Blood vessels are like pipes that carry blood throughout the body. While arteries carry oxygen-rich blood from the heart to the organs, our veins have the job of taking waste-filled blood back to the heart to complete the circuit.
We don't give a lot of thought to our veins – but we should. Host, Jonathan Fialkow, M.D., welcomes two vascular surgeons to help explain why.
Guests:
Blood vessels are like pipes that carry blood throughout the body. While arteries carry oxygen-rich blood from the heart to the organs, our veins have the job of taking waste-filled blood back to the heart to complete the circuit.
We don't give a lot of thought to our veins – but we should. Host, Jonathan Fialkow, M.D., welcomes two vascular surgeons to help explain why.
Guests:
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Dr. Jonathan Fialkow:
Welcome back to Health Talk, podcast listeners. I'm your host, Dr. Jonathan Fialkow. I'm a Preventative Cardiologist and Lipidologist at Baptist Health Miami Cardiac and Vascular Institute, where I'm also Chief of Cardiology at Baptist Hospital and Chief Population Health Officer at Baptist Health.
Dr. Jonathan Fialkow:
Our blood vessels are like pipes. They carry blood throughout the body. While the arteries carry oxygen-rich blood from the heart to the organs, our veins have the job of taking wasteful blood back to the heart to complete the circuit. While much attention gets paid to our arteries, especially as the cause of strokes and heart attacks, we don't give a lot of thought to our veins. But we should.
Dr. Jonathan Fialkow:
Today I'm happy to welcome two vascular surgeons from the Baptist Health Systems to tell us why. Dr. Eileen de Grandis was Medical Director of the Vein Center at Boca Raton Regional Hospital's Christine E. Lynn Heart and Vascular Institute. And Dr. Libby Watch who's a Vascular Surgeon and a Specialist in Veins at the Miami Cardiac and Vascular Institute. Thanks for joining us today, guys.
Dr. Libby Watch:
Thanks. It's great to be here.
Dr. Eileen de Grandis:
Thanks.
Dr. Jonathan Fialkow:
So let's start with some basics. Eileen, let's start with a question to you. We mentioned veins and arteries, what's the difference?
Dr. Eileen de Grandis:
You mentioned before that arteries bring blood down from the heart and veins bring blood back up. Arteries are thicker blood tubes that really has some muscle layers to pulsate blood down. And so we have a pulse with the arteries. And when we talk about veins going back up, they are thinner walled, and they work through valves, which help push flood up one way against gravity, to return blood to the heart.
Dr. Eileen de Grandis:
As a result, the disease processes that happened in arteries and veins are slightly different. Arteries will sicken and form plaque, and they can also dilate and form aneurysms. The veins when they have problems can form clots. And they can also primarily dilate to form what we call varicosities.
Dr. Jonathan Fialkow:
Yeah. That's very helpful. So I think they're not just passive tubes taking blood in different directions. They're actually structurally different. And as you say, veins have valves, so there are differences beyond just the direction the blood is flowing within them.
Dr. Eileen de Grandis:
Correct.
Dr. Jonathan Fialkow:
Fair to say, right? Okay. So with that level set, Libby, vein problems, are they mostly in the legs and the feet, or do they occur in other parts of the body?
Dr. Libby Watch:
So you can have vein problems everywhere in the body. But the majority of the vein disorders that we treat are in the legs and the feet. The veins in the legs and the feet are more susceptible to issues because of gravity. And if the valves aren't working, the veins will dilate and cause symptoms that occur in the lower part of the body more often.
Dr. Libby Watch:
There are other malformations that can happen in other parts of the body, but that's the majority of vein issues. Veins are also duplicated, different from arteries. There are very few arteries in the body that can be spared, but veins tend to be duplicated in the leg. So there are two systems working together. And that's why I think more issues occur in the legs and the feet than in the other parts of the body.
Dr. Jonathan Fialkow:
So in your practice, again, that both of you guys mentioned, there are veins throughout the body that can become problematic. The majority have to do with the lower extremities. The majority have to do with problems in the legs. Is that fair to say to both of you?
Dr. Libby Watch:
Yeah.
Dr. Jonathan Fialkow:
So Libby again, expanding on what you discussed, what are the more common vein problems that one would experience in their legs?
Dr. Libby Watch:
We divide the leg veins into two systems, deep and superficial. And so there are veins that clot and that can lead to deep vein thrombosis in the leg, which is often a serious problem requiring medical treatment, usually non-surgical treatment.
Dr. Libby Watch:
And then the superficial veins can clot as well, which can cause sort of painful areas like patients will have a big vein that they can see in their leg and that's painful. So that's what's called a phlebitis.
Dr. Libby Watch:
And then the most common thing that we treat for a venous disease is superficial venous insufficiency, where the superficial veins themselves don't empty blood. They don't return blood to the heart as well as they should. And that can lead to a number of different symptoms in the legs that people will seek out treatment for.
Dr. Jonathan Fialkow:
We've actually done a podcast regarding leg swelling and obviously a big component of that came up with a vein. So we're certainly sensitive to what you're speaking about.
Dr. Jonathan Fialkow:
I do want us to talk about clots because they're fairly serious. But before we get to that, Eileen, let me ask you, are there people who are predisposed to vein conditions? Are they either genetic or body habitus things which might make someone need to be more alert or more aware of the potential vein problems?
Dr. Eileen de Grandis:
There's definitely a genetic component. A good portion of my patients come in saying their mother or their sisters or fathers have had vein disease, large varicose veins that were treated or untreated.
Dr. Eileen de Grandis:
In terms of a more environmental cause of vein disease, we look at people who are standing a lot or sitting a lot, or are in construction, carrying heavy weights, obesity and pregnancy can certainly cause vein disease just from the pressure blocking the veins. Or causing extra weight that your veins have to work against when pushing blood up against gravity. Certainly blood clots can themselves damage it and so lead to vein issues in the long run and worsening reflux and damaging the valves.
Dr. Eileen de Grandis:
One of the newer things that we see causing vein problems in the pathology is COVID-19. And this is causing blood clots and thrombotic complications.
Dr. Jonathan Fialkow:
Elaborate on that a little bit, because it is out there in the present and in the community. Are you talking about people in an ambulatory home setting or are you talking about more people who are hospitalized with severe conditions? Are you talking about both? Elaborate on that a little bit.
Dr. Eileen de Grandis:
Definitely those who are hospitalized in an ICU setting. There are really good studies showing that the critically ill, the ICU patients were on ventilator or what we call BiPAP or assisted breathing device. These patients have a higher risk of thrombotic complications. We're seeing these in veins as well as arteries. So causing heart attacks, causing strokes, causing DVTs.
Dr. Eileen de Grandis:
The DVT rates in a number of papers after COVID-19 was discovered, demonstrated anywhere between a 20 to 40% risk of DVT or incidents of DVT on the critically ill, ICU population.
Dr. Eileen de Grandis:
From a less critically ill or the ambulatory DVT rates, there is a propensity to be higher risk for DVTs or higher incidents of DVT, simply because when you have COVID, you feel terrible and you don't want to ambulate. They're largely more sedentary. The you're not being able to breathe makes you feel terrible and you don't want to move.
Dr. Jonathan Fialkow:
So being stationary, less movement, less contraction of the legs increases your risk of blood clotting. And COVID puts you in that situation. So again, another negative consequence of COVID that we're dealing with.
Dr. Jonathan Fialkow:
And that's a great segway back to Libby regarding blood clots, deep venous thrombosis, major component of venous disease. What are the more common signs and symptoms of a deep venous thrombosis? When should someone be concerned to say, "I need to get this checked out?"
Dr. Libby Watch:
Yeah. So, circumferential swelling and pain, any part of the leg is absolutely [inaudible 00:08:15] deep venous thrombosis.
Dr. Jonathan Fialkow:
If I can interrupt, is it usually one leg or can it happen in both legs at the same time?
Dr. Libby Watch:
It could happen in both legs. It's more common to be a one leg at a time. Both legs, it's usually a problem, even higher up in the pelvis with a bigger vein called the inferior vena cava can cause a problem with both legs at the same time. But it's more common just to have it in one leg.
Dr. Libby Watch:
And I do want to add in addition to what was mentioned, the risk factors for deep vein thrombosis are birth control pills and malignancy as well. So patients who have been sick with COVID or are taking birth control pills or have malignancies should definitely be on the lookout for these issues. Because they can be easily treated most of the time. So we want to make sure they're aware of that.
Dr. Libby Watch:
But again, the circumferential swelling, pain especially in pain with walking immediately upon ambulation, not paying that gets worse with walking for a long time are the things to look for.
Dr. Jonathan Fialkow:
And so what's the concern? If I got a clot in my leg and it's a little swollen, what's the big deal?
Dr. Libby Watch:
So there's various short-term and long-term risks. The most immediate risk is a clot that's not treated can get larger. And then can break off from the leg and travel to the lungs. And we call that a pulmonary embolism. And that's very dangerous, can be fatal. And we have seen a definite increase in pulmonary emboli during this COVID.
Dr. Libby Watch:
The long-term sequella or the long-term complications of having a deep vein thrombosis is the valves in the deep veins can be damaged and patients will have chronic swelling that really doesn't get better. And so patients who have really massive swelling in their legs should be treated with a blood thinner and with some compression on the leg to prevent those long-term consequences of chronic leg swelling after deep vein thrombosis.
Dr. Jonathan Fialkow:
So it's pretty clear that anyone that may have, or certainly has a blood clot in the leg or deep venous thrombosis should seek medical care. No question about it.
Dr. Jonathan Fialkow:
How urgent should that be? Should patients at any time rush to an emergency room or there're symptoms where you maybe call your doctor? What generally... And again, I know it's a tough question, but Eileen, what would you recommend? What would trigger someone to say, "I got to go get this taken care of right now," or alternative methods?
Dr. Eileen de Grandis:
I think if patients are having a significant amount of pain, swelling, shortness of breath. Definitely pain and swelling, no shortness of breath, call your doctor and see if they can see you today or go into a walk-in clinic. That's the safest thing to do.
Dr. Eileen de Grandis:
I definitely would not sit on this, especially overnight. Since some of these clots, it can develop further and break off and go to the lungs at any time. If there's shortness of breath or chest pain, that gives grave concern that some clot has already broken off and gone to the lungs and the heart. So you do want to go to the emergency room at that time.
Dr. Eileen de Grandis:
In general, with blood clots, a lot of people think it's a leg cramp and they want to walk it off. If you have a history of being on a slight or having the birth control pills or malignancy or COVID, don't sit on this. I would tell people to go in. It's better to be safe than sorry to get checked.
Dr. Jonathan Fialkow:
Both of you guys alluded to the fact that being stationary for long periods of time could increase the risk of blood clots in legs. Any advice when people have to take a long plane flight, do you tell if anyone asks you, is there anything I should do to avoid a blood clot? Eileen, is there anything you'd tell them in particular?
Dr. Eileen de Grandis:
I'm a big fan of compression stockings, found that can certainly help with providing the veins some external support walking around those lines. I don't know if they let you do that anymore. If that seatbelt sign goes off and you want to start your legs, walk to the bathroom, definitely, if it's a long flight. And these things can help.
Dr. Jonathan Fialkow:
So certainly people at high risk, we would really emphasize that being preventative, prophylactic compression stockings with the flights would help, but good advice for anyone that might be having a long flight or even a long drive.
Dr. Jonathan Fialkow:
All right, let's switch gears again from the disease states and whatnot. There are a lot of these vein clinics out in the community. I'm going to ask both of you about this, but Libby, can you start by what would be the difference regarding what you guys are doing and at a very high end vascular medicine specialists, vein specialists for people with significant medical conditions? Where do those have a place if any?
Dr. Libby Watch:
I think that everybody is born with a saphenous vein, which is a superficial vein. And it's not hard to actually treat the problem. It's not a challenging procedure to perform. It's really important to know when to perform a major. So understanding the disease process and making sure I think that the biggest thing that I do differently from somebody who's treating veins for cosmetic reasons is I make sure that there's no other underlying problem. I'm going to check your deep and your superficial veins.
Dr. Libby Watch:
And I talk to you in real time about the risks and benefits of taking away the saphenous vein. If it's not actually causing a problem, treating the superficial veins if it's not really causing the problem. And I would say that's the big difference between seeing a bonafide vascular specialist who can be a vascular surgeon, a vascular medicine specialist. And that's what sets us apart. I think from the cosmetic vein centers.
Dr. Libby Watch:
Having said that, I do understand the importance of cosmesis and people not liking how their veins look. And so we do that as well, but making sure that we're not missing some underlying problem is probably the most important thing that we can do as vascular specialists.
Dr. Jonathan Fialkow:
I appreciate that. Eileen, I'll give you a chance to comment but specifically towards, it's not that people who may have a cosmetic issue, which triggers an evaluation, but a broader evaluation to make sure it's not due to some underlying medical condition as well as you can handle the cosmetic situation as well. So maybe I'll just ask you to comment on that further, Eileen.
Dr. Eileen de Grandis:
I agree with everything Dr. Watch said. The things you [inaudible 00:14:28] do is veins are a part of the entire vascular circuit. And there is a good proportion of people with concomitant arterial disease as well. And I think that's what separates the vascular surgeons and vascular specialists from the cosmetic centers.
Dr. Eileen de Grandis:
About 20 to 25% of the patients, at least in my practice who come to me with these vein diseases have arterial disease. And they're treated in a very different manner. And if you miss one and treat the other. It is an issue [inaudible 00:14:57] patients as service. And what I have seen from a lot of cosmetic centers is they'll address only the veins. And the patients won't feel better. And so they often neglect to ask the important question, what else is really going on?
Dr. Eileen de Grandis:
So there's a lot of cardiac issues that cause leg swelling, which is not just the veins. If you don't address that and you just treat the veins, their issues, the cardiologist don't really like it and if we take the saphenous vein and they're going to need that later for a heart bypass, because the heart's the real issue, what's causes the leg discomfort, not really the legs.
Dr. Eileen de Grandis:
So to reinforce Dr. Watch, you really have to look at all of the issues that cause the vein symptoms or leg symptoms.
Dr. Jonathan Fialkow:
So it emphasizes what both of you bring from an expertise, but from an approach to patient, more holistic, more generally about the patient, not just about the vein, so to speak. And using all the resources available in the Baptist Health Systems to provide that care, which is again, well-established in your comments.
Dr. Jonathan Fialkow:
A couple other quick things. Eileen, what's pelvic congestion syndrome?
Dr. Eileen de Grandis:
So pelvic congestion syndrome is for a lack of a better word, varicosities in the pelvis. So you can have these big varicose, lumpy veins in the legs. You can actually develop them. They're over overexcited growth of veins in the pelvic system around the ovarian system. Mostly commonly seen in women. Men can have this overgrowth of the veins in the pelvis as well from tumors or blockages of the full veins in the pelvis.
Dr. Eileen de Grandis:
It causes feelings of fullness in women. It can cause pain and cramping during menses. Women often get it post-birth or after pregnancy. And it can cause a lot of debility. Imagine having cramps in your pelvis every month that are so debilitating, you can't get out of bed. Or this feeling of fullness that affects your bowel function, that and bloating where you can't wear clothes. They're all related to a complex venous overgrowth in the abdomen and pelvis that can be treated.
Dr. Jonathan Fialkow:
Is it a particular body habitus? Is it more age-related, is it more related to being overweight or it can happen at any age and body type?
Dr. Eileen de Grandis:
It can happen at any age and any body type. I do see these mostly postpartum women, but it's not necessarily. So I also see these patients who've had tumors resected from their pelvis. So I do see this occasionally and that as well.
Dr. Jonathan Fialkow:
And how is it approached? What can you do with these people?
Dr. Eileen de Grandis:
So we do a full diagnostics review. So Dr. Watch could do this as well. We do ultrasounds of the legs. We look at the [inaudible 00:17:54] of the veins. We do ultrasound of the pelvis. And sometimes advanced imaging like CT scans or MRVs of the venous systems. And we can take a look at just these pictures to see whether or not there is an overgrowth and an extra abundant vein that shouldn't be there.
Dr. Eileen de Grandis:
From there, we can do more advanced imaging, invasive imaging that can also be a treatment modality. For us, what we call a venogram.
Dr. Jonathan Fialkow:
Libby, do you find most patients self-refer with that potential evaluation? Or are they referred by other doctors who might recognize the patient might have it?
Dr. Libby Watch:
I think it's a mixture of both. But I would say the majority of my patients who come in with what we call varicose vein complaints are self-referred. They usually try to do their research and see who they want to go see for this. And that I think they're educated and they have a problem.
Dr. Libby Watch:
And a lot of the times they want to understand probably the most important thing that what they have is not life-threatening. And they're not at risk of losing their leg. So I do find that self-referring patients who have done their reading will come on with a lot of information.
Dr. Jonathan Fialkow:
Good, good, good, which is what an informed patient is. It's certainly desirable.
Dr. Jonathan Fialkow:
Any final comments you guys have? You've given us great information, great context, really appreciate you sharing your expertise with us. Eileen, any final comments you want to make to the listeners?
Dr. Eileen de Grandis:
I think it's really important when people approach their veins just to get as much information as possible about the procedures that you can and should undergo. Definitely correlate to see is it worth having, if you're having a lot of symptoms, should you see a more advanced vascular specialist versus going to a cosmetic center?
Dr. Eileen de Grandis:
I think getting opinions from your primary care physicians as well. And even your OBs or an orthopedic specialist is a good idea, as opposed to just straight jumping to a vein center.
Dr. Jonathan Fialkow:
Libby, anything to add?
Dr. Libby Watch:
I'll just put in a plug for our oldest treatment for vein problems, which is compression stockings.
Dr. Jonathan Fialkow:
Yeah, yeah, yeah. Good.
Dr. Libby Watch:
Remind people that you can get fitted for compression stockings. And you can wear them on long driving trips, on flights. They will make your legs A-class, they're good for putting on after you exercise. And it's what I recommend, I think all good vascular surgeons, is what we recommend to our patients who have superficial vein problems and discomfort from that.
Dr. Jonathan Fialkow:
Great. Great short and long-term benefits of doing such. And again, I think to our listeners, pay attention to your veins. Take care of your veins. Let's not neglect this important part of our body in our cardiovascular system. Thanks again, guys. I really appreciate it. To our listeners, if you have any comments, thoughts, or ideas for future topics for this podcast, please email us at baptisthealthtalk@baptisthealth.net. That's baptisthealthtalk@baptisthealth.net. Thanks for listening. And until next time, stay safe.
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