Vascular information from Dr. Bunke

Vein & Vascular News, Tips, Treatments and More!

Is it Varicose Veins or Spider Veins?

Varicose and spider veins develop gradually and progressively. They are unsightly and are often a source of considerable discomfort. Both varicose and spider can cause symptoms. Symptoms often become worse during the menstrual cycle and pregnancy for women. 

The symptoms of varicose veins can include:

  • Aching, tenderness
  • Heaviness, fatigue
  • General restlessness in the legs
  • Burning pain
  • Throbbing pain
  • Itching
  • Leg cramps, particularly at night
  • Ankle swelling
  • Skin discoloration at the ankle
  • Skin ulcers above the ankle

The symptoms of spider veins can include: 

  • Aching in legs
  • Heaviness in legs
  • Worsened pain after sitting down 
  • Itching around one or more of the veins
  • Changes in skin color around the veins 
  • Web like pattern of blue, red, or purple lines in the skin 
  • Skin darkening 
  • Burning sensation when standing for long periods of time

At La Jolla Vein & Vascular, we treat both varicose and spider veins with various types of treatments depending on the patient’s case. 

So, how can you tell if you have spider or varicose ? 

Varicose are large, raised, swollen blood vessels that twist and turn. They usually develop in the legs and can be seen through the skin. Spiders are smaller, red, purple, and blue vessels that are also twisted and turning. Spiders are easily visible through the skin as well.

Below you will see numerous cases of both varicose and spider treated at La Jolla Vein & Vascular. 

Varicose Before & After: 

Spider Before & After: 

Treatments for Varicose include: 

1.Conservative Management & Lifestyle Modifications

2.Radiofrequency Ablation

3.Laser Ablation 

4.Mechanico-chemical ablation

5.Varithena Foam

6.VenaSeal

Treatments for Spider Veins include: 

1.Sclerotherapy 

 For more information and to book a consultation, please give our office a call at 858-550-0330. 

For more information please check out our Youtube Channel at this link.

For more information on varicose veins and eliminating underlying venous insufficiency, check this link out full of resources. 

Is it Varicose Veins or Spider Veins?2022-08-17T15:43:09-07:00

Skin Darkening and Varicose Veins

Untreated varicose veins and underlying venous insufficiency can cause changes in the skin, including skin darkening. We call this skin hyperpigmentation.  This usually occurs in the inner ankle and can worsen to involve the lower portion of the leg as shown in the picture.  Over time, the skin becomes firm, dry, eczema-like, and can even break open, causing a venous leg ulcer. When the skin becomes darker as a result of a vein problem, this is referred to as chronic venous insufficiency (CVI). This can be prevented by addressing the underlying venous insufficiency and varicose veins early on. 

 

What is chronic venous insufficiency?

Chronic venous insufficiency (CVI) is an inflammatory condition caused by long standing, untreated venous reflux disease.  Commonly, venous reflux disease causes a collection of symptoms such as leg swelling, heaviness, fatigue and varicose veins. But, over time, when blood is no longer circulating properly in the leg veins, skin changes can also appear. When skin changes appear, this is termed, chronic venous insufficiency (CVI). Venous stasis is another term used for this condition.   Chronic inflammation from CVI causes the skin around the ankles to darken, become dry, itchy, and firm. In severe cases, the skin can start to break down and ulcerate. The ulcer (wound) occurs in the inner or outer ankle and is also referred to as a stasis ulcer or venous ulcer.

Venous stasis skin changes associated with venous insufficiency include:

  • Darkening of the skin along the ankles
  • Itching and dry skin around the ankles (venous eczema)
  • Development of wounds around the ankles, called venous leg ulcers

How La Jolla Vein & Vascular treats patients who experience darkening of the skin:

 

Step 1: The Underlying Problem

The first step is to treat the underlying problem, the venous reflux. The specific pattern of venous reflux was detected by ultrasound. Venous reflux usually starts in the saphenous veins. The saphenous veins are most effectively treated with vein ablation procedures. This involves placing a small catheter within the vein and using heat or a solution to produce injury and eventual closure of the vein. The most commonly used treatments for the saphenous veins are radiofrequency ablation (RFA), laser ablation, mechanico-chemical ablation (MOCA or Clarivein), and in some cases Varithena Foam. The treatment Step recommendation is customized, based on where reflux is present and other clinical factors.

Step 2: Varicose Veins

After the underlying saphenous vein reflux is corrected, the bulging veins (varicose veins) can be treated by injecting a foamed medication that will cause them to scar and eventually dissolve (foam sclerotherapy), or to remove them using tiny incisions. The most common method is foam sclerotherapy. This is also known as ultrasound-guided foam sclerotherapy (UGFS).

Step 3: Spider Veins

Spider vein treatment is always considered a cosmetic procedure. If improved cosmesis is a goal of treatment, make sure to discuss this with your doctor and plan on having cosmetic treatment as the last step. Spider vein treatment is accomplished by sclerotherapy, which is an injection of a liquid medication into the spider veins. Ask your provider for an estimate about how many treatment sessions/ vials are necessary to get the results you want.

 

Skin Darkening and Varicose Veins2022-07-20T16:21:50-07:00

Varicose veins or muscle hernia?

A muscle hernia of the legs is frequently confused with varicose veins. Patients may present with bulging along the outer part of the shin, that looks like a varicose vein. It may or may not be painful. It goes away with flexing the foot (pointing your toes to your head).  But, to experienced vein care specialists, it is clearly a muscle herniation.

Varicose veins are the twisted, bulging veins just beneath the surface of the skin. Unlike a muscle hernia. Varicose veins are swollen, twisted veins that you can see just under the surface of the skin. These veins usually occur in the legs, but they also can form in other parts of the body. Varicose veins are a common condition.

Varicose veins are caused by leaky vein valves, which allow blood to pool within the veins causing them to stretch and become enlarged. Varicose veins can be an isolated finding, but the majority of the time, they are caused by underlying venous reflux disease. Venous reflux disease is also known as venous stasis, venous insufficiency or venous incompetence. Reflux may occur in the deep and/or superficial leg veins.

In our study, led by Dr. Nisha Bunke and published in the Journal of Vascular Ultrasound in 2018, we studied over 1,000 legs with varicose veins. Over 90% of the time, the source of the varicose veins were the great and small saphenous veins. The Great Saphenous Vein (GSV) courses up the middle of the thigh and calf and the small saphenous vein (SSV), which courses along the back of the calf. Normally, there are one-way valves within the leg veins, which help blood flow in one direction: toward the heart. This means blood is traveling against gravity. The calf muscle also helps move blood toward the heart. When vein valves are leaky, blood flows backward (reflux) towards the feet. Blood pools in the lower legs, causing bulging veins at the surface.

A Muscle hernia is a focal protrusion of muscle tissue through a defect in the deep fascial layer. Anterior tibial muscle is the most commonly affected muscle of the lower extremities because its fascia is the most vulnerable to trauma. Clinically it is characterized by asymptomatic or painful, skin-coloured, soft, subcutaneous nodules of various size depending on the position. The diagnosis is usually made clinically based on its typical manifestations, but ultrasonographic examination is useful for detecting the fascial defect and excluding other conditions caused by soft tissue tumors such as lipomas, angiolipomas, fibromas, schwannomas, or varicosities.

Usually, surgical treatment is not needed for a muscle hernia, but may be necessary for increasingly painful hernias.

At La Jolla Vein and Vascular, we frequently see muscle herniations that are confused with varicose veins. Using ultrasound technology and a clinical examination, we can make an accurate diagnosis.

 

 For more information and to book a consultation, please give our office a call at 858-550-0330. 

 

For more information please check out our Youtube Channel at this link.

 

For more information on varicose veins and eliminating underlying venous insufficiency, check this link out full of resources. 

 

Varicose veins or muscle hernia?2022-07-20T16:14:11-07:00

The most important things you need to know about sclerotherapy

By using sclerotherapy to remove spider and varicose veins, we’re able to minimize patient discomfort. At the injection site, patients might feel a slight burning sensation for only a few seconds. To maximize patient comfort, we use a sclerosant that was developed as a local anesthetic. To modernize the patient experience, we want to offer the most advanced treatments available—and we want to keep it painless.

 

Sclerotherapy Treatment for Spider Veins

You have been recommended to have sclerotherapy injections. Spider veins and reticular veins of the legs are most commonly treated with sclerotherapy. Sclerotherapy involves an injection of a medication into the vein.  This will cause the vein to collapse and gradually fade away. Sclerotherapy has been used to treat spider veins for decades, but newer solutions such as AscleraTM allow for spider veins to be treated with minimal discomfort and immediate return to activities. Vein specialists rarely use saline solutions these days, because alternative solutions are less painful and better tolerated. Sclerotherapy is preferred by most vein specialists over laser because spider veins often have underlying ‘feeder veins’ that can easily be treated with sclerotherapy, but are not addressed by laser. Many people will require more than one treatment session for optimal results. The national average is 2 to 5 treatment sessions. Treatment sessions are often spaced a month apart, but your health care provider will help determine your customized care plan. Wearing compression stockings after treatment will improve results.

For larger veins, the medication may be turned into a foam, this is referred to as foam sclerotherapy. Foam sclerotherapy is similar to sclerotherapy of spider veins but instead of a liquid solution, a foamed-solution is injected directly into the vein via a small needle. The solution can be seen on ultrasound monitoring which allows it to be directed into nearby varicose veins painlessly. The veins will seal shut, and gradually be broken down by the body.

 

 For more information and to book a consultation, please give our office a call at 858-550-0330. 

 

For more information please check out our Youtube Channel at this link.

 

For more information on varicose veins and eliminating underlying venous insufficiency, check this link out full of resources. 

 

The most important things you need to know about sclerotherapy2022-07-20T15:48:23-07:00

What you need to know about vein valves

In the circulatory system, the vein valves carry deoxygenated blood back to the heart. The leg veins carry blood toward the heart, against gravity. Therefore, the leg veins have one-way valves to prevent backflow of blood. When the valves do not function properly, they allow blood to flow backward, causing the pooling of blood. This is referred to as venous reflux or venous insufficiency. Eventually, the backflow of the blood will cause varicose veins to develop and symptoms related to the increased pressure in the leg veins such as leg heaviness, aching, swelling, restless legs, night cramps, throbbing, and pain. Varicose veins  can be treated with different lifestyle changes.

 

Conservative Management & Lifestyle Modifications Include for varicose veins and vein valves:

 

The goals of treatment are to relieve symptoms, prevent complications and for some to improve appearance.  Lifestyle changes can ease the symptoms, but do not cause the veins to vanish.  These treatments include:

  • Avoid standing or sitting for long periods of time:  To keep blood moving when you have to sit or stand for long periods, try these tips: at work, take walking breaks and try walking during your lunch hour. While sitting, try flexing your feet up and down ten times an hour.
  • Exercise: Exercising is good for your veins because it improves blood flow. Walking, cycling or swimming are great exercises for vein health. But be sure to check with your doctor before starting any exercise program.
  • Weight loss or maintaining a healthy weight: Being overweight puts extra pressure on your veins.
  • Leg elevation: Use leg elevation three or four times a day for about 15 minutes at a time. Even elevating your legs on a step stool or ottoman is beneficial. If you need to sit or stand for a long period of time, flexing (bending) your legs occasionally can help keep blood circulating. If you have mild to moderate varicose veins, elevating your legs can help reduce leg swelling and relieve other symptoms.
  • Compression stockings: These elastic stockings squeeze or compress the veins and prevent blood from flowing backward. Compression stockings must be graduated, medical-grade compression to be beneficial. Over the counter,support hose or TED hose are not adequate to reduce symptoms in venous disease for active patients.
  • Supplements such as horse chestnut and grape seed extract can help reduce symptoms of venous disease. Check with your doctor before starting supplements.
  • Anti-inflammatory medications such as ibuprofen.
  • Anti-inflammatory topical agents such as OTC Arnica, or prescription voltaren gel may be helpful for painful phlebitis.
  • Ice packs can be applied to veins that are tender to reduce inflammation

 

Leg veins have one-way valves that prevent blood from flowing backward. Diseased valves are ‘leaky’ and allow blood flow both forward and backward, eventually causing bulging of the veins, i.e., varicose veins.

 

The valves inside the leg veins can be seen on ultrasound. 

 

 For more information and to book a consultation, please give our office a call at 858-550-0330. 

 

For more information please check out our Youtube Channel at this link.

 

For more information on varicose veins and eliminating underlying venous insufficiency, check this link out full of resources. 

 

What you need to know about vein valves2022-07-20T15:40:53-07:00

What you need to know about varicose veins and pregnancy

It’s important to know about your vein health during pregnancy.

It’s estimated that 70% to 80% of pregnant women develop varicose veins during the first trimester. Pregnancy causes an increase in blood volume; however, it’s the hormonal changes that cause the veins to enlarge. Elevated levels of progesterone, which the body produces to stabilize the uterus, allow the veins to dilate. Later, the uterus enlarges and causes increased pressure on the veins in the pelvic area. While varicose veins often disappear after delivery, the venous valves are damaged. When varicose veins are still visible after three months, it’s time to contact a vein specialist. It’s important you look good, feel good, and remain healthy—particularly after pregnancy. Here is some helpful information to better understand varicose veins. 

 

Varicose Veins and Venous Reflux Disease

Varicose veins are the twisted, bulging veins just beneath the surface of the skin. Varicose veins are swollen, twisted veins that you can see just under the surface of the skin. These veins usually occur in the legs, but they also can form in other parts of the body. Varicose veins are a common condition.

What causes varicose veins?

Varicose veins are caused by leaky vein valves, which allow blood to pool within the veins causing them to stretch and become enlarged. Varicose veins can be an isolated finding, but the majority of the time, they are caused by underlying venous reflux disease. Venous reflux disease is also known as venous stasis, venous insufficiency or venous incompetence. Reflux may occur in the deep and/or superficial leg veins.

In our study, led by Dr. Nisha Bunke and published in the Journal of Vascular Ultrasound in 2018, we studied over 1,000 legs with varicose veins. Over 90% of the time, the source of the varicose veins were the great and small saphenous veins. The Great Saphenous Vein (GSV) courses up the middle of the thigh and calf and the small saphenous vein (SSV), which courses along the back of the calf. Normally, there are one-way valves within the leg veins, which help blood flow in one direction: toward the heart. This means blood is traveling against gravity. The calf muscle also helps move blood toward the heart. When vein valves are leaky, blood flows backward (reflux) towards the feet. Blood pools in the lower legs, causing bulging veins at the surface.

What are the symptoms of varicose veins and venous reflux disease?

The symptoms can include:

  • Aching, tenderness
  • Heaviness, fatigue
  • General restlessness in the legs
  • Burning pain
  • Throbbing pain
  • Itching
  • Leg cramps, particularly at night
  • Ankle swelling
  • Skin discoloration at the ankle
  • Skin ulcers above the ankle

Over time, complications can develop from untreated veins. These include:

  • Superficial phlebitis (painful inflammation of the vein)
  • Superficial thrombophlebitis (blood clots within the varicose veins)
  • Spontaneous vein hemorrhage (the vein can rupture spontaneously)
  • Skin discoloration and eczema around the ankle (venous eczema)
  • Skin sores or ulcers usually near the ankle

If you experience any vein disease symptoms, please call our office at (858)-550-0330 to schedule a consultation with one of our knowledgeable doctors at La Jolla Vein and Vascular. 

 

For more information on vein health please check out our Youtube Channel or visit our helpful guide of resources. 

 

What you need to know about varicose veins and pregnancy2022-12-13T13:19:49-08:00

Signs of Venous Disease

Signs of Chronic Venous Insufficiency & Venous Disease

Chronic venous insufficiency (CVI) is an inflammatory condition caused by long standing, untreated venous reflux disease which can cause very unique signs and symptoms.  Commonly, venous reflux disease causes a collection of symptoms such as leg swelling, heaviness, fatigue and varicose veins. But, over time, when blood is no longer circulating properly in the leg veins, skin changes can also appear. When skin changes appear, this is termed, chronic venous insufficiency (CVI). Venous stasis is another term used for this condition.   Chronic inflammation from CVI causes the skin around the ankles to darken, become dry, itchy, and firm. In severe cases, the skin can start to break down and ulcerate. The ulcer (wound) occurs in the inner or outer ankle and is also referred to as a stasis ulcer or venous ulcer.

Venous stasis skin changes associated with venous insufficiency include:

  • Darkening of the skin along the ankles
  • Itching and dry skin around the ankles (venous eczema)
  • Development of wounds around the ankles, called venous leg ulcers

HOW IS CVI TREATED?

The treatment of CVI cannot reverse the skin changes but it can prevent it from worsening and ulceration. In our experience, treatment of underlying venous reflux reduces the inflammatory changes and the skin may become less itchy and dry, but the permanent skin discoloration does not disappear. Treatment involves correction of the underlying venous reflux.

HOW ARE LEG ULCERS TREATED?

Venous leg ulcers, depending on the severity can be healed with a combination of correction of the underlying venous reflux, wound care clinic referral, and compression therapy. A detailed ultrasound will determine what specific treatment is needed depending on where the underlying reflux lies (for example, in the saphenous veins, perforator veins and tributaries). Deep vein reflux is also present in many individuals with ulcers.

Recognize the signs and symptoms of venous disease:

-heavy, tired and aching legs

-swollen legs and or ankles

-cramping in the legs

-dull or sharp pain in the calf

-varicose veins and spider veins

-red or warm veins

-itching around the veins

-skin changes around the ankles such as pigmentation, brownish discoloration, eczema, new red and blue veins, breakdown of the skin

-Heavy legs are a common sign of venous insufficiency and varicose veins.You should see your vascular specialist for any of the above signs and symptoms

If you experience any vein disease symptoms or signs, please call our office at (858)-434-5998 to schedule a consultation with one of our knowledgeable doctors at La Jolla Vein and Vascular. 

 

For more information on vein health please check out our Youtube Channel or visit our helpful guide of resources. 

 

 

 

 

 

Signs of Venous Disease2022-07-20T15:06:13-07:00

Vein Disease Prevention

What is chronic venous insufficiency and how can you understand it for vein disease prevention?

Chronic venous insufficiency (CVI) is an inflammatory condition caused by long standing, untreated venous reflux disease.  Commonly, venous reflux disease causes a collection of symptoms such as leg swelling, heaviness, fatigue and varicose veins. But, over time, when blood is no longer circulating properly in the leg veins, skin changes can also appear. When skin changes appear, this is termed, chronic venous insufficiency (CVI). Venous stasis is another term used for this condition.   Chronic inflammation from CVI causes the skin around the ankles to darken, become dry, itchy, and firm. In severe cases, the skin can start to break down and ulcerate. The ulcer (wound) occurs in the inner or outer ankle and is also referred to as a stasis ulcer or venous ulcer.

Venous stasis skin changes associated with venous insufficiency include:

  • Darkening of the skin along the ankles
  • Itching and dry skin around the ankles (venous eczema)
  • Development of wounds around the ankles, called venous leg ulcers

When it comes to vein disease it is certainly possible to take measures that will help. Remember that varicose veins are veins that have been stretched so often that they have become chronically dilated. The trick is to limit the opportunity to distend the veins.

Here are some helpful tips to aid in vein disease prevention:

  1. Wear compression stockings
  2. stay fit and maintain a healthy weight
  3. exercise: exercising helps your veins pump blood.
  4. avoid prolonged sitting or standing
  5. avoid prolonged exposure to direct sunlight
  6. elevate your legs as much as possible
  7. Exercising the muscles in your legs helps your veins pump blood. This, in turn, will reduce the pressure within the veins and can help reduce symptoms related to vein problems

If you experience any vein disease symptoms, please call our office at (858)-550-0330 to schedule a consultation with one of our knowledgeable doctors at La Jolla Vein and Vascular. 

 

For more information on vein health and vein disease prevention please check out our Youtube Channel or visit our helpful guide of resources. 

 

Vein Disease Prevention2022-12-13T13:16:18-08:00

Results of non surgical vein treatment

At La Jolla Vein and Vascular, we treat venous reflux disease which includes varicose veins. Venous reflux disease is also known as venous stasis, venous insufficiency or venous incompetence. Venous reflux disease refers to ‘leaky valves’ in the veins of the legs. Reflux may occur in the deep and/or superficial leg veins. The deep veins are those within the muscle; they bring at least 80-90% of the blood from the legs back to the heart. The superficial veins are outside of the muscle and under the skin.

The main superficial veins are the Great Saphenous Vein that courses up the middle of the thigh and calf and the small saphenous vein, which courses up the back of the calf. Normally, there are one-way valves within the leg veins, which help blood flow in one direction: toward the heart. This means blood is traveling against gravity.

The calf muscle also helps move blood toward the heart. When vein valves are leaky, blood flows backward (reflux) towards the feet. Blood pools in the lower legs, causing bulging veins at the surface. Symptoms include leg heaviness, leg fatigue, leg pain, ankle swelling, phlebitis (inflamed and painful veins), restless legs at night, and night cramps.

Venous reflux disease is progressive and worsens over time. Skin changes may also develop, including darkening of the skin around the ankles. The darkening of the skin is sometimes referred to as venous stasis skin changes. The skin can become dry and itchy (venous eczema). Eventually, the skin can break down causing a wound, called a venous leg ulcer.

 

Below you will see various before and after pictures of non-surgical removal of varicose veins at La Jolla Vein and Vascular. The before picture shows bulging varicose veins that arise from an incompetent great saphenous vein (this vein is not visible to the naked eye). In the past, these veins would have been stripped with vein stripping surgery. Fortunately, new technology allows for even large varicose veins to be removed without surgery. This patient underwent radiofrequency ablation (or endovenous ablation) of the great saphenous vein and foam sclerotherapy of the bulging varicose veins at La Jolla Vein and Vascular. 

varicose veins varicose veins 9 10 11 12 1

If you experience any vein disease symptoms, please call our office at (858)-434-5998 to schedule a consultation with one of our knowledgeable doctors at La Jolla Vein and Vascular. 

 

For more information on vein health please check out our Youtube Channel or visit our helpful guide of resources. 

 

Results of non surgical vein treatment2022-07-20T14:37:06-07:00

Blood Clotting & Vein Health

When blood moves too slowly in your veins, it can cause a clump of blood cells (a blood clot or Thrombus). Deep vein thrombosis (DVT) is a condition in which a blood clot forms in the deep vein located in the leg, thigh, or pelvis. While Deep vein thrombosis (DVT) is common in the lower leg, it can also develop in other body parts, including the arms. So, how do blood clots form in the veins, and is it dangerous? 

To answer this, let us look at how the blood circulates in the body. The blood circulatory system consists of two blood vessels, namely the arteries and veins. The arteries carry blood rich in nutrients and oxygen from the heart, while the veins carry the deoxygenated blood back to the heart. Arteries have thin muscles within their walls that make them capable of withstanding the pumping pressure from the heart. However, the veins have no muscle lining and entirely depend on the muscle movement to take the blood back to the heart. 

Blood clots may form when something slows or changes the flow of blood in the veins. Risk factors include:

  • After a pacemaker catheter has been passed through the vein in the groin
  • Bedrest
  • Cigarette smoking
  • Family history of blood clots
  • Fractures in the pelvis or legs
  • Giving birth within the last 6 months
  • Heart failure
  • Obesity
  • Recent surgery (especially hip, knee, or female pelvic surgery)
  • Too many blood cells being made by the bone marrow (polycythemia vera), causing the blood to be thicker and slower than normal

You’re also more likely to develop DVT if you have any of the following conditions:

  • Blood that is more likely to clot (hypercoagulability)
  • Cancer
  • Taking estrogens or birth control pills.
  • Long airplane flights: London’s Heathrow Airport reports one passenger death a month from DVT. One nearby hospital recorded thirty passenger deaths from DVT in the past three years including a 28-year-old man. To reduce the risk of DVT during air travel,  passengers are advised to wear compression stockings on flights, frequently moving around the cabin and pumping the calf muscles, leg elevation and avoidance of sedentary positions for long periods of time without moving.

 

An interesting finding: A point mutation (G20210A) in the Factor II (prothrombin) gene is the second most common cause of inherited blood clots and accounts for 20% of the inherited blood clotting disorders. The incidence of this mutation in the Caucasian population is 1-2% and in African Americans it is 0.1%. Carriers of this mutation have an increased risk (3x) of developing a blood clot in the deep veins (deep venous thrombosis or DVT).  A test for this mutation is usually only recommended if there is a family history of blood clots (DVT) or in cases where the cause of the blood clot is not clear or in pregnant women with recurrent miscarriages.  A more common cause of a blood clotting disorder that is inherited from the parents is the Factor V Leiden mutation.

 

If you experience any vein disease symptoms, please call our office at (858)-550-0330 to schedule a consultation with one of our knowledgeable doctors at La Jolla Vein and Vascular. 

For more information on vein health please check out our Youtube Channel or visit our helpful guide of resources.

Blood Clotting & Vein Health2022-12-13T13:24:38-08:00

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