September 2, 2010
Douglas Joseph, DO
Director of the CIMT Core Laboratory and Vascular Medicine Outpatient Department
in the Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart & Vascular Institute at Cleveland Clinic.
Varicose veins are swollen, enlarged veins that rise above the surface of the skin, often appearing purple or blue in color. This condition is common and is usually not a life or limb threatening problem. For many patients varicose veins may cause no symptoms, but for some, varicose veins can be very painful and lead to more serious problems such as blood clots. Learn more on how you can treat your varicose veins by joining us in a free online chat. Dr. Douglas Joseph, a specialist who treats varicose veins questions about this condition as well as the latest treatment options available.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Douglas Joseph. We are thrilled to have him here today. Thanks for joining us Dr. Joseph, let’s begin with the questions.
Dr__Douglas_Joseph: Thanks for having me.
Varicose Veins: Symptoms, Diagnostics, Treatments
SanibelJay: About 25 years ago a hard hit tennis ball broke a blood vein in my left leg. The ankle turned black and there was considerable pain. An ER doctor at the time said the leg just required time to repair itself. During recent years very prominent varicose veins have appeared on this leg, while there are none on the right leg. Only a slight discoloration remains at the ankle and I have no pain from the veins. Should I never the less have them looked at? Thank you.
Dr__Douglas_Joseph: Having it looked at is dependent on symptoms and if there is a cosmetic concern as well. If it is painful or causing discomfort or related to sores forming then definitely it should be evaluated - and additionally if you don't like the appearance - you could have it looked at as well.
tunnel34: I have severe varicose veins and multivessel coronary disease? Are these related? Do you have any doctors at Cleveland Clinic that could see me for both problems?
Dr__Douglas_Joseph: Coronary artery disease is not related to varicose veins. There are doctors at Cleveland Clinic that could evaluate you for both varicose veins and your coronary artery disease. We would be happy to help you find the right doctor for you.
carriedaway: I have an aneurysm in my femoral vein and also very bad varicose veins on both legs. Can you tell me what the treatment would be for that and who I should see in Cleveland?
Dr__Douglas_Joseph: The first line treatment I would advise is gradient compression stockings, leg elevation, exercise and taking meticulous care of your skin. Further treatment depends on the severity of your condition. I would suggest if this is a concern seeing someone in our vascular surgical department would be most helpful.
bethm: What causes varicose veins? I thought they were hereditary but my mom does not have them and I do.
Dr__Douglas_Joseph: There are many risk factors for developing varicose veins. Family history is definitely a risk factor, But not the only one. Multiple pregnancies, female gender, increasing age, standing occupation are a few of the risk factors. Varicose veins can also be secondary to a deep vein obstruction.
sinclair09: I have a painful large varicose vein in my groin area and wonder what the best treatment is for this - it is becoming more painful. I had a DVT in that leg a couple years ago. could that be the cause?
Dr__Douglas_Joseph: For those that don't know - DVT stands for deep vein thrombosis. This condition results in blockage of blood flow in the deep veins. If the blockage becomes chronic or long lasting it can result in developing bulging veins on the surface of the skin. First line therapy is gradient compression during the day. Additional treatment may be advisable depending upon how you respond to compression and your specific anatomy.
jjsjjs: I have had surgery for varicose veins in the '70's and recently have exceptional swelling around the ankles. The lower part of my leg seems to fill and I wonder if there is anything I can do holistically , or need to eat that could reduce the swelling. I take vitamins and fish oil, and several times a week take aspirin.
Dr__Douglas_Joseph: There are many causes of leg swelling - so the first thing I would do if you had a recent increase in swelling is have your family doctor take a look. Problems with your heart, kidneys and other things can cause swelling.
Swelling can also be caused by a high sodium diet so trying to eliminate salt from your diet may help. Other conservative treatments may be compression, elevating your legs and exercise (such as swimming or walking).
Patricia: Varicose Veins: What can I do to reduce swelling in my ankles? Does walking or a stationary bike help? I currently walk 2-4 miles several times a week. Anything I should eat to prevent some of this fluid buildup in the ankles? Thank you
Dr__Douglas_Joseph: Wearing gradient compression stockings during the day will help reduce and prevent ankle swelling. The best exercise to reduce swelling in the legs is walking. Walking stimulates the calf muscles to contract and results in a greater degree of calf muscle pump activation. Exercise on a stationery bike does not result in as much contraction of the calf muscles so is not quite as effective as walking. I would also avoid foods containing a lot of sodium.
bobross: The ABI is a standard test to diagnose PAD. Why has the venous refill time (VRT) not been promoted to diagnose venous insufficiency?
Dr__Douglas_Joseph: Venous insufficiency is often a clinical diagnosis. VRT for those that do not know is information obtained by performing a test using blood pressure cuffs. Most often, the diagnosis is clinically apparent but sometimes using additional testing is warranted.
collisionbend: I have varicose veins - large ones - twisting around both calves. Not painful, but ugly as heck. And standing long periods produces a dull spot running up the center of the calf. Compression didn't relieve anything. I recently had a heart attack, and now I'm concerned about having these large varicosities. What should I do?
Dr__Douglas_Joseph: Heart disease and varicose veins are not related in terms of risk. Having varicose veins does not increase your risk of heart disease. I would suggest having your legs looked at by a vein specialist if you tried conservative therapy with compression and still having symptoms.
9012relly: I started out with one varicose vein which was not too bad - but now it seems they are spreading on my legs and becoming more painful. Is there any way to stop the progression? If I have treatment for the ones I have - will I still get more?
Dr__Douglas_Joseph: The best way to prevent additional varicose veins from progressing is to diligently wear gradient compression stockings. In addition, if you have ongoing symptoms and developing additional varicose veins, I would suggest evaluation by a vein specialist to consider minimally invasive treatment options. Most people don't develop recurrent varicose veins but it is a possibility.
ladybug2: I have FMD - could that cause the varicose veins in my legs? Would treatments help if I have FMD?
Dr__Douglas_Joseph: For those that don't know FMD stands for fibromuscular dysplasia. I don't know of any association between FMD and varicose veins. If you have symptomatic varicose veins, and conservative therapy has not been adequate, then I would consider additional evaluation by a vein specialist.
leenzz: Are spider veins treated differently than varicose veins?
Dr__Douglas_Joseph: Yes. Not all people with spider veins will go on to develop varicose veins. And some people with varicose veins do not have spider veins. Both varicose veins and spider veins are forms of venous insufficiency.
Spider veins can be treated with injection liquid sclerotherapy or foam sclerotherapy or a special laser for treatment of veins on the skin.
matty00: I have varicose veins on my left leg below my knee down to my foot. Can injection help remove the damaged veins
Dr__Douglas_Joseph: Some doctors use foam sclerotherapy to treat even larger varicose veins up to 6 mm and even larger. What treatment option will be best for you depends on your specific anatomy and the experience and preferences of your doctor.
brownam: If varicose veins are removed, does it affect the circulation in the leg?
Dr__Douglas_Joseph: Yes. Most often varicose veins result from refluxing veins above. Once the reflux is eliminated and the varicose veins are removed, blood will then travel through veins with functioning valves resulting in improved blood return up the leg.
srtru: I had veins stripped about 10 years ago but now my veins are getting bigger and my blood flow is decreasing. It is causing pain and swelling and cramping. What do you suggest?
Dr__Douglas_Joseph: I suggest seeing a vein doctor who can look at your leg and order an ultrasound test to better determine the cause of your worsening symptoms and varicose veins.
jjred: I was looking at my report and it said I have a varix that is related to varicose veins. This is very painful on my foot. How is this treated?
Dr__Douglas_Joseph: This could be treated by removal of the vein in a procedure called phlebectomy - or sclerotherapy may work. You may find relief by wearing compression stockings.
vicky77: My husband has varicose veins in his legs. He also plays on an adult soccer team. Could kicking a vein cause a problem or permanent damage?
Dr__Douglas_Joseph: Trauma to the veins could cause a condition called Phlebitis, where the veins become painful, red and inflamed. The skin overlying varicose veins is often thin and can break open and result in bleeding. This can usually be easily managed with compression and leg elevation.
sammy: I have varicose veins. They really do not hurt but I notice they are increasing. Can this lead to more serious problems if they are not treated. I just wear pants more often and would not necessarily treat them if they do not have any future risk.
Dr__Douglas_Joseph: I would suggest wearing gradient compression stockings if you have asymptomatic varicose veins. There is a slight increase risk for deep vein thrombosis (DVT).
lilu12: I would like a couple varicose veins removed but was told this is not covered by my insurance. When is it covered and when is it not? How much does this cost?
Dr__Douglas_Joseph: Treatment for varicose veins is usually covered by insurance when it is symptomatic and usually when conservative therapy has failed. Many insurance companies require 3 months of conservative therapy before covering the cost of treatment.
Varicose Veins – Compression Stockings
Cleveland_Clinic_Host: Dr. Joseph, can you please talk a little more about compression stockings?
Dr__Douglas_Joseph: There are different classes of gradient compression stockings. Some stockings can be bought over the counter without a prescription. These provide a mild degree of compression and can be effective for mild conditions. They provide usually around 15 - 20 mm Hg of compression.
The first prescription level of compression is class I - 20 - 30 mm Hg. The second class - II - is 30 - 40 mm Hg and class III is 40 - 50 mm Hg. The amount of compression a particular patient will need will depend on their symptoms and other medical conditions.
jjsjjs: Are compression knee high stockings sufficient, or do you need a full length stocking?
Dr__Douglas_Joseph: Most people do well with a knee high gradient compression stocking. Most important is to provide compression and support to the calf muscle. Some patients prefer compression of the thigh and some prefer a pantyhose style compression.
Varicose Veins – Interventional Treatments
raj: can you talk about EVLT method of treating varicose veins? is that the best treatment?
Dr__Douglas_Joseph: EVLT - stands for endogenous laser therapy. Which method of treatment is best for you depends on your individual anatomy. There are a number of other ways to treat veins including radiofrequency ablation, chemical ablation, vein stripping and all are good treatments for the right situation.
hh867: Do you use laser vein surgery?
Dr__Douglas_Joseph: Yes. Lasers can be used to eliminate problem veins and is one of many treatments that can be offered. Which particular treatment that is best for you is dependent on your anatomy and condition.
shannon: I have heard about the Versapulse Laser procedure to treat varicose veins - that sounds like it is very successful, do you know more about it?
Dr__Douglas_Joseph: I am not familiar with this type of laser.
carol: if I was interested in traveling for varicose treatment, what does it involve? how long does surgery take and how is the recovery?
Dr__Douglas_Joseph: The first step is to have a consult and if warranted, proceed with diagnostic imaging - usually an ultrasound. If you are a candidate and it is decided to proceed with a procedure, it would be scheduled. It does take time, but when possible we will certainly try to perform this within one trip to Cleveland.
On procedure day - The time to come in for the procedure and complete the process is about two hours. If you have a laser procedure, you would need to return in about 72 hours for a follow up ultrasound. Most often patients return for a follow up 2 weeks after the procedure. Immediately following the surgery, patients are walking and able to perform routine activity. Most patients take about 3 days off from work.
bobross: Does chronic venous insufficiency cause rashes on the ankle and foot?
Dr__Douglas_Joseph: Yes. Venous insufficiency commonly causes a brownish pigmentation especially in the inside of the ankle
rullit: my dermatologist told me to wear compression stockings for "stasis dermatitis" but I still have pain in my legs. Is that related to varicose veins? What do you recommend?
Dr__Douglas_Joseph: It certainly could be related to varicose veins and venous reflux. You may need to wear compression stockings with a higher degree of compression and there may be additional treatment options. I would suggest if you have ongoing symptoms to seek additional advice from your doctor or a vein doctor.
Cleveland_Clinic_Host: Can you please describe or elaborate on venous reflux?
Dr__Douglas_Joseph: I am impressed by the sophistication of questions but in case some people don't know - reflux is defined by the flow of blood in the veins in the wrong direction. Normally blood should go up the leg to return to the heart. Patients with reflux have blood flowing in some of their veins down the leg toward the ankle.
Grtfulmom: Greetings! Is it possible to heal Saphenous Vein Reflux by removing (sclerotherapy) varicose tributaries to the Saphenous Vein? I would like to avoid endovenous ablation if at all possible, however, I would like to initiate measures to heal and/or prevent additional reflux. Thank you for your time.
Dr__Douglas_Joseph: First line therapy for venous reflux is gradient compression stockings. These help reduce symptoms caused by venous reflux and can prevent the changes seen in the skin from vein disease such as swelling, brown coloration, and developing sores.
There is research underway investigating if removing the veins and leaving the saphenous vein in place can result in resolution of saphenous reflux. But this is not the standard of care at this time. Current practices are to remove the highest level of reflux first before removing branches.
Peripheral Arterial Disease (PAD)
marion12: Does the drug PENTOXYLLINE ER help with leg circulation in PAD patients? Or does walking work just as well?
Dr__Douglas_Joseph: For those that don't know - PAD stands for peripheral arterial disease and is not related to vein disease. The medication has been shown to help patients with PAD and symptoms of leg pain when they walk. In fact, a regimented walking program works better at improving pain free walking distance.
Cleveland_Clinic_Host: I'm sorry to say that our time with Douglas Joseph, DO, is now over. Thank you again Dr. Joseph for taking the time to answer our questions about Varicose Veins.
Dr__Douglas_Joseph: Thank you for having me today.
jjsjjs: Thank you for this wonderful opportunity.
Technology for web chats paid in part by an educational grant from AT&T Ohio and the AT&T Foundation (formerly SBC).
This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.