Compression Stockings

March 7th, 2014 by Dr. Charles Gould, ll No comments »

Compression Hoes

Compression stockings, while generally unpopular, provide many benefits for patients with various venous disorders ranging from spider veins to venus ulcers. The Society for Venous and Lymphatic Medicine (formally the American Phlebologist Society) and the American Venous Forum stress three conditions for which there is evidence-based medical data to show clear benefits of compression stockings: to help heal active venous ulcerations, to prevent developing an ulcer after having had a Deep Vein Thrombosis (DVT), and to prevent deep clots from forming after surgery and therefore reducing the risk of a pulmonary embolism (clot in the lungs that can be fatal).

Compression stockings are beneficial for everyday use as well, particularly for those whose occupation require standing for long periods: teachers, hair stylists, and nurses to name a few. The Roman army learned this lesson during long marches that by wrapping their legs with strong leather straps, their legs were much less swollen and much stronger in battle.

TED hoes (the thin, white stockings that patients routinely get in the hospital while at bed rest) are NOT appropriate for the management of venous disease and should not be prescribed for ambulatory patients.

Compression stockings work by decreasing the diameter of dilated and enlarged veins in the legs, thereby increasing the blood flow velocity and promoting blood return to the heart. Compression reduces the filtration of fluid out of the veins and therefore reduces leg edema (swelling) when standing. Compression decreases inflammation in the legs and helps heal venous skin disorders and ulcers. Post-operatively it reduces the risk of developing a deep vein clot by promoting venous flow out of the leg.

Various classes of graduated compression stockings exist and newer, lighter fabrics are available. Many stockings are made of sheer microfibers that are comfortable, attractive, and lightweight while providing the adequate compression needed. In clinical practice, the worse the disease, the higher the compression required to get results. Jobs that require long periods of sitting or standing in one place are particularly prone to cause leg aching, swelling, and lead to varicose veins. Compression stockings, even though they are tight, hot, or just “hard to put on” are helpful for this group. Remember, the next time you struggle to put on your stockings, all the physiologic good they are doing for your leg. Assist devices are also available to aid putting the stockings on. All local pharmacies that sell compression stockings carry these devices or can order them.

In addition to stockings, more helpful tips for healthy legs include:

  • Regular Exercise
  • Elevate Legs
  • Move Your Legs Frequently
  • Avoid Wearing High Heels
  • Maintain Proper Weight
  • Wear Proper Support Hose

I am often asked if crossing one’s legs cause varicose veins. After a through review of the literature I found that it is very unlikely. Varicose veins are caused from defective valves inside the veins and not from external compression such as crossing your legs. Several well identified risk factors however are strongly associated with the development of varicose veins: family history, pregnancy, standing professions and aging.

Your doctor can prescribe many health items to aid in your care, known as durable medical equipment (DME). Compression stockings are considered to be “DME,” since they are required as part of your treatment plan. We provide these stockings for our patients since they are necessary for the procedures that we do at the Richmond Vein Center.

Some insurance companies will reimburse you for a portion of your costs (this varies between plans and insurance companies). The Richmond Vein Center does not have the required license to file on your behalf for durable medical equipment. Upon request, we can help you with the paperwork (receipt, CPT and diagnosis codes) so you can file for a refund if this is a covered cost with your insurance. We also give a surgical discount to our patients for their stockings in an effort to keep their procedure cost to a minimum.

My Journey

February 26th, 2014 by Kathryn Niederer No comments »

KathrynN

At a very young age, earlier than my memory can recall, my interest steered me toward a medical career. It motivated me to volunteer as a candy-striper at the hospital and later as a physical therapy aid at an outpatient clinic. At twelve years of age, I was fascinated when allowed in an operating room to observe a total knee replacement. In college I gave up athletics (soccer and swimming) to devote myself to study necessary for success at Emory University. During my tenure at Emory, Summer Olympics were held in Atlanta, Georgia and my lucky parents were able to use my Olympic venue tickets while I remained home in St. Louis studying for my MCATs required for medical school applications. My soccer served me well the following winter, when an injury incurring while playing, enabled me to observe roles played by mid-level care providers. I came to realize that a physician assistant (PA) profession was the perfect fit for my life’s work. It would enable me to interact with and help people to improve their physical well-being.

The PA profession was created to improve and expand healthcare in the 1960s. The PA concept gained acceptance and was eventually used as a creative solution to physician shortages. A PA can perform physical examinations, diagnose and treat illnesses, order and interpret lab tests, write prescriptions, perform procedures, assist in surgery, and provide patient education/counseling. PAs take a national certification standardized examination every ten years, are licensed in the state which they practice, and complete 100 hours of continuing medical education requirements every two years. Physicians and PAs work together as a team, and all PAs practice medicine with physician supervision. This team model is an efficient way to provide high-quality medical care.

My career as a PA has allowed me the opportunity to provide direct patient care while balancing life as a wife and mother of three. During my decade practicing internal medicine, I learned that I enjoy providing patient education. I volunteered my time to provide care and education to Migrant Farmworkers in south Georgia. I have also precepted students to have an opportunity to teach them in addition to teaching at Emory University following my graduation. Throughout my PA career, I have also learned that I enjoy working with the female population and treating illness and disease that commonly affect our gender. Richmond Vein Center is a perfect fit as I have the opportunity to educate a lot of patients, the majority of whom are female. I am privileged to have the opportunity to work alongside Dr. Gould and Chris Cox, PA caring for patients.

-Kathryn Niederer, PA-C

Pregnancy and Venous Disease

April 24th, 2013 by Dr. Charles Gould, ll No comments »

Maternity Compression Stockings

While pregnancy unquestionably is one of the most joyous, profound and miraculous times in a woman’s life, it unfortunately may be one of the most dangerous as well. Pregnancy creates the PERFECT PHYSIOLOGIC STORM for creating damaging and even dangerous venous problems in the legs.

The blood volume in a woman doubles during her pregnancy and the pelvic circulation increases by 6000%. This produces extraordinary stress on the leg veins attempting to return the extra blood volume uphill, against gravity back to the heart. In addition, the expanding uterus places external compression on the larger pelvic veins which in turn produce increased resistance for blood trying to “drain up and out “ of the leg. Venous blood in the legs normally requires a functioning system of one-way valves and muscular pumps to return the blood uphill back to the chest.

During pregnancy, there are active hormones, progesterone, estrogen and relaxin that are secreted in large quantities and each has a direct deleterious effect on both the vein valves and the vein walls themselves. Progesterone and estrogen weaken the venous valves and stretch the walls making the leg veins less competent which encourages blood to pool in the legs causing swelling. Relaxin, another hormone secreted during pregnancy, has a similar effect–compounding the problem of blood in the legs returning back to the heart. This effect on collagen may also be seen on the skin during pregnancy where there is a gradual loosening of skin on the breast and abdomen during the third trimester.

In as much as the extra stress placed on the leg veins by the increased circulating blood volume and loss of competency of the vein valves and stretching of the vein walls are damaging enough, these changes are pale compared to the potential dangerous hypercoagulable state that is created during pregnancy. Multiple clotting factors increase during pregnancy as well as do the platelets which produce a pro-thrombotic state (pro-clotting).

This places a pregnant woman at risk of developing blood clots in the legs which tragically may result in the clot moving into the lungs and causing death. Pulmonary embolism is a major cause of death during and for several months after pregnancy. This hypercoagulable state, compounded by the enlarging uterus and extra blood volume pooling in the leg veins is a set-up for the venous blood to clot. This hypercoagulable state extends well into the postpartum period for several months extending the risk of pulmonary embolism and death.

There are several important measures that can be taken to mitigate the damage to the leg veins during pregnancy and reduce the risk of leg clots. The importance and use of compression hose during the nine months cannot be overstated. Compression promotes the drainage of blood out of the leg, reducing leg edema, and decreasing the chance of developing blood clots. Compression hose very likely supports the strength of the vein walls and reduce the risk of developing varicose veins. Most stocking companies offer a variety of compression garments designed to apply a specific amount of pressure on the legs depending upon the clinical circumstance. This includes specifically designed “maternity” compression panty hose, for example the SIGVARIS Maternity Line of Compression Stockings. Exercise during pregnancy is very important as well, since the calf muscle is an active pump which helps eliminate pooling and promotes venous drainage “uphill“ and out of the legs. Lastly, elevating the feet and legs whenever possible helps to decrease venous pressure and reduces leg and ankle swelling.

Seeking Medical Vein Treatment

March 2nd, 2013 by Dr. Charles Gould, ll No comments »

Woman Researching On Web

In general, there are two reasons why people seek treatment for venous disorders of the lower extremities. Some people have only cosmetic concerns and are unhappy with the appearance of their legs or worse are frankly embarrassed of the presence of their spider and varicose veins. Others seek treatment because of health concerns from symptoms ranging from annoying to incapacitating spider veins, varicose veins, edema, ulcers, bleeding and generalized leg pain. Typical pain includes a heavy, aching fatiguing discomfort alleviated by elevation, usually ambulation (walking) and sometimes by compression stockings. I remember several years ago a 35 year old patient who after his legs were treated stated post operatively that the “cinder blocks that he had been caring around for so many years were gone!” The common theme of venous disease of the legs is one of an annoying, heavy, aching feeling which almost always is relieved by correcting the venous abnormality.

The leg veins rely on a coordinated and complex system of valves and pumps to move blood out of the leg “uphill against gravity” and return it to the heart. When this process fails, either by weakened and incompetent valves located in the veins or by the vein walls themselves becoming tired (aging), weak and dilated, the leg veins especially in the calf muscles “fill-up” with venous blood which pools in the leg causing it to feel heavy and ache and ultimately fatigue. This is called chronic venous hypertension or insufficiency (CVI). As pressure builds up in the deeper leg veins, stress is placed on the surface veins and they become enlarged and result in varicose veins or spider veins.

Treatments of venous disorders until relatively recently (past 15 years) has been for the most part sketchy and poorly organized. Spider veins have been treated by dermatologist, plastic surgeons, general and vascular surgeons, and even primary care physicians with various areas of expertise and training.

The treatment of varicose veins has been historically the “stripping procedure” where a wire is passed along the abnormal vein from the groin to the ankle. A barb was then placed on the distal end (near the ankle) and the vein was then “pulled out” of the leg from the groin until the entire superficial vein was removed. This required general anesthesia, several nights stay in the hospital and weeks of recovery.

In 2000, a paradigm shift occurred when a vascular surgeon in California suggested that by using a thermal ablation catheter it might be possible to cauterize (collapse) from within the vein and close it off eliminating the need to perform the major stripping procedure. The procedure (VNUS Closure) was successful and an entirely new industry was born: The Out Patient Vein Clinic. The idea of treating venous leg pathology exclusively in an outpatient setting (physician’s office), revolutionized vein treatment and provided access to thousands of patients who otherwise would not have been candidates for treatment. Consequently, hundreds if not thousands of Vein Clinics have sprung up worldwide and it is as if “Cinderella finally has arrived at the ball”.

Treatment, never imagined before, can now be performed with local anesthesia, minimal risk and pain and essentially little to no loss from work. To keep pace with the ever growing number of Vein Clinics, two Venous Societies (American College of Phlebology, American Venous Forum) have led the way to establish standards of excellence in promoting advanced vein care.

Many vascular surgeons have changed direction from hospital work and responsibilities to perform office vein surgery. Other physician specialities have also begun treating venous disorders i.e. plastic surgeons, dermatologist, radiologist, cardiologists, general surgeons and primary care physicians.

As with any medical treatment finding a qualified specialist is important to obtain the best result. Vein specialist are called “phlebologists” and have had advanced training in ultrasound, sclerotherapy of spider veins, surgical removal of small vein and catheter ablation techniques for longer, larger and straight veins.

In general, it is a good idea to find a phlebologist who spends the majority of his time treating patients with venous diseases, who has had advanced training and who is a member of the major vein societies such as the American College of Phlegology and the American Venous Forum.

According to the American College of Phlebology Patient’s Guide to Phlebology
Handbook “Healthy Veins…Healthy Legs” there are ten important questions to ask your phlebologist (found in chapter 22):

  1. What training do you have in phlebology and where did you receive it?
  2. What is your primary specialty and are you board certified in it?
  3. What percentage of your practice do you devote to phlebology?
  4. Are you a Diplomate of the American Board of Phlebology?
  5. Are you a member of a professional phlebology society?
  6. Are you trained in ultrasound?
  7. What procedures do you perform, how many have you done, and who actually performs the treatments?
  8. Will I need more than one procedure? Why or why not?
  9. What complications have you seen with these procedures?
  10. What kind of follow-up will I need, and what should I do after the treatment to decrease recurrence of my varicose and spider veins?

My Journey

February 23rd, 2013 by Chris Cox, PA-C No comments »

Chriscox

My journey to specializing in vein care began in 1995 while at Virginia Tech. I began to explore various career paths and wanted to combine my love for working with and helping others with my love of science. A career as a physician assistant seemed a perfect fit given my interests and the current trends in healthcare. In 2003, I graduated from Eastern Virginia Medical School with a Masters of Physician Assistant degree. Upon graduating, I was the first physician assistant hired by the Interventional Radiology team at the University of Virginia hospital. During that time, I specialized in venous access procedures that included various central line placements using ultrasound guidance. I was also exposed to the first generation VNUS Closure procedure and found the new technology fascinating. In 2005, I joined the Interventional Radiology team at MCV Hospital and helped start a vein service for the practice. I immensely enjoyed this aspect of my job and in 2008 joined Richmond Vein Center to dedicate myself fully to the treatment of vein disease. Thus far, my time spent at Richmond Vein Center and working with Dr Gould has been the highlight of my career.

-Chris Cox PA-C

My Journey

January 14th, 2013 by Dr. Charles Gould, ll No comments »

Dr Gould Headshot  Labcoat

Early on, I came to the realization that I wanted to be a “helper” and “giver” along the journey of my own life. This feeling may have come from my days as an ocean guard, rescuing people from the surf, or from my mother who was a nurse and who helped all the sick “old people” in our neighborhood when I was growing up. That strong sense of purpose led me towards Medicine as a career. I have been fortunate to have had the opportunity to be a surgeon and contribute to many lives in a powerful and meaningful way.

For years I had dreamed of developing my own Clinic where I could help people in need no matter how big or small the problem, no matter how rich or how poor. In more than twenty-five years of practicing general and vascular surgery, I have learned that there is no better feeling than to help someone who is hurting or is in need.

As a result, I have been fortunate to have made so many friends along my private professional journey. Complete strangers, who I first met at night in an emergency room, who put their trust in me have later become my friends. Memories of surgical successes and, yes, of disappointments as well, have shaped who I am and have greatly influenced how I practice medicine. I have learned to listen to my patients for frequently they will correctly tell you what is wrong with them. I have learned the important principle of first “do no harm” and only perform surgery when necessary. I have learned that being kind and compassionate goes a long way in helping someone get well.

I feel very privileged to be a physician and have the opportunity each day to contribute to peoples’ lives. Having developed my own Clinic and establishing a philosophy of helping whoever calls on us is a very special opportunity to help those in need.

One evening, when I was a younger surgeon performing serious procedures in the operating room my son, who was mature well beyond his young age, asked me why I was so sad. I replied that I was very concerned about patients that were not doing well in the hospital. My son’s response was for me to visualize being in a large white room and imagine that all of the patients that I had helped along the way were smiling and thanking me for caring about them.

This image profoundly affects how I approach each day’s challenges and will forever affect how I treat patients, no matter how big or small the problem.

In conclusion, the Vein Center has provided me with a supportive and caring environment, without the distractions that are so frequent in hospitals today, to take advantage of the lessons that I have learned along the way to be a better person and surgeon. Lastly, I would like to thank my devoted wife who helped develop the Clinic and has been with me every step of this journey.

-Dr. Charles F. Gould M.D.