You’re So Vein

You probably think this blog is about you.  Don’t you? Don’t you?  And you would be absolutely right.  Okay I’m sure I’m not the first vein doctor to use Carly’s perfectly written breakup song about Warren Beatty for purposes of encouraging patients to get their varicose veins treated.  If you are old enough (like I am) to remember vividly when this song was released (1972) then you are also in the age group of the population with the highest incidence of venous disease of the legs.  These are problems that can affect both young and older people, but we know the incidence definitely increases with age.

I spend lots of time educating patients about what the symptoms of lower extremity venous disease are and how important it is to seek treatment for varicose and spider veins.   I grew up listening to Paul Harvey on the radio.    “The rest of the story” was always something different and deeper than what you were expecting.   Venous disease in the legs usually progresses and gets worse, involving more and more areas of the leg in the path of whatever vein has gone bad.  Early intervention is what I preach.

The rest of the story with venous disease is that there is such a wide variation in just how a patient will develop problems.  Most patients will have typical symptoms of aching, fatigued feeling legs that feel heavy towards the end of the day, usually with a bulging vein here or there.  Swelling that seems to go away overnight, only to return in the calves and ankles by quitting time is pretty typical.   Changes in the appearance of the skin over time are a big tip off.  This usually includes darkening, or an increase in pigmentation in the lower legs, a reddish itching rash on the skin of the lower calves and ankles, thickening or hardening of the skin in these areas, and the most advanced skin change is the appearance of a non-healing skin ulceration, a venous ulcer.  There are patients who will only have bulging veins or a covering of spider veins and no symptoms at all.   Wide variation.

Right lower calf venous ulceration before and after treatment.

The trick is heading all of this off at the pass.  Getting treatment for venous disease is more important than ever.  Bulging veins at the skin are at risk for lots of bad things.  Superficial blood clots can form in these surface veins that can progress to deep vein thrombosis (DVT).   Bulging veins just under the skin are often in vulnerable areas of the legs that are at risk for rupture and significant bleeding with even minor injuries.   Even more concerning is the tendency of these veins for spontaneous rupture due to the high pressures that develop from underlying veins that are allowing reverse blood flow into them.

The good news for most people is that treatment is not anything like it used to be.  There is an entire generation of people that still believe that “vein stripping” is still the only treatment.  This was invariably a very painful procedure that had a very long recovery period with serious risks.   Today, highly effective treatments are performed in an office-based setting in my clinic, extremely well tolerated under local anesthesia and mild sedation.   There is minimal down time with patients able to return to work on the second day and pain is easily managed typically with over the counter medications.

Don’t wait a minute longer.  Don’t daydream about getting something done.  Don’t be naive like Carly.  She had some dreams but apparently, they were clouds in her coffee.   Gulp that coffee down, grab your phone and give us a call at Precision Vein Therapeutics 205-710-3800 for an evaluation.  Two years after she released “You’re so Vein” she released my favorite song of all time, “I Haven’t Got Time for the Vein.”   You don’t either.

Michael R. Barlow MD, RPhS

All content copyright 2019


The Big Picture on Vein Disease and Leg Swelling

Vein Screening Form


“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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