11, 5, 2023

Patient Transformation: Varicose Veins

2023-02-15T19:12:23-08:00

Varicose Veins: Patient Transformation!

What are varicose veins?

In the pictures below you can see in the patient case that they are the twisted, bulging veins just beneath the surface of the skin. These 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 them?

Varicose veins are caused by leaky vein valves, which allow blood to pool within the veins causing them to stretch and become enlarged. These 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. 

As you can see below, these patient transformations after varicose vein treatment are remarkable! 

transformation transformation transformation 52 BA VV varicose DSCF9790 fotor 2 1

“Bringing Experts Together for Unparalleled Vein and Vascular Care”

La Jolla Vein & Vascular (formerly La Jolla Vein Care) is committed to bringing experts together for unparalleled vein and vascular care. 

Nisha Bunke, MD, Sarah Lucas, MD, and Elliot DeYoung, MD are specialists who combine their experience and expertise to offer world-class vascular care. 

Our accredited center is also a nationally known teaching site and center of excellence. 

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

 

For a deeper dive into vein and vascular care, 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. 

Please follow our social media Instagram Profile and Tik Tok Profile for more fun videos and educational information. 


Patient Transformation: Varicose Veins2023-02-15T19:12:23-08:00

Venous reflux disease 101

2023-02-15T19:01:31-08:00

In addition to your physical exam findings and medical history, an ultrasound examination is an important tool in the assessment of venous disease. Not all venous disease is visible to the naked eye, and it usually arises from veins that are beneath the surface of the skin, only visible by ultrasound technology.

The ultrasound allows us to see if the valves are leaky; it can detect the direction of blood flow and also detects blockages in the veins, for example from blood clots or scars within the veins from previous clots.  The ultrasound will determine exactly which veins are ‘bad’ or incompetent.  Reflux may be detected in the deep veins (within the muscle), the great and small saphenous veins, and/or branches of the saphenous veins.  This will help determine the treatment plan.

Below are some photographs from our ultrasound exams. Take a peak for an inside look on what to expect during your ultrasound appointment. 

venousvenous11reflux

“Bringing Experts Together for Unparalleled Vein and Vascular Care”

La Jolla Vein & Vascular (formerly La Jolla Vein Care) is committed to bringing experts together for unparalleled vein and vascular care. 

Nisha Bunke, MD, Sarah Lucas, MD, and Elliot DeYoung, MD are specialists who combine their experience and expertise to offer world-class vascular care. 

Our accredited center is also a nationally known teaching site and center of excellence. 

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

 

For a deeper dive into vein and vascular care, 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. 

Please follow our social media Instagram Profile and Tik Tok Profile for more fun videos and educational information. 


Venous reflux disease 1012023-02-15T19:01:31-08:00

How can you tell your vein disease is worsening?

2023-02-15T18:57:27-08:00

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.

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.

 

“Bringing Experts Together for Unparalleled Vein and Vascular Care”

La Jolla Vein & Vascular (formerly La Jolla Vein Care) is committed to bringing experts together for unparalleled vein and vascular care. 

Nisha Bunke, MD, Sarah Lucas, MD, and Elliot DeYoung, MD are specialists who combine their experience and expertise to offer world-class vascular care. 

Our accredited center is also a nationally known teaching site and center of excellence. 

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

 

For a deeper dive into vein and vascular care, 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. 

Please follow our social media Instagram Profile and Tik Tok Profile for more fun videos and educational information. 


How can you tell your vein disease is worsening?2023-02-15T18:57:27-08:00

Treatments for varicose veins

2023-02-15T18:53:12-08:00

Conservative Management & Lifestyle Modifications

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

Procedures for Treating Varicose Veins

 

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 or Venaseal.

The treatment recommendation is customized, based on where reflux is present and other factors that need to be considered when making this decision.

These will involve the following:

  • Your age, overall health, and medical condition.
  • Extent of the condition.
  • The findings of your venous ultrasound.
  • Your signs and symptoms.
  • Your tolerance of specific medicines, procedures, or therapies.
  • Expectations for the course of the condition.
  • Your opinion or preference.

Step 2: Varicose Vein Treatment

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). Phlebectomy is another option which includes making small incisions to remove the vein.

 

“Bringing Experts Together for Unparalleled Vein and Vascular Care”

La Jolla Vein & Vascular (formerly La Jolla Vein Care) is committed to bringing experts together for unparalleled vein and vascular care. 

Nisha Bunke, MD, Sarah Lucas, MD, and Elliot DeYoung, MD are specialists who combine their experience and expertise to offer world-class vascular care. 

Our accredited center is also a nationally known teaching site and center of excellence. 

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

 

For a deeper dive into vein and vascular care, 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. 

Please follow our social media Instagram Profile and Tik Tok Profile for more fun videos and educational information. 


Treatments for varicose veins2023-02-15T18:53:12-08:00

Patient Reviews & Testimonials

2023-02-15T18:48:11-08:00

La Jolla Vein & Vascular is a state-of-the-art medical center dedicated exclusively to the patient and the diagnosis and treatment of vein and arterial conditions.

 

Vein conditions of the patients we see and treat include varicose veins, spider veins, and venous leg ulcers, chronic venous insufficiency, edema, lymphedema, and deep vein thrombosis.  Arterial conditions and treatments such as peripheral arterial disease (PAD), atherectomy, angioplasty, stenting.  We also offer prostate artery embolization (PAE) to treat BPH, varicocele embolization for men and uterine fibroid embolization (UFE), pelvic venous congestion (PVCS), pelvic and labial varicose veins for women.  Osteoarthritis treatment includes genicular artery embolization (GAE) to alleviate knee pain due to arthritis in the patient. 

 

Below are some patient reviews and testimonials. 

patient patient 11 4 12 4

 

“Bringing Experts Together for Unparalleled Vein and Vascular Care”

La Jolla Vein & Vascular (formerly La Jolla Vein Care) is committed to bringing experts together for unparalleled vein and vascular care. 

Nisha Bunke, MD, Sarah Lucas, MD, and Elliot DeYoung, MD are specialists who combine their experience and expertise to offer world-class vascular care. 

Our accredited center is also a nationally known teaching site and center of excellence. 

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

 

For a deeper dive into vein and vascular care, 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. 

Please follow our social media Instagram Profile and Tik Tok Profile for more fun videos and educational information. 


Patient Reviews & Testimonials2023-02-15T18:48:11-08:00

Patient Transformation: Spider Veins

2023-02-15T18:42:47-08:00

What are spider veins?

Spider veins are the fine, thread-like reddish veins at the surface of the skin. These veins are not healthy. Veins are often considered a cosmetic issue, but they can be associated with underlying feeder veins, not visible to the naked eye.  Feeder veins are the ‘blue veins’ also known as ‘reticular veins,’ that give rise to spider veins. Spider veins may also be a sign of underlying venous insufficiency. For example, spider veins located in the inner ankles and inner thighs can indicate an underlying problem with the saphenous vein. As a result, an ultrasound examination may be recommended to identify and effectively treat the underlying source of these veins.

What are the symptoms?

Vein conditions affect people differently. For some, these veins can be a painless cosmetic concern, and for others they may cause symptoms. The most common symptoms of spider veins are burning, throbbing, and localized pain. They can also feel hot and itchy and bleed.

What causes them?

Spider veins in the legs are caused by the same condition that causes varicose veins. Leaky vein valves allow blood to pool within the veins causing them to stretch and become enlarged. These veins on other areas of the body, such as the face, and chest can be caused by sun damage, hormone changes or liver disease. Hormones, such as with pregnancy, birth control or hormone replacement therapy can weaken the vein wall.

Below you can see the transformation of 3 of our patients who received vein treatment.

spider spider spider

“Bringing Experts Together for Unparalleled Vein and Vascular Care”

La Jolla Vein & Vascular (formerly La Jolla Vein Care) is committed to bringing experts together for unparalleled vein and vascular care. 

Nisha Bunke, MD, Sarah Lucas, MD, and Elliot DeYoung, MD are specialists who combine their experience and expertise to offer world-class vascular care. 

Our accredited center is also a nationally known teaching site and center of excellence. 

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

 

For a deeper dive into vein and vascular care, 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. 

Please follow our social media Instagram Profile and Tik Tok Profile for more fun videos and educational information. 


Patient Transformation: Spider Veins2023-02-15T18:42:47-08:00

Self care for varicose veins

2023-02-15T18:32:05-08:00

Conservative management and lifestyle changes can ease the symptoms of varicose veins and help reduce complications such as thrombophlebitis (blood clots within veins) and vein rupture, but do not cause the veins to vanish.  These measures are helpful if an individual is not a candidate for vein procedures or wishes to delay interventional treatment. Conservative options include:

Compression stockings: These elastic stockings squeeze or compress the veins to help circulate blood. The compression stockings prevent blood from flowing backward and pooling in the legs. Compression stockings must be graduated, medical grade compression to be beneficial. TED hose are not adequate to reduce symptoms in venous disease for active patients. Compression stockings come in different strengths and the most common strength for the treatment of varicose veins is 20-30mmhg. Your doctor should advise you which strength of compression stockings you should wear. In patients with peripheral arterial disease (PAD), diabetics, and neuropathies, compression may be contraindicated or lesser strengths of compression may be advised

Avoid inactivity: Standing or sitting for long periods of time can aggravate your vein condition.  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 10 times an hour. When standing, raise yourself up and down on your toes or rock back and forth on your heels.

heat can worsen symptoms of leg pain and varicose veins

Dietary Supplements:  Supplements such as horse chestnut and grape seed extract can help reduce symptoms of venous disease. Vasculera is a prescription medication that may be helpful for some. Always check with your PCP before starting supplements or new medications as there may be side effects.

 

Dietary Changes and High Fiber Diet:  A flavonoid rich diet including berries, green teas can reduce inflammation and pain. A high fiber diet can increase abdominal pressure and may be helpful for varicose veins. Make sure to drink plenty of water with your high fiber diet.

Anti-inflammatory Medications  are helpful to reduce pain and inflammation, but check with your doctor first to make sure you don’t have contraindications to using them. Ibuprofen and Advil are common oral anti-inflammatory medications. There are also anti-inflammatory cream or gels that can be applied topically to the painful veins, such as Voltaren gel.

Ice Packs and heating pads can be applied to tender veins. Ice packs and heating pads can be used in an alternating manner.

Weight loss or maintaining a healthy weight: Being overweight puts extra pressure on your veins.



“Bringing Experts Together for Unparalleled Vein and Vascular Care”

La Jolla Vein & Vascular (formerly La Jolla Vein Care) is committed to bringing experts together for unparalleled vein and vascular care. 

Nisha Bunke, MD, Sarah Lucas, MD, and Elliot DeYoung, MD are specialists who combine their experience and expertise to offer world-class vascular care. 

Our accredited center is also a nationally known teaching site and center of excellence. 

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

 

For a deeper dive into vein and vascular care, 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. 

Please follow our social media Instagram Profile and Tik Tok Profile for more fun videos and educational information. 


Self care for varicose veins2023-02-15T18:32:05-08:00

28, 4, 2023

Patient Reviews & Testimonials

2023-02-15T17:19:10-08:00

La Jolla Vein & Vascular is a state-of-the-art medical center dedicated exclusively to the diagnosis and treatment of vein and arterial conditions for patient care.  

 

Vein conditions that we treat for patient care include varicose veins, spider veins, and venous leg ulcers, chronic venous insufficiency, edema, lymphedema, and deep vein thrombosis.  Arterial conditions and treatments such as peripheral arterial disease (PAD), atherectomy, angioplasty, stenting.  We also offer prostate artery embolization (PAE) to treat BPH, varicocele embolization for men and uterine fibroid embolization (UFE), pelvic venous congestion (PVCS), pelvic and labial varicose veins for women.  Osteoarthritis treatment includes genicular artery embolization (GAE) to alleviate knee pain due to arthritis in the patient. 

 

Below are some patient reviews and testimonials. 

patient patient patient 11 3 12 3

 

“Bringing Experts Together for Unparalleled Vein and Vascular Care”

La Jolla Vein & Vascular (formerly La Jolla Vein Care) is committed to bringing experts together for unparalleled vein and vascular care. 

Nisha Bunke, MD, Sarah Lucas, MD, and Elliot DeYoung, MD are specialists who combine their experience and expertise to offer world-class vascular care. 

Our accredited center is also a nationally known teaching site and center of excellence. 

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

 

For a deeper dive into vein and vascular care, 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. 

Please follow our social media Instagram Profile and Tik Tok Profile for more fun videos and educational information. 


Patient Reviews & Testimonials2023-02-15T17:19:10-08:00

Sclerotherapy 101

2023-02-15T17:11:37-08:00

Sclerotherapy Treatment for Spider Veins

sclerotherapy

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.

What should I expect on my treatment days?

sclerotherapy

Sclerotheraphy Injecting Foam Sclero into vein

You will sign your consent form then change into shorts provided by the office. We will clean your skin with alcohol.  The sclerosant medication will then be injected into your veins with a fine needle.  After your treatment, we will help you into your compression stockings, then you will walk for 30 minutes prior to getting in your car.  It is normal for your legs to be achy and tender to the touch after treatment

 

“Bringing Experts Together for Unparalleled Vein and Vascular Care”

La Jolla Vein & Vascular (formerly La Jolla Vein Care) is committed to bringing experts together for unparalleled vein and vascular care. 

Nisha Bunke, MD, Sarah Lucas, MD, and Elliot DeYoung, MD are specialists who combine their experience and expertise to offer world-class vascular care. 

Our accredited center is also a nationally known teaching site and center of excellence. 

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

 

For a deeper dive into vein and vascular care, 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. 

Please follow our social media Instagram Profile and Tik Tok Profile for more fun videos and educational information. 


Sclerotherapy 1012023-02-15T17:11:37-08:00

FDA Approved treatment to treat varicose veins

2023-02-15T17:06:00-08:00

The U.S. Food and Drug Administration (FDA) approved the VenaSeal™ closure system to permanently treat varicose veins by sealing the affected superficial veins using an adhesive agent.

The VenaSeal™ Sapheon Closure System

is a unique, minimally invasive treatment that uses a safe-for-the-body medical glue to quickly and effectively treat varicose veins (venous reflux disease). Using ultrasound, a doctor will guide a tiny catheter through a small access site in the skin and into the diseased area of the vein. Next, the VenaSeal™ dispenser delivers a very small amount of medical glue to close the vein. Once the affected vein is closed, blood is immediately re-routed through other healthy veins in the leg.

Unlike other treatments, VenaSeal™ does not require anesthesia to be injected into the leg via multiple needle sticks (tumescent anesthesia), and because there are no pre-procedures drugs involved, patients can return to their normal activities right after the treatment. Unlike heat-based procedures, with VenaSeal™ there is no risk of skin burns or nerve damage. VenaSeal™ usually does not require any post-treatment pain medication or uncomfortable compression stockings.’

varicose

The VenaSeal™ closure system is the only non-tumescent, non-thermal, non-sclerosant procedure that uses a proprietary medical adhesive delivered endovenously to close the vein. This unique approach eliminates the risk of nerve injury when treating the small saphenous vein, which is a risk sometimes associated with certain thermal-based procedures. Clinical studies have demonstrated that the procedure is safe and effective.

varicose

“Bringing Experts Together for Unparalleled Vein and Vascular Care”

La Jolla Vein & Vascular (formerly La Jolla Vein Care) is committed to bringing experts together for unparalleled vein and vascular care. 

Nisha Bunke, MD, Sarah Lucas, MD, and Elliot DeYoung, MD are specialists who combine their experience and expertise to offer world-class vascular care. 

Our accredited center is also a nationally known teaching site and center of excellence. 

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

 

For a deeper dive into vein and vascular care, 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. 

Please follow our social media Instagram Profile and Tik Tok Profile for more fun videos and educational information. 


FDA Approved treatment to treat varicose veins2023-02-15T17:06:00-08:00
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