Episode 3 – Vein Disease Part 2: Symptoms of Vein Disease

The following program discusses medical information that is general in nature and not intended to serve as medical advice, to treat any medical condition in either yourself or others, please consult your own physician. For any medical issues you may be experiencing.

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Welcome to episode #3 of nice living with Dr. Kamran. I’m your co-host, Aimee Bowen, and while this podcast is dedicated to shedding light on many health and Wellness related topics our show’s, namesake and host Dr. Kamran Goudarzi, of Scarless Vein Care is one of the top experts in the nation when it comes to the treatment of varicose veins and spider veins. In these initial episodes, we’re leveraging his expertise and digging a bit deeper into various aspects of the world of vein disease. In part one of our series on vein disease, Dr. Kamran , gives an overview of the vascular systems form and function and discusses how risk factors such as genetics, lifestyle, maybe even your profession can influence your chance of developing varicose veins, spider veins, and vein disease. So be sure to give that episode a  listen if you missed it. Today in Part 2, we’re taking a closer look at the symptoms of vein disease and when it could be time to seek help from a physician, so let’s dive right in. Welcome Dr. Kamran.

 

Thanks Aimee.

 

So you’ve specialized in the treatment of venous disease for years and as we’ve talked about before, we’re really finding out that more people are affected by this condition than many realize.

 

Well, venous insufficiency I read somewhere awhile back, and I think most people agree, is one of the most under diagnosed or undiagnosed condition, seems to be in the world. In that, again, most people think it is trivial and they don’t necessarily pay attention to it, I started that way. You know, I was, all the years of training I’ve had, I was always told venous disease is more cosmetic and if they bleed or cause any issues  then of course you would treat it, but otherwise you can leave it alone. Now, having said that, it was because there wasn’t much we could do for veins. The only thing we could do is just do vein stripping, which never cured anything. Now that we have become much better at treating venous insufficiency for identifying all the bad veins and destroy them and leave the good veins behind, we find out that patients do get better, a lot of their symptoms get better. So, if the symptoms get better, then they must have been related to the veins.

 

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So outside of maybe having varicose veins or spider veins, how would someone know if they have an issue? You know, from your experience and knowledge of this condition, what are some of those symptoms someone might be experiencing if they have vein disease or venous insufficiency?

 

Symptoms are very commonly missed. The number one to me is cramps or Charlie Horses people call it. Patients say that they get cramps or Charlie Horse in the legs, sometimes in the foot, usually in the calf at night. As the disease progresses, it gets more and more severe, to the point that you have to get up and walk. I mean, that’s classic when they have to get up and walk. I know it’s got to be venous disease because the minute you walk the calf muscles pump blood out and makes him feel better, so it’s not because of dehydration. I mean the hydrogen can cause it, but you have to be severely dehydrated to get it. It is not your magnesium or potassium. They can cause it, but if you have bad veins, and getting cramps, I would say the most likely thing is probably coming from your veins. So, cramps are right on top of the list. Swelling happens quite early on. I have venous insufficiency, I remember the first time, I got up in the Charlotte Airport, I’d come from, I think it was California or something and my legs were so sore and then I thought my God I hope I don’t have any clots in my legs and then as soon as I got to the office they did an ultrasound found that I had pretty bad veins. So swelling around the ankles, particularly if you’re on a plane. We talked about the negative pressure in airplanes and some of these patients say, “I don’t have any swelling.” Then, I asked him, “if you’ve been on a long flight what happens?” “Oh yeah, my ankle swells up.” That suggests you probably have venous insufficiency. Some people don’t even see the swelling because it’s so gradual.

 

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You know if you’re wearing socks or stockings and you find it puts a big mark on it, that’s probably what it is. If your feet, you find your feet are growing, it’s not your feet are growing, you’re getting chronic swelling in the leg and it gets to the point you go from a size, they say 10 to size 12 or 13. You know, your feet don’t grow anymore after you’re like, you know 17, 18 or even younger. So if you’re wearing a large, much larger shoe or larger boot now, the chances are you got swelling and especially if you’re relatively young, 40, 50 years old, it’s not because of heart failure, kidney failure, most likely is related to your veins. Because as you said, Aimee, it is a very common condition. So swelling would definitely be one of them. A restless leg, we used to think that restless leg was all these condition that there wasn’t much you could do. I have had patients coming up to 2 or 3 medications. Medications for life, about, people on usually. An anti seizure medicine just for the, you know, restlessness in the legs and…

 

Treated almost as a neurological condition.

 

Exactly. Absolutely. And then once we treat their venous disease, not because I was thinking about treating the restless leg, but treating venous disease, they come and say, “Doc, you know my restless leg is better” and a lot of them actually literally came out of the medication. So, I’ve definitely seen that happen. Some people don’t fully understand what restless leg is. I think, what patients at least tell me is that either husband or wife says, “you know my wife or husband is running the marathon every night.” They’re, you know, wiggling all the time, moving all the time, can’t keep it still. I don’t know why that is. Maybe they get cramps and they don’t know it, and they are wiggling to get it going. But, restless leg is common.

 

So, I think that the major ones are cramps, swelling, the more vague one is achy, heavy, tired feeling at the end of the day. And remember Aimee, everybody gets heavy, achy, tired, feeling at the end of the day and they blame it on

age.

 

(6:00) They blame it on arthritis. They blame it on the floor. They say, “ah it’s a concrete floor.” Well, you know, if it was a gold floor or it was any other floor it would still cause it. So usually that is caused by venous insufficiency,so…

 

What about visual signs? Are there things a patient might notice or that maybe you look for in particular when making a diagnosis?

 

I’m really glad you asked me that because again, having treated venous disease for so many years, probably 30 years now, if not longer, and the past 17 years, I’ve spent so much time seeing these patients, it’s getting to a point where as soon as they show me their legs you can pretty much tell if they have venous disease or not, because the signs are quite obvious usually. So if you got a leg again, the blood is not getting out of it, so what are you expect to see? You expect to see congestion there almost bluish discoloration. And there’s swelling of course, and then because the red blood cells were sitting in the veins in the leg and just cannot get back to the heart because of the amount of pressure, which is, in one study I read was 300 millimeters of mercury, which is almost three times as much that you would get from an artery. When there’s that much pressure exerted on a vein, some of the red cells kind of ooze out of the vein around the ankle. Remember, the pressure is the highest at the ankle because that’s the lowest point. And of course there are some feeders there, we call them perforators, but there is, there’s a lot of pressure there.

 

So when these vein, these red blood cells get out of the vein, it’s like a fish jumping out of other water on land, he can’t survive. You know you’re going to die, so the red cells die. And when the red cells die, they break down. And what gives the color of the red blood cells is iron, so you get a lot of iron deposit in your legs. So these patients usually have what we call hyperpigmentation. Hyper means, you know, more pigment.

 

So you look at the leg it’s almost a dusky dark discoloration and some of the people (8:00) with very severe venous insufficiency, the skin almost looks black. It approaches black and because of the amount of congestion for long periods of time having gone untreated, you find that the texture of the skin changes. So the skin is not as pliable. It is almost like a leather feeling. In fact, the term for that is Lipodermatosclerosis, which LIPO means fat, the DERMA means the skin, and the SCLEROSIS means the scarring. In other words, you get the scarring of the skin and then the lying fat. So in some of these patients they look at their leg and very severe case of Lipodermatosclerosis you can almost looks like an upside down champagne bottle, because the ankles are really pulled in and the top part is dilated. And that is actually a very unique situation in that we think it’s related to inflammation. Inflammation is like an infection minus the bacteria. For some unknown reason, the body doesn’t like it, that all these red cells are coming out and sitting in the tissue and it tries to wall it off, so you get a lot of scar tissue. So you get his leathery feeling to the skin, the texture of skin changes. And then as the disease progresses you can actually get some itching and rash and like a scaly skin almost like eczema, but it’s always on the, pretty much always, not always, on the inside of the angle, not on the outside. So when you get that you get this, some people don’t even see it, they just get a you know, they have to scratch their legs because it itches or it gets a little red. So they think it’s inflammation, so you know, I had this patient who actually thought it was he had walked with his dog into Poison Ivy. But that was two years ago and it still kept on taking steroids and said that clears it up and that had nothing to do with it, the rash and the itching was related to vein. So it’s called Venus, Venus, meaning VEIN, related venous dermatitis, which means inflammation of the skin secondary to veins. And of course the next thing is ulceration. Usually they’ll get ulcers next, either because you scratch it and skin breaks down, or is about

 

(10:00) to turn into an ulcer. So when the skin breaks down to get an ulcer, now you’ve got quite severe disease, and then you have to try to heal the ulcer before you can even take care of the vein. So venous ulcer, because it is also caused by veins, is one of the signs that we look for. Especially on the inside of the leg, that’s probably where they’re coming from, and the funny thing is you treat the vein and it also goes away. One of the papers we published, I think it was 2013 was a lady who had an ulcer on her leg and I treated it and also healed. So I think it was one of the earliest reported cases of Venous Ulceration which was treated just by you know laser and the patient healed up. So Venous Ulceration happens. Other things you look for is you find that, Varicose veins, if you have varicose veins then also you have venous insufficiency just because you see a vein, why is the vein so dilated? If the vein is emptying properly, there is something problem somewhere. So with varicose veins the chances are you have venous insufficiency. And sometimes even if you have spiders, spiders turn into what are called blebs, there almost you know, like a little aneurysm like little balloons, sticking out of your veins and they can rupture. When they rupture they get quite significant bleeding and that again is really the venous insufficiency. There are  patients who look at their legs, they don’t even know their venous insufficiency because I compare it to the tip of the iceberg. Right? The Titanic, there was somebody sitting on top of the Titanic looking for iceberg, and if they didn’t see it, it didn’t exist. They didn’t know there was a lot of, you know, if the iceberg was under the water, so when this patient come and see us, they don’t see many veins. As soon as we put an ultrasound on their leg, it’s like looking under the water. You see, there’s a lot of very large diseased veins which are actually causing the patient symptoms. So, ultrasound for us is like a stethoscope. As soon as we see somebody with something which resembles venous insufficiency, we look with an ultrasound to see if there is indeed any issues underneath, you can see those large diseases dilated veins.

(12:00) I remember reading something about a symptom that involves hair loss which could be welcomed by some folks, but maybe not so much others. Could you explain the connection between this?

 

We are taught in medical school or so when we’re doing our residency program that if  there’s a problem with the arteries, that’s how the blood gets to the leg of course, that they have hair loss, but we never thought they would get hair loss if there was venous disease. In other words, if the blood can get out. Now, we talked about it during the last episode that it is venous congestion that if the traffic is not getting out and then there is poor circulation, so why wouldn’t you have hair loss if you have venous disease? Not many people have thought about it until one of my patients and then more and more patients over the past 18 years they started mentioning that “Doc” you know, “Thanks for taking care of my legs. It feels great, it looks great. But now I have to shave 2 three times a week.” So, I realize it wasn’t a coincidence that is probably related. Then one gets more and more observant and I notice people with venous insufficiency do have something, you have hair loss, so you’re absolutely right, venous insufficiency, if you got hair loss for no real reason it’s quite possible you have venous insufficiency.

 

OK, so clearly there are a lot of indicators that could potentially signal someone has vein disease. Are there times when some of these symptoms could be a little bit more noticeable or bothersome?

 

Absolutely. So if again, if you know job related, if you’re sitting around for a long time, or you know standing in the same position, that really indicates it. Today I actually had a patient that’s a very young, healthy young lady, she’s a police officer. She says, you know they have to sit in the car for long periods of time and their legs just get so achy at the end of the day and she had no idea she had venous insufficiency. Of course it was pretty advanced by the time I saw her so there is this, you know, young lady, very

(14:00) healthy otherwise, you look at their legs again, they look a lot older than she is, which it looks as they the legs look older than than the patient, and that’s usually a sign that there is something going on.

 

OK, Dr. Kamran, so you yourself, you know you’re a tall man, you’re a surgeon, you’re on your feet a lot and in our last episode we learned that these are actually, pretty big risk factors when it comes to developing vein disease, and you mentioned earlier you have venous insufficiency and mentioning some of the symptoms related to swelling after long flights and things like that. So I’m curious. Are there any other symptoms we’ve talked about today that you’ve experienced as well?

 

Roughly, about a month and a half ago I noticed that I was having some pain on the outside of my ankle. And of course being a physician I was thinking about all the worst things. Then I said this probably because I sprained my ankle, so I tried to put this splint on it, didn’t make any difference. And one day I was in the office and I decided to look with the ultrasound just to see if there was any problem with the ligaments that I could see, and lo and behold there was a vein which had actually ruptured through the fascia, the lining, and that was what was was hurting.

 

So the doctor becomes the patient at that time.

 

That’s right, but you learn, you know and now, honestly I wear these compression socks and as long as I have them on, I don’t hurt. So, I was telling my wife, who’s a nurse, and say, “look how often somebody comes in and says my ankle hurts.” The last thing you think about is veins. Oh it’s probably a sprain, it’s probably, I don’t know… Gout, it’s probably, you know you think about everything except veins and in medicine when you go well, you’re not looking for the right things, you’re not gonna find it. When the last thing which crosses your mind is veins. So now I’ve just learned something new. Next time somebody comes in and says my leg hurts, I’ll probably look at an ultrasound and see if there’s a vein there pushing through. In fact, now I’ve actually literally I can see them coming through ’cause it’s a dark spot there, and maybe I just won’t have my leg treated so I find that all the things which happened. What else can go wrong?

 

(16:16) So doctors, yeah, they’re the worst patients I’ll tell you that. And so I really got to get somebody to take care of my veins because that’s really it is getting from bad to worse.

 

Well I suppose then at that point you’ll have the full range of ability to better relate to your patients and what they experience from symptoms to even treatment and all that good stuff. Let’s go back to those compression socks you’re wearing and that temporary relief you’re getting is that something you find most patients experience. And, would you even consider that somewhat of a symptom? You know, the relief aspect, or maybe even a diagnostic tool when it comes to pinpointing the presence of vein disease?

 

It’s very interesting that you asked that because around 2000-2003 main insurance companies were trying to prove whether they should pay for your treatment or not. Their decision was, if you wear the stocking and it doesn’t help, then we allow you to have your veins treated. But if they wear the stocking and it doesn’t help, maybe there’s something else wrong. Because stockings really push those veins in and always expect to see some improvement. So sometimes you have a patient who says, “I’m just fine,” they say, “I don’t see much of a symptom, but I do have this bad varicose veins.” You put them in this stocking they come back and say, “you know, what? I had no idea how my legs were hurting and I didn’t even notice. Now when I wear my stocking at the end of the day, my legs feel like they did first thing in the morning. I have more energy. I can walk more, I can do more. I thought I was getting old and I realize no, it was just my veins.” So call it both diagnostic and therapeutic so it’s diagnostic because when you put their stockings on your leg feels better, it’s probably venous related and it’s therapeutic because it also helps relieve the pain and the discomfort and slows down the

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disease. Then it gets to a point where OK you know I’m tired of wearing this stocking or I want something done then of course you can have it, so definitely, if you wear a stocking and it gets better. So medicine is a we call it a series of probabilities, right? So when you complain like I was  complaining about the ankle pain, it could have been all the way from cancer of the bone to, you know, nerve, tumor, to sprain to anything. But once I put the stocking on, it went away. That immediately rules out a lot of other things. Because If I had arthritis it wouldn’t get better. If it was arterial disease it would make it worse. If it was gout, it wouldn’t help at all. In fact, probably make it worse. The only thing that it would help if you wear this stocking would be venous disease, so it’s really, if in doubt, just get the compression sock and put it on. If you feel better, that’s probably what it is. Just briefly, we’re asking a few other questions, what are the other things you look for? Well, you know, thickening of the skin I’ve had people who thought they had psoriasis, it turned out to be dermatitis, secondary to venous disease? Another lady who thought she had scleroderma, come to find out this is what we call lipedema sclerosis, which is where they get thickening of the skin with vein disease.

 

So there’s a lot of information to digest here and really a lot of potential symptoms to look out for. At what point should someone actually consider seeking treatment? Is it as soon as they notice any potential mild symptoms? Or maybe a combination of symptoms?

 

That’s  a very good question, so we all have different pain thresholds, so obviously some of us don’t even feel the pain until the pains are almost so big they rupture or they bleed or they clot and then  other patients seek help very early on. And of course, if you’re aware of the disease, you probably as soon as you see the sign of it, try to have it taken care of. Right now there is no clear consensus when you should seek help. For example, one study I read in Holland, the majority of people from a very early age when in a teenage years,

 

(20:00) and I believe they have socialized medicine, they seek help. So the question is, do you treat all these patients, everybody? It’s a very common disease. Can you imagine you could bankrupt the health system just by if there’s 30-40% of people suffered with this disease. So when do you treat? And that’s a very good question, and that there’s a lot of factors associated with that. You know, the severity of disease, how bad it is, how much of it is cosmetic, how much of it. So what is the right answer? So all I could tell you is what I would do for my children and for myself.

 

If I see signs that suggest venous insufficiency, I seek help. I’ve never been hurt by too much diagnosis. You know, let somebody check it. Then you know we usually do an ultrasound, there’s no radiation, there’s nothing involved. Most vein centers, most doctors who deal with veins offer free consultation anyway, and you know at least let them look at your leg and see what you’ve got. Now, the degree of disease depends on the experience of the doctor. You know I’ve done, God knows how many, 1000 cases and I’ve been doing it for 18 years, just doing lasers and I finished medical school in 78, so I’ve seen a lot of venous disease in my lifetime. So when I look at it I try to compare to the worst case I had and the best case I had, and I’ve also seen how they progress because you get a feel of it. I compared it the other day to cooking, right? You sometimes you just have to know how much salt to put in or when the color of the, you know,  the dishes is good enough that it is cooked. So experience really does matter in treating venous disease and you’ve got to remove your bias away from it, in that if this patient was me, would I’d need treatment right now or could we just sit back a little bit and see how it progresses. So we know people have varicose veins in their 80s. Then they say, “Oh God, I’ve had this all my life, it really  didn’t

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get that much bigger. Yet you have 28 year old, I had a 28 year old with an ulcer on his leg and his disease was obviously very progressive. So, who gets the treatment? Hard to tell. So what would I do? If you think that you have venous insufficiency with his family history, get yourself checked. I mean it might not even cost you anything, because it’s a free consultation. At the very least, put yourself in the stocking and start doing exercise and weight loss. They say that an ounce of prevention is better than a ton of cure, so at least we put you on the right track. And then of course, the risk of clots which we haven’t talked about. You know, you’ve got venous insufficiency when you have bad veins, your risk of getting clots in those veins and those clots can eventually end up getting into your lungs and potentially kill somebody. So you could even be saving your life by getting it checked.  So get it checked and then ask your doctor and see what their opinion is and even get a second opinion, get a third opinion. Just like buying a car or house or whatever, right? Get everyone’s opinion and then decide you know, is this you know, works well for you. And then of course you know the financial issues, how much time off, where if any, you know, does insurance pay for it? Does it not pay for it? So then other factors come into play. So there is what we call a C classification. This is different degrees of venous disease, so we just have a few spiders is like a C1. When you get a rash on your ankle, it is already about C4 and C5 is when you get an ulcer. If you get an ulcer, you waited too long.

 

If you get a rash you really need to seek help. If you get a cut on your ankle or your leg, is not healing well, or you had a biopsy is not healing well, you really need to have that treated. You have already waited too long. If a vein bleeds, don’t wait till it bleeds again because I guarantee it’s going to bleed again. So get that taken care of. I had a patient who is a Forester and she was also blood thinners and she had horrible veins. She used to wrap her legs up with cloth every time she went in the forest. Now imagine if the vein was cut and she was

(24:00) on blood thinner. She would bleed to death before somebody could find you. So, you know, we treated her semi emergency. So, you know, talk to your physician. Somebody who’s got experience. You know, I think to give you guidance and then even then get a second opinion, third opinion, before you have anything done.

 

And that Dr. Kamran is an excellent point that I’d love to talk with you more about in our next episode. What should patients be looking for when choosing a physician to diagnose and treat vein disease? And then what could treatment and recovery time look like as well?

 

Absolutely, I can’t wait until we get to the next episode when we can talk about this very important topic and common condition in much more detail.

 

This is the nice living with Dr. Kamran podcast. Thank you so much for listening. We invite you to subscribe to the show on your favorite platform. You can find us on Apple and Google podcasts, Spotify, and many others as well. Head to scarlessveincare.com/podcasts

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to view the notes for this episode. You can find links to topics we’ve discussed, and even recommend topics for upcoming shows and take a listen to some of our previous episodes. Again, these initial episodes are focused on vein disease, but we’re soon going to be covering all sorts of topics ranging from dermatology to cosmetic surgery and so much more. So if you want us to tackle a specific medical or health related topic, send it on in. Until next time, I’m Aimee Bowen.

 

And I’m Dr. Kamran.

 

And we wish you the best of health, happiness and nice living in the meantime.