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

 

Pregnancy and Varicose Veins

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.