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Melanie Cole (Host): For those people who struggle with varicose veins; it becomes more than cosmetic. It’s a condition that can cause significant leg pain and fatigue and really affect your self-esteem and your daily lifestyle. My guest today, is Dr. Aaron Schwaab. He’s a general surgeon with Stoughton Hospital. Dr. Schwaab, let’s start with a little lesson. What are varicose veins and how do they differ from spider veins?

Aaron Schwaab, MD (Guest): Hi Melanie. Thanks for having me on. So, yeah so varicose veins are basically veins that are dilated. That’s really what the definition is and the difference between a varicose vein and a spider vein is the spider veins are the very tiny little almost like capillary veins. They look more like a spider web, that’s why they are called spider veins. Whereas the varicose veins are those larger veins that are kind of bulging through the skin. They kind of have a rope like consistency. So, that’s the difference between those two.

Host: And when we are noticing those as we get older and we’ve been standing, or we’ve had babies; all of these reasons that we start to notice those varicose veins and or the spider veins starting to pop up. What are some of the main causes and are these mostly something that happen in women or do men get them too?

Dr. Schwaab: Yeah, so, we see them both in women and men. And really the cause of it is that the veins in our legs we have two systems of veins. We have what we call a superficial system and a deep system and the way the blood gets from our feet back up to our heart is it travels up these superficial veins which then connect into the deep veins and then the deep veins carry the blood back to the heart. And these veins because they have to fight gravity, have valves in them and those valves are supposed to be one-way valves that only allow the blood to head back up towards the heart.

But as we age, these valves can become leaky and when they leak; they allow the blood to flow backwards in the veins and that increases the pressure in the veins which causes them to dilate and then the rest of the valves, because the vein is dilated they become all the way down the chain, they become leaky and pretty soon the blood is just kind of pooling down at our ankles. And that increased pressure in that superficial vein causes the connecting veins to dilate and get bigger and that’s where we see these varicose veins. But the other problems that we can see that are even more serious is that blood pooling down at the ankles can actually damage our skin and create ulcers and so there’s a whole spectrum that we see of symptoms from these varicose veins ranging from just they are visible and we can see them to they are painful to leg swelling to getting discoloration in the skin to getting ulcers. And it is that whole spectrum that we need to be aware of when we are taking care of patients with this problem.

Host: Is there a genetic component Dr. Schwaab? If your mother had them or your grandmother had them, are you more likely to have them?

Dr. Schwaab: Sure. There is some genetic component. It’s also lifestyle and occupational, so meaning that if you are someone who is standing on their feet all day, that obviously puts more pressure on these veins and over the years that can help contribute to the leakiness in the veins. You mentioned women and pregnancy. That can have an effect on these veins. So, it’s really multifactorial.

Host: So, then what do we do? When is it time to see a physician about this Dr. Schwaab? Because people live with them and say oh it’s just cosmetic, but really, they can be as I said in the intro, really painful, cause heaviness in the legs. When is it that we look to go see somebody about them?

Dr. Schwaab: So, to some degree, it’s – I’m going to have to answer that a couple of different ways. So, one way to look at that is to say when you start having symptoms. So, if you are actually feeling that the veins are painful, your legs are heavy; those kinds of things, that’s kind of the start on the early spectrum of when we can start looking at interventions and consider getting your insurance company to help pay for some of those interventions because obviously, that’s something we all have to be aware of is how much is this going to cost, right? So, if you are looking to have some sort of treatment on these veins and have some help from your insurance company; they have to be causing some symptoms.

That being said, there are people who don’t like the spider veins which are just the smaller – we talked about those, the smaller spider web type veins. They don’t like the appearance of those, and they would like to have these taken care of. If you are talking about purely appearance; then that’s where it falls into the cosmetic side of things. Your insurance company is probably not going to reimburse you for that. But for someone who that’s important, that they don’t like the appearance of these, and they would really like them taken care of; there are options for someone to pay for themselves out of pocket to have these taken care of.

So, it really depends on which angle you are looking at. Most of the patients that we are seeing at Stoughton Hospital are having symptoms and so, our goal then is to get them in, get them treated, get their insurance company on board so that we can take care of this problem for them.

Host: Before we talk about some of the interventions you might be able to help them with; what can people do at home and do compression stockings, do they really help? What are we supposed to be doing to help?

Dr. Schwaab: Yeah so, the standard treatment is the compression stockings. You have that exactly right. Now the thing that you need to know about compression stockings is number one, you have to have the right size and number two, you have to have the right compression. So, they come in different strengths and typically you are going to see what’s called 15-20 mmHg, 20-30 mmHg, and 30-40 mmHg. So, that is the strength of compression and I can tell you that the 30-40 mmHg are crazy tight. I mean they are really hard to get on. Most people don’t feel they are very comfortable. The 20-30s are really kind of the sweet spot. That’s where they are still tight, they are a little bit difficult to get on; but once people get them on; they really – most people will tell you that they make their legs feel better because what they are doing is, they are keeping that blood from pooling in those veins. They are helping the blood get out of the legs so that that heaviness feeling that people get, the achiness in the veins because they are getting stretched because of the pressure; that all kind of goes away.

So, wearing the compression stockings is very helpful. Now the 15-20s, we will sometimes have people use those because that’s the best they can do. That’s all they can get on and they will help, but if we are looking at getting insurance approval for various treatment options; most insurances do require that patients have at least tried the stockings, the 20-30 mm stockings and worn them for about six weeks to see if they have helped. And in most patients, they are going to notice some improvement.

Host: Tell us about some of the interventional treatments that you might try with somebody after they’ve tried the compression stockings and done all of the things that you have recommended. Tell us a little bit about endovenous laser treatment. What does that even mean for someone with varicose veins?

Dr Schwaab: Sure, so traditionally, how this has been treated surgically, was a surgeon would go in and do what’s called vein stripping and it was a pretty barbaric procedure. Basically, they would go in and they would literally just kind of rip that vein out and they didn’t worry about all the connections that it had. They would just kind of rip it out and then you wrapped the leg really tight and people would get black and blue and swollen for weeks and really, I mean it works, but it was a very barbaric treatment.

So, fortunately now, we have a better option and that is ablation. And basically, what ablation means is that we are going to seal the vein. We are not removing it. We are just going to seal it so that the blood can’t pool in that vein anymore and the way I explain it to patients is that these veins that we are ablating, you consider them like the highway. So, that’s where the main highway – it’s the easiest pathway for the blood to go back to the heart. So, if we seal it, now the blood can’t go up that highway, so it basically has to take the detours. So, now it’s going to be forced to go through a lot of the other littler branches and those branches because they haven’t been used as much, the valves are typically still intact and so, the little country roads off the highway, the blood can get back to the heart and it has the valves, and everything are still working.

So, that’s how the ablation works. And there are two ways that you can do ablation. There is something called radiofrequency ablation which basically uses the radio frequency or radio wave technology to create heat which then seals the vein. Or what we offer at Stoughton Hospital, is the laser ablation which is just like its sounds. It’s a little laser fiber that we put into the vein that creates heat and seals the vein. And that procedure is an outpatient procedure, literally done through a needle poke. So, there are no cuts, there are no incisions or stitches. It’s just a little needle poke. You are awake when we do it. It’s relatively painless. And you can leave, walk out that day and resume your normal activities very quickly. Within a day or so you are back to your normal activity.

Host: Wow. So, are these veins able to come back? Will they come back in a collateral fashion? What happens afterwards?

Dr. Schwaab: Well, so, the laser treatment and incidentally, the laser treatment and radiofrequency ablation – there’s really not much difference, it’s just kind of a preference of whatever technology you want to use. But they are about 98% effective. So, it’s not 100% and by that, I mean there’s about a 2% chance that that vein could reopen up. But 98% of this is pretty good. So, the answer is yes, they can come back. We do monitor patients after we do this. So, for example, we will bring them back three to six months after we have done the ablation to ultrasound them to make sure that that vein is still sealed and if it’s not, then we can consider doing it again. It’s something that can be repeated. But in general, it works very well to seal that vein and then what happens is those varicose veins that are coming off of that main highway; those veins now don’t have the pressure so they are going to shrink, and those varicose veins will become much less visible. If you have an ulcer in your leg related to venous insufficiency, that ulcer, the studies show will heal 50% faster and you’ll be 50% less likely to have that ulcer come back at a later date if you’ve done this vein ablation. So, it’s a very useful treatment.

Host: Wow, what a great description. So, understandable. You are such a good educator. Dr. Schwaab, wrap it up for us. What would you like people who notice that they are starting to get varicose veins or maybe they are already a little bit more advanced and they are starting to really affect their daily life and how easy this procedure can be and your great success rate?

Dr. Schwaab: Right, so how I would wrap it up is number one, something that they can do on their own is they certainly can go get these stockings. These stockings are more accessible than ever. You can find them on Amazon. They tell you how to measure yourself. So, you can pick up these stockings for about twenty dollars and start wearing them and see if they help. And for many people, they may decide that that’s all they need. If they feel that they need more; they can look us up at Stoughton Hospital and the first step is a screening test and it’s an ultrasound screening test to evaluate the veins to see if the valves are leaky. And if the valves are leaky at that point, then we would go forward with getting insurance approval for that procedure if you wanted to pursue that.

So, and then certainly, I would mention for our patients with wounds; if you have an ulcer on your leg that’s not healing; most of the ulcers that we see on the legs that are not healing are related to this venous insufficiency or this high pressure in the veins and look again, look us up at Stoughton Hospital. We have a wound clinic where we are seeing these patients and we are screening them for the venous insufficiency and then taking them on to the next steps in treatment.

Host: Great information. Dr. Schwaab, as always, you are an excellent guest. Thank you again, for coming on and sharing your expertise and explaining something that people suffer from and they sometimes suffer in silence, but they really don’t have to. So, thank you again for clearing all of that up for us. This is Stoughton Hospital Health Talk. For more information, please visit www.stoughtonhospital.com, that’s www.stoughtonhospital.com. I’m Melanie Cole. Thanks so much for tuning in today.