Inovia Vein Specialty Centers, now part of Center for Vein Restoration

At our specialty vein centers in Oregon, varicose veins are one of the most frequently treated issues we address for our patients. Varicose veins are swollen bulging veins under the surface of the skin that can be dark purple or blue in color. Although varicose veins can occur anywhere in the legs, they most often occur in the calves and behind the knees. Varicose veins develop on legs due to long standing venous insufficiency. Venous insufficiency leads to venous stasis, or pooling of blood in the lower legs, which can stretch out the veins leading to pain, swelling, and ultimately skin problems such as stasis dermatitis or venous stasis ulcers. Venous insufficiency simply means some of the leg veins are not working efficiently enough. The function of veins is to bring blood back to the heart. Because the veins of the legs work against gravity, they contain one-way valves to prevent the blood from flowing backward as it travels back to the heart. If the one-way valve becomes weak, some of the blood can leak back down the vein, causing the veins to become pressurized in the veins. This causes what is known as venous insufficiency, vein reflux, or venous reflux. With venous reflux, veins start to bulge out on the legs. There is both a deep and superficial venous system in the legs. Venous insufficiency can be superficial, deep, or a combination of both. Varicose Veins Causes Venous reflux is a condition that develops when the valves that usually keep blood flowing out of your legs become damaged or diseased. When this occurs in the superficial veins, the congestion will cause the veins to abnormally enlarge, which in turn leads to either varicose veins and/or spider veins. When this happens over the long term, complications such as thrombophlebitis, deep vein thrombosis, chronic venous stasis changes in the skin and venous stasis ulcers can occur. The cause can be primary, for example from genetic influences, or secondary, due to damage to the vein valves from prior blood clots (Deep venous thrombosis) or phlebitis (superficial vein inflammation). Varicose Veins Symptoms While many varicose veins are asymptomatic, patients with bulging veins often complain that their legs feel heavy, or ache, and often their legs throb or feel more uncomfortable as the day goes on. Typically, these symptoms are worse at the end of the day and with prolonged standing. It is thought that these symptoms are due to a stretching of the veins as the blood abnormally pools in the leg vessels when the patient is standing. With time the skin by the ankle can become red, purple or brown, and inflamed whereby the patients complain of itching or burning of the skin. In some cases the inflammation is so profound over time the skin breaks down, leading to a venous stasis ulcer. Expert Diagnostics For many patients, an office evaluation by a vein specialist is all that is needed to determine the extent of the varicose and spider veins. At our Oregon vein centers in NW Portland, Tigard and Bend, this is the first step in developing an initial treatment plan. In other patients, however, there is evidence that some of the larger superficial veins might be incompetent and contribute to the visible varicose veins. When this is suspected, a detailed examination using a sophisticated Duplex Doppler ultrasound scanner is done to ‘map’ the points of venous insufficiency and characterize the size and location of vessels. This non-invasive test, performed in the office setting, allows the treating physician to better characterize the extent of the problem and develop a treatment plan that will minimize the chance of recurrence and maximize the potential to obtain the best results. Ultrasound is also used after treatments to monitor progress, rule out complications, and assure optimal results. All this is performed on site in our vascular laboratory. Treatment Options For Varicose Veins There are a number of treatment options for patients with varicose veins. The most important first step is for the patient and care provider to consider the goals of the treatment. In many cases the goals are medical, when patients are seeking to reduce the symptoms of ache, swelling, heaviness, tiredness, night time cramping or skin issues such as stasis dermatitis or venous ulceration. In other cases the goal is cosmetic, when the patient is bothered by the appearance of of veins but not by these venous symptoms.

What is a DVT? DVT, or deep vein thrombosis, is a blood clot in the large veins of the legs (most commonly) or less commonly the arms. The general function of the cardiovascular system (heart, lungs, and blood vessels) is to deliver oxygen and nutrients to the cells of the body. The heart pumps the blood through arteries to supply oxygen and other nutrients to the tissues throughout the body. Veins are needed to carry deoxygenated blood back to the heart and lungs. The blood from the legs must make its way against gravity back to the heart. This is done by a series of veins that have valves in them to prevent back flow of blood. As the leg muscles move, the blood is squeezed up the veins, and the valves keep the blood from flowing back down with gravity. The veins start as a series of small parallel passages that join to form progressively larger veins, which in turn join larger and larger veins until they meet the Inferior Vena Cava, which is the largest vein in the body. The inferior vena cava is connected to and drains to the heart, where the blood is again pumped through the lungs and then is sent back out to the arteries. The venous system to the lower part of the body can be viewed as an upside down tree, with smaller branches joining larger and larger branches until they join the inferior vena cava, which is like the tree trunk. The veins next to the skin are called superficial veins, and the veins deep to the muscle are called deep veins. The deep veins carry the majority of blood out of the leg. A clot in the deep veins can be a serious medical condition. Another way to look it this is to think of the veins in the legs like a highway system. The deep veins are the main south to north interstate system heading to main destination (the heart). This interstate highway (deep vein) has more traffic (volume) and travels at a higher speed (pressure). All the state highways and side roads that feed into the interstate are like the superficial veins. These have less volume and lower pressure. Eventually all roads lead back to the heart. DVT and blood clot On a highway, what happens when there is an accident on the main interstate highway going north? Of course this can lead to a massive traffic jam. In the veins, this blockage can result in a pressure build up, and ultimately re routing of flow around the blockage. When this happens in the veins due to a clot in the deep veins, it is called a deep vein thrombosis, or DVT. What causes DVT? There are a number of reasons why clots can form in the deep veins. Long ago it was recognized that clots form in veins for three basic reasons which are (1) damage to the vein wall; (2) lack of blood movement (also called stasis), and; (3) a pre-disposition to form clot called hypercoagulibity. Damage to the vein wall Damage to the veins can happen in a number of settings, including recent surgeries, accidents and falls or other types of trauma. Injury to the vein is a very common cause of DVT. Lack of blood movement (stasis) Stasis occurs when a person is immobilized for any number of reasons, including sitting in an airplane or car for long periods of time without movement, or having your leg in a cast. A pre-disposition to form clot called hypercoagulibity Finally, and perhaps the least well understood, is hypercoagulability. There are certain people who for one reason or another simply have a predisposition to form blood clots. Sometimes this is due to a very subtle genetic defect where there body does not have the right balance of coagulation factors that either create or more likely, break down clot once it occurs.1 In addition to genetic factors, some patients can develop an acquired propensity to form clot. This is very common in some types of cancer, as well as after surgery or trauma. dvt blood clot Due to a combination of these factors, DVTs are common after certain types of surgery, especially any operation in the abdominal, pelvis, and the legs. This is especially true after orthopedic surgery, where the DVT rate can be as high as 40%. For example, after many types of surgery, there is a variable combination of injury (from the surgery itself), stasis (from being immobilized during and after surgery) and hypercoaguabity (due to an acquired imbalance of natural coagulation factors) that make the risk of a DVT a not uncommon event after certain operations. For this reason, there are a number of efforts undertaken to try to limit DVTs after surgery. This effort, called DVT prophylaxis, includes the use of low dose injectable blood thinners, intermittent pneumatic compression devices (leg squeezers), elastic compression stockings and early ambulation, all of which are designed to reduce the chance of a DVT at the time of surgery. Unfortunately, although the risk can be reduced, at this time it is impossible to reduce the risk of a DVT to zero.

Leg swelling, also called edema, is a common complaint among patients with vein disorders of the legs. Edema can be due to a variety of causes. Leg swelling can occur when leg vein valves become “leaky” and allow fluid to pool in the lower legs, filtering fluid into nearby tissues by the ankles and lower legs. The extra fluid accumulates, causing the tissue to swell. What Causes Leg Swelling? There are a variety of causes of leg swelling. One hint of the cause can be considered when considering if the swelling is one sided (unilateral) or both (bilateral). Also, it can help to understand if the swelling is new (acute) or has been around for a while (chronic). Finally, it helps to understand if it gets better at night, or is always the same. A vein specialist can take a history and do physical exam and learn a lot about the possible causes of swelling. Is Leg Swelling a Serious Problem? Leg swelling can be serious. Because some causes of leg swelling are related to other serious health problems, it is important to know which signs to look out for. We recommend that you seek an immediate medical evaluation if there is: A rapid onset of swelling in one or both legs (less than 72 hours), which can indicate deep vein thrombosis. Rapid swelling in both legs can also suggest an issue with the kidneys, heart, liver, or thyroid. A large amount of swelling in one or both legs, which can indicate a blood clot or tumor. Redness, warmth, leg pain, or skin ulceration, when the swollen leg should be checked for blood clots and infection.. Extreme pain in a swollen leg that looks pale or feels numb, as the swelling may be cutting off circulation to the leg. Swelling combined with other concerning symptoms, like dizziness, weakness, shortness of breath, and/or chest pain, as these may be a sign of pulmonary embolism or a serious heart, kidney, liver, or thyroid condition. Diagnosis & Treatment for Leg Swelling Our area of expertise is the medical evaluation, often with diagnostic ultrasound of the veins, and then discussions with our vein experts to discuss options to treat the poorly functioning veins when indicated. Generally, a commonly prescribed approach for edema treatment is movement, compression, and elevation. Other approaches include manual lymphatic drainage and decongestion therapy from certified lymphatic massage specialist and pneumatic compression pumps for some patients on a long-term basis. Minimally invasive office-based vein treatments can help reduce swelling over the long term in some patients. Frequently Asked Questions Are there any home remedies for edema? How do you reduce swelling in the feet? What do I do if my edema is caused by heart or kidney failture? Why is only my left leg swelling? What causes swollen legs from the knee down? What is the difference between a pitting vs a non pitting edema? Which doctor should I consult for leg swelling?

When the valves in our leg veins become weak, either from heredity or injury, blood can pool in the lower legs under pressure. This leads not only to swelling, but also to skin damage. With time the skin can break open, known as a venous stasis ulcer. Also known as a venous leg ulcer, these are chronic wounds on the lower leg – typically around the ankle. One characteristic is that they can be very slow to heal or not heal at all without treatment. Leg ulcers sometimes spontaneously open up, or develop after a minor injury. This is a progressive problem and there are causes & conditions that can lead to venous ulcers. The primary underlying cause is chronic venous insufficiency. If the underlying cause of the ulcer is not treated, venous ulcers will fail to heal or repetitively return. venous stasis ulcer diagram Symptoms of Venous Ulcers Patients who experience venous ulcers often have long-standing venous insufficiency and experience high venous blood pressure in the lower legs for an extended period of time. This can occur even when varicose veins are not visible on the surface of the leg. Venous leg ulcers are often associated with: Swollen ankles Skin discoloration around the ulcer Hardened skin around the ulcer Heaviness in the legs Aching in the legs Varicose eczema Varicose veins Signs of an Ulcer Infection Because they are open wounds, a venous leg ulcer can be prone to bacterial infection. An ulcer may be infected if patients experience: Pain that gets worse Discharge that can be green or foul-smelling Redness and swelling around the ulcer Fever if there is surrounding infection Many venous ulcers look infected, even though most are not. Most are colonized with bacteria but that does not mean there is an invasive infection in the tissue around them. However, for those that do become infected, this infection can be life-threatening and may require hospitalization and/or long-term IV antibiotics. The surrounding infection is known as cellulitis or lymphangitis. This is why it’s important for all venous ulcers to be evaluated as early as possible by a vein or vascular specialist since early treatment can reduce the risk of infection leading to hospitalization. venous leg ulcer CALL 1-800-VEIN-DOC TO SCHEDULE A CONSULTATION OR USE OUR Frustrations Around Non-Healing Leg Wounds There are other types of non-healing leg wounds, but venous ulcers are a highly common cause. When a patient visits one of our offices with a venous stasis ulcer, they are often frustrated with a wound that has been on going and has not yet healed. Some have had the venous ulcer for many years, as their small wound has opened up, become larger, and failed to heal. We often hear: Patients have seen multiple doctors and clinics, without any luck in figuring out what is wrong. Patients may not have been told by other providers that their non-healing leg wound could, in fact, be due to venous insufficiency. Patients often think they had a bug bite, or assume the wound is entirely due to an infection. At Inovia Vein Specialty Centers, we specialize in Venous Stasis Ulcer Treatment and we have the diagnostic tools and experience needed to help make an accurate diagnosis and develop a definitive short-term and long-term treatment plan. We can both diagnose and treat these problems in our office without having to send patients out for more tests. Frequently Asked Questions Venous Leg Ulcers What is the fastest way to heal a venous leg ulcer? What should I do if a venous stasis ulcer does not heal after adequate treatment? I think I have a venous ulcer. How soon can I be seen by a vein specialist? Do I need to see a vein specialist for my venous leg ulcer? Is there a difference between a varicose ulcer, vascular ulcer, venous leg ulcer, and venous stasis ulcer? How can I treat a leg ulcer at home? Do wounds heal faster covered or uncovered? Why is my leg ulcer not healing? What do venous leg ulcers look like when they start? Can venous stasis ulcers be prevented?

Spider vein treatments are a frequent reason patients seek consultation in our clinic. Spider veins are small blue or red veins at the skin’s surface. They are also known as telangiectasias. They can range from less than 1 mm to 4 mm in size. Spider veins are often fed by other veins, known as reticular veins. These are also known as “thread vein.” Sometimes patients have only a few spider or reticular veins in one focal area. In other cases, they can have many, on both legs, both front and back. It is suspected that there is often a strong genetic component to the development of spider veins. Most do not go away without treatment. The exception is that in some cases where patient develop a lot of spider veins during pregnancy, they can resolve after the baby is delivered. Factors that contribute to spider veins include hormone changes, injury, sun exposure, pregnancy, injury and aging. In many families, there appears to be a genetic component. Patients seeking treatment in this setting are usually doing so for cosmetic appearance reasons because they do not like how they look. In that case, treatment can help them fade and the cosmetic appearance can improve. This is the common reason patients seek treatment for spider veins. Spider Vein causes graphic When there is ache, throbbing from the vein or other pain, this can suggest a medical rationale for seeking treatment. Symptoms can suggest there is underlying venous insufficiency of the saphenous veins or other veins under the skin. This is especially the case when there are a lot of veins around the ankle and foot, known as corona phlebectasia. Occasionally, some patients can experience bleeding spider veins. When this occurs in the legs, especially around the ankle, the bleeding can be quite severe due to the high pressure from the underlying chronic venous insufficiency. In these cases, patients are usually seeking treatment for medical reasons. In some cases, the concerns are both medical and cosmetic. For example, some pregnant patients see a lot of spider veins develop during pregnancy. Many will explain they are both concerned from a medical perspective, but also cosmetic. If you are not sure which category you fit into, a simple evaluation by a vein specialist can usually help you determine the best treatment path. Developing a Spider Vein Treatment Plan Once a patient seeks treatment, the most important thing is to develop an adequate treatment plan with the care provider. Patients seeking treatment should see a vein specialist who is experienced not only in techniques such as sclerotherapy, but also in diagnosing and treating the entire spectrum of venous disorders so they can help you choose the optimal treatment plan. This usually starts with a consultation where the care provider examines your legs. At this time they also take a detailed medical history, especially focusing on your venous history. They will be particularly interested in your family history, or if you have leg swelling, or a history of blood clots (deep venous thrombosis or superficial venous thrombosis). When it is simply spider veins and the primary reason to treat them is cosmetic, one can often proceed without a venous ultrasound directly to sclerotherapy treatment sessions. When significant venous insufficiency is suspected, they will often order a lower extremity venous ultrasound. This helps map out the normal and varicose veins. When one has indications to evaluate the veins with a venous ultrasound and significant venous insufficiency is found in the veins below the skin (like the greater saphenous vein and its branches), then treatment plans may be more comprehensive to include approaches like radiofrequency ablation of the greater saphenous vein (Closurefast), endovenous laser therapy, Venaseal or Varithena polidocanol endovenous microfoam. Depending on the indications and findings, these treatments are covered by most insurance companies as being medically necessary. It's Important to Get Appropriate and Complete Treatment Appropriate treatment varies from patient to patient, but requires estimating the total number of treatment sessions needed, and making sure to treat the source feeder veins during these sessions. When treating spider veins, it is important to sort out with the provider how many sessions will be needed. If it is just one focal area, then one session may be sufficient. But when it is both legs, above and below the knees, and the front, back, and sides of the legs, it is not uncommon for several treatment sessions to be required to achieve the best results.

Compression therapy uses controlled, gentle pressure to improve blood flow back to the heart and reduce swelling, which can lead to greater comfort for patients. Compression therapy, such as the use of graded compression stockings, is often prescribed to: Manage varicose veins Manage lymphedema and swelling in the legs Assist with venous leg ulcer & wound healing Prevent blood clots after surgery Address pregnancy-related leg & vein symptoms When used preventatively, compression therapy can help prevent: Worsening of venous insufficiency symptoms Leg swelling in those who stand or sit for long periods of time Development of venous thromboembolism due to immobility Recurrence of venous leg ulcers Types of compression Compression stockings are the most common method of compression therapy. Most compression stockings are graduated, meaning they are tighter around the foot and ankle than at the knee or thigh. This is critical in most cases, since most leg swelling occurs by the ankle. Compression stockings can be knee high, thigh high, or cover the pelvis depending on need. Open toe options are available as well. Compression wraps or bandages, like Unna Boots, are also used when indicated. Mechanical compression devices, like wearable compression boots or compressed air devices, are available for home or clinic use as well. compression socks Levels of Compression Some lighter use compression socks are available over the counter at drugstores or online. These are not considered to be medical grade can be purchased without a prescription. Higher degrees of compression often require a prescription. Light Support Compression (15–20 mm Hg) Mild foot and lower leg swelling Mild varicosities with minimal swelling Preventative support for work or travel Standing, sitting or traveling for extended periods of time Post surgical “anti-embolic” or TED hose provided by hospitals at the time of surgery Non ambulatory patients who are bed ridden Moderate Compression (20–30 mm Hg, Class I) Chronic leg fatigue and heaviness Ankle, foot and leg swelling Mild varicosities Preventative and treatment of swelling during pregnancy Superficial thrombophlebitis Post-vein treatment including sclerotherapy Heavy Compression (30–40 mm Hg, Class II) Moderate varicosities with advanced swelling Chronic Lymphatic edema Prevention and treatment of venous ulcers CALL 1-800-VEIN-DOC TO SCHEDULE A CONSULTATION OR USE OUR How Does Compression Therapy Work? Compression therapy helps to improve blood circulation in the lower legs, ankles and feet by applying the correct amount of pressure on a consistent basis. The goal is to reduce the amount of venous fluid filtered out from venous insufficiency, to help return the filtered lymphatic fluid back to the heart. Here’s how compression works for the different conditions it’s used for: For chronic venous insufficiency, including varicose veins: Compression can help reduce the amount of venous blood pooling in the lower legs, thus reducing the amount of fluid that filters into the tissue as edema. This helps push blood to the deeper veins, where the leg muscles can pump the blood back toward the heart. For deep vein thrombosis (DVT): With a DVT, blood flow to the heart can be obstructed by blood clotting in the veins. Compression therapy can help prevent blood from pooling and clotting, especially when coupled with an anticoagulant. However, it’s important to speak with your healthcare provider before starting compression therapy for DVT. For swelling (edema): Compression therapy applies pressure circumferentially to the lower leg to help move fluid back to lymphatics, where it can be returned to the circulation. For leg ulcers: Wounds do not heal well in the presence of high vein pressures from venous insufficiency and in the setting of swelling. Compression therapy can aid recovery from leg ulcers and wounds by encouraging blood flow. Frequently Asked Questions Compression Therapy Can I wear athletic recovery stockings instead of graded compression stockings? Do I ever need to change the compression I use? How should I take care of my compression stockings? What is the difference between graduated and uniform compression stockings? What kind of compression socks do I need? Where can I buy compression socks locally? Should I wear compression hose at night? Can wearing compression socks be harmful? What do compression socks do? Get Started with Compression The optimal degree of compression needed can vary depending on the patient & medical condition being treated, the type of compression being applied, and the material used in the compression garment.