Episode Transcript
Dr. Nayan Desai:
I want to, through this podcast, tell people that it is a medical problem. People historically have equated varicose veins that it’s more a cosmetic problem. Thought about it as you know, more cosmetic problem, but that’s not true.
Alan Helgeson (announcer):
This is the “Health and Wellness” podcast brought to you by Sanford Health. The conversation today is about varicose veins, signs, symptoms, and treatment options. Our guest is Dr. Nayan Desai, interventional cardiologist with Sanford Heart, Bismarck, North Dakota. Our host is Amanda Potter with Sanford Health.
Amanda Potter (host):
Thank you for joining me, Dr. Desai. I am genuinely excited to talk with you about varicose veins. I feel like there are a lot of old wives’ tales and misinformation about the topic, so, really happy to have your expertise here. Just for everyone listening, can you just tell us briefly about yourself and your background?
Dr. Nayan Desai (guest):
Sure. So my name is Nayan Desai. I’m one of the interventional cardiologists at Sanford Hospital in Bismarck. I’ve been at Sanford Hospital in Bismarck since 2018. I came here from New Jersey, and I live in Bismarck with my family. My wife is also a physician, and we have two young kids, Ohm and Mira, who are 8 and 5 years old.
Amanda Potter:
Bismarck is a great community to raise a family in, isn’t it?
Dr. Nayan Desai:
Yeah, that is so true.
Amanda Potter:
So, let’s just start at the very beginning. What exactly are varicose veins?
Dr. Nayan Desai:
That’s a great question. You know, when people think about varicose veins, they come to my clinic, and they talk about is it a circulation issue? And the answer is kind of a little more complex. Yes, it is a circulation issue. When you think about the blood flow to the legs, you think about the arteries which give us the oxygenated blood to our legs that keeps the blood moving, helps the tissue to stay alive, and then the veins are returning the bad blood flow from the legs to the heart, right? So that’s where the veins come in. These are the same veins we see underneath our skin or when we get IV access. So yes, it is a circulation issue, but it is different than arterial issue. Like when you think about diabetics or diabetics with gangrene or, you know, having people amputate their foot because the blood flow was not good, that is an arterial issue. That is a blood flow issue because of good blood not reaching to their feet.
With varicose veins, I call it more a nuisance problem. So there are two different vein circulation systems in our leg. One are those superficial veins, which just run underneath the skin, and the others are deep veins, which are located right near the bone, which are carrying most of the bulk of that bad blood flow up to the heart.
So, with varicose veins, these are those superficial veins which are underneath the skin, and these are nuisance vein. It is a disease, I would say, of healthy people. So, when they come to my clinic, I say that you are healthy, you are active, you are on your feet a lot, you’ve been standing in prolonged occupations, and that’s why you have the problems with varicose veins.
Amanda Potter:
Wow, I’ve learned so much, and I love that it’s a condition of healthy people. That’s really interesting. Is there any relation to something like deep vein thrombosis or any other conditions?
Dr. Nayan Desai:
Yeah, so as we just kind of said, right, the deep veins are the veins which are running deep inside the legs. The varicose veins are typically the superficial veins. There could be a connection. So, imagine, like, if you have a clot in your deep veins, now the blood is not going up to the heart, right? So, the blood has to magically figure out a way to reach the heart; otherwise, your leg is acutely swollen, painful. And then those superficial varicose veins come into play in some people where they have deep vein thrombosis. But, typically, the deep veins — we like to separate this condition out from DVT, or deep vein thrombosis from varicose veins. But, as a sequela, if somebody has had scarring or deep vein thrombosis, they could later in their life get varicose veins.
Amanda Potter:
Interesting. So, you touched on it a little bit, some of the potential symptoms, but can you talk more about how someone might know if what they’re experiencing is varicose veins?
Dr. Nayan Desai:
So, with varicose veins, it is a slow disease process, right? It’s very seldom an emergency. It’s a nuisance problem. As I said, it’s a problem of healthy individuals, people who are older, genetics, pregnant women, people who are standing a lot on hard surfaces, right? Of people working in restaurant industry. We have our farmers and ranchers here in North and South Dakota. So, those kinds of people who are on their feet a lot, especially even smoking, and women who have been pregnant multiple times.
I say, you can blame it on your kid because the uterus, when you’re carrying the baby, is pressing on the veins. The veins are very light there. Amanda, like, even if you hold a little bit of pressure, they can collapse, right? So, the baby’s head can press on the mother’s veins, and that’s where they can get the problems with varicose veins.
Amanda Potter:
Are there any hereditary factors at all? Like, if my mother or grandmother struggled with it, is that a sign that I might struggle with it as well?
Dr. Nayan Desai:
Yeah, I think genetics are a big player, because there are some genetic conditions. But, yes, you would want to ask that history. When I see that patient, those patients in my clinic, I’m typically asking them, yes, is there any familial component, like, your mom had it, or your dad had it, grandparents had it? You are likely more predisposed to have it.
Photo by Sanford Health
Amanda Potter:
Okay, so let’s say someone feels like they are struggling with this issue. What are their first steps? Do they go to their primary? Can they see someone like you right away?
Dr. Nayan Desai:
I feel like with every disease process, right, it comes in different flavors, I would say. So you have patients early on with mild disease – they’re like, huh, my legs just get a little bit achy. It’s more a nuisance, but I can carry out my daily activities.
And then you have those patients – every time I walk, I feel my legs are hurting, they’re heavy. And I want to, through this podcast, tell people that it is a medical problem. People historically have equated varicose veins that it’s more a cosmetic problem. Thought about it as, you know, more cosmetic problem, but that’s not true.
With varicose veins, you would see those veins are big enlarged. The blood is not reaching the heart. So, the blood is pooling in their lower extremities, and they would feel heaviness, pain, swelling worse at the end of the day and get slightly better when they’re elevating their legs.
So, yes, they can directly see a specialist, but through this podcast, what we want to convey to our patients is, what are the steps which I can take if I start seeing this problems on my own? And that would be elevate your legs, do leg exercises, strengthen your calf muscles, right? Those are simple stuff which we can do if you’re prolonged standing in one position.
Even health care, like I see patients, a lot of them are nurses standing in the operating room, doctors. And compression socks are a great tool. Those compression socks, as I said, those varicose veins don’t need a lot of pressure. You can just kind of press lightly, even with your hand. So, 20-30-millimeter compression socks, which is available through any local pharmacy or through any big stores, you can start wearing them, and that’s a great habit. It strengthens your musculature, it protects you from worsening symptoms of varicose veins, and it gives you good relief.
Yes, like anything in life, it’s an adjustment. So when you start wearing those compression socks, initially you would start noticing pain, swelling and it’s like, oh, it’s uncomfortable. But trust me, over a period of time you will like those compression socks. That’ll become kind of your second habit. And, for us, in our kind of guidelines and where all the society guidelines come in, we don’t want to do any invasive procedures till somebody has at least tried it for three months.
Amanda Potter:
So, what I’m hearing is that maybe a lower-risk intervention like compression socks or doing these exercises, that’s something anyone can start at any time. Would you say that’s correct?
Dr. Nayan Desai:
Yeah, and as I said, you have to be careful. If you have arterial disease — as we talked about at the beginning of this recording, if somebody has arterial disease, they don’t have good blood flow going down to their legs, they’re having gangrenous diabetic foot. It’s best to talk to your local doctor or your primary care physician before you kind of take that on your own. But if you’re otherwise healthy, you’re young, you don’t have any diabetes, your circulation overall is good except for some superficial varicose veins, then I think it’s generally safe to go ahead and start using those compression socks.
Amanda Potter:
You kind of touched on this again, that it’s a disease of a healthy person. But are there ever any times when it’s a sign of a more serious problem or something that people should be really worried about?
Dr. Nayan Desai:
Sometimes, you know, if you have had longstanding DVT or those clots in the deep veins, then you would start seeing a lot of superficial veins, right? And deep vein clots can be a big issue, because those clots can go to the lungs, and you can have pulmonary embolism from those, and that can make you really sick. Sometimes, with varicose veins, you could have obstruction much higher up, which means blood is not able to return way higher up into your pelvis. So, it’s kind of those two can become a more kind of from a nuisance disease to more a little more serious medical problem.
Amanda Potter:
So, let’s talk about the treatments that are available. What can people expect if they do need a more intensive treatment?
Dr. Nayan Desai:
When I see those patients in the clinic, I usually go through a checklist in terms of, tell me about your symptoms, right? And we spent a little bit of time talking about those symptoms. My legs are heavy; my legs are swollen. Some patients would just have spider veins, and they are not really same as varicose veins, but they would be more like superficial veins or nuisance veins, as I call. There are two main superficial veins in our leg. One is the great vein, another is the small saphenous vein. So, you could have leakage in either of those.
So normally when you think about those veins, Amanda, you have good valves in those circulation, right? Those valves open and close and allow the blood to go up against gravity. And with varicose veins, the definition is the veins are enlarged and they’re leaky. Now, the valves are not functioning; the valves are not able to close to allow that blood to go up to the heart against gravity.
And that’s where you would see pooling in the legs. You would see swelling at the end of the day, you would start seeing those ropey earthworms patients complain about in their calf or in the upper part of their thigh. Weight is a big risk factor. So, somebody who is overweight is obese, as you can imagine, that also puts a lot of extra pressure not allowing that blood to return to the heart. Itching can be a symptom sometimes because you can imagine those veins are stretching the skin, the skin is getting dried out, restless leg, pigmentation. If you allow these veins to sit with these varicose veins for a long period of time, you would start seeing the skin becoming dark in that area. You would have rupture of those varicose veins are bleeding inside, internally, underneath the skin, and the skin slowly becomes dark.
And if you really let the problem progress, you would start seeing ulceration, ulceration typically around the ankle. As you can imagine, somebody who is upright erect, the maximum pressure is right around their ankle. The blood is pooling there; it’s not able to reach up to the heart, and you would see skin breakdown and ulceration in those areas around the ankle. So, these are the different spectrums. Of course, people come sometimes very early on with just superficial spider veins to way down to skin pigmentation, swelling, and then the worst would be the ulceration.
Amanda Potter:
And by ulceration you mean open wound?
Dr. Nayan Desai:
Exactly. So, ulceration is like open wounds. These ulcers or open wounds right around the ankle, right around the bony areas of the ankle, on the inside of the ankle, would be more considered a venous, or from varicose veins. They usually don’t heal, as you can imagine, because the circulation is not good. The veins are not returning the bad blood flow, so the blood is sitting there.
So, sometimes, it’s not uncommon for these patients to have ulceration for, you know, six months, one year, two years. These are chronic, non-healing, open wounds, and that can be risk for sepsis infection. It’s an open channel and, you know, usually with our feet, they’re not usually the cleanest areas of our body, right? There are a lot of germs around, especially if it’s a hot, sweaty day. You can imagine what all goes inside from that wound. It’s a direct entry for those microorganisms to get into your system. So, these are the various flavors it would come in.
"Any of our Sanford primary care doctors are very astute in terms of recognizing the varicose veins, understanding that these are real medical problems, and then referring to appropriate specialists." Dr. Nayan Desai, Sanford Heart
Amanda Potter:
Yeah, that’s so interesting and scary, like you said. I was sitting here thinking that’s not a good place to have open wounds down by your feet, by the floor, by the street, not a good place. So, if someone’s at that point, what are their treatment options?
Dr. Nayan Desai:
So, when they come into our clinic, as I said, if you have symptoms which are lifestyle limiting, which are affecting your daily activities of life, you have tried the basic conservative measures: leg elevation, leg exercises, compression socks for three months, then we would go ahead with a dedicated ultrasound. So, it is more an involved ultrasound; it takes about 90 minutes. Try and make sure that you have that time. The sonographer gives me a roadmap. It shows me how big those varicose veins are and how leaky those veins are, right?
So, I get that two information, the size and the leakage. And then we put that into a map, and we kind of see which veins are leaky, which veins are enlarged. And that helps us to then plan their treatment and then going straight into the treatment options, that the treatment options over the last, you know, 10, 15, 20 years has just kind of exploded in this field.
Just because of the need, you start seeing so many patients. The original treatment, if you would hear, I have had my vein stripped—the most barbaric treatment. And what that means is they would just go in and yank that leaky vein out, right? So, sounds barbaric. We don’t usually recommend or do it now because we understand that when we are taking away, or yanking those veins out, you’re still exposing so some small veins to come around and have the problem recur again in a couple of years down the road. So, I would say stripping is usually not the first line of treatment we would recommend. Some of the office-based procedures—we talked about those spider veins where it’s just more underneath the skin. Some people do have pain, but most of the time I think it’s cosmetic for patients when they see those small spider veins around.
And that can be easily treated with just an alcohol treatment. You would kind of make some alcohol and form in the clinic; you would go inside those small spider veins and inject alcohol. And what that alcohol does is destroys those leaky varicose veins or spider veins. And then we move on to something which is more involved or something which we do more in as a procedure. There are different procedures available. As I said, I call it a destructive procedure. When your veins are unhealthy, they’re leaking blood, they are enlarged. You want to get rid of those veins. You want to allow the blood to flow into those deep, healthy veins. So that’s why we would actually destroy these varicose veins. And there are various options available: you can destroy them with heat energy, you can destroy them with laser, or you can destroy or seal them off with a glue.
And the procedure that I typically do on my patients is the VenaSeal procedure, or a glue-based procedure. So, we would go ahead around their ankle, put a small IV in. It’s not painful at all, but you can keep the patients comfortable when we are doing these procedures. Run the catheter all the way up from their calf up all the way into their thigh inside that leaky varicose veins, and we would start shooting small amount of glue and seal that leaky vein completely off. And then patients is like, where my blood goes, it goes into the healthy veins, right? If you can imagine that leaky varicose veins can keep getting stretched, enlarged and start pulling more blood when it is not working correctly. So, now we are redirecting the blood to the healthy veins.
Amanda Potter:
Rerouting it. That’s amazing. So, sometimes I see med spas advertising that they do treatments for this kind of thing, or you might have even seen maybe some storefronts in, like, a strip mall. Can you tell me what’s the advantage of going to an actual health care system like we have at Sanford Health?
Dr. Nayan Desai:
As I said, I don’t want to kind of, you know, give that impression, but there are different clinics; there are vein clinics available where you’re seen and evaluated by a health care professional versus these are these more cosmetic med spas. The problem with those happen is they can only do that alcohol injections, right? Those are those simplified procedures. But if you are not checking if your main vein is leaking or not, you are kind of just doing it more for cosmesis, but you’re not taking care of the pain, heaviness, swelling. If your main vein, the great saphenous vein, or the small vein is leaking blood underneath the skin, doing those med spa treatments are not going to be effective long-term.
You would have recurrence of those varicose veins as well as those problems will still persist. Yes, the skin at that area might look better because you have gotten rid of that spider vein. But I tell my patients, what is our aim? Is our aim cosmesis, or is our aim symptom relief? And that’s where I can help you more with symptom relief. The cosmesis component may or may not happen depending on how long you have had the problem for.
Amanda Potter:
It sounds like it’s truly more of like a band-aid-type approach, just put a band-aid on it. But, hey, great business model because they’ll come back and (laugh), they’ll have repeat customers, right?
Dr. Nayan Desai:
That’s correct.
Amanda Potter:
We’ve talked a little bit about some of the measures that people can take to prevent varicose veins, some of the risk factors. If someone has this concern, how can they start that conversation with their primary provider or their doctor?
Dr. Nayan Desai:
When you start seeing those superficial varicose vein come up, I would say actively bring that up. Most of the patients don’t even think about talking to their primary care doctor because the mindset is that it’s very cosmetic. People don’t think that this is going to, kind of, affect their quality of life. They would not think that, oh, my legs are hurting at the end of the day, it’s my varicose veins, or I have itching in my lower extremities. I have started to notice swelling at the end of the day. Think about these as real medical problems and discuss it with your family doctor or your primary care doctor.
As I said, we live in North and South Dakota right here in our Sanford Health System. Our patients, usually in the winter months, are wearing long clothes. Sometimes, it’s not even easy for your doctor to kind of, in that 15, 20, 30 minute visit, to get to that. And, if you’re wearing long clothes with stockings and stuff like that, they might not be able to see your legs. But I would say when you’re seeing that for the first time, bring that actively up. Tell them that these are concerning. What should we do next? Do you recommend anything? And I would say are any of our Sanford primary care doctors are very astute in terms of recognizing the varicose veins, understanding that these are real medical problems, and then referring to appropriate specialists like myself, if needed or indicated.
Amanda Potter:
What would you say is the most important takeaway that you would like to leave people with when we’re talking about this issue?
Dr. Nayan Desai:
Don’t be embarrassed; be proactive. And I’m going to just repeat those lines again. Get medical attention. There are great treatment options available where we can seal those veins. We can, you know, remove those veins as well with small incisions. We call them phlebectomies, or inject alcohol or foam-based sclerotherapy and make your leg truly better. When I talk to my patients after, it’s not just the cosmetic look of the leg, but it’s also when they say, oh, I feel right away my leg is less heavy. I can walk distances now. I’m not aware about my leg as much as I was aware about it before the procedure. You know, I can stand on my feet much longer. So, it is truly game-changing. If you do have moderate to severe venous insufficiency from varicose veins, which in common terms are leaky varicose veins.
Amanda Potter:
It’s quality of life, right? And people don’t have to suffer with it, is what I’m hearing.
Dr. Nayan Desai:
Yeah, and one of the other questions I get asked, Amanda, is as a heart doctor, is like, oh, if I get my varicose veins sealed, if I need bypass in future, the surgeons typically use these veins for open heart surgeries and bypass. And my answer to that question is, if these veins are leaky and not working well, they’re not going to work well in the heart. You don’t want those varicose veins to go inside your heart as well. And at that time, the surgeon can either use some of the arteries in your hand or other areas of the body which are more healthy. So, thinking about, oh, I don’t want to get this procedure done because I might need open heart surgery 15, 20 years down the road.
Amanda Potter:
Well, Dr. Desai, thank you so much for your time today and for explaining this topic, and we just really appreciate your expertise.
Dr. Nayan Desai:
Thank you for having me.
Alan Helgeson:
This episode is part of the “Health and Wellness” series by Sanford Health. For additional podcasts series by Sanford Health, listen wherever you hear your favorite podcast. And on news.sanfordhealth.org.
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Posted In Bismarck, General, Genetics, Health Information, Healthy Living, Heart, Imaging, Internal Medicine, News, Specialty Care, Symptom Management, Vascular, Women's
