Onsite Treatments

La Jolla Vein Care provides advance treatments for a wide range of venous conditions, including:

  • Facial Veins
  • Spider Veins
  • Varicose Veins
  • Pelvic and Labial Varicose Veins
  • Venous Leg Ulcers
  • Post-Thrombotic Syndrome
  • Venous Malformations
  • Thrombophlebitis

Expert Consultations

Get a consultation by a doctor trained specifically in evaluating the following conditions:

  • Blood Clotting Disorders
  • Deep Venous Thrombosis
  • Pelvic Congestion Syndrome
  • Lymphedema

Onsite Diagnostic Studies

We conduct advanced vascular diagnostic studies for patients at our facility. By leveraging duplex ultrasound studies for venous reflux examinations, vein mapping, and Deep Venous Thrombosis (DVT) studies, we provide patients with a complete picture of their venous system in the legs.

Understanding Common Vein Disorders

fig1A
fig1B

What Are Veins?

Veins are the blood vessels that carry dark red blood, which is low in oxygen, towards the heart from the rest of the body (Figure 1A). As you move, the leg muscles contract, pushing blood up the leg veins (Figure 1B). The blood flow through the veins is controlled by a series of one-way valves which work like little gates: they open to allow blood to flow up, then they close to prevent blood from traveling back down with gravity (Figures 2 and 3). Arteries work in reverse: they carry bright red blood, which is rich in oxygen, away from the heart. Veins have thin walls that cannot handle high pressures, making them much more delicate than arteries.

Venous Disorders

fig3
fig2

Venous disorders cover a wide range of conditions from life threatening blood clots to unsightly cosmetic blemishes. To understand the various venous disorders, it is necessary to start with an understanding of the normal anatomy. The venous system of the lower extremities can be divided into three systems: the deep venous system, the superficial venous system, and the connecting perforating veins (Figure 4). The majority of blood flow from the legs occurs through the deep system. The deep veins lie within the muscle and cannot be seen with the naked eye. In contrast, veins that are visible on the surface represent the superficial veins. The superficial veins are abundant and carry the blood to the deep veins by the perforating connecting veins. Problems most commonly arise in the superficial venous system, but can also occur in the perforating and deep veins.

fig4

The veins in the lower extremities that are not working very well can be called dysfunctional. Dysfunctional veins can occur from vein valve or vein wall weakness. When the vein valves become weak, the flaps separate and blood can flow backward through the valves (Figure 5). The backflow of blood fills the veins and stretches the walls even more. As a result, the veins get bigger, swell, and often get twisted as they try to squeeze into their normal space (Figure 6).

fig6
fig5

Dysfunctional veins in the superficial system come in three sizes. The smallest, sometimes referred to as spider veins or thread veins, are really miniature varicose veins. They are elongated, tortuous, and their color varies from bright red to dark purple. Varicose veins have no color but protrude to cause the skin to look as though it is covering a bunch of grapes. Intermediate in size between gross varicose veins and tiny telangiectasias are flat, blue-green veins seen through the skin usually at the back of the knees. These are called reticular varicosities. Knowing that these three are varieties of the same condition allow simplification of treatment.

Common Vein Disorders

Spider Veins

fig7A

Spider veins or telangiectasias are small thin blood vessels that lie close to the surface of the skin (Figure 7A). Spider veins usually appear on the legs, face, or chest—but can occur in other locations. Spider veins on the face are often caused by sun damage or heredity. In contrast, spider veins in the legs are more than a cosmetic issue and often indicate a problem not visible to the naked eye. Often, there are ‘feeder veins’ or reticular veins, which are the source of the problem. These underlying veins can produce significant pain and discomfort, just as problems with larger veins.

They can cause itching, burning, heaviness, or fatigue in the legs. Occasionally, superficial spider veins rupture and cause spontaneous bleeding (hemorrhage). These hemorrhages occur at sites where particularly delicate thin skin covers the spiders; this usually happens in the ankle or foot.

Spider veins in the legs are more prevalent in women, but occur in men as well. Often, hormonal influences in women during pregnancy or by using birth control pills cause the veins to enlarge. They can also appear locally after trauma and are more common as one ages. Spider veins in the face are most frequently caused by sun damage, genetics, or skin conditions such as rosacea.

Reticular Veins

fig7B

Reticular veins, often known as feeder veins, are veins that are larger than spider veins, but small than varicose veins (Figure 7B). They are often found in association with spider veins, but not always. As a result, most people who have them do not recognize that they are abnormal. They can be clearly seen with examination using a special trans-illumination light. Reticular veins are often found in the backside of the knee and appear as bluish-green prominent veins, but do not become bulgy like varicose veins. They often cause symptoms such as aching and heaviness. Women often have aching pains behind the knees and never associate it with reticular vein problems, until they are treated and the symptoms resolve.

Varicose Veins

fig8

The word varicose comes from the Latin word varix, meaning twisted. Varicose veins are abnormally enlarged, twisted blood vessels with valves that do not function properly (Figure 8). Veins channel blood back to the heart using a series of one-way valves. When the valves in the vein fail to open or close completely the blood is not circulated properly and tends to pool. This creates increased pressure and stretches the thin vein walls, causing abnormally enlarged, twisted blood vessels that appear under the skin as blue, bumpy, rope-like veins that are varicose veins. Varicose veins are a vascular disorder that requires treatment for medical reasons.

Causes of Varicose Veins

Many factors contribute to the development of varicose veins. Among them are: heredity, gender, pregnancy, occupation, activities, trauma, age, weight, and hormones.

  • Heredity: is a major factor to most medical conditions
  • Gender: women are affected more than men (though the number is not certain because men do not seek treatment as often as women) Pregnancy: As many as 70% to 80% of pregnant women develop varicose veins during the first trimester. Varicose veins tend to worsen with each pregnancy but sometimes resolve or improve after birth
  • Occupation and Activities: people who spend a great deal of time on their feet are much more likely to develop varicose veins. Workers such as teachers, flight attendants, and those in food, health care, and retail industries experience more symptoms and greater discomfort than people of the same age who work in more sedentary occupations.
  • Age: Varicose veins and spider veins occur at any stage of life but they worsen with advancing age. They occasionally develop in childhood.
  • Obesity: Obesity is related to varicose veins; however, the reason is not known.
  • Hormones: Hormone Replacement Therapy has been linked to the development of varicose veins. Hormonal changes are responsible for the increase in venous symptoms such as aching, fatigue, and leg swelling during menstruation.


Symptoms of Varicose Veins

Varicose veins develop gradually and progressively. They are unsightly and are often a source of considerable discomfort. Symptoms often become worse during the menstrual cycle and pregnancy. The symptoms can include:

  • Aching, tenderness
  • Heaviness, fatigue
  • General restlessness in the legs or Restless Leg Syndrome
  • Burning pain
  • Throbbing pain
  • Itching
  • Leg cramps, particularly at night
  • Ankle swelling
  • Skin discoloration at the ankle
  • Skin ulcers above the ankle


Pelvic and Labial Varicose Veins

fig9

Varicose veins in the labia or pelvic region are commonly associated with varicose veins in the legs (Figure 9). At the same time, they can also be associated with varicose veins in the pelvic area, such as the ovarian veins. Enlarged veins in this region can easily be treated, but examination with a physician and ultrasound examination is crucial prior to treatment. Such patients may have associated pelvic pain, known as Pelvic Congestion, as described below.

Pelvic Congestion Syndrome (PCS) is a common, yet under-diagnosed condition in women who have chronic pelvic pain. PCS is a disease that is characterized by constant pelvic pain, pressure and heaviness. Similar to symptoms in the legs, the pelvic symptoms in PCS are caused by varicose veins that lie in the pelvic region. Similar to vein problems in the legs, dysfunctional veins in the pelvic region become engorged with blood and enlarge. In PCS, the varicosities occur near the ovaries, uterus, fallopian tubes, vulva and even the vagina. It most commonly occurs in women who have had multiple pregnancies.

Symptoms of PCS are associated with pelvic heaviness or pain that is worse, typically before the onset of the menstrual cycle, at the end of the day, after prolonged standing, after intercourse, and during later stages of pregnancy. Women with these symptoms may have varicose veins in the labia or groin. If PCS is suspected, it can be diagnosed by history and physical exam by a vein specialist familiar with the condition. A transvaginal ultrasound and a venogram can confirm the diagnosis.

Venuous Leg Ulcers

fig10

An ulcer is a non-healing sore in the skin (Figure 10). Most people associate leg ulcers with diabetes or arterial disease. The fact is that over 70% of leg ulcers are caused by vein problems. Over time, chronic venous disease can cause skin changes and skin breakdowns, resulting in open sores that are referred to as venous ulcers. Venous leg ulcers are the ultimate problem to affect individuals with seriously diseased leg veins because they represent a late stage of lower extremity vein disease. They occur in 1% of the population and up to 10% of people who have the post-thrombotic syndrome. They have a serious impact on the individual’s quality of life and ability to work. It has been estimated that the annual cost of caring for a leg ulcer is approximately $20,000 per individual $1 billion for all patients in the US. Venous ulcers are significant cause of disability in the United States and cause the loss of two million worker days per year. One percent of the population has evidence of an active or healed venous ulcer.

Ulcers may affect anyone with abnormally functioning vein valves; however, ulcers are more common in older persons and for those who have had deep venous thrombosis. They usually occur near the ankles, either on the inner or outer sides. Venous leg ulcers can be painful or painless—nonetheless, all cases require treatment. Left untreated, a venous leg ulcer can grow progressively larger until it encircles the leg and severely disables the individual. They are very slow to heal, taking many months when treated in the traditional manner and tend to recur over a person’s lifetime.

Causes of Venous Leg Ulcers

The root of the problem is increased pressure of blood in the veins of the lower leg. This causes fluid to ooze from the veins beneath the skin, followed by swelling, thickening, and damage to the skin. The damaged skin can eventually breakdown to form an ulcer.

The increased pressure of blood in the leg veins is due to blood pooling in the smaller veins next to the skin. This pooling occurs because the valves in the larger veins are damaged by a previous thrombosis (blood clot), causing blockage of the vein, or by weakening of the walls of the veins. This causes the valves to malfunction, as in varicose veins. When the valves no longer function properly, gravity causes blood to backflow (known as reflux) down the leg and pool in the lower leg veins. This produces high pressure in the veins that results in damage to the surrounding tissue and ultimately to skin breakdown and ulceration.

Chronic Venous Insufficiency (CVI)

The term CVI is used when there are visible signs of long standing venous disease, such as skin changes or leg ulceration. CVI is the modern term for Post-Thrombotic Syndrome. In the past, it was thought that all cases of CVI were caused by a previous blood clot. The use of duplex ultrasound imaging, however, illustrated that only about 50% of cases were actually caused by blood clots. As a result, both terms describe the skin changes associated with long standing venous disease; however, Post-Thrombotic Syndrome is used only when a prior history of a blood clot has been confirmed. CVI on the other hand, refers to the entities of leg swelling, brownish discoloration of the skin (hyperpigmentation), skin eczema (dry and flaky skin), thickening and hardening of the skin, and leg ulceration in the most severe cases.

Post-Thrombotic Syndrome (PTS)

The post-thrombotic syndrome is a long-term complication of deep venous thrombosis (DVT) that is characterized by chronic, persistent pain, swelling and other signs in the affected limb. About 50% of patients who have a symptomatic dvt above the knee, will develop PTS within 1-2 years. People who have thrombosis more than once are at higher risk for post-thrombotic syndrome.

PTS is caused by damage to the veins by the blood clot. The damage venous valves allow the blood to reflux and pool in the leg veins. Over time, this leads to increased pressures. This increase in pressure causes a cascade of events, which ultimately leads to symptoms such as pain, swelling, cramps and heaviness. In severe cases, skin changes and leg ulcers (open wounds) may develop.

Acute Venous Disorders

An acute venous disorder is a condition of the veins that arises suddenly. In contrast, varicose veins take months to years to develop.

Varicose Vein Hemorrhage

Occasionally, superficial varicose veins and spider veins rupture and cause spontaneous bleeding. This type of complication occurs at sites where particularly delicate thin skin covers the veins. Varicose vein hemmorhages typically occur near the ankles, feet, or shin. These are the areas where there is the greatest amount of pressure within the veins. Hemorrhage can occur unprovoked. A significant amount of blood can be lost since the varicose veins are under higher than normal pressure. Definitive treatment of these veins is sclerotherapy to prevent recurrence.

Deep Venous Thrombosis (DVT)

Commonly known as DVT, this condition refers to a situation in which the blood forms a clot. Blood clots in the deep veins can become loose and break off. When the piece of the blood clot breaks off and travels, it is called a venous thromboembolism (VTE). It can travel to the heart and lung, causing a pulmonary embolism (PE), which can be fatal. The annual U.S. incidence of VTE is 250,000. Health consequences of VTE can be severe, including death from PE, recurrence of VTE, and chronic morbidity from post-phlebitic syndrome. Of individuals with proximal DVT (affecting the popliteal, femoral or iliac veins), 50 percent have PE and it is fatal in 10 percent. Calf DVT carries a low risk (1 percent) of clinically significant PE, but if left untreated, extends proximally in 15-25 percent of cases.

Awareness of the potential for blood clots is important for everyone because the symptoms are often very mild, and sometimes there are no symptoms at all. Swelling or pain in one leg that is not explained by another cause should be investigated promptly with an ultrasound examination. Early diagnosis and treatment results in prevention of death in nearly all cases.

Causes of DVT

There are many known risk factors for developing a blood clot. Some people have blood that has an abnormal tendency to form clots, referred to as hypercoaguability. Hypercoaguable conditions may be inherited or acquired by certain states such as cancer, obesity, and by the use of hormones in birth control pills, hormone replacement therapy and pregnancy. Certain inherited blood disorders (such as factor V Leiden) can make blood thicker or more likely to clot than normal.

Blood is more likely to clot when it is stagnant. As a result, people who are inactive due to obesity, stroke, or disability are at an increased risk for developing a blood clot. For this same reason, people who travel by long car drives or airplanes are at an increased risk of DVT due to lack of movement in the legs. Injury to the vein wall may cause a blood clot, such as by trauma.

Signs and Symptoms of DVT

In an acute DVT, a person may have sudden swelling of one leg, with associated venous congestion, which gives the leg a pinkish discoloration and sudden pain. Some DVTs may have no signs at all. Trouble breathing should prompt an evaluation for pulmonary embolus.

In a long-standing, chronic DVT, symptoms may or may not be present depending on the size and location of the blood clot. Many blood clots resolve or decrease in size. In some cases, however, they create a partial or complete obstruction of the deep veins. This causes blood to be re-routed through other veins and new varicose veins may form. Varicose veins in the abdomen suggest blockage of the deep system at the groin level. Also, constant swelling of the leg and signs of chronic venous disease may occur.

Diagnosis of DVT

Blood tests may be helpful in excluding a DVT, but diagnosis is made by ultrasound testing in most cases. This test is called duplex scanning; it is painless, non-invasive, affordable, and widely available in hospitals and specialized medical settings such as the La Jolla Vein Institute. Moreover, the test provides an actual picture of the blood clot on a computer screen and is the standard of diagnosis for blood clots in the legs. When the diagnosis is made it is important to determine the length of the blood clot and the exact veins that are involved.

Blood clots in the veins can be very long. They can extend from the up to the groin or even into the abdomen. Blood clots in the groin area or low abdomen cannot be seen on ultrasound examination, and sometimes require an additional study such as an MR or CT venogram. In some centers, an intravascular ultrasound is used.

Superficial Thrombophlebitis (STP)

When the clot is limited to the superficial veins (the veins just under the skin), it is less dangerous than when it involves the deep veins buried in the muscles of the lower extremities. The clot usually causes inflammation of the vein, which is called superficial thrombophlebitis. Unlike DVT, which can be silent, STP is usually painful.

Diagnosis of STP

Diagnosis of STP is usually by clinical exam. A physician examination is often necessary because the signs and symptoms of STP can be confused with cellulitis, which is an infection of the skin. Most people have symptoms and notice a palpable lumpy cord. This is the blood clot within the vein. The overlying skin is often red from inflammation and not infection (although infections can develop in rare cases).

Causes of STP

Often, STP is caused by trauma to a vein such as a leg injury or an intravenous line placed in the hospital. Moreover, STP can occur in varicose veins because the blood in these veins is stagnant, making it possible for clotting to develop. Additionally, it can occur after vein treatment. If STP develops in a healthy, non-varicose vein that is unprovoked, further evaluation is necessary. It has been discovered that people who develop STP without an obvious cause have an associated DVT in 15% of the cases and may have an underlying problem causing the blood to thicken. As a result, no phlebitis should be considered inconsequential or ignored because the problem is often found in both deep and superficial veins.

Treatment of STP

Management of superficial phlebitis when the cause is known is simple. It involves the use of anti-inflammatory medication, heating pads, compression stockings but may take 4 to 6 weeks to resolve. But it must be observed to make certain that it does not extend too close to the groin or develop in the deep veins.

Congenital Vein Disorders

Congenital vein disorders are abnormalities present at birth, although they may not cause a problem until later in life. Klippel Trenaunay Syndrome (KTS) and May Thurners are the more common congenital venous disorders.

Klippel Trenaunay Syndrome (KTS)

KTS is a congenital vascular abnormality. It is characterized by capillary malformations, abnormalities of the deep and superficial veins, and soft tissue. Varicose veins in KTS are not the same as other varicose veins. They often present at an earlier age and more frequently occur on one left leg. The affected leg may appear much larger than the non-affected leg. The vein specialist may be familiar with KTS because persons with this disorder often suffer from leg pain due to the large varicosities. In some persons with KTS, sclerotherapy may be used to treat the varicosities that cause pain and may relieve symptoms.

May-Thurner Syndrom

May-Thurner Syndrom is not an unusual condition. It is a variant of normal blood vessel anatomy. In May-Thurner Syndrom, the left iliac vein is compressed by the overlying artery. This can occur as an antatomical variant because the arteries and veins lie close together, and all major veins have accompanying arteries.

Mild to moderate compression of the iliac vein usually does not cause problems. However, more severe narrowing can obstruct the blood flow, resulting leg swelling and pain. The narrowed vein reduces blood flow, which increases the risk of developing varicose veins or a blood clot. Often, May-Thurner Syndrom is only diagnosed when a person develops a blood clot without an obvious cause because their symptoms cause them to seek medical care. The term May Thurner Syndrome is used when these patients develop a blood clot.

May-Thurner Syndrom cannot be diagnosed with an ultrasound examination and requires venography or other imaging such as an MR or CT venogram. Treatment is directed at opening the area that is compressed by a ballon, called venoplasty or by placing a stent to keep the segment of the vein open. MR or CT venograms can be done at the Imaging Center located in the same building as our office. The Vein Institute specializes in office based procedures, and a patient will be referred for therapeutic intervention.

Related Conditions

Lymphedema

The lymphatic system is intricately related to the venous system. The lymphatic system is responsible for fluid balance, among other roles. When the lymphatic system is impaired, fluid accumulates in the tissues. The protein-rich fluid that is trapped in the soft tissue causes skin hardening, leather or cobble stone appearance and can cause disability if left untreated. Lymphedema patients are at an increased risk of skin infections.

Lymphedema can occur in the arms usually related to injury to the lymph nodes from breast cancer treatments, or in the legs for a number of reasons, such as congenital causes, injury, vascular surgery (such as vein harvesting procedures), pelvic surgery and radiation, repeated skin infections, malignancy, parasitic infection and other causes.

Swelling of the legs in lymphedema in distinctly different than other causes of edema (i.e., heart failure, etc). Therefore, accurate diagnosis is important to receive proper treatment. Treatment should be initiated as quickly as possible, to prevent skin changes and complications such as infection.

The vein specialist is trained to diagnose and treat lymphatic conditions. Leg swelling can occur in both lymphedema and venous insufficiency. As a result, the clinical picture may be confusing. Patients with lymphedema often have a combined condition of both lymphedema and venous insufficiency called, phlebolymphedema. The venous component can be treated, thereby reducing swelling.

The role of the vein specialist in lymphedema is to establish accurate diagnosis by physical evaluation and appropriate imaging studies if needed. At La Jolla Vein Care at Scripps, we provide expert consultation and appropriate referrals for continuing management. Management includes the use of compression garments, manual lymphatic drainage, self-therapy, and skin care. Manual lymphatic drainage is a technique performed by trained physiotherapists. The duration and amount of treatments varies, but on average a session is three times per week. Depending on the patient’s demographics and preferences, a physician referral will be made to the desired lymphedema clinic. The Scripps Lymphedema clinic on the Scripps Memorial Campus is located next to our office.