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In this podcast episode of "Living Heart Smart," Dr. Matt DeVane and Dr. Carolyn Lacey discuss venous disease with guest Dr. Christopher Wulff. They explain the difference between arterial and venous problems and how to identify symptoms of venous insufficiency. They also discuss lifestyle changes, such as limiting salt intake and wearing compression stockings, as well as more invasive treatment options for venous disease.


Matthew DeVane, DO, FACC: [00:00:08] Hi, I'm Dr. Matt Devane.

Carolyn Lacey, MD, FACC: [00:00:09] And I'm Dr. Carolyn Lacey. We are cardiologists at John Muir Health, and this is our podcast, Living Heart Smart.

Matthew DeVane, DO, FACC: [00:00:16] Our physician partners and colleagues are going to help guide you through many different and important cardiovascular topics to help keep your heart happy and healthy.

Carolyn Lacey, MD, FACC: [00:00:24] Thank you for listening and we hope you enjoy our show.

Matthew DeVane, DO, FACC: [00:00:33] Hi, [00:00:30] this is Dr. Matt Devane. Dr. Lacey and I are going to be talking with Dr. Wulff today. Dr. Wulff is going to be telling us all about venous disease. If your legs are heavy, swollen, discolored, and really achy, by the end of the day, you may have this problem known as venous insufficiency. We're going to be talking about the symptoms in detail, things you can do on your own to relieve those symptoms, and even some procedures that may help you down the road. We look forward to learning all about it [00:01:00] with Dr. Christopher Wulff.

Carolyn Lacey, MD, FACC: [00:01:02] Venous Disease. I get asked questions about this all the time. What do I do? I did a Google search. Dr.. I think I have poor circulation in my legs. And when you get that Google search, you get a mess of information that comes up. And how do you talk to patients about where you start unpacking that question?

Christopher Wulff, MD: [00:01:23] Well, first off, thank you for having me here this morning. I try to delineate [00:01:30] what it is the patient is asking because when we as a cardiologist or physicians think about vascular disease, we or I have blood vessel disease, we tend to think of that as being arterial disease. The venous system has not really had that much attention directed to it until the past 20 years ago or so. Well, that's not entirely true. We had treatments, but they weren't as effective as the things that we have now. So try to tease out [00:02:00] from the patient what it is that their concern is. Are they having pain when they walk? Are they having sores on their legs that don't heal? Are they having swelling That doesn't get better when their doctor gives them a diuretic. We see a lot of patients in our practice who have swollen legs and not all of that is due to heart failure. Some of that is due to poor venous circulation.

Matthew DeVane, DO, FACC: [00:02:25] Good morning. Thanks for so much for joining us. Can you help kind of describe for us the difference between [00:02:30] arterial problems versus venous problems? How would a patient differentiate between those two things?

Christopher Wulff, MD: [00:02:36] Well, I'm sure you're aware of this, but arteries take blood away from the heart and veins take blood back to the heart. Arteries are high-pressure systems and you can get arterial disease, and that causes symptoms of impaired oxygen delivery when you use the muscle that the blood flow is supposed to go to. So arterial symptoms tend to occur with exertion [00:03:00] walking primarily. Venous problems are low-pressure systems that the venous system has valves in it to keep the blood flow going in one direction. Since we're upright creatures, if the valves in our legs don't work very well, then when we are upright and we're standing or we're sitting for long periods of time, restaurant workers, health care workers, people who program computers and sit all day at their chair, teachers, you're on your feet all day. You need that blood to go up [00:03:30] against gravity, against gravity. And what prevents it from flowing backward are little valves in the veins. And so what works like locks in a river. But if one of those locks doesn't work, then the flow doesn't stay in one direction and gravity keeps it at the lowest point, your lower legs and feet.

Carolyn Lacey, MD, FACC: [00:03:50] I also started explaining to patients that it's not only the valves, but veins are really stretchy and distensible. So you have sort of a stretchy [00:04:00] conduit or a little tube that is always fighting against gravity all day long for many, many, many.

Christopher Wulff, MD: [00:04:09] For a long time.

Carolyn Lacey, MD, FACC: [00:04:10] For a long time.

Christopher Wulff, MD: [00:04:11] Right. So the term we use for veins is that they are capacitance vessels. They have a lot more ability they have to hold more fluid, blood than arteries do. Arteries don't expand to the extent that veins can. But if [00:04:30] veins get very full and their pressure increases their thin little walls can't hold that and they dilate. And if you see it on your leg, you see a varicose vein. But we see with an ultrasound test, which is the method we use to diagnose this is in large veins that are under the skin by two, an inch or two. Primarily, they're deeper in the thigh. They can be more superficial below the knee. And you can see a dilated [00:05:00] vein there. And sometimes people see a network of these ropey appearing vessels that look like a bag of worms under the skin.

Matthew DeVane, DO, FACC: [00:05:09] Is that what they call spider veins?

Christopher Wulff, MD: [00:05:10] Spider veins are is the term we use to describe the sort of fan-like appearance of the really small blood vessels. Reticular veins and Telangiectasia are the name for those. Those are the types of veins that we [00:05:30] treat by injecting them. Sclerotherapy. There are laser devices that can coagulate the blood in that little vein so that it disappears. But they don't tend to create the symptoms that larger varicose veins cause. Achiness, heaviness, swelling, tired skin discoloration.

Matthew DeVane, DO, FACC: [00:05:55] Okay, so you did mention people who are standing a lot during [00:06:00] the day are at risk for having these varicose veins and venous stasis. What are some of the other risk factors that you see in people having these types of symptoms?

Christopher Wulff, MD: [00:06:10] There tends to be a familial association. Men tend to have them more than women. If you have had a blood clot in the vein, a DVT, a deep venous thrombosis that can destroy [00:06:30] the vein. Valves and trauma in some cases can do that.

Matthew DeVane, DO, FACC: [00:06:37] How about is diabetes a risk or having too much weight?

Christopher Wulff, MD: [00:06:41] Diabetes is a risk primarily for arterial disease. And that is why often diabetics that have advanced disease will have to have amputations. It's not a common thing to require an amputation because of venous insufficiency. Weight plays a role [00:07:00] in that, the pressure from the excess abdominal weight tends to impair the venous return. So you may not even have valvular incompetence and you can still be quite swollen. And even if you do, if you have both treatment of losing weight, treatment of your condition can improve your lower extremity swelling.

Carolyn Lacey, MD, FACC: [00:07:27] I think even pregnancy at [00:07:30] times can have increased risk of varicose veins, but it's not necessarily during the pregnancy. It's changing the vessel during the pregnancy. And then down the road, when you see women presenting, there's big uterus with a big baby.

Christopher Wulff, MD: [00:07:45] Or something in.

Carolyn Lacey, MD, FACC: [00:07:45] There is something in there, and it's impeding flow back.

Christopher Wulff, MD: [00:07:49] Often I see women who are many years postpartum who have had veins that they noticed when they were pregnant. They [00:08:00] tend not to be as prominent after delivery, but they oftentimes come back.

Matthew DeVane, DO, FACC: [00:08:07] You mentioned earlier DVT as a potential cause for leg swelling. So I just want to kind of dole out a little bit because DVT is are potentially dangerous, whereas all the leg swelling we're talking about with this venous disease other than DVT, is not a dangerous or potentially life-threatening problem. How is it that you help identify DVT or deep vein thrombosis issues [00:08:30] versus just venous stasis and bad valves?

Christopher Wulff, MD: [00:08:35] So there are two venous systems in the body. One is the superficial venous system, and primarily in the lower extremity. We're talking about the small saphenous vein which travels from around your heel up to around the bend, in your knee, in the back, and the great saphenous vein which starts in your foot and goes a little bit in front of your ankle bone and then travels all the way up into the groin area where it joins the deep venous [00:09:00] system. The deep venous system has a straight route to the heart and lungs. So DVT generally is an acute process. Something happened. My leg was in a cast and I couldn't move my leg for a while. I was in bed because I had surgery. I was on an airplane flying from some faraway country. And because I was sedentary and my legs were bent, maybe, you get a blood clot. So you have a sudden onset [00:09:30] of a swollen, painful leg. Chronic venous stasis is just that. It is a longer-term, more slowly developing condition that results in gradual increase in swelling that occurs when you're upright, resolves when your legs are up. So overnight, your legs improve. Not so much with a with a DVT. Your leg is red and hot and painful.

Matthew DeVane, DO, FACC: [00:09:57] Yeah. And typically with a DVT too. I also think one-sided. [00:10:00] You know, you got one leg that's swollen and painful and red versus venous stasis and swelling from venous problems. Otherwise is oftentimes both legs.

Christopher Wulff, MD: [00:10:11] True, but one of the hallmarks of swelling that you see and have a sense is related to the venous system is when somebody comes in and one leg is more swollen than the other. And it's been that way for a while. If you have heart failure as an explanation, that should not be the manifestation.

Matthew DeVane, DO, FACC: [00:10:31] So [00:10:30] can you summarize? Okay. Patients come into your office. You're seeing them for the first time. What are they? What is the classic set of symptoms and the look that you see to the leg that makes you think they have this problem?

Christopher Wulff, MD: [00:10:45] Usually it's a patient who says that by the end of the day, their leg or legs feel like tree trunks. They're heavy, they're tired, they don't want to stand. They put their feet up and they notice immediate [00:11:00] relief. It feels like their legs are draining. So it may be somebody who works on their feet and maybe somebody who goes to a museum and doesn't want to stand there for a long period of time because their legs don't feel good. And then you look obviously to see swelling and you don't necessarily see it below the ankle and on the top of the foot, the dorsum of the foot. So if you see a big lump of swelling there, that often is not a venous sign and you tend to see what we call hyperpigmentation [00:11:30] darker skin above the ankle on the inside of the leg. Initially, it can progress to this sort of brownish discoloration all around the leg and you may not even see a vein that is the culprit for that because these are the veins that are under the skin, although they are termed the superficial system, they are not the ones that you see on the top of the skin, the cutaneous veins. So you look for swelling, you look for discoloration, you look for sores, you look for. [00:12:00] You ask the patient, do cuts, nicks trauma on your legs? Does it take a longer time for that to heal? Have you lost hair?

Matthew DeVane, DO, FACC: [00:12:10] Yeah, We see a ton of those patients.

Carolyn Lacey, MD, FACC: [00:12:12] It's really common.

Christopher Wulff, MD: [00:12:14] Well, the reason I started doing this 15 years ago or more was that there were a lot of people we see with swollen legs. And what do we do? We give you a diuretic. We look to make sure you don't have heart failure. And a lot of times people come in and they say, you know, this thing [00:12:30] doesn't make me go to the bathroom a lot, but my legs don't look any better.

Matthew DeVane, DO, FACC: [00:12:33] Yeah, there have been many times where you're trying to help the patient relieve some of the symptoms, make them more comfortable. And so in our mind, at least as cardiologists, we're always thinking diuretics, Let's get the fluid out, let's get the fluid out. And there are so many non-responders to that. That is another clue also that we're just dealing with a venous problem that is due to the bad valves rather than fluid overload or volume overload.

Christopher Wulff, MD: [00:12:57] We want, we want to make people feel better, right? And [00:13:00] so we try things. And it's frustrating because there are far more patients out there who have venous insufficiency as a mechanism. And that's not going to get better with diuretics.

Matthew DeVane, DO, FACC: [00:13:12] That's an excellent description of many of the patients we're seeing. So thank you so much. So if you see somebody, they've got these symptoms, they've got the legs that are discolored and swollen, what are some of the tests that you think about that will help you identify to the next level the issues that the patient is dealing with? [00:13:30]

Christopher Wulff, MD: [00:13:30] Well, first thing look to see because we are cardiologists and see people with hypertension is that they are not on a medication that may be causing lower extremity swelling because there are several classes of medications or pills that do that. Okay. I assume they don't have that.

Matthew DeVane, DO, FACC: [00:13:44] Can you name maybe the top one that does,

Christopher Wulff, MD: [00:13:46] A medication called Norvasc or Amlodipine or another one? Diltiazem Cardizem can do that. But if you have a suspicion for venous insufficiency, they don't appear to be in heart failure. The test you need is a venous duplex [00:14:00] and many patients will come in and they'll say, you know, I had that vein ultrasound test and they didn't find a blood clot. Glad to hear that. That's not the only thing we're looking for. Most of the times a patient goes for a venous ultrasound. The test is limited to looking for and excluding the presence of a deep venous thrombosis. We actually look for that as well. But in addition, we look for the presence of reflux, backward flow in [00:14:30] the vein, and we measure that with a what's called a Doppler signal in the vein. And a certain amount of reflux is considered a normal thing. Usually, it's under one second, but if people have dilation of the vein. So we look for the vein size and we look for venous incompetence, backward flow, and sometimes people's veins, we stop counting when the backward flow exceeds seven seconds and people will say how, how if it's flowing backward this [00:15:00] long time, what's happening,   ell veins, other veins are taking over for that function. Because simplistically, if you look at it and a patient has 60 heartbeats per second, they per minute, they have one heartbeat per second. If it's flowing back for seven seconds, a lot of beats are going by without flow going up.

Matthew DeVane, DO, FACC: [00:15:20] I've never heard it described that way. That's cool.

Carolyn Lacey, MD, FACC: [00:15:23] Thats a good way to put it. And I also like to just sort of add that with the ultrasound tests that you're talking about, the Doppler, the [00:15:30] Doppler portion of the test doesn't change the mechanism of how we obtain the test. So the technique of the test, just for patients to sort of understand there's more things that you can do with the probe on the leg. There's nothing invasive about this. It's all through the same ultrasound technique that they had. When they have any kind of ultrasound, you can just get more flow characteristics, the different the different sort of Doppler characteristics that [00:16:00] Doctor Wulff talked about.

Christopher Wulff, MD: [00:16:01] This the same procedure, same procedure, added information gathering of information, additional information. Right.

Matthew DeVane, DO, FACC: [00:16:08] So want to be clear about that. So if the test you're talking about to make this diagnosis is called what compared to what the average person is getting.

Christopher Wulff, MD: [00:16:16] So we call it a venous duplex that includes assessment for the presence or absence of a clot size of the vessel and flow characteristics of the, of the blood vessel when they have a DVT [00:16:30] study. Just a vein ultrasound to exclude a DVT. They look at vascular size. They also look to see if the vein is what we term compressible. If they push on it from the outside, does it collapse because a vein that has a thrombus in it, a blood clot in it, will not collapse when you press on it. But they don't do the flow measurements like we do in the duplex study.

Matthew DeVane, DO, FACC: [00:16:56] Okay. Doctor Wulff So a lot of my patients come in, their legs are swollen, [00:17:00] they're a little bit discolored, and it limits them a little bit. It's uncomfortable, but for the most part, they're not too worried about it. And so but there are some complications from letting this go without treatment that could potentially get them a bit of trouble. So what are the complications from not treating this?

Christopher Wulff, MD: [00:17:19] But before I get into that, let me, let me mention that this is not a life-saving procedure or a life-limiting disease. This is primarily a [00:17:30] lifestyle problem. You feel uncomfortable, your legs hurt. You don't want to stand up. That's fair to fair to treat that.

Matthew DeVane, DO, FACC: [00:17:37] It's a quality-of-life issue.

Christopher Wulff, MD: [00:17:38] It is. Is it a quality-of-life issue? Right. So but it depends on the individual. So if somebody comes in, they have minimal symptoms that's not really interfering their quality of life. They don't have discoloration. They don't have signs of skin ulceration or poor wound healing. You may just recommend compression, hose, and [00:18:00] elevation and limiting your lifestyle to that extent if that's unacceptable to the patient or inadequate to them to restore their quality of life, then you talk about more of the invasive type treatments.

Matthew DeVane, DO, FACC: [00:18:17] Got it. Excellent. Before we get into some of the more invasive, invasive treatment options, can you, what are the things that you tell your patients to do on their own lifestyle [00:18:30] type changes they can make to improve their symptoms?

Christopher Wulff, MD: [00:18:36] Limiting salt in your diet? To some extent walking because when you walk, you move your foot up and down. It compresses the calf muscle. That's called the muscle pump. It can help push fluid out of your leg, not standing still in one place for long period of time, periodically elevating your legs if you have that opportunity during the day, losing weight, if that is a factor. [00:19:00]

Matthew DeVane, DO, FACC: [00:19:00] What about compression stockings or compression hose? What's going on there?

Christopher Wulff, MD: [00:19:05] So when we talk about compression hose, we talk about primarily a knee-high sock or stocking that has some pressure applied to the outside of the leg and they tend to be graduated compression. It's higher in the ankle and lower as it goes up your leg. And it doesn't fix anything, but it [00:19:30] holds pressure from the outside to keep your tissue from swelling. The symptoms you get and the problems you develop from venous insufficiency are from the swelling and then the effect that that has on the skin. So a compression stocking is the first thing you should use. There are three levels of compression, the kind that you buy at a drugstore or maybe a men's store, department store tend to have 15 to 20mm of mercury pressure compression from the outside. Those [00:20:00] aren't considered truly therapeutic. The first level of therapeutic compression begins at 20 to 30 and then there is 30 to 40. 20 to 30 can be challenging for patients to get on or older patients who have arthritic conditions or limited mobility may find it hard to get this elastic band over their foot and up their leg. There are devices that can help you with that. Friends can help you with that, but it's hard [00:20:30] to put socks on somebody else. 30 to 40 is a serious level of compression that is hard to wear. But, you know, the stuff that we have now. These aren't your mother's support hose. They are made of different materials. They are easier to get on than the sort of traditional manila-colored elastic.

Matthew DeVane, DO, FACC: [00:20:53] What about that? Get questions too. Is it below knee stockings or above knee stockings or does it matter [00:21:00] which is better or worse?

Christopher Wulff, MD: [00:21:03] So there is the requirement that insurance puts upon us to authorize a procedure, and the necessity for that is only knee-high. But you as the individual may find more comfort with a thigh-high. They tend to be hot. We live in a climate that is hot in the summer. If you want to wear [00:21:30] shorts, you may look a little dorky, but knee highs for most people are sufficient. And but it's important. Pardon me to make sure that you wear the correct size so you have a diameter around your ankle, you have a diameter around your calf. And those are typically how they are sized.

Carolyn Lacey, MD, FACC: [00:21:51] There's a lot of information out there about the sports compression. You can buy them now and everywhere. And for people who maybe are just trying [00:22:00] to start the process or prevent something from happening, they know that their dad, their grandmother had horrible varicose veins and don't want to have that when they get to be that age. Is there, is there some is it is there is it better to have some compression rather than nothing? Or and where do the sports things fall into play other than their they're really expensive. They're actually more expensive than the things you can buy online [00:22:30] on Amazon.

Christopher Wulff, MD: [00:22:31] Well, tell patients that the least degree of compression that alleviates their symptoms may be the best for them because they are easier to get on. I  don't, I'm unaware of any study that has shown that compression sleeves decrease the likelihood that you will develop venous insufficiency. And as you know, there are tube that goes from above your ankle to your knee. It's supposed to improve recovery.

Matthew DeVane, DO, FACC: [00:23:01] Well, [00:23:00] from my personal experience, compliance with these stockings tends to be the issue, right? As you mentioned, hard to get on. They're hot. They have plus or minus benefit when people do wear them. I mean, you have to be pretty faithful to wearing them every day almost. So that's a big challenge, at least from what I'm seeing.

Christopher Wulff, MD: [00:23:22] It is you should put them on when you get up. You should leave them on until you go to bed. But realistically, I tell my patients, [00:23:30] wear them as much as you can to give you the benefit that you can get from them.

Matthew DeVane, DO, FACC: [00:23:36] Okay, well, let's think. We've covered the veins pretty nicely. I think we're going to all talk to our patients about all the lifestyle changes they can do to make their legs feel better, which is low salt, diet and exercise and weight loss and keeping legs elevated, and the use of compression stockings on a regular basis. Is there anything else in the big picture you can think about at veins that [00:24:00] you just want to pass along before we move into sort of a more a little bit more of an invasive approach to this problem?

Christopher Wulff, MD: [00:24:08] Typically, patients who have had this have had it for many, many years and think it's important to be aware that this condition is there. A lot of people have it. Far more people have it than seek treatment for it. But there are now things to do, as we will talk about in the future, aside from [00:24:30] the surgery that my parents had to to remove their veins, which was a pretty invasive technique,

Matthew DeVane, DO, FACC: [00:24:40] Yeah. Don't see many people have had that procedure done anymore. Do they even do that still?

Christopher Wulff, MD: [00:24:45] Well, not so much.

Matthew DeVane, DO, FACC: [00:24:48] Yeah. Okay. Based on the newer treatment options, that's something that's not being done. Okay, Chris. Dr. Wulff, thank you so much for sharing that information with us. I mean, it's affecting so many of our patients. I hope I [00:25:00] hope I hope that patients listen to this and really help.

Christopher Wulff, MD: [00:25:04] Thank you very much. I appreciate you having me.

Matthew DeVane, DO, FACC: [00:25:10] This is Dr. Matt Devane, and on behalf of my co-host, Dr. Carolyn Lacey, and our partners at John Muir Health, we hope that you enjoyed this show and we really hope that you keep living heart smart.

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