Evo Terra (Host): Vein-related issues can cause discomfort and make you feel self conscious, but is the problem more than skin deep? Let's find out with Dr. Edward Arous, a board-certified vascular surgeon at the Vascular Care Group.

This is Answers in Vascular from the Vascular Care Group. I'm Evo Terra. Dr. Arous, thank you for joining me today.

Dr. Edward Arous: Thank you very much for having me.

Host: So, let's get into this. Superficial and deep veins sound like two very different things, but are they related? And how are they different?

Dr. Edward Arous: Yeah. So, you know, we're, of course, talking about veins in the leg. So, everyone has a set of superficial veins and a set of deep veins in their legs. And they really have very different roles, and problems with them can manifest very differently. So, superficial veins are really the veins, pretty much the ones that you usually can see. So, if you have someone that complains about varicose veins or spider veins, those are pretty much limited to the superficial veins. Similarly, If you know someone who's had bypass surgery, heart bypass surgery, you oftentimes will find a patient that has a segment of their superficial veins removed for that purpose. And so, you don't actually need to have most of those veins.

Conversely, deep veins carry the majority of blood from your leg. So, 90% of the blood typically gets drained through the deep vein system. So, those are deeper. The veins you need, you cannot remove them. So, what I tend to describe it is that arteries pump blood flow away from your heart. Everything from your heart out down to your toes, your fingers is out to an artery, but veins bring the blood back towards the heart. And they're related in that sense, but it's oftentimes a misconception. People say, "I have bad circulation," and there's really two components. There's an artery side and the vein side.

Host: Which direction are you talking about, right?

Dr. Edward Arous: Exactly. So, the other important component of this is that, you know, your heart is on the artery side. You have a heart that functions as a pump. So, your heart pumps the blood through your arteries, but there is no heart on the vein side. So for your legs specifically, you use your calf muscles. So when your calf squeezes, so think when you step on the gas pedal, you squeeze that calf and it squeezes the veins and that propels the blood upwards towards your torso. Now, it doesn't get all the way with one squeeze, so you really need to squeeze and relax, squeeze and relax. So, you have valves in your veins that keep the blood going in one direction, at least it's supposed to go in one direction. So when you squeeze, it'll go up maybe, you know, a portion of your leg and then those valves should close until you squeeze again. So, some of the problems that I'm sure we'll discuss will be an issue if someone has problems with those valves.

Host: Right. Right. That's fascinating. Yeah, that's good to know. It makes sense. We don't want just the blood pooling down on our feet as we're standing. And it needs to keep going up, right?

Dr. Edward Arous: And so, that's when people say, "Oh, you know, my legs feel heavy" or "I have very swollen legs." And that very well may be a sign of vein disease. If those valves become dysfunctional, then whenever your legs are down with gravity, the blood's just going to pull back down towards your lower leg, towards your feet. So now, you can have asymmetric swelling of one side, and now your veins may be holding more blood than they were intended to. And so, that's how veins will dilate and you can get varicose veins. And so, people will complain about that as well. So, varicose veins are very much a symptom of superficial vein problems.

So, varicose veins is probably one of the most common reason that someone goes to see a vascular surgeon. Honestly, in all-comers, a high percentage of the population actually has varicose veins or superficial vein disease, someone over 30, 40%. More common in women. More common in women around the time of pregnancies is due to hormonal changes. I tend to find that men have vein problems, but they just don't go to the doctor. And maybe they show up later in time maybe with larger veins, et cetera. So, it's really the same issue. It's all fundamentally a valve issue. So if those valves become dysfunctional, these veins can become dilated and you can get these bulging veins because of it. So, the hard part to describe to patients is that the veins that you look at in your leg that are bulging on maybe your thigh or inner calf are not actually the problem veins. It's really a problem with the valves.

So, there's a number of treatments we can do to treat varicose veins where we don't actually need to poke the veins or treat the veins that are sticking out in your leg. It's really a function of treating those valves. If once you've corrected the valve issue, now you've restored a normal pathway for the veins to go back up and now your veins are less dilated than those varicose veins that once worked, it can become smaller. And certainly, there's some that are really big that we end up having to remove ultimately, but there's a lot of treatments that are all done really in the office. And they're all done with patients awake, take note of 10 to 15 minutes, just local anesthesia, just like going to the dentist. So, you know, a little bee sting and then do the treatment.

Host: So, give me a very brief rundown of this process. I go when I need my valve cleaned out, and what are you doing to me?

Dr. Edward Arous: So essentially, we're closing the vein. You might hear something called the closure procedure. And there's a few different types of methods to close the vein. So, I mentioned that if this valve isn't working, you just have blood going back down, you really got to think that it's like a column of blood that's just filling down the legs. So if I have a patient that comes in with bulging veins on their lower calf, and we first do initial consultation. And then, we will do an ultrasound to really get a sense of which valves are dysfunctional, where are the valves that are not working? Is it a superficial vein, which I could treat? Or is it a deep vein, which I cannot? Treatment meaning I cannot remove. Then, that helps me pinpoint how to best treat it. So, if it is a superficial vein, I give the analogy patient, you know, "If I go and remove the varicose veins that are problematic to you, you'll be happy with me for maybe six months, but I haven't really treated the underlying issue of the valve dysfunction." So, we're going to turn off the faucet by closing that vein.

So typically, what we do is with patient awake, we numb off the skin. I put a needle inside the vein. And then, there's a couple different methods. One is like a thermal or heat-based method where we use radiofrequency energy to get the vein to scar down. There's another method where you use a biological adhesive, like a biological glue, to get the vein to close or there's a foam sclerotherapy, like a foam method, sort of irritates the vein.

Now, I did jump ahead a little bit. These are all sort of obviously invasive methods to treat varicose veins, but there certainly are non-invasive methods. So, we have to make sure that patients are optimized conservatively first. So if you've ever had someone who's worn compression socks, compression stockings, they are meant fundamentally to replace the valves. So if you have a pair of compression stockings, you may notice they have a set of numbers on them. It might say 10 to 15 or 20 dash 30, and it's all millimeters of mercury. The larger number is how much pressure the stocking has at your toes. And then the lower number is the pressure that's being delivered at the top of the stocking to create a gradient to push the blood upwards. So, if patients come in and they feel better with compression socks, it really helps me confirm that the diagnosis of leg pain is related to vein disease.

Now, I will say that I don't know that many people that love wearing compression stockings, especially during the summer. But it is a fundamental initial treatment method. And, of course, the alternative is elevating your legs. And so, elevating your legs above your heart to really create a gradient for the blood to drain from the leg. And so, those are the first. So, typically, when someone comes in to get seen for a consultation, they get set up with those two methods, and we do an ultrasound beyond that to see which valves are dysfunctional and then decide whether a procedure would be beneficial to them.

Host: Right, right. Okay. You brought up compression socks and I know that my stepdad wears compression socks when he flies, because he has had DVT, deep vein thrombosis, if I'm pronouncing that properly. So, let's talk about DVT, blood clots, all of that stuff. What are we doing with those? And do compression socks really help there?

Dr. Edward Arous: Yeah. So, you nailed it. So DVT, deep vein thrombosis. By its name, that involves a blood clot involving a deep vein and the deep vein system. You may have superficial blood clots. So, it's called SVT, superficial vein thrombosis, or you might hear the term superficial thrombophlebitis, which is a blood clot in a superficial vein. And I'll get back to that.

So, what are the symptoms of a DVT? What makes someone concerned that they have a DVT? So, I mentioned that the veins bring the blood back up towards your heart. And so, if you have leg swelling or a problem, you really can have two problems. You can have a valve problem, where when your legs are dependent, the veins are returning the blood back down towards your foot, or truly an obstructive problem. If you have a clot in that vein, now the main pathway, I think the main highway to drain your leg is obstructed. So inevitably, you're going to have some degree of swelling, particularly in the acute phase. So if you have a blood clot within the first couple of days, you'll notice that your leg has become increasingly swollen. It's pretty important to get that diagnosed, because DVTs, deep vein thrombosis carry a risk of what's called pulmonary embolism or a PE, that's the main risk of a DVT is that if a fragment or a portion of the clot breaks off, it will travel upstream, it will travel up to the heart and get to the lungs, and it will obstruct a segment of the blood flow to the lungs, which can lead to like difficulty breathing, lower oxygen levels.

So if you have a DVT, in most scenarios, you are placed on blood thinners for a portion for a period of time usually on the order of three to six months the first time. And if you have a recurrent blood clot, you might get put on lifelong blood thinners.

Host: Okay. All right.

Dr. Edward Arous: The other reason it's important to get diagnosed with DVT as early is that there are treatments for it, meaning not just blood thinners. So, I tell patients the blood thinners don't actually dissolve the blood clot, your body does that. The blood thinners are really meant to prevent you from propagating the clot, meaning we don't want it to extend, get bigger or break off and go to your lungs. So, there are treatments which we do most commonly in the office now, where we actually try to suck out the blood clot. And so, we'll put a catheter into the vein and use varying types of devices to try to remove as much of the blood clot as possible. And that sort of has been shown to sort of reduce risk of sort of chronic leg swelling, chronic leg pain. One of the main risks of having vein disease is getting ulcers down the road. So, we really want to reduce the risk of long-term venous disease, particularly these ulcers, which can become very challenging to treat down the road.

Host: What can we do for a healthy, active lifestyle? Like, I don't want these things . I'm 56 years old. I would like to not have either varicose veins, even though it's not quite as serious as the DVT. But what should I do so that I don't have to go see you?

Dr. Edward Arous: Yeah. So, if you're active and exercising, have regular active lifestyle, then you're probably doing most treatment that you need to. I'd say patients that are more non-ambulatory, if they don't really get around very much wheelchair-bound, et cetera, they're more likely to have chronic vein disease simply because their legs are in a dependent position. So, compression stockings are oftentimes beneficial for those patients even without the History of blood clots. They're just increased risk for it. And you mentioned about patients with varicose veins, with vein pooling and stuff, you're at higher risk for having a superficial vein clot, so an SVT, superficial vein thrombosis, if you have varicose veins, because that blood is stagnant, and many times in the lower part of the leg. So, you can imagine your legs might be down, maybe you're at work a lot, and you sort of sit at a desk, the blood is just typically more stagnant, particularly in the lower part of the leg, when your valves are non-functional. So, those are patients I really would say should be wearing compression socks, if not ambulatory. And that's probably why you said your family member probably wears them on planes, because one of the risks are prolonged periods of immobilization. Make sure you get up every hour and a half in a plane. Long car rides, recent surgery all may be risk factors for blood clot formation.

Host: And as you also said, you know, staying active and exercising is a helpful thing too, which means once again, you're not going to let me fire my personal trainer. Okay. I'll have to deal with him. Real briefly before we wrap things up, I know you mentioned previously some of these symptoms that come up here, like leg swelling and then also ulcers. Talk me a little bit about ulcers and what do you do when these ulcers develop?

Dr. Edward Arous: Yeah. So, venous leg ulcers are actually the most common ulcer that can occur on the lower leg, so ulcer meaning a breakdown of the skin, so any sort of wound that takes a long period of time to heal. So, nationally, it's by far the most common reason that patients get seen at a wound clinic or a wound center because of notoriously hard to treat venous ulcers. So typically, you'd see these in patients that have had chronic vein disease, maybe they had blood clots when they were younger or chronic leg swelling, and there's a lot of reasons for leg swelling. You know, you might have a component of heart failure or lung disease or liver disease, all that leads to excess fluid in your body, but just from gravity will travel down to your legs, particularly if someone's sitting down most of the day.

So, it can be very much multifactorial. People may have history of blood clots, these other medical problems, or what's important to test are those valves. So if you have a non-healing ulcer, and it may represent a venous ulcer, so I will tell patients that venous ulcers are usually above the ankle, meaning inner calf, outer calf, but they're usually limited to below the knee and above the ankle. You may also notice patients that have dark-colored skin, particularly in that area, above the ankle and below the knee, that's a sign of chronic vein disease. So if you, I tell patients, you know, if you go to the beach, you might notice that there are people that walk around and have really dark-colored skin down below, darker than their normal complexion. And that's something called hemosiderin staining, hemocitarin meaning hemo from like hemoglobin. So, your body uses hemoglobin to carry oxygen and you're actually using iron to carry, to transport the oxygen around. If the blood is stagnant in your lower leg, that iron escapes from the blood and can dissipate into the tissue. And what does iron do? It rusts. So, it gives your skin a rusty appearance. And so, that's permanent. That will not change, but the compression socks can prevent them from getting worse. But once you have discoloration like that, you are at high risk for cellulitis and ulcer formation. So, those are patients that we really look to treat their non-functional valves, if we can get them in and get them tested to really as a source of prevention. So, unfortunately, there's a lot of patients out there that don't get diagnosed really is what it comes to.

Host: Yeah. And I think the step one is if you're having any symptoms that are unusual, right? I guess I should let you say this. What should people do? When do they know when they need to go see a vascular surgeon like yourself or just have the doctor check out the issues that they might have with their veins and their legs?

Dr. Edward Arous: Correct. So if you have these ulcers or varicose veins or dark discoloration, or they're typically more unilateral leg swelling. If you have both legs symmetrically swollen, it's usually a sign of something else, but still a sign that we would check for. It's worth seen by a physician or seeing a vascular surgeon. And most commonly, we would arrange for an ultrasound. Now, this is not a standard ultrasound for a blood clot as we're concerned about a DVT, because you really need to be doing one to check for those valves in addition to the formation of a blood clot. And then, you may end up being a candidate for one of these procedures to close the vein, or one thing we didn't touch on is sometimes we put stents in the veins as well. So just as you get stents in arteries or for your heart, you know, your coronaries, for your heart arteries, if you have a narrowing or an obstruction in some veins, that can predispose you to getting these venous ulcers, we can put a stent into those veins to help improve the drainage from your leg.

So, another thing that only a vascular surgeon would do, but important to get tested for because most patients, unfortunately, a lot of physicians don't know that that's really an option, but all this is done in the office. So, all these tests and procedures are done in an office setting, so it saves you a hospital trip, you know, no general anesthesia, much lower co-pay as you can imagine. Your insurance company prefers you to have this done in office as it is.

Host: I would imagine less invasive is good for everybody, bodies, our pocketbooks, and everything else definitely.

Dr. Edward Arous: A hundred percent. Yeah. I think things have just have changed quite a bit in the several years, at least since I was in training too. Everyone I think knows someone who's had the term vein stripping or they've had their vein stripped. And that was sort of a surgical way to remove varicose veins, which is very much a way of the past. There was sort of a more morbid way to pull out veins. And now, we really have the tools to do this all using ultrasound and with needles. And it's sort of thing that's very expeditious and you get home right away.

Host: Hooray for living in the future, for sure. Dr. Arous, thank you very much for joining me today.

Dr. Edward Arous: Thank you very much for having me.

Host: Once again, that was Dr. Edward Arous, a board certified vascular surgeon at The Vascular Care Group. For more information, please visit thevascularcaregroup.com. And if you found this episode helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. I'm Evo Terra, and this has been Answers in Vascular from The Vascular Care Group. Thanks for listening.