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Varicose veins are bulging, enlarged veins that lie close to the skin’s surface, often causing discomfort and concern. In this episode, Kathleen Berger, MD explains the causes, symptoms, and treatment options for this common condition. And what to discuss with your provider on how to recognize and manage varicose veins to improve your quality of life.
Dec. 26, 2024
Podcast transcript
INTROWelcome to Docs in a Pod, presented by WellMed. Over the next half-hour, Docs in a Pod will educate you about the health and wellness of adults everywhere. Co-hosts Dr. Tamika Perry and award winning veteran broadcaster Ron Aaron will share information to improve your health and well being. And now, here are Ron Aaron and Dr. Tamika Perry.
RON AARON
Well, hello everybody and welcome to Docs in a Pod. We come to you either over the air on the radio or via podcast. The award winning Docs in a Pod is available wherever you get your podcast. I'm Ron Aaron. Our co-host is Dr. Tamika Perry. She's an associate medical director at WellMed. Oversees several large clinics in the Optum Care North Texas region. As an associate medical director, Dr. Perry's goal is to support the providers at these clinics, so they deliver quality care and a compassionate patient experience. Dr. Perry earned her undergraduate degree from Prairie View A&M University. Went on to graduate from Philadelphia College of Osteopathic Medicine, where she was National Health Service Corps scholar. Next, she completed her family medicine residency at Methodist Charlton Medical Center, where she served as chief resident. She's board certified by the American Osteopathic Board of Family Physicians. When she's not playing doctor, she spends time with her daughter when she comes home from college.
DR. TAMIKA PERRY
Yes. Who goes to my alma mater.
RON AARON
Hey, Tamika. It's great to have you on.
DR. TAMIKA PERRY
Hey, Ron. How are you?
RON AARON
Well, I'm good. This is a very interesting topic we're going to take up with Dr. Berger, varicose veins.
DR. TAMIKA PERRY
Yes, the bane of our existence. Look, I tried to throw a joke in there.
RON AARON
I like that.
DR. KATHLEEN BERGER
That's a good one.
RON AARON
Yes. All right. Let's introduce Dr. Berger, who we're delighted to have on again. She is a skilled and compassionate general practitioner at WellMed at Gulfgate in Houston. She provides high quality care to her patients. With a doctorate in medicine from the prestigious University of Guadalajara in Jalisco, Mexico, Dr. Berger brings extensive international training and expertise to her practice. She's board certified in wound medicine. I can use you, Dr. Berger. Dr. Berger specializes in comprehensive wound care, utilizing the latest advancements in medical treatment to ensure optimal healing and patient outcomes. While we're not going to be talking about wound care today, Dr. Berger, with a high-patient population with diabetes, wounds don't often heal well.
DR. KATHLEEN BERGER
That's right. It is something I see frequently. I mean, we all do in the family practice field. But yes, learning how to manage them and just getting them adequate wound care is crucial and getting their glucose under control, of course.
RON AARON
And wounds can degenerate into something really worse.
DR. KATHLEEN BERGER
Yes, if we don't address them quickly or if they're infected even more so, that can lead to digit loss or limb loss. So, it's a serious complication of uncontrolled diabetes or even what we're going to talk about today, venous insufficiency. Varicose veins are a manifestation of that.
RON AARON
Now, I think most of us know what varicose veins look like. People who have all kinds of red streaks up and down their legs. It's seen as a cosmetic problem, but it's more than that. Is it not?
DR. KATHLEEN BERGER
Yes. In some people, they will have symptoms. Other than cosmetic, they will be feeling like heaviness or pain or burning due to varicose veins. Varicose veins are due to chronic venous insufficiency, which is due to the valves in the veins, which are supposed to push blood from the legs back to the heart. The deoxygenated blood, those values are faulty or what we call incompetent.ÊSo, that causes fluid to pool in the lower extremities, also known as reflux of the blood and can cause swelling in the legs and predict production of collateral veins, which are varicose veins. So, the more superficial veins, if those valves aren't working, that blood is going to pull in the leg and cause the blood to form smaller vessels, which are what these varicose veins are.Ê
DR. TAMIKA PERRY
When Dr. Berger says superficial, she means the ones that are closer to the surface, as opposed to the veins that are deep, where we get concerned about things like blood clots. So, the ones closer to the surface is the ones that she's referencing now. I liked it when she referenced earlier, talked about venous insufficiency. Our body ages, and we can't like stop time, right? I wish we could. I like to tell my patients, our body ages on the inside, just like it does on the outside. Some people are under the impression that I dye my hair on a weekly basis.ÊThat's a rumor around the office. Because why? Because we age on the outside, just like we do on the inside. That's part of that aging process, but there are things that we can do about it. Right, Dr. Berger?
DR. KATHLEEN BERGER
Yes, Dr. Perry. Absolutely. Some of the non-invasive or non-surgical modalities to help with chronic varicose veins are mainly compression and elevation. What I mean by that is compression stockings or compression hoses. What that compression does is helps push that blood that is pooling, blood and fluid that's pooling in the legs back towards the heart. The more compression, the more effective that processes. Then elevation. Due to gravity, fluid is going to pull more in our legs. So, when we're sitting, we tell our patients, keep your legs at waist level. DonÕt let them sit at a 90-degree angle. That's going to help reduce that pulling of fluid in the legs. Even when laying down, I tell patients to put a couple pillows or a rest under the knee to keep those legs elevated 30 or 35 degrees, if possible. Whatever most they're comfortable with. Anti-gravity measures, so to speak, and compression are the best non-invasive.
RON AARON
Hold that thought. I'm going to come right back to you. I want to let folks know who may have just joined us. You're listening to the award winning Docs in a Pod. I'm Ron Aaron, along with our co-host, Dr. Tamika Perry. We're talking about varicose veins, and our special guest is Dr. Kathleen Berger. You can find her at the Gulfgate Clinic in Houston. When I was a kid growing up, I remember my grandma walking around complaining about her varicose veins, but back then nobody really did much about it.
DR. KATHLEEN BERGER
We used to say there's more predisposition in women to develop this pathology, but a lot of studies show we see it in both genders. There are some studies that say it's a little more common in women. I think we're more active, our society today. If we're having leg symptoms, pain and swelling and we're not able to be as active as we would like to be it, that may be one of the reasons why we're seeing this topic discussed more or talking about it more within medical circles.ÊAs Dr. Perry mentioned, yes, the superficial venous system and the deep venous system are different. The superficial venous system we can treat. We can treat this problem without affecting the deep venous system, which would be detrimental to disrupt the deep venous system. The superficial venous system. If those valves aren't functioning properly, some of the treatment options that exist surgically would only affect the superficial venous system.
RON AARON
What do you do? Do you remove the vein?
DR. KATHLEEN BERGER
Yes. Removing the vein would be the most effective option. It's the greater saphenous vein and the smaller saphenous vein. Those are the two most common superficial veins that cause these collateral veins to develop. The faulty valves in those veins. So, removing the vein itself is going to solve the problem more effectively because the source of the problem is gone. That main vein with those faulty valves, we're removing it. The only problem with that is there are more adverse effects long-term. There's more risk of that because it's more invasive. We have to ligate the vein closer to where it meets at the groin. The femoral vein where the greater sapnus meets the femoral vein, we ligate there. A catheter is introduced. A wire rather is introduced. We tie the wire right below where we ligated the vein.
RON AARON
What does ligated mean?
DR. KATHLEEN BERGER
It's tied with a suture. So, we basically remove that vein from its origin at the femoral vein. We cut it off, tie it off, basically.
DR. TAMIKA PERRY
Think of ligation as if you have a sausage and where the sausage breaks.
DR. KATHLEEN BERGER
Yes.
RON AARON
Right.
DR. TAMIKA PERRY
That's a ligation.
DR. KATHLEEN BERGER
Yes. I like that analogy.
RON AARON
I don't want to know how sausage is made, however.
DR. TAMIKA PERRY
I don't. Well, the sausage break is the ligation.
RON AARON
Where do you go from there, Dr. Berger?
DR. KATHLEEN BERGER
Once the wire is inserted from kind of above the ankle, it goes to right below where we ligated, where the end of the sausage plication is, for lack of a better word, and we tie around the vein, tie the wire kind of where it's cinched, so to speak, to the wire, so when you pull that wire, from right above the ankle, the whole vein will come out.ÊNow there's risk. There's more risk of bleeding there. You apply compression immediately to the leg. Measures are taken beforehand to lower risk of bleeding, but there's more risk of pains and infection with that form. It's the most effective because you're removing the source of the problem.
RON AARON
Where does the blood go? It had, it had built this new vein, what, what does it do then?
DR. KATHLEEN BERGER
There are other small perforator veins that will take up the work that the greater Saphenous was doing. The small saphenous, the pudendal vein. Those will help do the work. Really, the main system involved in draining the blood or bringing the blood back to the heart is the deep system.
RON AARON
Right.
DR. KATHLEEN BERGER
YouÕre not really going to see any major complications from removing that vein because the deep venous system will take over most of that. That's the most important system in removing the deoxygenated blood from the leg, bringing it back to the heart.ÊWhat's used more frequently though is radiofrequency ablation or laser ablation or something called sclerotherapy because of the lower rate of complications, infection and equal patient satisfaction. So, radiofrequency ablation uses a catheter that is inserted into the vein, and it uses radiofrequency waves to slowly heat the vein, which collapses it. And over a period of weeks, that vein will slowly get reabsorbed into the body. It'll disappear. Patients can go back to work that same day, usually after this procedure. So, it's outpatient. Laser therapy uses a light source, which basically does the same thing, just instead of using radio frequency, radio waves, radio frequency waves, it's a light source that produces the heat to collapse the vein.ÊSclerotherapy would be the least invasive, where the vascular surgeon or vein specialist will inject a small sclerosing agent. The type of agent that will slowly dissolve those spider veins. So, the sclerotherapy is more for those spider veins. It looks like a spider web. That's the best way you can describe it. Since those are so superficial, sclerotherapy works really well for those types of varicose veins.
RONA ARON
All right. We'll pick this up in just a moment. And I thank you so much for being with us, Dr. Kathleen Berger. We're talking about varicose veins. I'm Ron Aaron, along with our co-host, Dr. Tamika Perry, and you're listening to the award winning Docs in a Pod.Ê
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RON AARON
We are so pleased you're sticking with us right here on the award winning Docs in a Pod, our podcast is available wherever you get your podcasts. We're also on the radio in several cities in Texas and Florida as well. I'm Ron Aaron. Our co-host, Dr. Tamika Perry is with us and we're having a fascinating conversation about varicose veins and spider veins with Dr. Kathleen Berger. She is at the Gulfgate Clinic in Houston, Texas. As we talk about this, you mentioned all those spider veins and sclerotherapy. How time consuming is it to inject something into every one of those veins?
DR. KATHLEEN BERGER
It's actually, fortunately, not very time consuming. Most of the three procedures, including the sclerotherapy, the vein stripping and the ablation, they take approximately about an hour, sometimes less. Sclerotherapy usually is a little shorter than an hour. It doesn't take that long. Within a period of weeks, we usually see the effects of that treatment, but the procedure itself, yes, I mean on average about an hour if everything goes as planned and it usually does.
RON AARON
Now who does those treatments?
DR. KATHLEEN BERGER
Most of the time it is a vascular surgeon that has decided to focus more on venous insufficiency. I don't know if there are other specialties that are allowed to get certified in doing some of those procedures. Sclerotherapy is not really surgery, so I don't know actually if there are other specialties allowed to do those types of procedures.
DR. TAMIKA PERRY
I've only known of like you said, vascular, like you don't want me to do it because I'm going to be like, turn to page one. Does the patient have spider veins? Ma'am, do you have spider veins?ÊYou do not want me to do that. I like to think I'm a superwoman, but I know my limitations. So, that's not for Dr. Perry. But you said something interesting earlier, Ron. You said we're talking about varicose and spider veins, but they're really one in the same. It's kind of progression of one from the next. So, spider veins are like stage one.
DR. KATHLEEN BERGER
Yes.
DR. TAMIKA PERRY
ItÕs how we first identify. Dr. Berger, am I correct?
DR. KATHLEEN BERGER
Yes, absolutely.
DR. TAMIKA PERRY
This is like stage one. So, when you recognize you have them, that may be there's something else to come. Like when, at that time when I was 22 years old and I parted my hair and I thought it was, you know, something in it and I realized that was a white strain growing from my scalp. It was a sign of something else to come, right? Spider veins are stage one. That's where we start at. So, at that point, even if they're asymptomatic, you still may want to talk to your physician about what you need to do. What does this mean? Do I need to lose weight? Do I need to exercise? Do I need to start wearing compression stockings? What do I need to look for after the spider vein?
RON AARON
Now does weight play a role in the development of varicose veins?
DR. KATHLEEN BERGER
Yes. I wouldn't say it's a causal relationship, but increased pressure, increased fluid, increased pressure on our venous system, which being overweight can do. Or increased states of where we have too much fluid in the body, heart failure or cirrhosis or advancing renal disease renal failure. Although, any state where we're retaining more fluid, including being overweight, can increase the risk of this happening. But it's mainly due to genetics. There's not really one cause of venous insufficiency, but sometimes, there's a hereditary component we will see.
DR. TAMIKA PERRY
There are lots of particularly women. I think women, like Dr Berger said earlier, not that it happens more than us, but we're maybe more cognizant of it. Women come in and say, you know what? My legs don't look like they did when I was 23. But a lot of times what happens next in that story is my mama had the same problem.ÊOr my auntie has the same problem. So, this happens over and over and over again. I don't know if any of the ladies in my family have varicose veins, but the patients that I know and as family physicians, we see families, right? We see families because we're family physicians. And that is very true. You'll see a line of mothers, daughters, aunts, dads, and they all have varicose veins.
DR. KATHLEEN BERGER
Yes, and going back to what you had mentioned, Dr. Perry, about the staging of what we see first in chronic venous insufficiency, there's actually a CEAP classification system, which clinically tells us how severe the venous insufficiency is. So, the first stage, as you mentioned, is seeing those spider veins. The worse that increased pressure in the veins becomes, it leads to bigger varicose veins, more symptomatic varicose veins, and it can eventually lead to ulcer formation, which would be the final stage and the worst stage.
RON AARON
What does that mean, ulcer formation?Ê
DR. KATHLEEN BERGER
As the pressure in the veins increases, fluid will seep out along with fibrin from the veins. That fibrin causes fibrosis of the tissue, the soft tissue, the fat. What that does is it makes the skin very hard, it actually pigments the skin and that change in that subcutaneous tissue, that fat layer, begins to damage the skin layers. That is what leads to the ulcer formation. So, once that occurs, it's difficult to reverse it. But, again, yes, there are treatments for that, for the ulcers. But we want to try to prevent it from getting to that stage in the first place because it's not reversible.
DR. TAMIKA PERRY
Right. It's tough when it gets to that point. There's a diagnosis called stasis dermatitis. And that just means it's a skin rash. Like those changes that Dr. Berger so eloquently just described has happened, and that skin becomes dark, it becomes hard and it'll look like it's weeping, almost like the skin is crying because it's like water. I've had patients say, why are my legs crying? I was like, I wish you would have come to me when the rash was happening, when that dermatitis was happening. Quite often, we'll see this, like Dr. Berger said before, patients in that volume-overloaded state. So, we see this a lot in heart failure patients, but they have this as a result of that increased pressure on those veins.
RON AARON
Too much water in their system.
DR. TAMIKA PERRY
Yeah.
RON AARON
You have to talk, not just shake your head, Dr Perry.
DR. TAMIKA PERRY
Yes, that would be correct. We're just listening to audio now, not video and audio.
RON AARON
Exactly. Thank you.
DR. KATHLEEN BERGER
We're agreeing with each other on video.
RON AARON
Dr. Berger, for a patient who notices varicose veins, what if they choose to do nothing?
DR. KATHLEEN BERGER
If they're having symptoms and they choose to do nothing, it's very possible that the symptoms are going to progress. It's possible they won't. Something should be done, I would say, because usually symptoms do develop. If some preventative measures aren't taken, it really just depends on the degree. If we're just talking about spider veins and there's no symptoms and they're physically active, they're doing exercise, keeping the legs elevated, they're wearing compression stockings, it may stay there. Those veins may not progress. The venous insufficiency may not progress. But if they have visible or palpable larger varicose veins and they're overweight or they have any of these comorbidities that we mentioned, it's possible that they will worsen.
RON AARON
As a GP, family doc, when patients come in for a visit this time of year, everybody's wearing long pants. Do you suggest they take their pants off so you can see their legs?
DR. KATHLEEN BERGER
Usually as part of any annual wellness visit or physical, I examine their legs and their feet to check their pulses and to assess their skin. And yes, at that time, I'm able to easily see if they have varicose veins or any problems with their arterial circulation. If they have any leg complaints, pain, or any symptoms in the legs, I'll ask to see their legs. But I won't ask them routinely to see their legs. If it's their physical, their annual wellness visit, or if they're having symptoms, yes.
DR. TAMIKA PERRY
Like Dr. Berger says, if you have certain comorbid conditions like that renal disease or congestive heart failure, we're going to check more often your lower extremities.Ê
DR. KATHLEEN BERGER
Yes.
RON AARON
We got about a minute and a half left, Dr. Berger. For those who are listening who haven't really looked at their legs, do you suggest they walk up to a mirror and take a look?
DR. KATHLEEN BERGER
I would, yes, because there are very effective treatment options that are available. Most of them are approved by insurance, the surgical procedures and the treatments that are done outpatient with the vascular surgeon. So, I would say yes, because we do not want it to progress to ulceration, which can lead to hospitalization, infection and all the complications that come with that.
RON AARON
How difficult are those infections to treat?
DR. KATHLEEN BERGER
It depends on their other medical conditions. If it's just venous insufficiency and there's no diabetes or heart failure, complicating their clinical picture, then they're not difficult to treat, but they do take a while to heal. Those ulcers do not heal quickly, and it depends how deep they are as well.
RON AARON
Interesting.
DR. KATHLEEN BERGER
So, they need wound care to follow with them or just weeks, months, sometimes.
RON AARON
Wow. That's when you put your wound care hat on.
DR. KATHLEEN BERGER
Yes.
RON AARON
We've got to leave it right there. We are flat out of time. Dr. Tamika Perry, co-host, thank you so much. Dr. Berger, we really appreciate you being with us. Thanks for joining us on Docs in a Pod.
OUTRO
Executive producer for Docs in a Pod is Dan Calderon. The producer is Cherese Pendleton. Thank you for listening to Docs in a Pod presented by WellMed. Be sure and listen next week to docs in a pod presented by WellMed.
DISCLAIMER
This transcript is generated using a podcast editing tool; there may be small differences between this transcript and the recorded audio content.
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