4, 8, 2022

Cellulitis & Varicose Veins

2022-07-19T17:21:50-07:00

Complications of Untreated Varicose Veins and Venous Insufficiency: Cellulitis

Cellulitis is a bacterial infection of the skin and tissues beneath the skin. Cellulitis infections can occur in the legs of people with untreated varicose veins and chronic venous insufficiency.  The reason for this is chronic venous insufficiency-which causes inflammation within the skin and underlying tissues. This inflammatory process causes the skin to become firm, eczema-like, dry, itchy, and fragile. Healthy skin acts as a barrier to bacteria, preventing infections. But, in chronic venous insufficiency, the skin is fragile and this barrier is susceptible to bacterial infections that can enter the tissues through cracks or breakages within the skin.  In chronic venous insufficiency, the skin around the ankles is most affected and infections can begin here.

Cellulitis usually begins as a small area of pain and redness on the skin. This area spreads to surrounding tissues, resulting in the typical signs of inflammation such as redness, swelling, warmth, and pain. Fever and chills may develop and the redness will spread affecting more of the leg. It is treated with antibiotics. If you believe you have signs of cellulitis, you need to contact your doctor right away as untreated cellulitis can spread rapidly.

This complication can be avoided by treating the varicose veins and eliminating underlying venous insufficiency, which will, in turn, reduce inflammation and improve the skin condition. 

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

Practicing good skin hygiene is important. Keep your skin moisturized so that it doesn’t flake or crack easily. If the skin is not broken or leaking fluid but is inflamed, your doctor may recommend an anti-itch cream, such as one containing hydrocortisone; a cream containing zinc oxide to protect the skin; or an antifungal cream to prevent fungal infections.

Skin that is leaking fluid is treated with wet compresses. If you have ulcers on your legs, we at La Jolla Vein & Vascular will show you how to apply layered compression bandages to protect the skin and maintain blood flow.

 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.

Cellulitis & Varicose Veins2022-07-19T17:21:50-07:00

What you need to know about DVT

2022-07-16T18:48:04-07:00

What do Serena Williams, Richard Nixon, Dan Quayle, Dick Cheney and David Bloom have in common? They have all suffered a potentially fatal deep venous thrombosis (DVT).

Deep venous thrombosis (DVT) mainly affects the large veins in the lower leg and thigh. The clot can block blood flow and cause swelling and pain. When a clot breaks off and moves through the bloodstream, this is called an embolism. An embolism can get stuck in the brain, lungs, heart, or another area, leading to severe damage.

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.

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. 

 

What you need to know about DVT2022-07-16T18:48:04-07:00

What you need to know about Sclerotherapy procedure

2022-07-16T18:32:09-07:00

Today, sclerotherapy is clearly the gold standard for removing spider and varicose veins. During this procedure, a specially trained physician injects a safe sclerosing agent directly into the blood vessel. The effectiveness of the procedure comes as a direct result of the training, experience, and judgment of the physician to make sure that the sclerosant’s volume, concentration, and exposure time are exactly right. 

 

What happens next? The solution displaces the blood in the vein, causing it to immediately appear lighter in color. The solution irritates the vein lining, causing it to collapse and blocking it from receiving more blood. Within a few weeks, the unused vein is absorbed by the body and disappears. With advancements in medicine, there’s no reason to go under the knife anymore—sclerotherapy is a safe, effective, and cost effective alternative to surgery.

 

Sclerotherapy Treatment for Spider Veins

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.

Below are a few patient cases after Sclerotherapy Treatment which you will see the before and after results. 

sclerotherapysclerotherapy

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. 

 

What you need to know about Sclerotherapy procedure2022-07-16T18:32:09-07:00

3 Ways to keep your legs looking healthy and beautiful

2022-07-16T18:16:24-07:00

Keeping your legs beautiful might require a little help. Varicose veins, for example, affect a large number of people around the world every year. In the United States alone, up to 55% of women are likely to experience vein-related problems in their legs, which can cause undesirable skin changes. There are three ways you can keep your legs looking healthy and beautiful. Sclerotherapy procedure, and using RECOVA Cream to reduce swelling and bruising and increase smoothness in legs. 

 

Today, varicose veins are easily treated through a procedure called sclerotherapy. As your veins disappear after treatment, you might want to know if they’re gone for good. While properly treated veins are removed permanently, new veins may eventually appear. Why? Different veins (that were not previously treated) may have weak valves that give over time, eventually resulting in new varicose veins. The good news? These veins can be easily removed using the same treatment. Take comfort in knowing you can easily remove your varicose veins now—and that you have a safe and easy option for keeping your legs beautiful for the rest of your life.

 

After vein treatment, there can be swelling, bruising, or redness on your legs which can be easily treated with RECOVA Cream. One of the most common side effects after surgery is bruising. Whether it is due to plastic surgery or vein surgery, bruising and swelling are inevitable. One of the most powerful tools that we recommend for patients undergoing any type of surgery is RECOVA post surgery cream. Another way is to use RECOVA to increase smoothness in your legs. 

 

Dr Nishe Bunke created RECOVA cream as a post surgical recovery cream specifically designed to reduce bruising, swelling, redness, and pain. RECOVA skin creams are packed with antioxidants and natural ingredients that promote healing and reduce inflammation. 

 

RECOVA cream aids in reducing pain, swelling, and discoloration after cosmetic surgery, injections, and procedures, laser treatments, varicose vein procedures, Sclerotherapy, minor injuries, and easy bruising. 

 

Our patients at La Jolla Vein Care have seen quick transformation post procedures. The combination of natural ingredients in RECOVA cream helps aid in quicker recovery.

 

 The powerful ingredients included in RECOVA are listed below:  

 

Arnica Montana is a flower extract that helps with inflammation, swelling, and bruise recovery. 

 

Grapeseed Oil has numerous benefits and includes numerous vitamins such as vitamin E. It is a flavonoid that aids in chronic venous insufficiency, varicose veins, and edema. 

 

Bromelain is an enzyme that is a natural remedy for inflammation and swelling.

 

Horse Chestnut is used to improve poor blood circulation, reduce swelling, and for varicose vein symptoms. 

 

Caprylhydroxamic Acid is an amino acid derived from coconut oil used as a gentle preservative that ensures product safety and longevity. 

 

Witch Hazel is used for swelling and inflammation. It is used to shrink varicose veins and hemorrhoids as well as reduce rosacea and clear redness of the skin. 

 

Butcher’s Broom is used for natural anti-inflammatory properties. It is used to reduce swelling and reduce varicose vein symptoms. 

 

Sunflower Seed Oil is packed with vitamins A, E, C, and D. 

 

Menthol is not present in the tinted RECOVA, since Tinted Arnica is often used around the eyes. 

 

The combination of these ingredients contributes to an overall comforting and healing sensation when applied to the skin and legs. 

 

RECOVA is a tool that stands out due to its natural ingredients that aid in venous disease symptoms. RECOVA is hypoallergenic, and non comedogenic. RECOVA is also free of parabens, phthalates, preservatives, synthetic additives, and dyes, and never tested on animals. 

 

Patients have used RECOVA cream after vein procedures for their legs and have seen quick and lasting results. We recommend physicians offer this for patients if they complain of redness, itching, and bruising after their procedures. RECOVA offers immediate soothing relief of discomfort for our patients. 

 

Check out RECOVA online for more information and to purchase RECOVA tinted arnica cream and RECOVA post surgery cream. 

 

3 Ways to keep your legs looking healthy and beautiful2022-07-16T18:16:24-07:00

29, 7, 2022

Complications of untreated vein disease

2022-12-13T13:17:26-08:00

Varicose veins and their underlying cause, vein disease can cause a wide array of symptoms, including leg pain, swelling, aching, heaviness, restless legs, and nocturnal leg cramps. 

If left untreated, superficial venous reflux disease can progress to cause skin changes and other complications. 

Complications of untreated vein disease include:

  1. Superficial Thrombophlebitis (STP) 

A thrombophlebitis is swelling and inflammation of a vein caused by a blood clot. There are two main types of thrombophlebitits: deep venous thrombosis (affects deeper, larger veins) and superficial thrombophlebitis (affects veins near the skin surface). This is often referred to as an STP.

The following symptoms are often associated with thrombophlebitis:

Inflammation (swelling) in the part of the body affected

Pain in the part of the body affected

skin redness, warm and tenderness over the vein

Often a ‘hard knot’ or lump can be felt within the vein.

An STP is common complication of varicose veins because blood is pooling and not circulating well. But, it can also indicate an underlying problem with blood clotting. In some cases, there may also be a concurrent blood clot in other veins, such as the deep veins (DVT) which can be serious. For this reason, a duplex ultrasound examination is used to look at the deep veins and other veins not visible to the naked eye for the presence of blood clots.

STP can usually be treated with aspirin or other anti-inflammatory medication to reduce pain and inflammation, compression stockings, and cold/warm packs to also reduce inflammation and discomfort. The discomfort is usually improved within 6 weeks but it can take a few months to resolve.

  1. Deep Venous Thrombosis (DVT)

If the blood clot is in a varicose vein near a deep vein or perforator vein, it can extend into the deep system, causing a DVT. For example, a spontaneously thrombosed great saphenous vein, can extend into the common femoral vein and cause a pulmonary embolism (PE). Also, a varicose vein blood clot can extend into a perforator vein and travel to the deep system. It is important to have an ultrasound examination of superficial blood clots to determine a concurrent DVT is present, determine exact location and extent of the superficial clot to make sure it is not near a deep or perforator vein. If it is, a blood thinner may be recommended or serial ultrasounds to monitor the clot may be recommended.

  1. Spontaneous Vein Hemorrhage

Untreated varicose veins are at a higher than usual risk of bleeding or spontaneous rupture. Over time, varicose veins become larger, and the vein wall becomes weak and stretched out. These veins, which are already weak are also under high pressure (because of venous reflux, or the ‘backflow’ and pooling of blood in these veins). As a result, the high pressure can cause the veins to spontaneous burst and bleed heavily. Because they are under high pressure, they bleed like an arterial bleed and patients describe the bleeding as ‘blood shooting across the room.’ The varicose veins that are susceptible are veins closest to the surface of the skin

Most patients describe that it occurs during or after a warm shower (warm water causes veins to relax and dilate, allowing more blood to pool within the veins) or during sleep. It is painless and patients report that they notice it because they feel something wet in bed. Patients who are on blood thinners can lose large amounts of blood, especially if it occurs while they are sleeping. Some people have required blood transfusions. The small blue spider veins around the ankle are equally at risk of rupture as are the larger bulging veins.If someone you know has experienced bleeding from their varicose veins, they should be seen by a doctor. Treatment will prevent the veins from bursting again. This is a common condition that we see at La Jolla Vein Care.

  1. Venous Leg Ulcer

A leg ulceration is the most severe form of chronic venous insufficiency. This is referred to as a ‘venous leg ulcer.’ Venous leg ulcers make up 70% of all chronic leg wounds. Therefore, the venous leg ulcer is much more common than a diabetic or arterial ulcer. It is caused from long-standing pressure within the leg veins, resulting from 1) venous reflux through faulty valves, 2) a blockage within the deep veins or 3) from the inability to use the calf muscles or a combination. Venous reflux is the most common cause for a venous leg ulcer. The increased pressure within the leg veins (we call this venous hypertension) causes an inflammatory response. Inflammation then causes changes in the skin, usually around the ankles (this is where pressure is the greatest). The inflammatory process will cause the skin around the ankles to become brown or discolored, and eventually the skin will break open. The leg wound can be healed by treating the underlying vein condition. 

  1. Venous stasis and venous eczema

Venous stasis skin changes refers to darkening around the skin. It is associated with itching often, due to inflammation of the skin. It indicates long standing venous disease, called chronic venous insufficiency. Progression can lead to ulceration.

Venous leg ulcers can also be prevented by early intervention with non-invasive procedures. If you have signs of chronic venous insufficiency (such as skin discoloration around the ankles) you should address your underlying vein condition to prevent the skin from breaking open.

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

 

Complications of untreated vein disease2022-12-13T13:17:26-08:00

Improving your vein health through exercise

2022-12-13T14:12:46-08:00

Physical activity and exercise provides a wide range of benefits for vascular health and may help to avoid evolution of mild cases of varicose veins. In fact, exercise is considered to be a fundamental element in improving the symptomatology of patients affected by varicose veins. A sedentary person diagnosed with this medical condition has a much higher risk of worsening the symptoms when compared with an active person with the same condition. This is a result of blood pooling in the veins, causing an increase in venous hypertension and symptoms.

The main goal of exercise in regards to varicose veins is to contract and move the muscles of the leg, helping to pump the blood upwards, avoiding edema or retention of liquid in the ankles. With this in mind, the recommended exercises are those with aerobic characteristics rather than those with anaerobic ones. Through this physical activity, the pressure in the veins is improved, as well as the resulting symptomatology.

Therefore, any exercise that involves moving the lower limbs and promote cyclical muscle contractions is advisable, including stand on tiptoes, move the toes, perform foot bending and rotation, do pedaling movements, among others. These can be easily performed throughout the day without the necessity to go out and exercise, and are especially useful during work hours or while doing daily tasks at home.

When walking or running, pressure is exerted on the sole of the foot, which causes the circulation to be activated from the bottom up, while the constant contraction of the muscles during cycling causes the same effect, but without the presence of high impact, an important factor for those with joint issues.

Swimming is one of the best exercises to practice when affected by varicose veins. The double effect of the water and the movement of the lower limbs cause an incredible increase in blood circulation. This is helpful also for patients who have significant symptoms related to the effects of gravity, like standing.

Other disciplines like yoga, pilates, or rhythmic gymnastics also help stimulate circulation by mobilizing the accumulated blood in the thighs, while relaxing the whole body.

Hiking is a great activity for using the calf-muscle pump. However, in warm weather, symptoms of varicose veins worsen. To get the maximal benefit of exercise and reducing symptoms, outdoor exercising when the weather is cooler, like in the morning is advised.

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

Improving your vein health through exercise2022-12-13T14:12:46-08:00

Blood Clots and Leg Vein Ultrasounds

2022-12-13T14:13:46-08:00

Most vein disease is not visible to the naked eye, but can be detected in a leg vein ultrasound.

What Leg Vein Ultrasound Can Uncover About Your Veins: blood clots and leaky valves

We can see beneath the surface of the skin with an ultrasound. Duplex ultrasound combines Doppler flow information and conventional imaging information, sometimes called B-mode, to allow physicians to see the structure of your blood vessels. Duplex ultrasound uses sound waves to get images of your blood vessels.  It also helps determine how fast blood moves through the vessels. It can also be useful to estimate the diameter of a blood vessel as well as the amount of obstruction, if any, in the blood vessel. Using duplex ultrasound technology, the structure of your blood vessels, the valve function, the movement of your red blood cells, and the direction of blood flow through the vessels, any blockages, blood clots, and leaky valves can be seen.

Venous Reflux (leaky valves)

Ultrasounds of the leg veins that look for leaky valves (venous reflux) are usually performed in the standing position.

The Duplex Ultrasound examination allows us to visualize the blood vessels that are not visible to the naked eye, even blood vessels that are deep within the muscles.  Ultrasound looks at deep and superficial veins in the legs to check for venous reflux or venous-valvular incompetence (the underlying condition that causes varicose veins). The ultrasound examination is used to both identify the veins that have faulty valves and to map the anatomy of the veins, creating a ‘road map.’  This is necessary to make an accurate assessment of the cause and extent of the varicose veins, as well as to formulate the best treatment plan.  This should be done for any individual being evaluated for varicose veins, leg swelling, patients who have failed prior treatment, patients who are symptomatic, and in some patients with certain anatomic patterns of spider veins.

Before your test:

This study does not require any preparation. You should not wear your compression stockings the same day as the examination.  Make sure to be hydrated.

How long does it take?

An ultrasound only checking for blood clots typically takes less than 30 minutes. An ultrasound that looks at both the deep and superficial veins including mapping is less than 60 minutes, the part of this exam that checks if the valves are leaky is performed in the standing position.

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 Clots and Leg Vein Ultrasounds2022-12-13T14:13:46-08:00

The Truth About Restless Leg Syndrome

2022-12-13T13:57:28-08:00

The restless leg syndrome was a reported symptom in 30% of people who suffer from varicose veins, in our study.

Those who suffer from varicose veins often report a feeling of restless leg syndrome, especially at night when in bed. In our study, about 30% of patients with varicose veins complained of nocturnal restless legs.

Restless legs refer to the specific symptoms of restlessness and urge to move the legs. This is different than Restless legs syndrome (RLS), which is a sensorimotor movement disorder characterized by uncomfortable sensations in the legs and an urge to move them.  This is a diagnosis based on a collection of nocturnal symptoms. There are many causes of restless legs syndrome such as neurological disorders, anemia, and kidney disease to name a few, and is often treated with medication. Vascular causes, such as venous insufficiency is often overlooked as a cause for Restless Legs Syndrome. We have case studies of patients who used medication to treat RLS symptoms for years without resolution of symptoms. In our study, 98% of the patients with venous insufficiency and restless legs, had resolution of symptoms following treatment.  In another study, by Hayes, CL et. al, 35 patients with RLS and superficial venous insufficiency underwent endovenous ablation of refluxing superficial veins and ultrasound-guided sclerotherapy of varicose veins. 89% of patients reported alleviation of symptoms.

If a patient has restless legs symptoms and evidence of varicose veins of the legs, a work-up for venous insufficiency should be considered. The workup involves a duplex ultrasound evaluation of the leg veins. This may eliminate the need for medication for RLS in some cases.

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

 

The Truth About Restless Leg Syndrome2022-12-13T13:57:28-08:00

Before & After Varicose Vein Treatment

2022-12-13T13:08:14-08:00

Varicose Veins: Patient Transformations 

What are varicose veins?

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!

varicose veinvaricose veinvaricose vein

 

 

La Jolla Vein Care Before and After Transformations:

 

At La Jolla Vein Care, we are here for our patients from beginning to the end. We love seeing the transformations that take place. Below are a few cases from our patient transformations from before varicose vein treatment to after varicose vein treatment. 

 

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. 

 

Before & After Varicose Vein Treatment2022-12-13T13:08:14-08:00

What a Duplex Ultrasound can detect

2022-06-25T17:57:32-07:00

Duplex ultrasound combines Doppler flow information and conventional imaging information, sometimes called B-mode, to allow physicians to see the structure of your blood vessels. Duplex ultrasound uses sound waves to get images of your blood vessels. It also helps determine how fast blood moves through the vessels. It can also be useful to estimate the diameter of a blood vessel as well as the amount of obstruction, if any, in the blood vessel. Using duplex ultrasound technology, the structure of your blood vessels, the valve function, the movement of your red blood cells and direction of blood flow through the vessels, and any blockages or blood clots can be seen.

 

Diseases of the blood vessels can affect both veins and arteries.

Vascular refers to the blood vessels in the body. There are two main types of blood vessels; the arteries and veins. Arteries bring oxygen-rich blood from the heart to every inch of the body; vein return the blood back to the heart and lungs for more oxygen. Vascular disease is when the blood vessels are no longer healthy.

Common types of vein disease include:

  • Varicose veins
  • Chronic venous insufficiency
  • Deep venous thrombosis

Common types of artery disease includes:

  • Carotid artery disease and stroke (TIA or Stroke)*
  • Lower extremity arterial disease (PAD)**
  • Upper extremity arterial disease
  • Abdominal aortic aneurysm (AAA)

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

 

What a Duplex Ultrasound can detect2022-06-25T17:57:32-07:00

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