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The Big Picture on Vein Disease and Leg Swelling

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“Why are my legs swollen?”  In this blurb I’m going to hopefully give you the big picture on a very common complaint, leg swelling (edema) that tends to go right along with venous disease.

When I give talks on venous disease of the legs, I emphasize that I believe one of the most important things I am trying to accomplish is educating patients on the importance of recognizing signs and symptoms of problems early when treatment can produce rapid recovery and return to function.  Doing this can prevent progression to advanced stages when recovery and improvement can be lengthy.   In addition to explaining the possible health consequences that could result from ignoring serious signs of developing vein disease in their legs, I like to focus on just how effective, well tolerated and elegant that modern vein procedures really are.

In most advertising for vein clinics (mine included!), you will see some version of “leg swelling?” being asked.   The typical pattern of swelling that is associated with what I treat (venous insufficiency) usually begins around the ankle and progresses up the leg.  Usually, this swelling tends to increase during the work day and decreases overnight or with simple maneuvers such as leg elevation.  Over time, swelling is noted to occur on top of the foot as well.

From here, keeping an eye on the big picture is challenging to say the least.  Figuring out the cause of swollen legs can be a complicated affair and frustrating for patients and physicians.   It’s very much like that scary forest right outside the Emerald City on the Wizard of Oz.  The second you walk into the trees it gets dark.  And thick.  So off we go.

First of all, when I see a patient for evaluation of a swollen leg, it is usually after studies searching for urgent situations such as acute deep venous thrombosis (DVT) have already been performed.  This is not always the case however.   Sudden swelling that occurs over hours to days is termed “acute” and if from a venous cause, is usually due to either a DVT in the leg or other obstruction higher up the venous circulation in the abdomen or pelvis.  These problems are usually managed in the hospital setting.

Leg swelling that occurs over a longer period of time, weeks to months, is termed “chronic” and when a patient comes for treatment, early investigation should start.  The most important thing to remember is that the longer swelling is allowed to continue without treatment, the more likely it will potentially become permanent.

My focus at Precision Vein Therapeutics is sorting out whether or not a swollen leg is the result of a vein that is not doing its job.  I perform a thorough venous ultrasound of both deep and superficial leg veins to determine this.  This exam is noninvasive and done right in our clinic on Watermelon Road.   The amount of information about the venous circulation that can be obtained from this elegant test is truly amazing.

In the setting of saphenous vein reflux, which I detail on the vein disorders and treatment pages of this website, mild to moderate swelling that follows the pattern I mentioned above, (gets better overnight), after treatment with endovenous laser ablation, typically resolves.  Longer standing or more extensive swelling that tends to remain unchanged over night on average may improve after correction of saphenous reflux, but in a percentage of patients, will need further management to deal with.   This is where the woods get dark and deep.   In medicine, we like to blame a set of conditions on one cause.  The swollen leg is a big ugly example of the situation where there can be multiple contributing causes.   It’s very important in cases of severe edema and venous insufficiency to help patients set realistic expectations.

The lymphatic system of the body is an extremely important little machine and it doesn’t get much air play.   For all practical purposes, it is microscopic, but it is the hardest working system in the body for its’ size.  It is responsible for collecting the plasma portion of the blood that is filtered out between arteries and veins at the cellular level.  Okay, there it is, we just lost the sun.  Walk with me in the dark for just a second.

There are many different medical and structural issues that can affect the load on the lymphatic system’s fluid transport ability and when it can’t keep up, you guessed it, edema happens.  The lymphatic system itself can have abnormalities that affect its ability to function correctly.  There’s even a little roundworm that is transmitted to humans by mosquitos mostly in tropical countries that has an appetite for human lymphatic vessels and basically destroys them.  Outside of developed countries, this is the #1 cause of lymphedema in the world.  120 million people have this.  120 million.  There are effective treatments but I’d still take some Deep Woods Off if you plan to go down there.  Here’s a classic example.

 

 

 

In developed countries, the #1 cause of lymphedema is obesity.   There are even some medications that can cause lymphedema.

I mention all of this mainly because of what I mentioned earlier.  Expectations. There is no question that venous insufficiency can cause or contribute to leg edema.  If I’m asking in my advertising if you have swollen legs then you might have venous disease, I better know what your next stop needs to be if you don’t.

The good news is that for patients clinically diagnosed with lymphedema, there are treatments available to help manage the disease.   There are lymphedema clinics that specialize in this very issue.

This brings us right back around to what I mentioned at the beginning of this.  Job #1 for me is providing education and awareness of the resource that Precision Vein Therapeutics can offer patients in terms of thorough evaluation for the presence of treatable venous disease, and then offering those definitive, effective outpatient treatments in the same office-based setting.  For those patients with a family history of venous disease, living with chronic leg and ankle edema, thinking it is just a sign of aging, working too hard or it’s something that just “runs in my family”, understand that waiting can be a very bad thing.   Make an appointment and get treatment.

That’s the big picture.

Michael R. Barlow MD, RPhS

Precision Vein Therapeutics

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Let’s Talk About Spider Veins

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I was asked just recently to talk about the “state of the art” in treating spider veins.  As I was preparing that presentation, I happened to notice a big review article on that very topic in the current issue of Phlebology, a major vein practice related journal.   Being already in the groove, I thought that would be the perfect topic for my second post here.

You would think in 2018 that modern medical science would have spider veins all figured out.  A common complaint we hear from new patients is that they have had injections performed on their spider veins in the past, experienced some initial clearing, but then the problem returned within several months and seems to be even worse now.  Spider veins can be stubborn and although the causes and risk factors are still largely unknown, there are some basic principles that we follow at Precision Vein Therapeutics to maximize your chances of a fantastic, long lasting result.

“Telangiectasias” is the medical term for spider veins but it’s way too hard for me to type.   From now on out, I will refer to them as spiders.   Anyone that knows me understands how little I care for spiders.  I’m the guy that is perfectly willing to jump out of a moving vehicle if I find a spider on me.  I want them off of me.  I want them off of you.   Know that my heart is in this.

Patients have lots of choices when it comes to the treatment of spiders.   As a phlebologist, my approach is geared towards not just treating what’s on the surface but understanding what the underlying cause is and treating that as well.  Insurance companies consider spider veins, even those that cause symptoms, as a cosmetic concern and not a medical necessity, and therefore, not covered.  Knowing that patients are paying out of pocket, with their hard-earned money, motivates me to make darn sure that I am not just treating a problem that will come right back in short order because the real, underlying issue has not been addressed.

Although spiders can cause symptoms, prickly type pain and a burning sensation are common complaints, most patients seek treatment due to aesthetic concerns.   Often, the problem has existed for many years and patients have been simply too busy with LIFE to have anything done about it.  At a certain point, either folks just get fed up with only being able to wear long pants, or sometimes it’s other issues that develop, such as varicose veins.  Whatever reason brings patients to treatment, the first questions usually asked are, “What causes this?  Can we just laser these off? and What can I do to prevent these in the future?”.    The big three.  Here we go.

What causes this?

We don’t for sure.   It’s “still a mystery”.  I’m not kidding.  That’s an exact quote and the reference to the review I mentioned earlier is at the bottom of this.  Make no mistake though, we’ve got theories.  There is good evidence for all of them too.  The simple explanation is that not all spiders are the same.  You see these big hairy tarantulas that have names and birth certificates and ride around on the guy’s shoulder on YouTube.   I absolutely hate those angry little jumper spiders that look like crabs with their pinchers up and dare you to brush them off the couch.  There is nothing more terrifying to me than walking right into the web that those freakishly large wolf spiders around my house build right across the path to the outside faucet.  You knock them down.  They come right back the next day.  Annoying.

Different types of spiders can occur on your legs at the same time too.   We know that somewhere between 30 and 50% of spider veins are associated with reflux, or retrograde blood flow in the underlying saphenous veins.  Simply injecting the spiders with sclerosants (see my website for more on this), will set you up for failure because without treating the underlying source of venous pressure, recurrence is almost certain.   This is the exact reason that we make great effort to explain to patients why we perform a venous ultrasound examination on every leg affected by spiders.   You will hear us talk a lot about results and reputation.  Everything we do is focused on that.   We don’t deny the fact that vein disease tends to be progressive and that recurrence, even with the most meticulous techniques is possible and we mention that with all patients and in all printed materials.   What we are after is the clearest, longest lasting result we can attain for the investment our patients are making.

In those cases where spider veins do exist in areas of underlying saphenous vein reflux, effective treatment with endovenous laser ablation of the saphenous vein (see the treatment section of my website), greatly enhances the success of sclerotherapy of the spiders.

For the types of spiders not caused by underlying saphenous vein reflux, two possible explanations include the failure of valves within the tiny vessels called perforator veins which connect the veins on the surface to the deeper veins of the legs, and also actual direct connections to tiny vessels from the arterial side of the circulation called arterioles.  This is the reason that we discuss the small possibility of ulceration, or the formation of a sore at the site of sclerotherapy injection.   This is also precisely the reason that we use low concentrations of sclerosing agents and special injection techniques when we perform sclerotherapy of spider veins.  This risk of ulceration is very small (<1%) with our considerations.

 

Okay that’s scary, can we just laser these things off? 

There are areas of the body such as the face where the success of laser treatment of spider veins is widely known.  Lasers employ thermal destruction of vessels and most have very specific settings for a particular depth of tissue.   In the legs, the vessels that need to be treated exist at deeper and more varied locations, with thicker walls requiring higher laser energies and specific measures to decrease the risk of burning the epidermis.  As stated earlier, most spiders are associated with increased reverse pressure from larger deeper veins.  Most lasers will not treat these associated high-pressure veins.  Injection directly into a target vessel with spread of a sclerosing agent (sclerotherapy) into connected spiders is a much more efficient method to treat larger areas more quickly than laser.  As this latest review states that I keep referencing as well as most books on the subject, sclerotherapy remains the treatment of choice for spiders because it has the advantage of eliminating the larger feeding veins as well.

Okay, sign me up but what can I do in the future to prevent these ugly things? 

Some risk factors such as heredity, hormones, pregnancy (see my last blog entry), and age we can’t do much about.  Those things are why we have to live with a certain risk of recurrence of vein problems no matter what we do and how much we hate to admit that possibility.   With good, thoughtful sclerotherapy, most patients will need a touch up to maintain their results about once a year.

The other risk factors, we jump all over.

 

 

Sun exposure.

There is a direct correlation here.  Sunlight degrades collagen and elastic fibers and that is what you don’t want.   If you already have a familial tendency to have spider veins or think you might want to have a bunch of babies (which I highly recommend), don’t forget the sunscreen.   Lather up with a reasonable number SPF (at least 30) when you are outside starting early in life and during the day and reapply at lunchtime.   Your 55 and 65 and 75 and 85-year-old self will thank you.

Obesity.

Yes, there’s a study.   We know that obese and overweight patients have a higher prevalence of the underlying venous pressure problems that cause spiders.  Not all obese patients have spider veins though so this again comes back to other risk factors.  With a strong family history of severe venous problems, the appearance of spider veins can be a sign of deeper issues which may only worsen in the presence of unmanaged weight problems.

Trauma.

Patients often relate an episode of localized trauma to the appearance of an area of spider veins.   Damage to blood vessels in an area of trauma releases factors that we know stimulate blood vessel growth.  Can’t really avoid trauma.  You never know when or where it’s going to happen.  It’s like the lightning bolt that took out the clock tower on Back to the Future.

Other things we discuss with patients regarding spiders:

It always takes more than one treatment session.  With sclerotherapy, as I stated earlier, patients pay for this out of pocket per session.  We know that good sclerotherapy will take out 60-80% of the total burden.  Even patients with a small amount of spider veins usually require at least 2 sessions.  Most require 3 or 4 sessions for clearance.   This goes back to the different types of spiders.  Some spider veins are more resistant than others.  Most clinics that perform sclerotherapy charge between $200-$300+ per leg.

Expectations are important.  Long standing spider veins carry a risk of staining of the skin in many instances due to the presence of hemosiderin, the breakdown product of hemoglobin that has accumulated in the skin over the spider vein as a consequence of long term extravasation of red blood cells under the venous pressure that exists in the area.  The spider vein that is treated will be resorbed by the body but the stain above it may remain for some time.  This is another great reason for patients to have early treatment of spiders.

Recurrence.  Said it before and it bears saying again.   We tell patients that have had previous sclerotherapy and have experienced recurrence they may have an untreated underlying source.   We perform a complete venous ultrasound on every patient and we are completely upfront about the fact that most insurance carriers will refuse payment for ultrasound examinations in cases of pure cosmetic spiders when no underlying reflux is found.   The ultrasound examination fee would be an out of pocket expense but we absolutely believe it is well worth the expense in avoiding that situation of needless repeated sessions of expensive sclerotherapy that are doomed to failure.  To fully milk my spider analogies for this blog entry, it’s like killing the house spider but leaving behind that nice big egg sac.

On this website, I describe the treatments we have available at Precision Vein Therapeutics and in the evaluation and effective treatment of spiders, microphlebectomy is an extremely important weapon in our arsenal.  In certain clinical presentations, particularly involving the outside area of the thigh, actual removal of the superficial vein feeding the spider vein cluster is curative.  Microphlebectomy is performed under local anesthesia, however we do offer mild sedation in one of our treatment rooms on site.  We use tiny incisions at short intervals along the vein and remove it using micro surgical hooks.  The incisions typically heal without a scar and do not require suturing.

To wrap this up, as in most areas of medicine, there’s still a lot about spider veins that we’ve yet to figure out completely.   The good news is that there are incredibly effective treatment options available and well-known techniques to maximize results.  Be confident and get fed up with the spiders in your life and don’t wait another minute to do something about them.  Call us at Precision Vein Therapeutics, 205-710-3800 for an appointment and let us help you rediscover healthy legs that look great and feel even better!

Reference:  Pathophysiology of telangiectasias of the lower legs and its therapeutic implication:  A systematic review.   P Kern.  Phlebology 2018, Vol. 33(4) 225-233.

 

 

Pregnancy and Varicose Veins

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Let’s Get Started

I wanted my first entry into the Precision Vein Therapeutics website blog to focus on the topic for which I receive the most questions.  Without a doubt, it’s pregnancy and varicose veins. It’s a great place to start because this is pretty much where all things bad with veins in women begins.  

First of all, we know that heredity is the most important risk factor for developing venous problems, for men and women.  “It’s baked in the cake” as my old friend and mentor Dr. Michael Manning would say. For women though, there’s no denying that pregnancy is a very close second place.  Population studies have found only 12% of women with varicose veins have never been pregnant.  It’s a double whammy at this point for women.

What is it about pregnancy that causes vein problems and varicose veins?  

Hormonal factors are primarily to blame.  Of patients that develop varicose veins during pregnancy, 70-80% appear during the first trimester when the uterus is only slightly enlarged.  Only 1-5% of patients will develop them in the third trimester. Circulating hormones increase distensibility of the vein walls and soften vein valve leaflets which does accommodate the natural increase in blood volume, but also allows blood to collect in the leg veins, increasing the venous pressure, and resulting in dilated “varicose” or spider veins at the surface.  Late in pregnancy, the enlarged uterus compresses the inferior vena cava, further increasing venous pressure, and contributing to the distention.

If I develop varicose or spider veins during pregnancy, should I get treatment?

Most sources dance around this issue. The newest recommendations state that Interventional treatment for varicose veins during pregnancy should only be carried out in exceptional circumstances.  Other sources suggest avoiding treatment during pregnancy except for unavoidably urgent cases. Good luck finding examples of these circumstances or urgent cases. In this country it’s all about medico-legal issues.  In general, physicians stay away from elective (non-emergency) procedures during pregnancy primarily due to the concern for premature labor. In addition, pregnancy by itself is well recognized as increasing the risk for deep vein thrombosis (DVT) and pulmonary embolism (PE).  In the event a pregnant patient treated with sclerotherapy developed a DVT or a PE, the treating physician would be in a difficult position due to the uncertainty of what caused it; pregnancy itself, or the sclero. Short answer: No, not with sclerotherapy or endovenous laser ablation.  There are effective conservative treatments which I will discuss below.

What if I discover I become pregnant in the midst of treatment?   

Having said all of that in the last paragraph, here’s the good news.  Thousands of women have been safely treated with sclerotherapy during pregnancy and physicians around the world continue this practice.  There currently is no evidence that this is unsafe or harmful in any way. In the US, treatment would be discontinued but the patient would be reassured that almost certainly there would be no impact on her pregnancy.  

The current recommendation is that interventional treatment including sclerotherapy is to be avoided in any patient known to be pregnant, who has indicated that she is actively attempting to become pregnant, or who has been pregnant in the last three months.  

Is there anything that can be done?  I’m miserable!

More good news.  Wearing compression hose dramatically reduces symptoms and swelling due to the effects of pregnancy on the venous circulation.  Compression minimizes dilation of superficial veins and maintains the vein valvular competence, reducing the likelihood of permanent damage.  It can also reduce or slow the process in future pregnancies.

Understand that in even severe cases of varicose veins during pregnancy, most will completely clear spontaneously after birth.  There is a catch however.  We know that with each successive pregnancy, the risk for developing ongoing varicose veins increases.  There is a study that looked at 400 women with varicose veins. Out of the 400 pairs of legs, 13% had been pregnant once.  30% of them had been pregnant twice. 57% of them had been pregnant 3 times.  Ouch.

We recommend that to reduce the likelihood and severity of varicose veins, all pregnant patients should use graduated compression hose as tolerated.  It’s important to get measured by a trained fitter for proper fit and purchase a good quality hose as they will be somewhat easier to put on and more comfortable.  Inexpensive compression hose typically has fabric with less stretch and will just make you more miserable! At Precision Vein Therapeutics, we stock Juzo brand compression garments and all of our staff are trained fitters.  

The regimen we recommend is at the first indication of pregnancy, 20-30 mmHg graduated stockings as thigh highs or panty hose should be fitted.  In patients with multiple pregnancies, or those with previous history of varicose veins, stronger 30-40 mmHg compression stockings should be worn.  In women with large legs or those who are unable to tolerate the higher pressure 30-40mmHg stockings, calf-length 20-30mmHg can be worn over 20-30mmHg thigh highs or panty hose.  

Here in the South, we have to live in the real world come July-November.  Combine this with a third trimester pregnant Alabama girl and you can get critical load on the power grid.  Who cares about varicose veins when you are in close orbit around the Sun. In that situation, even lighter 25mmHg stockings can reduce significantly the discomfort and ankle edema during the third trimester of pregnancy.  

We are trying to slow down the clock here and make the ride easier.  Understand that there’s no way to completely prevent varicose veins but we know that you can delay or slow progression.

Other helpful conservative measures are staying active, exercise as recommended by your OB/GYN and elevating your legs when you can.  

Hey these varicose and spider veins are not going away like you said they should.   How long do I have to wait before I get them fixed and would it be better to wait until I’m completely done with having babies?  

We approach the evaluation of residual varicose veins after pregnancy the same way as any patient, male or female, with venous disease.  In addition to a careful history and physical, a duplex ultrasound exam is done to evaluate the lower extremity veins to determine underlying cause of the dilated veins or spider veins.   After delivery, at Precision Vein Therapeutics, we recommend a full 6 months prior to evaluation and treatment of ongoing varicose veins. This allows time for natural postpartum improvement to occur and for enhanced effects of pregnancy on the clotting system to normalize.    

We know that spontaneous clearing can occur for up to a full year after delivery but important factors such as severity of symptoms, risk of superficial thrombophlebitis, potential of hemorrhage from exposed varicosities and overall decrease in quality of life must be considered and patients are counseled concerning these issues.  

At Precision Vein Therapeutics, if major reflux is noted in the superficial saphenous system after pregnancy and continues for 6 months, interventional treatment with endovenous laser ablation and/or sclerotherapy is typically performed.  This will prevent reflux in the treated saphenous vein in future pregnancies.

Can I have sclerotherapy if I am still breastfeeding at 6 months?  

There is no factual evidence as to the safety during breast feeding of modern sclerosant agents to treat varicose or spider veins.  Even having patients use a breast pump and discarding an amount while waiting a period of time to resume breastfeeding should be avoided because the true half-life of sclerosants in breast milk is unknown.  Sclerotherapy is generally not performed while a patient is breast feeding.

I have a varicose vein on my leg that seemed to have come up over a couple of days.  Is this normal?

As I stated earlier, pregnancy itself is a risk factor for deep vein thrombosis.   The sudden onset of a dilated varicose vein could indicate the presence of an obstruction to the outflow of blood from the leg, producing a back-pressure effect on superficial veins.  This obstruction could potentially be a deep vein thrombosis and the sudden onset of the varicose vein at the surface might be the only sign. Certainly, any pregnant patient who reports acutely changing varicosities or varicosities associated with leg pain or swelling should have a duplex ultrasound examination to look for DVT.  

I hope this information is helpful.  If you would like to schedule an appointment for evaluation, please call our clinic at 205-710-3800.  We look forward to meeting you!

Michael R. Barlow MD

Precision Vein Therapeutics, Inc.