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How is your circulation?


Have you ever heard someone say, "I have bad circulation"? It is a commonly used expression but many people don't really know what it means. Our circulatory system is composed of the heart and blood vessels. In simple plumbing terms, a pump and pipes. The heart pumps blood thru the lungs, where it becomes rich in oxygen through arteries to the entire body. Veins are the blood vessels that return the de-oxygenated blood back to the heart so it can be re-oxygenated in the lung.

Circulatory issues can be related to problems of heart, arteries or veins. Heart disease includes disorders of the heart muscle, the valves that separate the different chambers of the heart, or the coronary arteries that feed oxygen to the heart. People with severe heart disease, may not be able to adequately pump enough blood to their muscles to allow for the extra oxygen needed for exercise. 

Arterial problems are most often related to blockages that prevent blood from flowing. Most blockages are caused by a process called atherosclerosis, hardening of the arteries. Cholesterol rich plaques form on the wall of blood vessels resulting in decreased blood flow, similar to a clogged pipe draining a sink. Atherosclerosis is the leading cause of death in the western world and is the source of most heart attacks and strokes. Sadly, many people suffer the ravages of this disease needlessly and could prevent heart attacks and strokes through risk factor modification: not smoking, eating a healthy diet, controlling high blood pressure and exercising. We have an epidemic of obesity in this country that is the major cause of adult onset type II diabetes. Diabetes is an important risk factor for atherosclerosis and can be frequently cured by weight loss and exercise. I have taken care of many patients without operating by monitoring their risk factors and exercise programs.

People with blockages of the arteries that supply blood to the legs can cause a condition known as PAD or peripheral arterial disease. PAD can cause pain in the calf or thigh associated with exercise. During exercise the muscles need more oxygen. The blocked arteries are unable to carry enough blood. The muscles build up lactic acid and a burning sensation is felt. As it worsens, people may experience pain in their feet at rest. Ultimately, the lack of blood supply can be so severe that a wound might develop leading to gangrene. People with PAD need to see a vascular surgeon for close follow-up. Most people with PAD do not progress to gangrene if they are able to modify their risk factors. People with PAD need to be checked by their doctor for heart disease. Atherosclerosis in one part of the body, like the legs is commonly found in other places like the coronary arteries of the heart or carotid arteries that supply the brain. How can you doctor tell if you have PAD? In most cases, simply by asking the right questions and feeling for the pulses in your legs and feet. A vascular surgeon can also perform non-invasive ultrasound tests to determine the severity of the blockages as a screening test. This testing is commonly performed in my office.

People may not have actual blockages in their arteries but still suffer from poor circulation, particularly during cold weather. Our arteries can change size due to exposure to cold. This happens to help us to preserve our core body temperature. This results in cold hands and feet. Some people's arteries go into spasm and cause an extreme decrease in circulation. This is known as vasospasm, or Raynaud's phenomenon. The fingers or toes turn white, then change to blue. Once blood returns, the digits turn cherry red. In general, this is not dangerous in most people. However, it can be a sign that something else is wrong. Vascular surgeons can assess people for Raynaud's. 

Lastly, disorders of the veins may cause circulation problems. The veins return the used blood back to the heart. Once the blood has made it through the tissues of the body, most of the pressure created by the heart is gone. How can blood return to the chest from your foot? When a person walks, their foot and calf muscles push on the veins of the leg. This causes blood to move. But why just back to the heart and not to the foot? Veins differ from arteries in that they have one-way valves. Normally, these valves only allow blood to flow in one direction, back to the heart. When the valves fail or are incompetent, a condition known as venous reflux, there is abnormal vein function. In the leg, this causes blood to pool and have trouble returning to the heart. Untreated, this leads to degeneration of the veins. Venous reflux can progress to cause itching, pain, restless legs, swelling, discoloration and even ulcer formation of the skin. The degeneration of veins is described as follows: spider and reticular veins are very small, dilated vessels in the skin with a blue or red appearance. Varicose veins are larger blue vessels under the skin that may feel firm or tense. Many people have varicose veins due to increased pressure in the veins due to abnormal valve function. There are exciting new treatments for venous reflux and varicose veins that are minimally invasive and cosmetically superior

So, if you think you might have poor circulation, it is important to discuss this with your doctor. It can be a complicated problem that should be addressed. You might have a problem with your heart, arteries or veins. Vascular surgeons are the circulation experts.


Are You at Risk? - March is DVT Awareness Month

You just got home from vacation last night. You spent 6 hours on an airplane traveling back from some exotic location. In the morning you wake up with a painfully swollen left calf. Should you be worried? The answer is a resounding yes!


What is a DVT?

DVT or deep vein thrombosis is a life threatening medical condition with serious consequences that affects 2 million Americans each year. A blood clot forms in a deep vein within the leg or in some cases an arm. The most common presentation of a DVT is a painful, swollen leg. The clot can travel to your lung causing a PE or pulmonary embolism, which kills over 300,000 people in the US per year. That is over 7x the number of people that are killed annually in automobile accidents.


What is the postthrombotic syndrome?

DVT can also cause something known as the postthrombotic syndrome in the years following the event. This condition includes a painful swollen leg, itching, and difficult to heal leg ulcers near the ankle. It is caused by continued blockage of the veins or destruction of the valves in your veins that normally prevent blood from pooling down by the ankle. To avoid this condition, proper medical care is needed. Patients with DVT should be seen by a Vascular Surgeon to avoid this difficult to treat chronic illness. The best way of avoiding this condition is to use doctor prescribed compression stockings or socks following the DVT. Should you develop a leg ulcer following a DVT, there are new treatments that we employ to help heal the wounds in far less time than in the past.


What is your risk for DVT?

The best way of finding out your risk for DVT is to talk with your doctor. I have spent over 20 years taking care of patients with DVT. Sometimes the only risk factor is a long car or airplane ride during which the patient was immobile for many hours. There are known risk factors for DVT, and you should be aware of them. The greatest risk is recent hip or knee replacement surgery, serious trauma with a broken leg or pelvis bones, and spinal cord injury. Other important factors are a prior blood clot in you or a family member, a family history of clotting disorders, and age over 75. There are other less obvious health problems that also put you at risk for DVT: cancer, recent surgery, being in a cast, bed rest, being over age 60, the use of birth control pills, hormone replacement therapy, inflammatory bowel disease, being overweight, heart disease, lung disease, and even just garden variety varicose veins.


How is DVT diagnosed?

If you suspect you may have a DVT, it is important to immediately contact your doctor or go to an emergency room. Sometimes a blood test, known as d-dimer is done to see if you have a blood clot. It is considered a good, but not perfect screening test. A positive result in a patient whom the doctor expects has a DVT is a strong indication that a clot is present. However, a negative test in a patient that the doctor has a strong suspicion of DVT is not enough to rule out that diagnosis. The best test to determine if a DVT is present is a venous ultrasound. Venous ultrasound, sometimes known as a venous duplex, looks at the blood flow and appearance of the veins. If blood flow is blocked, a clot exists. Venous duplex is over 95% accurate in the detection of DVT.

Recently, I had a patient come to see me in my office for a same day, urgent appointment. She had been having leg pain and swelling for ten days. I performed an ultrasound in my office and was able to diagnose a DVT in under 15 minutes with this non-invasive technique. I was able to talk with her primary care doctor and coordinate her treatment. She was lucky that she sought medical attention, before she experienced a life threatening pulmonary embolus, or PE.


How is DVT treated?

The standard treatment for DVT is anticoagulation (thinning of the blood in layman's terms) with the use of a drug called heparin. Heparin prevents the blood clot from getting larger, but it does not destroy the clot that is there. In the past, all patients were admitted to the hospital and heparin was given through an intravenous catheter for about one week. There are new forms of heparin that patients can take just once or twice a day as an injection just under the skin, very much like insulin, allowing treatment as an outpatient. Following heparin therapy, a pill called warfarin is started, to further prevent the spread of the clot. Treatments last typically for 6 months to 1 year. For patients with very extensive DVT, clot-busting drugs similar to what is used for a heart attack or brain attack can be used to destroy the clot. This would be followed by anticoagulation with heparin and warfarin. Sometimes, patients have medical conditions that prevent them from being anticoagulated with drugs. In those situations, a medical device called a vena cava filter can be placed in the inferior vena cava (the large vein in the abdomen that collects the blood from your legs) to trap a blood clot travelling. 

Rarely, surgery by a Vascular Surgeon is required to save a leg that DVT has threatened. In 15 years, I have only had to perform limb saving surgery 3x for DVT. In those situations, the blood clot had spread throughout all the major veins of the leg, and blood could not get back to the heart. There was no room in the leg for new blood to enter by the arteries. In surgery, the clot was removed with catheters allowing blood to return to the heart and supply the leg.


How is DVT prevented?

Ask your doctor to assess your risk at your annual check-up. For some patients, preventative blood thinners are needed. For others, just wearing compression stockings or socks is enough. If you had a DVT in the past, it is important for your doctor to try to find out why the DVT happened in the first place, and see if your risk factors can be modified to make it less likely to happen again.

Venous Disorders

Commonly, people's thoughts about circulation are limited to the arteries. Arteries are the blood vessels that carry high pressure blood from the heart to the body. However, veins serve an equally important role. Veins return low pressure blood from our organs back to the heart. Malfunction of the veins can lead to significant medical problems.

In some ways, the structure of veins is more complex than the arteries. Veins differ from arteries in an important aspect, they need functioning valves to maintain the normal direction of blood flow. Normally, these valves only allow blood to flow in one direction, back to the heart. When the valves fail or are incompetent, a condition known as venous reflux, there is abnormal vein function. In the leg, this causes blood to pool and have trouble returning to the heart. Untreated, this leads to degeneration of the veins. Venous reflux can progress to cause itching, pain, restless legs, swelling, discoloration and even ulcer formation of the skin.

The degeneration of veins is described as follows: reticular and spider veins are very small dilated vessels in the skin with a blue or red appearance. Varicose veins are larger blue vessels under the skin that may feel firm or tense.

There are three main categories of the veins of the leg. They are classified anatomically as the deep, superficial and perforator systems. The deep veins are located inside the leg along the muscles. Clotting within them, known as deep vein thrombosis or DVT, can cause life-threatening problems such as a clot traveling to the lung, pulmonary embolism or PE. Over time, clots can destroy the function of the vein valves causing progressive symptoms of pain, swelling, skin changes and ulceration of the leg. However with proper care, the risk of this post-phlebitic syndrome can be prevented.

The superficial system includes what is known as the truncal veins such as the long saphenous and the short saphenous veins that travel from the groin to the inside of the ankle and from the back of the calf up to the knee. The non-truncal superficial veins are those that one can commonly see on the surface of the leg. Dysfunction of the valves of the superficial veins can lead to progressive varicose, reticular and spider veins along with symptoms of itching, pain, swelling, restless legs, skin changes and ulceration. Sometimes clotting can occur within the superficial veins that on occasion can extend into the deeper veins causing DVT. These complications may be prevented with proper treatment. 

The perforator veins normally carry blood from the superficial system of the skin back into the deep veins. In the setting of valve dysfunction, the perforator veins allow blood from the deep system to reflux into the superficial system causing overload. This can cause the complications associated with dysfunction of both the deep and superficial veins.

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