Scott Webb (Host): Spider and varicose veins are common. And though they can sometimes be painful and signs of a more severe issue, they're often more of a cosmetic nuisance than anything else. And joining me today to discuss spider and varicose veins, the various treatment options, and the importance of being treated by a vascular surgeon is Dr. Chelsey Lewis. She's a vascular surgeon with Elliot Vascular Surgery. This is Your Wellness Solution, a podcast by Elliot Health System and Southern New Hampshire Health, members of SolutionHealth. I'm Scott Webb. Dr. Lewis, it's great to have your time today. We're going to talk about some conditions that are fairly common and how we can spot them, what we need to know about them, the different treatment options, and so on. So, as we get rolling here, what are spider veins and varicose veins?

Chelsey Lewis, MD, RPVI, FSVS (Guest): This is exactly like you said, a very common complaint that we have people come into the office with. So, it's great to be able to share some of this information in a more public way. Varicose veins are basically veins that are twisted, dilated, enlarged, and close to the skin. Basically, think of it like an overstretched elastic band.

Any vein that naturally occurs close to the skin can become what we call varicosed or dilated. Different people have different amounts of veins close to the skin naturally. Some people seem to have more surface veins than others, and we don't really have a good reason for that. But they just do. So, the way that we classify them is if the vein is greater than three millimeters in size, that's called a varicose vein.

If it's less than three millimeters but larger than one millimeter, we call it a reticular vein. And if it's less than one millimeter, we call it a spider vein. To make it even more confusing, very, very small, kind of matted areas of spider veins can be called telangiectasias. So, the thing about varicose and spider veins, and surface veins is that they may be their own problem and that's all you have going on, and you're just getting them for no real good reason other than, mom and or dad had them, or they could be a sign of a deeper problem. And so, when we see people with those, we like look for the deeper problem, as a source of the surface problem.

Basically what's going on in that scenario is that deeper veins may not be functioning normally.

So veins are supposed to be a one-way system. They're supposed to bring blood back to the heart from wherever they are. They have valves inside them to prevent blood from moving backward. A couple of other things that get blood moving, you know, every time your calf muscles start to work, it'll push blood up. And then, like you said, in between those impulses, the valves are supposed to close properly. And if the valves don't close properly, you get what we call a reflux of blood back down into the deeper veins and then that can dilate surface veins and cause varicose veins as well. So that's basically what varicose veins are.

As I mentioned, there's not really a lot known about why some people get them and some people don't. We know that genetics plays a very, very strong role. So, if you have one parent that has varicose veins, you have a 50% chance of getting them. And if you have two parents, you have about a 98% chance of getting them.

Host: Woah, yeah.

Dr. Lewis: So, we talk about some of these different things that they're usually more common in women, that often has to do with pregnancy, hormones, different things. Oddly enough, they're more common in people who are very tall. Why that happens, we don't really know, but really the risk factor is your genes. Everything else just either makes it better, makes it worse, or, you know, maybe makes you more prone to having a more serious case of varicose veins.

Host: Well, that's great. And I've never had any of these, the whole range that you gave us there from spider up to varicose. But when I look at them, they look painful. And I've often wondered, is that just a cosmetic thing and people may be treated for them because they just look a little unsightly maybe, or are some folks actually experiencing pain?

Dr. Lewis: It can run the gamut. And the really interesting thing to know is that the appearance of the veins does not necessarily correlate with the severity of the symptoms. So, for example, I'll have someone come in with just a really small cluster of veins and they are really uncomfortable. They itch, they ache. Aching is, the most common phrase that people will say they itch, they ache, they feel full, they feel tender. They hurt when they're touched, usually worse at the end of the day, you know, they come in with this really tiny cluster of veins and you think, how could that possibly be hurting this person, but you take them out, you fix them and they feel much, much better.

And then, you know, occasionally I'll get people with very extensive varicose veins on both legs. And their primary care doctor will rightfully look and say, this person should be evaluated by somebody who can, you know, look at these veins. They come in, and you look at their legs, and you think, God, that must be awful.

And say, no, no. I've had these for years and years. They don't bother me at all. You know, I may not love the way they look, but they don't hurt. You know, I don't want anything done. If nothing has to be done. And the good thing is in those cases, nothing has to be done if the only problem is the surface appearance of the veins.

Host: Yeah. And I'm sure there are some advantages, as you mentioned there, you know, we reach out to our primary. We have them look at them, and maybe they're even doing those in video visits and telehealth now. But if we get moved on past our primary, are there some benefits to seeing a board-certified vascular surgeon?

Dr. Lewis: Absolutely. So, a lot of different specialties will do what I call dabbling in veins. And some of them are very good at it. Some interventional radiologists do vein work. I mean, a lot of people have sort of jumped into the sclerotherapy, which we'll, I think we'll talk about a little bit later, injection of surface veins and things like that. Some general surgeons do it. I think on an individual basis, there can be some people outside of our specialty who are good at it. But in general, you know, a vascular surgeon, there are two different ways to become a board-certified vascular surgeon. One is out of medical school; you go to a vascular surgery residency, and you spend five years learning about vascular surgery.

The other way to do it is to do five years of general surgery and then an additional two years of vascular surgery training. Then, you take a series of tests and become board-certified. And the real benefit is severalfold. One is that vascular surgeons are really well-trained in the entire gamut of possible procedures that you might need to take care of veins. So, we can do everything from the surface injections, the sclerotherapy, we can do the minimally invasive laser therapies, and we can do open surgery if that's what's necessary. So, I think it's good that we can see it, evaluate it, and do every treatment.

The other thing is that most vascular surgeons, have something called a registered physician vascular interpretation, meaning that we can interpret ultrasounds. So that's really, the diagnosis is made through an ultrasound, and the ultrasound helps us with planning and treatment options.

But for us, we have a lot of special training in interpreting and using ultrasound. So, in general and again, I think there are probably people here and there who have trained themselves and done a lot of training in vein work, and that's great for them. But in general, I think seeing a board-certified vascular surgeon, you're going to have a really pretty good guarantee that the person that you're seeing has a really extensive knowledge of venous disease.

Host: Yeah, it certainly sounds that way. And you've mentioned a little bit there, some of the treatment options, some of the really cool advanced stuff that's going on now. And let's go through that. Take us through the range of treatment options for varicose veins.

Dr. Lewis: The options really depend on what is going on. And I mentioned earlier, that, you know, oftentimes the problem is just the surface veins. And so, there are treatments for that. And then sometimes there's a deeper problem. And so the way that we work this up is we initially start after we see you in the office and we see that you have a vein problem or maybe you've come in and said, my skin is starting to be itchier or feel funny down there, and I'm swelling and aching and heaviness, or something has gotten you into my office. We do a specialized ultrasound that looks at the function of the veins, and that's going to really guide us and map out your surface veins, guide us in what the best therapy is going to be for you.

So initially, the really least invasive and really the gold standard in nonsurgical treatment is graduated compression stockings, and a note everybody doesn't love them. But they are extremely helpful. So basically, the way they work is they're a little tight around the ankle, and then they gradually become looser as they go up in the leg.

They come in all different varieties: knee-high, thigh-high, full pantyhose, and calf sleeves; they come without toes. Nowadays, you can find them in fun fabrics and designs that you can possibly imagine, which is great. So, these are really helpful for the symptoms. They're not going to make your veins go away. They're not going to cure anything, but they're very helpful for the symptoms. Some of the other things that we tell people conservatively, losing weight, you know, being overweight will make some of the symptoms worse. And again, like I said, it doesn't cause varicose veins, but it can make the symptoms worse.

So weight loss, exercise, elevating the legs, using non-steroidal anti-inflammatories or Tylenol as necessary. And then some people will find a lot of relief with topical pain medicine. So again, you pick your poison. There are a million of them that they sell at the pharmacies nowadays. And so sometimes those can be really helpful.

In addition to that, we always encourage really good skincare. Moisturization, using stuff without perfumes and dyes, is really important to keep it from irritating the skin. So, that's really the basics of nonsurgical therapy. And then as we get onto surgical options, and again, I'll go over some of the different things that we do, but it's very dependent on what your ultrasound shows and what your physical exam is like. So, not everybody's a candidate for all of these procedures, but the big one that people used to do, and I think it's important to touch on. This is rarely done now, but I have a lot of people come into my office and say, oh, my mom or my grandma had vein stripping 30 years ago, and it was miserable, and they were in so much pain, and they stayed in the hospital forever.

And true, vein stripping is really not done anymore. So, I have had people come in and say, I waited a really long time to see you because my, you fill in the blank, the mom and grandma had a horrible experience. And so just to tell people, we really don't do that anymore. Really, we do a lot of the more minimally invasive things. Stripping was, you know, a week in the hospital, weeks off work, really invasive. So now, really, the mainstay of therapy is catheter-based treatments when you have an underlying problem. So, a couple of ways that that can be done. A lot of times, it can be done in the office with no sedation or just an oral anti-anxiety medicine right before you come in. We basically introduce the catheter into the vein, use ultrasound, and use either heat or a chemical, or glue, even medical-grade glue.

That's a little on the newer side from some of the other ones, to shut the vein down, shut the vein that's not working down, which will allow other veins that are working well to take over and the blood will reroute itself. So, that's really the mainstay of therapy. And then, in addition to that, there is a very minor surgical procedure that can be done called a phlebectomy. So, if somebody has a very, very, very large, thick varicose vein that we don't think is going to go away if we treat the underlying vein, we might do that. It's a two-millimeter incision right over the vein, and basically, it uses what amounts to a crochet hook to pull the vein out. It's very, very simple.

And then just a little dab of glue or a little, a piece of tape, you know, surgical tape to close that incision. And, and that's very well tolerated. Injections: so everything from the smaller vein sclerotherapy can be done on spider veins and reticular veins, and then it can even be done on larger veins using ultrasound. Or if we, if turn the chemical into a foam, we can do that on the larger veins. And that can be a really good treatment that doesn't leave any scars. So those are basically the gamut of what we do. I would say that would encompass about 98% of the invasive management that we do for veins.

Some people will go to a dermatologist for laser therapy for surfacing. There are some benefits to that. There are also some downsides to that. It's a little bit more treatment is required, but that works pretty well too. Some vascular surgeons will do that, but most limit it to the injection.

Host: Well, it sure sounds like there are a lot of options, which is great, you know, from nonsurgical, less invasive to more invasive, and you make it sound so easy, but I guess that's the benefit again, as you discussed about seeing a board-certified vascular surgeon. I’m wondering what the results are like, what are the outcomes?

Dr. Lewis: People overall are very happy. I would say the vast majority of my patients are really happy. I think good results, especially for people who come in with symptoms. Once we treat this, their symptoms are really, really much improved. After a couple of weeks, their legs feel less heavy. They get less swelling. The varicose veins are obviously gone, so they're not painful.

Some things that can happen. So, some of the complications that can happen: there's a very small risk of getting blood clots and things like that with procedures, you know, nothing is zero risk. And we always really sit down with the patient once we figure out a treatment plan and go over all of the risks and benefits. So, things like that. Occasionally, people will get a little bit of what we call brown staining. So, the iron in trapped blood, after we treat the vein, the iron will leach out into the skin, usually over time that can fade. But I would say the vast majority of my patients are really happy with their results, cosmetically and symptom-wise.

Host: Yeah, that's really good to hear. And as we wrap up here, Doctor, you sort of touched on this a little bit that sometimes the varicose veins or spider veins, whatever they are, might just be those things and they're isolated to the, just that little area. And it's not a sign of something worse, but sometimes it might be. And I'd like to have you finish up just by telling folks, hey, if you're not sure, if you haven't spoken with somebody, that you haven't had an expert see them, you probably should because they could be an indication of something more severe, right?

Dr. Lewis: I would say, if you have a couple of varicose veins on your skin, your skin looks totally normal. They're not hurting you. You honestly, probably don't need to see anybody. But if you have any symptoms, like heaviness, the aching, the swelling, those would be great reasons to come in and see somebody. When it gets really critical that you do see somebody, if you start to have skin changes and that can look a couple of different ways.

So usually early on it some of that discoloration I talked about that can happen after treatment, if that starts to happen before treatment, especially if it's around the inside of your ankle, those skin changes can be very hard to reverse if you wait too long on them. In very severe cases, which is not typical, but definitely can happen, people can actually get superficial skin ulcers that are very hard to treat. And again, they usually occur down by the inner ankle. And, the earlier you treat the vein, the more reversibility you're going to have in that condition. So, yeah, I would say the time that you really want to come in and see somebody as if you start to see any difference in your skin, whether it gets red or brown or the texture feels different. If you start to get little bumps, those would be the reasons that you really want to go in and see somebody ASAP.

Host: Yeah, well, this is perfect. It's so great to have experts to take us through all of this. And folks can click play and get some free medical advice. And of course, we want folks to, you know, speak to their doctors, their primaries, see board-certified vascular surgeons if they have these issues, if they think they're severe enough. So, thank you so much for your time. You stay well.

Dr. Lewis: I very much enjoyed it. Thank you so much.

Host: And for more information, go to Elliothospital.org/vascular. If you enjoyed this podcast, please be sure to tell a friend and share it on social media. This is Your Wellness Solution, the podcast by Elliot Health System and Southern New Hampshire Health, members of SolutionHealth. I'm Scott Webb. Stay well, and we'll talk again next time.