'm sorry, lemme back up a second. So it sounds like they should order a CTA of the abdomen, but with thin cuts like the 0.7 millimeters? 

Dr. Robert Hacker: Yes. Okay. So if you're ordering a CT scan, I would order a CT scan of your abdomen and your pelvis. I would ask for it to have both arterial phase and venous phase, which means they just run you through the machine with a slight delay because of the way the test goes in.

And then you would ask them to, [00:28:00] uh, make sure that you have thin slices. That's a CT scan. M-R-I-M-R-A can be a little bit tricky. MRI is really great for like the pelvic congestion syndrome to show those big dilated varicose veins. And then you can use that to infer that there's a problem elsewhere, right?

If someone's having low pelvic pain, MRI's, great, but CT scans and MRIs are really expensive, right? And, uh, um, sometimes getting access to them is hard or you're exposed to radiation or maybe you're pregnant or you think you're pregnant, right? This is, you can't, these are no-nos. Um, so ultrasound is a great test.

Uh, for ultrasound. We, uh, rarely do the celiac, but if you do the celiac, you say, Hey, I need to look for median AR ligament syndrome. I need inspiration velocities and expiration velocities, because as you breathe, your diaphragm goes up and down and pulse tighter on those bands or releases them, and you can demonstrate a change in veloc.

Objectively, very scientifically. So that's a great test. The [00:29:00] Nutcracker we've been working on, uh, we've noticed that there's a lot of people who have it. You can see it if you're not eating, you have a thin body habitus. Um, you have a good tech, but even my technologists sometimes have trouble seeing it.

But we check it and we use that as a rule in rule out test for the venogram, because if it looks like everything is open, well then you don't have it. But if you're having symptoms and it looks like you have what we call flat line or monophasic waveforms on the left with dilation, you're able to measure the vein.

And then you see on the, the compression, it's very small. You can infer there must be some compressive process going on. Even though you don't know all of it, it makes one feel more comfortable to go to the next level. The ultrasound, as we find useful again for screening. 

Dr. Linda Bluestein: And that's exactly what I was, uh, hoping that you would do.

And you did that in a stepwise fashion because right. You don't, you don't send somebody right away for the more invasive test if you're not sure if you're actually in the right ballpark or not. So thank you. That's very [00:30:00] important. 

Dr. Robert Hacker: Yeah. We believe in education and empowerment. I mean, by the time many people hit our office, they've seen 12, 13 doctors.

They've had every blood test, they've had endoscopy colonoscopy, they've had intravaginal ultrasounds, they've had CT scans galore. And you know, everything is negative. So you sit and you talk, you keep an open mind, you do an ultrasound, and I would say 99% of the time the people who walk in the door and you do the ultrasound screen positive, and if they screen positive, we will then feel more comfortable doing a diagnostic venogram.

And we never treat at the first visit. The beauty of a nice private practice is. Um, we have great flexibility, great availability, right? The insurance companies are a little bit difficult to deal with, but usually we can get people in within a week, uh, from the time of diagnosis to, to a di, uh, to the or.

And we diagnose everything with [00:31:00] intravascular ultrasound because a straight venogram, actually I must have missed a ton of it. I used to do the venogram. And again, remember we talked about compensation. The body finds a way to compensate, so it elongates the iliac vein. It, it pancakes itself out, so it's able to try to carry the blood flow, but not unless you look for it.

We actually find it and it's been sitting there the whole time. 

Dr. Linda Bluestein: Okay? Uh, we're gonna take a quick break and when we come back, we are going to talk about how you address these problems, what the kind of therapeutic options are. And so we're gonna take a quick break and we'll be right back.

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Okay. We are back with the Dr. Hacker and we're going to be talking more about treatment options, and I think we're gonna take a little quick diversion into POTS patients and pelvic venous congestion. You shared with me during the break that you had a theory about pots and pelvic venous congestion. If you could share that with me.

Dr. Robert Hacker: Sure. Absolutely. So one of the things we've observed, and it actually links very closely into our theory about mcass, uh, uh, doctor, I don't know if you ever had a chance to work at a trauma center, did you? 

Dr. Linda Bluestein: Uh, you know, in training level one at Mayo, but, you know, post that level two, level three, um, you know, as the anesthesiologist, so, 

Dr. Robert Hacker: yeah.

But this is very powerful because you can maybe correlate what we've been talking about and we'll, I'll, I'll blend it all together. So, as a surgeon, we trained very heavily for trauma, stabbings, gunshot [00:34:00] wounds. I trained in New York, I was in Philadelphia, I was in Pittsburgh. Right. I've dealt with my share of messes, but one of the things we've noticed is that when someone loses blood very quickly, or in, they're in an acute situation, they go into shock and their body behaves in a very specific fashion.

Right. Their blood pressure behaves in a certain way, and their heart rate behaves in a certain way. And what does that weigh? Well. If you have no blood going to your heart, the speed goes up and your blood pressure goes down. Now, in the POTS patients, they are able usually to maintain their blood pressure eventually, but you usually see a small drop.

If you have pelvic congestion syndrome. As we talked about earlier, before the break, you have these large dilated veins depending on how much volume you have, because these veins are what we call in parallel, meaning they're all next to each other. There's a tremendous, what I would call, or we would call potential space, and as we know from probably talking to your other guests, a large majority of our blood is actually [00:35:00] stored in our legs.

The legs we can deal with. So if you have a compressive syndrome that's preventing some of your venous blood to quickly mobilize when you change positions from a sitting or a lying position to a standing position, if that's flowed right, your heart's beating and all of a sudden it's beating dry.

Figuratively, right? Every time it beats, it's kind of not pulling as much blood as it should. If you compound that on with a potential space in the pelvis where there are no valves, where the blood can kind of slosh, figuratively, wherever it wants, you're adding more blood from the heart. So if you can just guess, and it would take a really eloquent study to do this, someone stands up, not only now can they not mobilize the blood outta their left leg or right leg, because some people have both legs compressed by the aorta, and then it's being held in the pelvis.

All of a sudden, you are losing 250 [00:36:00] milliliters, 500 milliliters until you're able to move and catch up, which can take a minute, two minutes, and so your heart is just beating away. You're behaving like a trauma patient. Now, how many of you out there get anxiety? Feel like blood pressure, shockey nervous.

You see this all the time in this community at a very high preponderance, more so than in the normal population. So one of the hypothesis is, you know, are you actually hypovolemic from these compressive syndromes, from these pelvic dilated syndromes? And is it leading to a shock state? And what is a shock state?

It's your body going crazy, your sympathetic system being upregulated in a, what we call compensatory mechanism. And I'm so sorry. It's the only way I notice it is a little doctory, but your body is trying to survive. And what happens when you lie down and you raise your legs? Well, you're able to compensate for that.

You're taking that stress away. And what [00:37:00] do the patients all do? They all lie down. Raise their legs, they transfuse themselves. Right? And they usually feel better and the headaches go away, right? Well, what else can a shock state do? So now we have the pelvis, lemme go back. So it's holding all this blood.

So we found some of the patients who we've treated for the pelvic congestion syndrome, and we've placed the stents into a few of them have completely resolved their symptoms, but most of them say their symptoms have improved because I think there's more to the pathology than just the blood flow. Right.

I think there's a nerve component to this, and so we're always very clear that we don't expect it all to go away. We just expect you to go from a 10 to a five and most people will say, I would love to be a five. Right. But MCAS Right. We all have heard about MCAS, right? Well, uh, Dr. Cuttin and I were having a discussion at the Dysautonomia Clinic and yeah, there's beautiful studies that say that the, the mast cells, the [00:38:00] cells that release all this histamine and, and, and these byproducts, they're built a little bit differently.

My argument is, okay, you have, you have a connective tissue disease and your cells are fragile little balloons, you still gotta throw the balloon for it to pop. So what does that throw? I think the constant trauma and stress of the, of the hypovolemia sympathetic parasympathetic system, right? The parasympathetics are being stimulated by the compression.

And why do I think that? Because I know from doing aneurysm surgery, the sympathetic system is on the right side of the aorta, specifically over the right iliac artery. I've seen it. I have to be very careful about it. When I do surgery, the parasympathetics are coming down from the stomach. They're going around that celiac artery, they're going around that superior mesenteric artery.

They're being compressed, the heart's beating, they're going around the left side of the body into the leg. And I think just like, uh, acupuncture, they're being overstimulated. [00:39:00] And that overstimulation is leading to the brain fog. Because you're not having pain, you're just having overstimulation and your body doesn't know what to do with it, so you're not thinking straight.

So alleviating the compressive syndromes is like alleviating all of this like cerebral noise. Then you're adding the shock-like state of the standing and the sitting, and the standing and the sitting, and what does your body do? It basically becomes fragile. Every time you stand up. It's like you're getting shot in the abdomen, you're losing a whole bunch of blood and your body has to compensate and you do this over and over again.

Everything is on on edge, and I think that's even where the mast cell diagnosis comes in because you, if you notice most of the patients, and I'm very curious in your population, if you did a survey who say that people don't show up and say, Hey, I have mast cell. Oh, and then I have pots or EDS. It's always I have these symptoms and then eventually I've also noticed I've developed an allergy.

Dr. Linda Bluestein: I would say that's, that's definitely very, very, very common that I'm asking them. A lot of people have, of [00:40:00] course, listened to the podcast. They know about mast cell, and so they kind of say, I really suspect that I have it. Or in some cases they've been diagnosed or a family member's been diagnosed. But you're right, a lot of people have, um, either diagnosed or suspected EDS or another connective tissue disorder, and it kind of starts, starts there.

Um, I'm curious to ask, when you say that you have 95 plus percent representation of females versus males, but you're also describing like the pelvic venous congestion. I'm thinking about, you know, males with pots, which we know there's fewer males than females with a lot of these, um, conditions, but are you seeing much in the way of males with, with pelvic venous congestion and, and pots, or why do you think there's such a massive difference there in your practice?

Dr. Robert Hacker: So literally I think we have six gentlemen who have the diagnosis of pots. Uh, several of them we've treated and we've done the venograms on them on two separate occasions, one during treatment and one during the diagnostic phases. And [00:41:00] the pelvis is just in a man is just so much tighter. Uh, there's much more distinction between the left side and the right side.

You don't see the same cross pelvic, you see there's a couple potential veins around the pelvic brim. What you will see is the gonadal vein reflux, but usually you can diagnose that they have it just from doing a physical exam and they have what they call a varicose seal or varicose veins on their scrotum.

You have to remember the scrotum and the labia are exactly the same organism in men and women. Embryologically except men is on the outside. And so we see it and so it gets treated and women, that ovarian vein gets seen. It doesn't. So I think, I think in men you have a much tighter pelvis and just female anatomy of a bigger pelvis.

You have this really a potential space, right, to hold a uterus and a baby. And I think [00:42:00] just from the way that we have developed, there's much more cross flow and you really see that flow around the, it's very hard to describe to the group, but if you were to look at someone from the inside, like peek over inside the bowl, if you will, opening from the belly button, you know, there's a big space around the vagina, around the inside where the organs are huge amount of veins around the outside of the uterus and a ton of veins around the ovaries, and they just cross.

I mean, when you, if you looked at again, the, the, the referred angiogram that I showed you, it's so representative of what we see so many times. And you can just see where all this blood goes. And then the man, you don't see it. Usually they have the, uh, the, the iliac vein compression, but yet they have the same symptoms many the time that they're feeling.

And that's why I say, okay, there must be more than just the anatomy we're identifying. That's why I keep going back to nerves and that's why I think one day if we have the community talks, we'll say, maybe pots isn't the [00:43:00] best answer. Maybe we just say you have dysautonomia, you have a dysfunctional autonomic system for various reasons.

So a little bit more general, a little bit more broad, but more and more inclusive if you'll And less specific. 

Dr. Linda Bluestein: Okay. And so I know this is gonna be hard 'cause we've talked about multiple different conditions in, in this conversation so far. But in terms of treatment options, how are you, uh, approaching this?

You talked about stents already, so can you run us through kind of like, what if, so now you've identified the prop. You've identified that there's either mals or pelvic venous congestion or nutcracker or mayner, um, which I understand are all different things. But, uh, what would we be looking at in terms of treatment?

And I guess actually that is another question that I have is why do some people have more than one of these problems too? 

Dr. Robert Hacker: Let's go with the last question. Why do they have more problems? There must be a, there must be a developmental component. [00:44:00] Meaning my best hypothesis is, is that, um, when the kidneys are formed, they start low in the pelvis and they rise up.

And so we see many different patterns of kidneys. So people have one renal artery, some have two. Um, and the venous system is kind of growing at the same time, and it's a very complicated way that blood vessels form. But what do you have? You have two shifting systems, an arterial system and a venous system.

There must be something in these patients where they're not aligning like the rest of the population. And it's almost as though the venous system is being crammed into the arterial system. Like, everything is too high. Don't ask me why, but that's the pattern we observe. Or because we'll notice a loss of fat on the renal veins.

Most of them all have a loss of fat right here at the corner where we see the vein run by. They all have it. And when we do normies, they have a nice fat pocket right around it. And, um, I think this is something that [00:45:00] would just have to be researched and followed and studied. So why, I don't know. But there must be some kind of connection to all of this.

'cause it's, it's too common for it to be coincidental. 

Dr. Linda Bluestein: Mm-hmm. Right? Mm-hmm. 

Dr. Robert Hacker: As far as treatments, um, treatments are a very interesting question because we kind of aren't fixing the problem. Some people say their problems go away. We're just trying to reduce the symptomatology because we've noticed a consistent pattern, right?

So what are we trying to do? Well, if we're doing with the malls, you're trying to take away the band and you're trying to free up that artery. But the most important part, and if you read the papers from the, the group in Seattle, they're trying to take the nerves and strip the nerves off the artery. It's more than just plucking a string.

You have to what they call de innervate the artery so that the pain goes away. The problem is that's a surgical procedure and you can develop scar tissue and it can come back. So there's no [00:46:00] guarantees. Right? Or you have to learn how to deal with your symptoms, which is a terrible thing, but we've all heard it.

But sometimes just knowing what you have and knowing that you're not broken, you're just a little bit different, is empowering. Right. How to get through an attack for the Nutcracker. Um, this is highly controversial and I'll lead with that. Uh, the traditional, if you go to the large academic centers here in St.

Louis, there's a very large academic center. The threshold for repair is tremendously high, and it's because the surgery was very complicated. So what was the threshold? You had to be urinating blood because the back pressure was so high, you had to be going into kidney failure. You had to have exquisitely bad flank pain, or you had to have some kind of organ threatening issue.

Why? Because they offered you what we call a left renal vein transposition, where we cut you open, move your guts, cut the vein, [00:47:00] put it somewhere else, and sew it back on the one year patency, or how long the opening stays open without any assistance is only 80% at one year from that operation. The other option was they cut you open, they spread your guts, and then they take your kidney out and then they put it somewhere else called an auto kidney transplant.

You can imagine these are tremendously large operations. So the threshold to treat has been, I think, appropriately, very high. Technology improves, people start doing stents. They start doing stents. Well, me saying stents is like me saying there's soda. How many versions are there out there? There's a tremendous amount of versions out there.

And I think one of the problem is, is people say, Hey, I had a stent, but it's so not specific. It leads the wrong thing. So I'll, I'll tell you. There was, uh, large studies performed at major institutions that you trained at [00:48:00] and they had terrible outcomes. Well, why They have terrible outcomes. I think it was for two reasons.

One, the technology was put on delivery devices that look like harpoon, literally look like harpoons. And they weren't made to make these shark turns and they were done with fellows. So you had bad technology and poor training. The training is excellent. You had people where. An attending wasn't doing it a hundred percent of the time.

So what did you have? You saw a high level of perforation or puncturing through the vein and failure. And the third thing is they used what we call open cell stents or a mesh work that you could see through. And in the venous system, we know from doing other types of surgery, the body starts developing scar tissue and it grows right through that, and you get an occlusion.

What do we do differently? Well, it's 2020, almost 2026. We use a stent by, uh, by gore. It's covered in a inert material called goretex, and it has [00:49:00] nitinol in it and it's covered. And I use a very large stent, the biggest one they make, and we've really perfected the technique, the wire we use, the delivery sheath or, or or straw that we use to get it there.

The, the stent itself is oversized to the vein so that it gets pinned by the compression. And opens everything up. So we have both a mechanical fixation and a length component. It's still a very risky procedure. They still can move, but the, it's far less. We've had zero preparations. We've had one migration and, um, I would consider it to be very safe and very good results.

And because it's covered, the body doesn't grow through it. But how you do it and who does it really does matter. And, uh, in the iliac vein, the Mayther Syndrome is a very well-known pathology. It's a very commonly [00:50:00] treated pathology, but what we do in our lab is very different from everybody else. And the way that we deploy it, uh, the stent we've selected, the why we've selected it, and the sizes that we use because the complication there is pain and again, migration.

And we've only seen one migrate. We've, and we've only, we've had no perforations and no thrombosis. So it's complicated. 

Dr. Linda Bluestein: Definitely. What about react mast cell type reactions to the stent? 

Dr. Robert Hacker: So it's fascinating. We've spoken to several dermatologists and immunologists, um, the stents and most, uh, medical hardware is made outta a, uh, a metal called nitinol.

So it's a titanium and nickel. It was produced by the Navy to prevent things like that Titanic from occurring. And nitinol is great because you can give it a memory and then shrink it down so it can deploy it. And when it gets hot, [00:51:00] it expands to its memory size and you say, oh, I have a nickel allergy.

Well, it's been brought up that the nickel in your watch, the nickel in your earrings, the nickel in your right is touching your skin and the immunologic cells in your skin and the content of nickel in those metals is very high. They're different. The intravascular system is unknown and we are unaware of anybody who's had a reaction, uh, to nitinol stents.

Um, they're commonly deployed in the country and it's not often reported that people have a problem with them. Um, we are cognizant of it. We've had discussions with colleagues in the community about this. Uh, we've even gone so far as to suggest maybe you should patch test, but again, you're only patch testing or taking a stent and taping it to your skin, and that's not your blood vessel system.

And the immune system on your skin is gonna be different. We hypothesize then the immune response [00:52:00] within your vascular system. Caution should be, of course. Um, given 

Dr. Linda Bluestein: And, and what are outcomes like, and again, I know we're talking about multiple different problems here, but in terms of like short-term and long-term outcomes for the, um, stenting and procedures that you were just discussing.

Dr. Robert Hacker: Sure. So I think outcomes can be kind of graded on several things. The first thing we've identified is that these can be painful, really painful, and that's one of the things we identified early on is we were following the traditional surgical literature of whatever your vessel size is, make the stent 20% bigger.

Why? It allows for what we call radial force or more external squeeze in these patients. The compression is so significant. I mean, we're talking from 16 millimeters down to four or five, and there's likely scar tissue with the nerves and the arteries, and there's a big muscle behind it that when we were doing [00:53:00] that, we had people in excruciating pain.

Now we've never had to have one explanted, but people have had their stents at other institutions removed because of this. So we started using the intravascular ultrasound to give us and guide us more accurately, uh, the size of the vessel. We've been sizing more what we call one-to-one to try to match what the blood vessel is before the narrowing and what it is after.

And it's usually a little bit smaller after to try to reduce the amount of pain and discomfort. So from an optimum standpoint, when people get both the renal stent and their iliac vein stent for mayner, they'll have pain between three days and two weeks. We've been found a really good cocktail with, um, with, um, cyclobenzaprine as a muscle relaxer at night coupled with a high dose, non-steroid anti-inflammatory for a few days to quiet the system down.

These are very physiologic drugs, and then we taper them off. So even people who have MCAS or have history of like gastric lining [00:54:00] issues, they can tolerate this for a few days. And I only had one patient who for a very long period had pain and it was because we did a very aggressive treatment. Oversized, um, from a symptom standpoint, this is.

The $10 million question that everyone's been waiting for. We do surveys before and we do surveys after. And the research paper that we presented at the DISAUTONOMIA 2025 was what was the statistical analysis of this? And it was a P value, meaning when they run it through the computer, they say, is this by chance or is this actually real?

The P value was 0.0001, and the statistically significant value would be like 0.05. So it didn't get any smaller. So we've noticed that when you examine people, they score on their testing, which we use the Malmo POTS score, which is a qualified test, I think from the Netherlands, if I recall correctly. Do not quote me on that, but it's [00:55:00] not from America.

The MALAL POP score, they score statistically significantly better after versus before. Some people, we've gotten letters. My partners received letters, like letters saying, you've changed my life. We've seen people get off disability, go back to getting jobs. We've seen tremendous improvement in life.

Nobody that I'm aware of has said, I feel worse. And there's a group of people say, I really don't notice anything different. But when you dig down, they'll say, okay, I have fewer symptoms, but we're very transparent. A lot of people, they'll still get the POTS like symptoms, they'll still get the dizziness, right?

Some of them are still gonna have the MCAS allergies, but I think the severities are decreasing. I'd really be interested to see that after a period of 1, 2, 3, 4, 5 years of being treated and still having good medical management, right, with the right meds, with the good pots doctors, do we actually see their bodies maybe [00:56:00] start recovering back to normal?

And I think that's the big question. 

Dr. Linda Bluestein: And, and what do you think are the biggest misconceptions amongst clinicians or, or patients when it comes to these problems? 

Dr. Robert Hacker: I think the, uh, the, the hardest thing is that this is unknown, right? So doctors want data. So the tests are all negative until we've been able to finally do these venograms, right?

And there's no education on it. And so let's face it, if you can't see it and you can't touch it, it doesn't exist. That's just how medicine works, right? And so people are coming to these clinics complaining of vague abdominal pain testing, negative, going to ob gyn is complaining of pain testing, negative, go to the cardiologist with these real symptoms, testing negative, or they have pauses, but it shouldn't be that bad, right?

And yet they're, and, and it's, we're just always falling short. We're always falling short. And so I think it's just a lack of education because I think. [00:57:00] Is exciting. It's like something new. We thought medicine was known right, except for a lot of neurology. And I think we're kind of on something that's just been missed.

It's been there the whole time. But with Angi, uh, access to less expensive tools or diagnostics, um, private practices like myself are able to go out and do these things because hospitals are not equipped to do this. Um, we're actually able to approve it and demonstrate it time after time after time. 

Dr. Linda Bluestein: And, and people listening to this, uh, podcast are from all over the world.

We have many, many different countries that, uh, listeners, which is amazing, and of course all over the US as well. If somebody is thinking that this is a potential problem for them, one of these conditions that we talked about, malls, Mayner, Nutcracker, public Venous disease, et cetera, what kind of things should they be looking for in a clinic that they might.

Be considering going to, or a clinician [00:58:00] that they might be looking at. 

Dr. Robert Hacker: So I think the, the first and foremost thing is if you think you have it, trust your gut. You know your body more than anybody else. I think that's the most important thing. And most of the patients have been advocating for themselves.

I think the second thing is, uh, it's our job as clinicians to be able to relate to patients, but I think in this particular case, the patients have to basically relate to the doctors. So what do I mean by that? You just can't come in with a stack of papers and say, I've had all these surgeons and this is how I feel.

I think if you had a journal or you, you have a story and you were able to show the doctor, right, this is what I do and I get these symptoms, but when I do this, I don't give that. You can help take someone who is willing to listen, because that's probably the next most important thing, is a clinician is willing to listen and explore this diagnosis with you.

Right? Help guide the clinician on what it could be. And what it couldn't be by breaking it up into little palatable [00:59:00] pieces, which I've been trying to do this whole time. Right? So I break it up into do you have upper GI symptoms? Do you have upper, you know, gallbladder, pancreas systems? Where's your pain?

When do you get it? And if you are looking for someone and you kind of journal this stuff, I think you'll have a much more, uh, friendly journey. And I think the doctors will be much more open to, I think we have a real problem here versus the typical dismissal that many people have. 

Dr. Linda Bluestein: Mm-hmm. Mm-hmm. 

Dr. Robert Hacker: How do you find those doctors?

I think that's also the million dollar question. I would advocate that the people who are involved in this community, which we've been trying to join, working together and developing a wood network to help patients, I will tell you right now, if any doctor or patient were to reach out to us, it would be our pleasure to help provide protocols, talk to patients, uh, talk to doctors on their behalf, even though they're not my patients.

Maybe we can help guide you in your local area if you can't make it and join us. 

Dr. Linda Bluestein: That's, that's an incredible offer. And I know [01:00:00] that, uh, you are trained as a vascular surgeon. Of course. You did general surgery first, and then you did vascular surgery. There are also interventional radiologists who are doing some of these procedures, correct?

Absolutely. So can you kind of explain, yeah. Can you kind of explain, because I, I think that, you know, there's areas in medicine where there's some, some overlap. Like there's, you know, pain, interventional pain procedures that might be done by an anesthesiologist or a physical medicine and rehabilitation doctor, or an inter, uh, interventional radiologist.

So this might be another one of those cases, but I think it might be really helpful as we're getting close to wrapping up here, for people to just know a little bit about what that difference is, to just kind of let, get a little better lay of the land. 

Dr. Robert Hacker: Yeah, absolutely. Um, I think there's a lot of just fantastic position in our country and around the world.

Uh, not everyone took the exact same path to train, and everyone sometimes ended up in the same room with different backgrounds. Uh, a vascular surgeon in the general surgeon, right? [01:01:00] I, I left medical school. I did five years of training, opening abdomens, learning, intraabdominal pathology, taking care of patients in the ICUI became a vascular surgeon operating on blood vessels, opening them up, looking at them, studying them, bypassing them, as well as doing catheter based procedures with IB D and x-Ray.

The radiologists end up going to school and they train on the interventional side, but they, short of maybe a residency experience for a year, didn't spend a lot of time in the abdomen and so. The wire skills, the, uh, interpretation of the images. They, they can be, they wicked. And I think, uh, the cardiologists who are involved in this space all do the same thing, but there is a difference when one looks at a problem, I don't look at the x-ray the same way that a radiologist does, and I don't look at the heart and the [01:02:00] pots data the same way that a cardiologist does.

And so everyone has something very valuable to bring at the table. And there's an area where we all overlap and there's areas where we're weak or we miss stuff. And so I think it's just learning who do you have access to? What are their qualifications? Does this person sound like they know what they're talking about or are they just trying to do something right, or is there something to be learned?

We realized from all of this, um, a lot of women were just getting their ovarian veins coiled because of the pelvic congestion syndrome. And if you talk to them. Again, I'd love to know in your comments section, you let me know later if anyone's had only their left ovarian vein coiled and their symptoms got worse.

We've identified that's because they actually had a nutcracker. The ovarian vein was a compensatory mechanism. Mm-hmm. And you just shut that down. And I have several patients who are like that, and we had to do, we did the stenting and they got better. Mm-hmm. Because we gave them that natural flow. And it's just something that was missed in the community because [01:03:00] everyone's been looking at one little part, the Mayer part, the mouse part, the Nutcracker part.

Mm-hmm. The gona vein. But if you take a step back, they're actually all linked together. And so that's where we came up with our diagno. Even how we treat it, we do it in a very, very specific order to try to do as little as possible. So we always do the diagnostics, have a discussion, then we'll treat the iliac vein compression, try to.

Drainage outta the leg, outta the pelvis, outta the ovaries. And if they're still having, then we'll do the embolization to try to close that up and isolate the left side from the right side. And then if they're still having problems, only then do we do the renal stuff, taking out the gonadal vein and doing the stent simultaneously.

So we do it very stepwise, very algorithm algorithmically and very thoughtfully because every person is different. Some people, we never have to do anything more than an iliac. That's all they need. Those are all my secrets. 

Dr. Linda Bluestein: Yeah. Good. Uh, [01:04:00] that's what I was hoping, I was hoping to get all your secrets. Um, speaking of secrets, um, and I think it's funny 'cause your last name is Dr.

Hacker, and I think as a surgeon, you know, you probably get teased about that all the time. I would, I would think. Uh, and we're gonna ask you for a hypermobility hack, speaking of, of which, so, uh, what do you have in the way of a hack first, speaking of giving us all your secrets. 

Dr. Robert Hacker: So I was thinking about this, but I've got a good one.

So. I hope it's a good one. Again, let me know if I'm right. So what's the biggest thing that a lot of hypermobility people past people have? Right? They get up and they feel really dizzy and they feel terrible, right? So let's have everyone try this for a month and see if it works. If you're gonna get up and you normally stand up and you start feeling lightheaded and you start feeling terrible, don't do that.

What I want you to do is start standing up, jump on your feet for about three to four seconds. Sit back down, Livy your legs. Okay? What is that gonna do? That's crazy. What it's gonna do is it's gonna [01:05:00] start telling your body to tighten up your arterial system. If you do have, uh, normal veins, they'll shrink down a little bit.

You'll move the blood out of your legs and you'll start to basically recruit blood for that engine of your heart so that you're not running dry when you stand up. So if you stand up, you tie your body, I gonna get up and you sit back down. You're no longer at at risk for a tip, a fall, a hit, right? You're prepping your system.

Do that for a couple more seconds. Maybe stand up one more time for a couple seconds. Sit back down. Give yourself, so maybe it's a 15, 22nd thing, stand up and walk. And I, and I'd be very curious to see if you do better, because I think from our experience, patients say that this really does help them. Okay.

Dr. Linda Bluestein: I love that. I, I often tell people to, you know, move their legs, squeeze their gluteal muscles, et cetera, but not stand up, jump and then sit back down. So I really like that. I, I can't wait to hear from people because, um. [01:06:00] If you're listening right now, well, of course you're listening right now. Lots of people are listening right now.

Um, and I please, please, you know, let us know what you think of this hack and how helpful you thought this was. 'cause I think that's, I think that's great. I love getting new hacks for people to, to try. So, um, so before we go, I would love to hear, uh, where we can learn more about you and your practice. And also a question that I get asked all the time is, does this doctor take insurance or not?

And also, you know, we know that medical licenses are state dependent, so some doctors will see people only from their home state, other people, you know, if they, obviously they have to travel to you for any kind of intervention. You can't do that by telemedicine. But could you explain a little bit about how your practice works and if there's any state limitations, et cetera?

Dr. Robert Hacker: Sure. So we're in Missouri. We're in St. Louis. We're about 20 minutes from the airport and the west. Our practice is called the St. Louis Vascular Surgical Specialist, and we're the only private vascular surgery practice in the entire ST for like 300 miles. [01:07:00] Um, insurance, we take almost all the insurances and we take cash and we have special cash rates.

Um, there is not a lot of places to get diagnosed for pops disease. We're just now going through a protocol, uh, shoring it up with, uh, some of the colleagues in the community to make sure that it would pass muscle. And we are gonna start doing some POTS testing for patients so they don't have waiting, have to be waiting for a long time.

Um, as you stated, state licenses are really crazy. So right now I only hold a Missouri State license, but I've been licensed in California and New York and Pennsylvania and Ohio for the years. Uh, I have been contemplating expanding those again, if there was a need or a resource and developing satellite clinics.

Across the country where maybe we come in for a few days and we'll have a big clinic and we'll work with existing physicians who have large patient populations, but we'd like to get 'em treated locally. [01:08:00] So if there's any physicians out there who said, Hey, I have a clinic, and we would love you to come out, you know, we would love to explore any way that we can share the expertise with the, with the community across the, uh, the state to reach us.

You could email us at info at stl vascular do com, or the website is stl vascular do com. And, uh, there's not a lot of hackers out there, so it's easy to find Google. I mean, with a name like Hacker, you can't be bad or you'd be both. So. 

Dr. Linda Bluestein: Right. Yeah, def definitely, definitely. So if somebody is from a state besides Missouri, so long as they're coming to see you, you will see people from other states.

I just wanna make sure that people are really super clear about 

Dr. Robert Hacker: that. Absolutely, absolutely. Okay. So we've had people come from Canada, we've had people come from Tennessee, Arkansas, Colorado, Illinois, California. Great, great. All over the place. As long as we're in our state, we can do it. 

Dr. Linda Bluestein: Perfect. And what [01:09:00] about when you said that you're working on POTS testing, are you talking about that you're gonna be getting a till table 

Dr. Robert Hacker: or.

We own a tilt table, we just wanna make sure we're doing the right, 

Dr. Linda Bluestein: oh, 

Dr. Robert Hacker: the right protocols, protocol. So it's testing out. Apparently there's not a lot of facilities out there that have them, so 

Dr. Linda Bluestein: it can be really hard to get tilt table, uh, tests and, you know, full autonomic lab testing can be very, very challenging.

So I used to send people to an autonomic lab and they would be on a wait list forever, and then they would often get canceled the day beforehand. So I can't do the full, you know, autonomic test that they would often do in those labs. But I will do stand up or, you know, the quote Nassau lean test. I'll do orthostatic vital signs for 10 full minutes after they stand up.

You know, have, have them lay down for 10 minutes first and then stand up and do it for another 10 minutes. And I will diagnose pots based on, based on that if it's positive. So. Okay. Well this was such a great conversation and I know that people will be learning so much from this, both patients and clinicians.

There's a [01:10:00] really vast, um, audience that we have. So thank you so much for taking the time to chat with me today. I know your schedule is very, very busy, um, but I really appreciate.

Well, I am so grateful to Dr. Hacker for coming on the Bendy Bodies podcast today and teaching us so much about compression syndromes and stents and these complicated conditions that are so often missed. I'm sure you found this super helpful, and hopefully you're gonna have more hope for future and alleviating some of your symptoms.

Thank you so much for listening to this week's episode of the Bendy Bodies Podcast with the Hypermobility md. Check out my other resources, including my newsletter, the Bendy Bulletin. Visit my website@hypermobilitymd.substack.com. Help us spread the word about connective tissue disorders by leaving a review and sharing the podcast.

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