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Background Information on Cardiovascular System
1 Phlebology:
The medical discipline that involves the diagnosis and treatment of venous disorders. Diagnostic techniques used include the history and physical examination, venous ultrasound, and laboratory evaluation related to venous thromboembolism.
2 American Medical Association (AMA):
A federation of state and territorial medical associations that promotes the art and science of medicine, the medical profession, and the betterment of public health. The AMA has added Phlebology to their list of self-designated practice specialties. A medical specialist in Phlebology is termed a Phlebologist.
3 Phlebologist:
A medical specialist concerned with the diagnosis and treatment of venous disorders, commonly referred to as a Vein Specialist.
4 American College of Phlebology (ACP):
The American College of Phlebology is the premier association for physicians and allied health professionals dedicated to the diagnosis and treatment of venous and lymphatic disease.
As the industry’s leading experts, the ACP seeks to improve the standards of medical practitioners, the quality of patient care and the level of assistance practitioners can access. Health professionals can use the ACP as a forum to exchange medical knowledge, access one-on-one, group and online training, accredited continuing medical education (CME) or access resources to help with practice and patient management.
The ACP is comprised of 2,000 vein care professionals, setting the pace and direction for the growth of the field of Phlebology.
5 American Board of Venous and Lymphatic Medicine (ABVLM):
ABVLM was established to: “Improve the standards of medical practitioners and the quality of patient care related to the treatment of venous disorders and all aspects of venous disease.
Serve the public and the medical profession by establishing initial and continuing qualifications for certification and maintenance of certification as physician specialists in the practice of venous and lymphatic medicine.
Establish educational standards for teaching and training programs in venous and lymphatic medicine.
Examine physician candidates for certification and maintenance of certification in the practice of venous and lymphatic medicine.
Award certifications in Phlebology to candidates who meet the established requirements.
Maintain a registry of individuals who hold certificates issued by the Board.”
The American Board of Venous & Lymphatic Medicine
6 Cardiovascular System:
Heart: Pumps oxygenated and nutrition rich blood to the rest of the body.
Blood: Blood consists of Red Blood Cells and Plasma
Plasma: 55% of blood. Transports blood cells throughout your body along with nutrients, waste products, antibodies, clotting proteins, chemical messengers such as hormones, and proteins that help maintain the body's fluid balance.
Red Blood Cells (RBCs): 45% of blood. Carries oxygen from the lungs to the rest of the body and then returns carbon dioxide from the body to the lungs so it can be exhaled.
Arterial system: Arteries carry oxygenated and nutrition rich blood from the heart to the all of the tissues and organs.
Peripheral Artery Disease (PAD): A blockage in the arterial blood-flow due to plaque build up.
Claudication: A symptom of PAD in which patients experience cramping after walking or exercise. This is due to the muscles not receiving enough blood to meet the increased demand during movement.
7 Venous system:
Carries blood that lacks oxygen and contains lactic acid, CO2, and other by-products produced by the tissues. CO2 is expelled by the lungs and other by-products are filtered through the liver. Veins return blood from the rest of the body to the heart, in order to be replenished with oxygen and nutrients to be re-circulated again. The venous system has 3 main types:
8 Deep venous system: Responsible for 90% of blood return to heart. These are our main veins that are typically situated in the muscle, and deeper from the skin. An ultrasound evaluation assesses the deep system to make sure that there are no complications such as: reflux (venous insufficiency), or DVT (blood clots).
If the deep system is found to be insufficient in any way, these veins cannot be closed because they are responsible for 90% of blood return back to the heart. However, if there is venous insufficiency in the superficial system as well, when problematic superficial veins are closed, it can help recuperate the deep system by encouraging blood flow through healthy veins, improving circulation.
9 Superficial venous system: Returns 10% of the blood to the heart. We have as much as a football field of superficial veins. Usually a few of the veins become insufficient. By closing these veins we are not affecting the deep system or the efficiency of blood flow because these are a small fraction of the veins we have. In fact, we are increasing the blood return back to the heart by closing the insufficient veins. This allows blood to flow through healthy veins instead.
10 Perforator Veins: Perforator veins carry blood from superficial veins to the deep system in order to bring venous blood back to the heart. We don’t have many perforator veins, but if they do become abnormal it could cause major venous problems, such as skin ulcers. This is because most of the time, the deep system passes through the muscle and the superficial system is above the muscle. If we have faulty perforator veins, when we walk, the muscle contractions push the venous blood back towards the superficial veins instead of toward the deep system. As a result, this causes bulging veins or the “pop-out effect”, which in turn pushes the blood and plasma out of the vessels and into the fascia, causing “edema” (see below). Due to the fact that plasma fluid contains proteins (and other enzymatic reactions), it causes oncotic pressure, which causes absorption of moisture from the skin. This can lead to dryness, itchiness, “venous eczema”, and breaking the skin and cause skin ulcers.
11 Lymphatic system: Consists of lymph nodes (antibody producing centers) and lymphatic vessels. This is a vital part of the immune system, carrying cells that help fight infection and disease via the bloodstream. This system is also responsible for returning excess fluid back to the vascular system from the body tissues and skin. The lymphatic system also serves as a secondary means in removing excess edema fluid. When it is overwhelmed or compromised, it can exacerbate edema (Lymphedema).
Lymphedema: Often appears as swelling of the ankles involving the feet. If the lymphatic system is compromised, excess fluid cannot be absorbed back into the lymphatic system, which exacerbates edema. The severity of edema in the legs indicates the severity of lymphedema.
12 Factors worsening Lymphedema:
Lymphatic obstruction
Faulty lymphatic system
Compromised lymphatic system
Chronic Venous Insufficiency (CVI) and varicose veins
Obesity
Lack of mobility
and more
13 Capillary Network:
Blood vessels, as thin as hair, that connect arterioles and venules, and therefore contain both venous and arterial blood. They function to bring oxygen and nutrients while removing CO2 and waste products from the tissues simultaneously.
14 Venous Return:
Similar to the heart muscle that pumps blood throughout the body, the muscles in the legs function to pump the blood back to the heart. For this reason, when someone is immobile or sedentary for any reason, the venous return is less efficient. This can cause edema because the fluid is not adequately being reabsorbed by the veins and brought back to the heart, which causes more pain and heaviness.
15 Calf Muscles:
Responsible for 65% of blood return, which makes them one of the most important muscle groups in our body, when someone wears high heels, causing the calf muscle to be in a contracting position, it does not let the blood pass through the deep veins, which essentially causes the calf muscle to be dysfunctional.
16 Thigh Muscles:
Responsible for 20% of blood return.
17 Foot:
(actual walking and placing pressure on bottom of the feet) is responsible for 15% of blood return.
At Aluna Vein Centers, Dr. Massoudi is not only looking at the patient’s circulation problems, but also at their function in general. This is to make sure that he is treating circulatory issues and also the underlying causes of the problem, such as immobility or medical issues that cause immobility. Dr. Massoudi always recommends walking at least one hour a day, and if someone has mobility issues he recommends structured physical therapy everyday, compression stockings, and other measures like the Intermittent Pneumatic Compression Device.
Diagnostic Measures:
1 CEAP Classification System:
Helps physicians and vein specialists determine how bad your varicose vein problems are. The CEAP chart was designed to provide an objective assessment tool for varicose veins and venous disease.
C: CLINICAL CLASSIFICATION: (observational)
C0: No visible or palpable signs of vein disease.
C1: Telangiectasia or reticular veins.
C2: Varicose veins.
C3: Edema.
C4: Skin changes without ulceration.
C4a: Pigmentation or eczema.
C4b: Lipodermatosclerosis or atrophie blanche.
C5: Healed venous ulcer.
C6: Active venous ulcer.
S: Symptoms including ache, pain, tightness, skin irritation, heaviness, muscle cramps, as well as other complaints attributed to venous dysfunction.
A: Asymptomatic.
E: ETIOLOGIC CLASSIFICATION: (indicates the source of the condition)
Ec: Congenital.
Ep: Primary.
Es: Secondary (ie: post-phlebitic).
En: No venous etiology
A: ANATOMIC CLASSIFICATION: (describes the structure/location of veins)
As: Superficial veins.
Ap: Perforator veins.
Ad: Deep veins.
An: No venous location.
P: PATHOPHYSIOLOGY CLASSIFICATION: (describes the processes associated with the condition)
Pr: Reflux.
Po: Obstruction.
Pr, o: Reflux and obstruction.
Pn: No venous pathophysiology.
2 Duplex Ultrasound:
An evaluation performed to study the dynamic of the arteries and veins. A Registered Vascular Technician (RVT) performs this test. With this test we can measure the diameter of the veins and see how blood flows through the venous and arterial systems. It is important in diagnosing certain disorders such as Chronic Venous Insufficiency (CVI), Peripheral Artery Disease (PAD), Deep Vein Thrombosis (DVT), etc.
3 Chronic Venous Insufficiency:
Failure of the veins to adequately circulate the blood due to dysfunctional valves within the veins, resulting in varicose veins.
Symptoms of CVI include:
1 Leg Pain:
May present as aching, cramping, heaviness, burning or tingling sensations, throbbing sensations, or tenderness. There are many reasons for leg pain. Your doctor needs to give extra consideration in order to eliminate other causes before treating for venous insufficiency.
2 Edema:
Swelling that forms (often in the lower extremities), due to the veins not functioning properly. Faulty valves allow blood to pool into the veins of the lower extremities. As a result, the vein walls stretch and bulge in order to accommodate the extra blood. This extra pressure forces blood and plasma through the vein wall, which causes edema in the skin.
3 Causes of Edema:
Congestive Heart Failure
Varicose Veins
Chronic Venous Insufficiency
Medications (ex. NSAIDs)
4 Tingling/Burning Sensation:
Due to the inflammatory reaction from leaky blood vessels.
5 Itching:
Leaky veins cause oncotic pressure in the the fascia in order to absorb moisture from skin’s surface causing dryness and itchiness.
6 Numbness:
Venous hypertension and venous inflammatory process causes nerve damage.
7 Heaviness:
Happens as a result of leaking plasma from the veins.
8 Fatigue:
A compensatory mechanism in order for our body to increase blood circulation.
9 Restlessness:
A compensatory mechanism in order for our body to increase blood circulation.
10 Stasis Dermatitis or Venous Eczema:
Usually presents as skin discoloration, changes in texture, and dryness due to the reabsorption of moisture from the skin in response to leaky veins.
11 Venous Skin Ulcer:
As a result of skin dryness, the skin can break.
There are two main kinds of skin ulcers: arterial and venous; however, venous ulcers are most common.
There are two main kinds of skin ulcers: arterial and venous; however, venous ulcers are most common.
12 Venous and Arterial Ulcer Characteristics
Since the characteristics of venous and arterial ulcers are very different, a physical examination will determine the ulcer type.
13 Venous Ulcer Characteristics
Ruddy color base
Brown staining on skin
Shallow wound
Irregular wound margins
Moderate to heavy plasma exudate
Pitting/non pitting edema
Warm skin temperature
Granulation tissue present
Critical colonization may lead to infection
Minimal to severe pain
Pedal pulses present
Capillary refill normal
14 Arterial Ulcer Characteristics
Pale base color when elevated
Shiny, taut skin
Deep wound
Punched out appearance
Minimal exudate
Variable edema
Cold skin temperature
Rare presence of granulation
Infection frequent
Pain present with rest and exercise
Pedal pulses diminished or absent
Capillary refill delayed
The Most Common Causes for Edema are Varicose Veins and Chronic Venous Insufficiency
Causes of CVI Include:
1 Genetics:
If one of your parents has varicose veins, the chance of you developing them is 47%, if both parents have varicose veins, the chance of you developing varicose vein is 97%.
2 Gender:
40% of females are likely to develop varicose veins whereas 25% of males are at risk. Estrogen tends to relax vein walls, making them more susceptible to becoming dilated. Progesterone can make the vein walls rigid and unable to recoil, which leaves them susceptible to enlargement. Taking hormones, such as birth control may increase the risk of varicose veins, as well as pre-menstruation, menopause, or other hormonal changes.
3 Pregnancy:
Aside from the hormonal changes during pregnancy, the added weight increases vascular blood pressure, which puts more force on the vein walls, giving them the potential to expand.
4 Obesity:
Like pregnancy, being overweight increases pressure on the veins.
Sitting or Standing/Sedentary lifestyle/Immobility: when you are sitting or standing for long periods of time the blood does not flow as well, which gives the blood the opportunity to pool in certain areas of the veins.
5 Age:
The risk of varicose veins increases with age. Aging causes wear and tear on valves within the veins. Over time, the repetitive expansion of the vein walls causes loss of elasticity. As a result, the walls expand, and cannot recoil as well in order to push blood toward the heart.
6 Blood Clots:
Blood clots can cause obstruction and as result causing reflux, which leads to post thrombotic syndrome and varicose veins.
7 Physical Trauma:
Having an accident, surgery, or being an athlete can result in the vein wall being damaged. Due to the natural process of the body healing itself, scar tissue accumulates, which causes the veins to lose elasticity, and bulge.
8 Pelvic and Abdominal Vein Obstruction:
Having an obstructive mass in the abdomen or pelvic area could increase pressure on the veins.
9 Muscular Hypertrophy:
When someone has enlarged calf muscles, obstruction of the deep system can occur when the knee is in the locked position. This causes reflux, or backflow in the deep venous system and the superficial venous system.
10 High Heels:
Like muscular hypertrophy (see above), wearing heels can cause a positional obstruction to the deep system due to the calf muscles being over contracted for a long period of time. Blocking the deep system has an adverse effect on the superficial system due to the backflow of venous blood.
11 Varicose Veins:
Visible, enlarged, bulgy, and twisted veins that lost their elasticity and cannot recoil back to their original shape. Often, varicose veins protrude from skin and have an unsightly appearance. They are mostly seen in a person’s legs and feet.
12 Spider Veins:
Tiny veins at the surface of the skin that can appear without any associated symptoms. Understanding the difference between cosmetic spider veins and medical varicose veins can make a difference in the long-term management of vein problems. Using state-of-the-art ultrasound and vein mapping techniques, our registered vascular technicians and board certified vein surgeon, Dr. Massoudi can help you diagnose and treat your problem veins. Spider and varicose veins may be an early warning sign of an unhealthy vein network. Also, varicose veins are frequently the cause for emerging spider veins!
13 Pelvic Congestion Syndrome:
Due to the fact that varicose veins are more common in the lower extremities, some of these varicosities on the upper thighs and pelvic area can stem from ovarian vein reflux.
Over 80 million Americans suffer from vein problems, related to venous insufficiency.
Varicose veins and leg pain are not just cosmetic problem, but can be serious medical conditions, that can lead to life-threatening complications, so don’t wait!
VEIN TREATMENTS
Dr. Massoudi recommends a variety of both preventative and curative vein treatments in order to fit your specific needs. All of our procedures are performed right here in the office, and require zero downtime. Important vein treatments include:
Exercise:
This is one of the most important things to improving and preventing varicose veins. Varicose veins can come from a sedentary lifestyle. Exercise, especially cardio, helps to create better circulation and increase blood return to the heart, which decreases the risk for varicose veins. Immobile patients are recommended to have a structured physical therapy regimen to increase circulation and venous return to the heart.
Weight loss:
Decreases pressure on veins, and increases mobility.
NSAID:
These “non-steroidal, anti-inflammatory drugs”, such as Aspirin, Motrin, Advil, etc. decrease pain and inflammation/edema.
Herbal medications:
Arnica, Horse chestnut seed extract, Rutin, Bioflavonoids, and vitamin C help with vein health and associated symptoms.
Graduated Compression Stocking Therapy:
Edema is the most common source of symptoms associated with varicose veins. The firm pressure from the stockings prevents and corrects this by pushing the blood plasma that has oozed into the surrounding skin back into the lymphatic system. We have prescription strength compression stockings (20-30 mmHg) or (30-40 mmHg) in all of our offices for purchase for your convenience.
Vasculera®:
An FDA approved medication that helps with venous insufficiency symptoms. It is indicated for the clinical dietary management of chronic venous insufficiency (CVI) and its complications. Vasculera comes in a once-a-day tablet and works in several metabolic ways to address CVI. As a result, the Diosmin in Vasculera (diosmiplex) helps manage several forms of CVI including varicose veins, spider veins, edema, lymphedema, traveler’s edema, stasis dermatitis, venous ulcers, and acute and chronic hemorrhoidal disease. Results may appear in as little as one week but may not be seen for 4 to 8 weeks. For venous ulcers, results may not be seen for several months. Physician supervision is required with Vasculera; so, ask your physician if Vasculera is right for you.
Endovenous Ablation Procedures:
Endovenous Laser Treatment (EVLT)
Endovenous Radiofrequency Closure (Venefit™),
VNUS Closure
ClariVein
Varithena
Venaseal
These minimally invasive procedures offer the latest advances in the treatment of varicose veins at the source. EVLT is the “Gold Standard” procedure, offering superior results with minimal side effects.
At Aluna Vein Centers, Dr. Massoudi uses an ultrasound to map out the insufficient veins. After applying a local anesthetic, a thin laser fiber is inserted through a tiny entry point into the defective vein under ultrasound guidance. The laser fiber then heats up and seals the vein shut. This procedure is performed in all of our offices, including Beverly Hills, Encino, and Glendale locations.
1 Ultrasound Guided Foam Sclerotherapy (UGFS):
Involves the injection of FDA approved Sotradecol and Asclera (Polidocanol) sclerosing solutions into the vein to close it. Using a vein light, or ultrasound for guidance, Dr. Massoudi performs sclerotherapy in the office, usually taking no more than 30 minutes.
2 Micro-Phlebectomy:
An in-office procedure that removes large varicose veins through small skin incisions. The procedure involves four steps:
Outlining/marking the varicose veins
Injecting local anesthesia
Surgically removing the bulging veins
Wearing prescription strength compression stockings
3 Microphlebectomy vs (regular, old fashioned) Phlebectomy
Smaller incision sites as result small scars
Faster recovery
Less bleeding because the Tumescent anesthesia
Less chance of skin numbness after recovery
Less chance of venous thrombosis
Faster recovery
Less bleeding because the Tumescent anesthesia
Less chance of skin numbness after recovery
Less chance of venous thrombosis
4 EVLT CONTRAINDICATIONS
Patients should not have their varicosities treated who have the following conditions:
Thrombus or blood clot- Deep vein thrombosis (DVT) or those with a history of DVT’s
Immobility (ie Parkinson’s Disease)
Severe arterial diseases like peripheral vascular disease
Pregnancy or breastfeeding
General poor health
Other contraindications may be raised by Dr. Ramtin Massoudi at Aluna Vein Centers at the time of treatment.
****** Patients on anticoagulant therapy (ie: Coumadin/Warfarin) are still eligible for vein treatment. But Dr. Massoudi will review all past medical history. ********