TED SIMONS: And welcome to "Ask a Vein Care Expert." I'm Ted Simons. When we have any type of medical problems or concerns, we all want the best care and this usually means looking for a medical specialist. However, it's confusing if you don't know the medical term for the type of specialist you need. For vein problems, you need to know the word "phlebology." Tonight we will hear from a panel of experts about venous diseases and disorders prevention, impactful lifestyle changes and treatment options. We’ll also give you the opportunity to call in and ask a vein care expert your questions. Phlebologists will be taking calls, throughout the show, at the toll-free number appearing on the screen. The phone lines will remain open until 9:30 p.m., and we encourage you to call.
Let's meet our panel, who are all phlebologists and members of the American College of Phlebology. Dr. Nick Morrison is a fellow with the American College of Surgeons; he’s the current president of the American College of Phlebology and has authored chapters in phlebology texts, published articles in phlebology journals and lectures nationally and internationally. Dr. Melvin Rosenblatt’s vascular and interventional radiology practice focuses on the treatment and venous and varicose veins. He’s dedicated to treatment of minimally invasive vascular disease using sophisticated imaging tools and techniques. Dr. Julianne Stoughton is an instructor at Harvard Medical School, a clinical instructor in surgery at Tufts University Medical School and a fellow of the American College of Surgeons. And Stephanie Dentoni is an expert in varicose vein treatment and peripheral vascular studies, she’s board certified in internal medicine and specially trained in vascular medicine. Again, our phone lines are open; if you have a question about vein care and want to speak with a vein care expert, call the number on your screen until 9:30 p.m. Let's go ahead and get things started here. Basic question: What is phlebology?
NICK MORRISON: Ted, phlebology is the study of venous problems. So a little bit of basic physiology: arteries take the blood away from the heart, and veins return it to the heart. So phlebology is the study of veins, the venous system that returns blood to the heart.
TED SIMONS: Specialized training, what kind of specialized training do phlebologists have?
JULIANNE STOUGHTON: We come from many different directions. Actually, I think that we have on this panel here--we have vascular medicine, interventional radiology, general surgery, vascular surgery, there are many dermatologists, other types of specialties that gravitate toward veins, but as Nick said that--we all kind of have a common ground and interest in the venous disease, and there are many of us that have really gone the extra mile to be experts in.
TED SIMONS: We were talking about specialty like radiology, these sorts of things. Again, talk about the training and the specialty that's involved here.
MELVIN ROSENBLATT: The treatment of venous disease has always been kind of a subheading of many different specialties who deal with--especially the specialists who deal with vascular disease in general. As a consequence, there’s a lot of overlap, and that’s why you have multiple specialties involved in the treatment of venous disease. And in addition to what we've seen is a kind of a collage of technology whereas my specialty, radiology, uses imaging tools, such as ultrasound and fluoroscopy, to treat venous disease in a minimally invasive fashion. These modalities have become available to non-radiologists and they are using those modalities in their offices to treat this disorder in a minimally invasive fashion.
TED SIMONS: And again, phlebology, venous disease, vein disorders, these sorts of things--training involved, specialized, just personally speaking, how did you get involved?
STEPHANIE DENTONI: I got involved because I went to a couple of meetings, and it fit in with my subspecialty, and it was very interesting and it was kind of on the cutting edge of how to treat. And so, that's how a lot of us become involved in vein disease, I think.
TED SIMONS: Okay, as far as how prevalent venous diseases are in the United States, what are we talking about here?
NICK MORRISON: In terms of numbers, we’re probably talking about--probably 25 to 50 million people with venous disease of some type. It's a spectrum, of course, and people can have as little as spider veins and then all the way up to, and including, varicose veins, and ulcerations and those sorts of things. So, we’re probably talking 25 to 50 million people.
TED SIMONS: Is that the kind of thing where the population ages, you get more?
NICK MORRISON: No question about it.
TED SIMONS: Yeah, as far as the major types of venous diseases, again, what are we looking at here.
JULIANNE STOUGHTON: Well, there's a spectrum, as Nick said, from the very tiny spider veins. I kind of think of it as a tree; so whereas the trunks, the branches and the twigs and the spider veins are really very minor, and usually cosmetic, issue, but there are some varicose veins which are more of the branches on the tree, which will usually bulge and cause some symptoms eventually, and usually are a source of--they're coming because there's some pressure in the system, some valves upstream that have been leaking and causing them to bulge out. And then we have the more major trunks, and they can get—they can have valve issues, or they can have blockages from clots and other things. So there's sort of a big spectrum between. And, you know--
MELVIN ROSENBLATT: Yeah, there's -- the way I like to describe it to my patients are there's really two venous systems in the lower extremity: what we call the superficial system and the deep system. The deep system carries the majority of the blood out of the leg, and, thankfully, valvular disorders rarely occur unless a blood clot happens, which can be serious. The superficial system, which also has valves, tends to be a weaker system, and the valves tend to be prone to failure on occasion. And what Dr. Morrison was saying earlier is that when you get above a certain age, when you get into your 60s, the incidence of some venous diseases can be as high at 75%. So, and this is mostly related to the superficial system, and that’s a lot of what we see. And the more serious conditions involve the deep venous system, which involve blood clots and traveling blood clots.
TED SIMONS: And a reminder, again: we're talking about vein care, venous diseases, disorders and these sorts of things. If you have a question and want to speak to a phlebologist go ahead and call the telephone number on your screen. We will have phlebologists standing by to answer your questions until 9:30 this evening. Spider veins, varicose veins, these sorts of things. Obviously prevalent. How do you know you got a problem? Explain for those of us who haven't quite reached that problem or disorder yet. What goes—what are the symptoms? What goes on?
STEPHANIE DENTONI: Sure. There are a lot of people that say they don't have any symptoms when they actually do if you dig down and try to find out if they have some problems with their legs because it’s such a slow progression of disease that they learn to live with the discomfort and think it's a normal thing. So if you start asking them about leg discomfort, their legs ache at the end of the day, they might have a little bit of swelling, their legs feel better if they elevate them at the end of the day. But some people do this routinely and don't think of it as being a problem. So those are things to look for. Some distribution of veins: if they have a lot of small spider veins around the inside of their ankles, sometimes that's an indication that there’s something else is going on causing them , and they usually do have symptoms if that’s the case.
TED SIMONS: Is it the kind of thing where they come to you? Or they don't really realize they have a problem until perhaps another doctor says, “Maybe you should go see a vein care specialist”? How does that usually work?
STEPHANIE DENTONI: I think we see patients that come to us because of their veins, or they get sent by other physicians that are concerned about it.
TED SIMONS: The—again, symptoms for folks who are watching right now going, “You know, my legs, my feet, sometimes I’ve got some problems here.” When do those problems need attention?
NICK MORRISON: You know, it kind of depends on the patient. Stephanie said sometimes patients have very little in the way of symptoms, but often those people are exercisers, so people who exercise a lot tend to have far fewer symptoms than people who don't. So we'll see somebody who has really significant venous disease and yet they're almost asymptomatic because they exercise a lot.
TED SIMONS: Does exercise help prevent some of these venous diseases?
NICK MORRISON No, the exercise can help symptoms and very often helps alleviate some of the symptoms but in terms of prevention, probably not.
TED SIMONS: It sounds like what we're talking about here is something that happens to a whole lot the folks and not a heck of a lot you can do about it. Am I wrong?
JULIANNE STOUGHTON: Well, there are a lot of things that we can do about it, and I think that we’re still sort of looking from one end, we’re trying to figure out how to--what the gene is that --it's usually hereditary as well, and we're trying to figure out where that's coming from and perhaps how we can identify people early. But at this point we have some great treatments, I think. We used to strip veins and do big operations, and it really wasn't the kind of thing you can ever cure, so it was a very difficult thing to put someone through a very big operation that you knew that would be back. I liken it to a garden that we have to tend every once in a while but we have some very nice minimally invasive treatments that don’t have a lot of downtime, and they really are—it’s worth it to keep up. I think one of the problems that you really should if you have, even without any symptoms I have a lot of patients who start to develop some brown color around their ankles, and that is a pigmentation that’s happening from the pooling of blood daily under the skin, and it sorts of almost like---a tattoo that occurs, and that's a sign that things are really progressing, and it can go on to ulcers which become life-threatening. We like to, sort of, fix it before it gets to that point on the curve of progression--so.
NICK MORRISON: Julie brought up something that’s really key. And that is: this is an inherited disorder; we're not going to cure anyone of this problem, but we can do a lot of things to control it. So it's basically what we're doing is controlling the problem, as opposed to curing it.
MELVIN ROSENBLATT: No, only there's some several points that were brought up that were very important. One is that if you're predisposed to developing venous disease, genetically, then it's a life-long process. Just like, I tell my patients going to the dentist, if you're prone to cavities even if you fill one you'll likely to get another, and the same is true for venous disease. So it's something that is not a one-time fix and then it’s all gone. However, it can, you know, with appropriate care it be--can be controlled to the point where you wouldn't even notice you have the disease at all. In addition, the symptoms can vary dramatically You can have patients who have achiness, heaviness, leg swelling, and you can have patients who have no symptoms, yet they walk into your office with a non-healing wound in their leg because of the venous disease. And so that whole spectrum--the skin--the important point is the skin is the end organ that sees the damage. When the pooling of blood in the leg becomes so extensive the circulation to the skin is compromised, and it can literally break down, discolor and it can develop all sorts of problems in that respect.
TED SIMONS: How do you differentiate between someone who’s got the onset of some sort of venous disease that can be treated, not all that serious, and perhaps something more serious – blood clots, these things?
MELVIN ROSENBLATT: Well, it's hard to predict who’s going to get a blood clot, but there are certain things that can concern you, such as if the patients have very large varicose clusters, those veins may be prone to developing clots because the blood is not flowing or circulating very quickly; it’s pooling in these large cavities, and those patients might be prone to developing what we call the superficial phlebitis. And patients who have superficial phlebitis, there's a percentage who can go on to progress to a full-blown deep vein thrombosis. Our biggest concern is those who progress to seeing the skin damage and ulcerations later down the road.
TED SIMONS: The--varicose veins, spider veins, I know that there's some folks who say it's all cosmetic, there’s really nothing else to worry about; if you want to treat it, go ahead if you don’t like the way it looks. But--take it from there. Is that accurate?
STEPHANIE DENTONI: I don't know if that's 100% accurate; there are some medical issues that can cause some spider veins in different distributions on their legs, and some varicose veins. So we typically do a diagnostic ultrasound to see exactly where the veins are coming from. We map them out and see how the function of the veins underneath are doing to see if they’re causing the problems that we see on the skin surface.
TED SIMONS: So and again, once you get that test, and once you get that information, you take it from there? That's the time to figure out whether treatment is needed?
STEPHANIE DENTONI: That's correct.
TED SIMONS: Is there--is there a sense sometimes: “spider veins no big deal just cosmetic, varicose veins take care of it if you want to but no big deal”?
NICK MORRISON: There certainly is, and this is a field with-- phlebology is a field that is really quite specialized, and so the information is not available to a lot of primary care physicians. And so, it's a process that we go through to try to educate the primary care physicians to recognize those patients that may have a more significant problem than just spider veins.
TED SIMONS: Is that how you see it as well? An evolving informational type of thing?
JULIANNE STOUGHTON: It definitely is. I think the education is crucial to have other—to have patients know what to watch for, to have the physicians know what to watch for. We have--as we said, there's a huge spectrum of problems that can occur with venous disease. And sometimes spider veins, as Stephanie said, around the ankle, for instance, that is a sign sometimes of deep vein issues. And so, it kind of—it’s a whole package that you have to look at, and you can't really say one way or the other whether that’s-- I think it's good to see someone that knows a lot about this and the different types of venous disease.
MELVIN ROSENBLATT: You do bring up some very important points because there are a lot of primary care physicians who may see a patient and say, “Oh, don't worry about that, and even if you have something done, they'll likely come back,” or something like that. And the patients will go years without treatment, and then have to, you know, encounter a serious problem and it's much more difficult to fix it.
TED SIMONS: And we want to remind you we do have phlebologists standing by to answer your questions. The telephone number on the screen is for you to call and get the information you need. Again, this is Ask a Phlebologist. If you have a vein care concerns, if you have a disorder perhaps you are interested in getting more information about, that's what the telephone number is for. Go ahead and give that a call. You talked about treatment and the evolving nature of treatment. Give us a range here from -- from most invasive to stuff that people don't even know?
STEPHANIE DENTONI: Well again, there are sort of two types of pathology that happens with veins: One is reflux when the one-way valves are either leaking because the veins have dilated and they’re not working anymore or they’re broken or been damaged from having a clot. So reflux can be treated in the deep vein system; we're working on some valves that can be replaced through a small catheter, and that's probably several years away, but that’s coming, hopefully. The surface vein system, though, is really something that can be more closed down because it’s not--they're not important circulatory veins. So we have--Instead of stripping the veins, which were incisions and stripping catheters, pulling the veins out, now we can close them from the inside with either heat or chemicals. The heat is laser, radio frequency, ablation; some other new methods are coming as well. So we have some great ways of treating the surfaces veins by closing down the reflux. Obstruction is another whole thing where we can open up clots with either medication or--a clot-dissolving medication or catheters that can almost Roto-Root the vein.
TED SIMONS: That sounds very complicated.
JULIANNE STOUGHTON: There’s many different types of—
TED SIMONS: Yeah—
JULIANNE STOUGHTON: But all minimally invasive treatments, which is very nice.
TED SIMONS: Interesting. There's also, I mean, everything from leg elevation to compression stockings, these sorts of things. This also viable?
MELVIN ROSENBLATT: Compression stockings allows someone who has superficial venous disease, and even some deep venous disease, to overcome the effects of gravity. If the valves are not functioning properly, then what occurs when you stand is gravity will cause the blood to pool in the lower extremity, causing the symptoms and consequences of the disease. The compression stockings compress on the leg, reduce the -- that kind of venous pooling and allow the blood to circulate better, and therefore has a significant impact on patients who have deep venous disease as well as superficial venous disease. It doesn't cure or change the--the outcome in the sense that-- I shouldn't say that. It doesn't change the veins. If you put on a pair of stockings in the morning and come back a year later and take them off, you'll still have the same veins that you had a year ago. But it does reduce the symptoms, and it does likely prevent the consequences that can occur, such as ulceration and brown discoloration of the skin.
TED SIMONS: Is that what see as well when you’re treating varicose veins, spider veins and these sorts of things? Everything from invasive to-- elevating your legs, something as simple as that, can that be a treatment option?
STEPHANIE DENTONI: It helps with the symptoms; it doesn’t necessarily treat your veins. So at the end of the day, a lot of people have achy legs from the blood-pooling, and they'll elevate their legs to get some relief from it. So that’s--it's important to some people to do that. I don't know that it really helps the progression of disease by elevating your legs, but it makes them feel a lot better. The compression stockings are very important, especially when patients have deep venous thrombosis; the clots that are in the deep veins, ones that can be very serious because it helps prevent complications if you wear them in a two-year time span after you've been diagnosed with your blood clot. So it's important for those patients that have the deep blood clots to wear their compression stockings on a daily basis for about two years.
JULIANNE STOUGHTON: Everyone in my office basically is referred for compression stockings before I even see them. Everyone--I live in the northeast though, where it's very cold and we are able to wear compression stockings most of the year. But I think that they are very important to help symptomatic relief and prevention of progression. Although, as Mel said, they don’t go away; what you have doesn’t doesn't go away, but helps to slow the progression, I think, and it's a healthy thing; Especially long car trips, plane flights, so—things like that.
TED SIMONS: I was going to mention something along those lines. In terms of travel, we hear that you got to move around, you got to get moving, you can't just sit there, or else bad things start pooling in bad places. Is that accurate?
NICK MORRISON: Absolutely is. There’s--there are a number of high-profile people, including a racecar driver two days ago that developed a clot who--and that ended his season—his driving season. So yeah, it's real important. We tell patients that there are certain times when it's very important to be wearing those compression hose, and one of them is when you're going to be sitting for a long period of time, or if you’re going to be standing for several hours and not moving around very much.
TED SIMONS: And a reminder: the telephone number is there for you to call. Ask a Phlebologist, that’s the name of this program. Vein disorders, vein care, we’re speaking with experts. You can speak with an expert if you call the telephone number on your screen right now. It seems like what we're talking about is nature, is gravity, is almost inevitable. When we talk about treatment, talk about prevention. Is there only so much you can do?
NICK MORRISON: Again, we can control this problem very effectively. But you should remember that what we're doing is controlling, as opposed to curing it, making it go away forever. We can't do that. But we can certainly—these measures, all of the measures that we're talking about, by the way, are all done as outpatients generally in an office setting. The old standard where you have to go to the hospital to be put to sleep and stripped, that's pretty much gone, thankfully.
TED SIMONS: Wow. All right, let's talk about some myths here, or maybe they're not let’s try to figure out true or false. True or false: Crossing your legs can cause varicose veins?
MELVIN ROSENBLATT: False.
TED SIMONS: Where did that come from?
MELVIN ROSENBLATT: Well, that's a very good question as to where it comes from. I think that patients who are prone to developing spiders and vein diseases, if they have trauma to the leg, the way the body heals itself is by forming new blood vessels. And you could kind of contemplate the concept that if you keep on crossing your legs, then maybe you cause some trauma to that area. But in general, that area is a common location for spiders to form. And as a consequence, people say, “well it must be from my crossing of my legs.” I doubt it, and I tell people all the time that, no, you know, you can stop crossing your legs and you'll still get them. So, that’s probably one of the myths.
NICK MORRISON: It's interesting that some patients, you'll see them cross their legs and then they’ll uncross them very quickly.
JULIANNE STOUGHTON: They even remember who first told them, women.
MELVIN ROSENBLATT: You know, another important myth that we didn't discuss is with the stockings; the stockings will help the symptoms, but a lot of times, people think that it will cure disease and we kind of alluded to that, but we didn't say that, you know, you can wear your stockings and you can still have all of the bad consequences because it's almost impossible for someone to wear stockings 24 hours a day, seven days a week, especially in a warm climate. So, it should never be used as a reason not to take care of someone’s venous disease. Stockings will not fix all venous disease. Sometimes it's the only treatment because there’s not much we can do. But sometimes there are very effective outpatient procedures that can make patients feel immediately better, literally slow whatever progression they might have down to a total crawl, and therefore they don't have to be married to their stockings.
TED SIMONS: Okay, let’s do another myth here, true or false. True or false: A woman should wait until after they're done having children before they get venous conditions treated, such as varicose veins, spider veins, these sorts of things? Wait until you’re done having kids, true or false?
STEPHANIE DENTONI: False.
TED SIMONS: How come?
STEPHANIE DENTONI: You can do it in between, but if you're going to have multiple pregnancies very close together, you might want to wait because the gravity uterus is actually going to put pressure on those veins, and might undo what you've just done.
TED SIMONS: Do you hear that often? Do you hear that concern?
STEPHANIE DENTONI: I do hear that often. And we will treat in between pregnancies; we usually wait until they're about six months postpartum, and then we’ll treat.
TED SIMONS: True or false, you're next, surgery is the only option to treat varicose or spider veins. The only option.
JULIANNE STOUGHTON: True -- no, I am a surgeon, so—
TED SIMONS: That’s why I’m asking you.
JULIANNE STOUGHTON: But, well actually, I think I've actually got my staff, you know, brainwashed not to say the word "surgery" anymore when we’re doing the office procedures for the superficial venous things because many times, these are really just procedures; they are a catheter, it’s just as simple as an IV in your hand-- numbing medicine. Patients walk out and go to lunch afterwards. So they’re really more procedural oriented. Some of things that we do--we still are removing little sections of vein with the microphlebectomies and things, but that really is so different than the old-fashioned making incisions, tying things and having the complications associated with surgery like anesthesia, and bleeding, and wound problems and things like that, which we really just don’t see anymore.
TED SIMONS: Okay, well I think we're out of time. That means you're off the hook, no true or false questions for you. Congratulations.
NICK MORRISON: Thank you.
TED SIMONS: And thank you all for joining us again, and great information, and good stuff to know. And a reminder for you: you can visit our website, azpbs.org/veincare for more information and links to additional resources. And a reminder: those telephone lines are open until 9:30 this evening. Ask a phlebologist, ask a vein care expert about anything, any questions you might have regarding vein care and vein care diseases. Thank you so much for joining us. I'm Ted Simons. You have a great evening.