24, 8, 2022

Signs of Venous Disease

2022-07-20T15:06:13-07:00

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

2022-12-13T13:16:18-08:00

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

Blood Clotting & Vein Health

2022-12-13T13:24:38-08:00

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

Symptoms of vein disease to look out for

2022-07-20T14:09:35-07:00

An estimated 80 million Americans suffer from a vein-related condition with symptoms. Since most veins lie deep under the skin’s surface, vein disorders are not always visible to the naked eye. As a result, it’s important to be aware of the symptoms that might reveal an underlying vein condition. If you’re experiencing pain, fatigue, heaviness, cramping, or restlessness in your legs, you should seek expert consultation. Today, a venous duplex scan is used to view internal images of your veins, even the veins beneath the muscles (deep veins). The ultrasound exam, which is painless with no additional symptoms takes fewer than 30 minutes, allows a trained specialist to examine your venous system to determine if your symptoms are connected to a vein-related condition. The good news is that many vein conditions can be easily treated. At La Jolla Vein & Vascular, we treat venous reflux disease with a tailored approach to the patient’s needs and symptoms. 

 

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.

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. 

 

Symptoms of vein disease to look out for2022-07-20T14:09:35-07:00

La Jolla Vein Care EXPANDS SERVICES, RENAMES LA JOLLA VEIN & VASCULAR

2022-07-20T13:26:27-07:00

La Jolla Vein Care EXPANDS SERVICES, RENAMES LA JOLLA VEIN & VASCULAR

 

Renowned vein clinic welcomes new physician, offers new services, and rebrands to La Jolla Vein & Vascular

 

La Jolla Vein and Vascular is a leader in vein treatment serving the Southern California community since 2010, announces a new name to reflect their recent expansion of services. La Jolla Vein Care is known for their renowned physicians, technically advanced and innovative approach to vein care. It was one of the first vein centers in the region to earn esteemed accreditation by the Intersocietal Accreditation Commission (IAC) for its dedication to quality patient care, positive patient outcomes, safety and physician expertise in the evaluation and management of superficial venous disorders. IAC accreditation is a “seal of approval” that patients can rely on as an indicator of consistent quality care and a dedication to continuous improvement. Varicose veins affect more than half of one half of Americans age 50 and older. Varicose veins occur when the valves in the leg veins no longer function, causing blood to pool in the legs. In some cases, this condition progresses to a more serious form of venous disease called chronic venous insufficiency (CVI). 

 

While LJVC has provided relief of painful varicose veins and ulcers of the legs, many people suffer from varicose veins in other areas of the body, such as the pelvic region in both men and women. These and other vascular conditions can be diagnosed and treated by interventional radiologists with special vascular training. Dr. Elliot DeYoung has joined LJVC’s  powerhouse team to continue its renowned venous care and add a complementary layer of medical specialization to the practice. 

Specializing in interventional radiology, with expertise The practice is enthusiastic to welcome Dr. Elliot DeYoung to their medical staff. Dr. DeYoung’s expertise spans vascular disease from angioplasty and stenting to embolization and ablation.  He will lead the center in the expansion of vascular services to provide crucial out-patient care to the community. The practice is enthusiastic to offer a wide variety of interventional procedures including treatments for other vascular conditions such as peripheral arterial disease, pelvic congestion, may thurners, deep vein thrombosis, varicocele, and uterine fibroids. 

 

‘It’s always been our mission to offer the most comprehensive vein care possible. Now, we are able to offer even more comprehensive vein and vascular care to the community. “Dr. Deyoung’s expertise and skills will help us continue to provide patients with leading edge therapeutics for venous disease,” said Dr. Nisha Bunke, founder of La Jolla Vein Care. We are proud to welcome him to our team.”The treatments Dr. DeYoung is able to offer are endovascular procedures that rely on “real-time” advanced medical imaging to precisely target areas of the body for treatment through millimeter-size incisions. It takes medical care to the next level beyond vein care. As a result, we saw fit to change the medical practice’s name to La Jolla Vein & Vascular (LJVV) to reflect these changes.’ Says Dr. Nisha Bunke, the clinic’s Founder and Medical Director. 

 

Dr. Elliot DeYoung is a board-certified interventional radiologist who has spent his career focused on minimally invasive procedures. He completed his training at University of California, San Diego where he specialized in vascular interventions and served on the patient safety committee. Dr. DeYoung’s expertise spans vascular disease from angioplasty and stenting to embolization and ablation. He values thorough patient education and the continuity of patient care. Dr. DeYoung received his bachelor’s degree from USC in Psychology followed by his medical degree from the University of Sydney, School of Medicine. He initially trained as a General Surgery resident in New York before transitioning his training to Interventional Radiology in San Diego. He has a passion for water sports and his free time is spent enjoying the outdoors with his family.

 

To learn more about La Jolla Vein and Vascular, visit ljvascular.com.  Connect with LJVV on Instagram and Facebook.

 

About La Jolla Vein & Vascular: 

La Jolla Vein & Vascular is San Diego’s most comprehensive endovascular center, dedicated exclusively to the diagnosis and treatment of vascular disorders. Vascular conditions permeate both women and men’s health. Vascular disorders treated include peripheral arterial disease, pelvic congestion, labial varicose veins, uterine fibroids,  may thurners, deep vein thrombosis, varicocele, varicose veins, leg ulcers and uterine fibroids.

 

La Jolla Vein Care enjoys positively impacting patient lives, health and overall well-being with its minimally invasive procedures, including an array of endovenous techniques such as radiofrequency, laser and foam sclerotherapy treatments. Learn more about La Jolla Vein Care’s specialty physicians, approach and what has driven its 10+ years of success at LJVascular.com.

 

La Jolla Vein Care EXPANDS SERVICES, RENAMES LA JOLLA VEIN & VASCULAR2022-07-20T13:26:27-07:00

What you need to know about compression stockings

2022-07-20T13:10:20-07:00

At La Jolla Vein and Vascular, we suggest patients use compression stockings for better vein health. There are a few different types to choose from listed below. But first, knowing the benefits of using compression stockings for your vein health empowers you to decide with your physician which type is best for you. 

Benefits of compression stockings for vein and vascular health: 

  1. Wearing compression stockings or socks places pressure on the veins in the lower legs.
  2. The pressure helps improve blood flow
  3. The pressure helps prevent further spider veins and varicose veins
  4. Compression stockings also relieve leg swelling
  5. Reduces the risk of blood clots in the legs

 

Anti-embolism stockings, also known as TED hoses, are designed specifically for non-mobile patients or those confined to a bed. These are the white stockings used for hospital patients. They are low-cost temporary solutions commonly used for patients in nursing homes and post-surgery to prevent deep vein thrombosis (DVT).

 

Graduated compression therapy provides external support to the vein walls and works in conjunction with the calf muscle pump. Compression stockings improve circulation while helping to minimize and control leg and ankle swelling.

However, for ambulatory (walking patients who are not bed-bound), TED hoses do not offer sufficient support to counter the effects of gravity.  They have not graduated compression and only offer about 8-18mmhg compression. TED hose does not help the symptoms of venous disease and varicose veins. TED hose cannot be used for vein treatment and should not be used for daily support in walking patients.

In comparison, graduated compression stockings are medically therapeutic and designed for people who are mobile. Graduated compression means that they are tightest around the ankle and gradually ease as they go up. These can help reduce the risk of DVT in patients who travel by plane or car and reduce symptoms such as leg swelling (edema), aching, heaviness, fatigue, pain from varicose veins, and useful for pregnant women to reduce pain from varicose veins.

 

 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 compression stockings2022-07-20T13:10:20-07:00

What you need to know about leg ulcers

2022-07-19T18:05:28-07:00

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, a venous leg ulcer is much more common than a diabetic or arterial ulcer.  It is caused by 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 of 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.  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.

 

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 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.

 

 

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 leg ulcers2022-07-19T18:05:28-07:00

Swelling & Varicose Veins

2022-07-19T17:52:04-07:00

Complications of Untreated Varicose Veins and Venous Insufficiency: Swelling of the Ankles/legs

 

Leg swelling (swelling is also known as edema), is a common complaint related to varicose veins and underlying venous insufficiency. Leg swelling can be present simply from underlying venous insufficiency without visible signs of varicose veins or spider veins. As a result, a venous insufficiency study by duplex ultrasound scanning is part of the recommended work-up. 

 

The Duplex Ultrasound involves using high frequency sound waves to look at the speed of blood flow, and structure of the blood vessels. The term “duplex” refers to the fact that two modes of ultrasound are used, Doppler and B-mode. The B-mode transducer obtains an image of the vessel being studied. The Doppler probe within the transducer evaluates the velocity and direction of blood flow in the vessel.

 

This usually usually affects the ankles. Most people with vein-related experience progressive swelling throughout the day, that is worse at night time and improved in the morning (they usually wake up with normal appearing legs in the morning but by night-time, shoes may feel tight.) Vein-related swelling is worse at the end of the day, with prolonged standing, sitting or with air travel, heat and menstruation. The degree of swelling varies from one person to another.

 

It is a common symptom of varicose veins and venous insufficiency. The legs often feel heavy. It is common to notice sock lines around the ankles by the end of the day.

 

Compression stockings and leg elevation will help reduce swelling. If the swelling can be attributed to the varicose veins or venous insufficiency, correction of the underlying vein problem will reduce swelling.

 

For more information check out our website resources 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. 

 

Swelling & Varicose Veins2022-07-19T17:52:04-07:00

Restless Leg Syndrome and Venous Insufficiency

2022-07-19T17:36:34-07:00

Varicose veins and venous insufficiency are neglected causes for restless leg syndrome.  Restless legs syndrome (RLS) is a neurological disorder characterized by throbbing, pulling, creeping, or other unpleasant sensations in the legs and an uncontrollable, and sometimes overwhelming, urge to move them. Symptoms occur primarily at night when a person is relaxing or at rest and can increase in severity during the night. Moving the legs relieves the discomfort. Often called paresthesias (abnormal sensations) or dysesthesias (unpleasant abnormal sensations), the sensations range in severity from uncomfortable to irritating to painful.

 

RLS is often felt to be a neurological problem that is treated with medication, but there are other causes such as thyroid disease, anemia, pregnancy, and varicose veins. RLS is actually common amongst patients with varicose veins. La Jolla Vein Care’s Dr. Bunke completed a clinical study at UCSD along with Dr. Maria Alfaro, MD evaluating the correlation between restless leg syndrome and varicose veins.  Eight patients who had restless legs syndrome, and underlying venous insufficiency were studied. These patients underwent treatment of their varicose veins either with foam sclerotherapy or endovenous ablation. All patients had either resolution or improvement of their restless legs symptoms, eliminating the need for neurological medications.  The impact of this study is that all patients with RLS should be screened for venous disease clinically by their doctors. If they have signs of venous disease such as varicose veins, Dr. Bunke recommends an ultrasound evaluation. ‘If RLS symptoms are related to varicose veins, it is correctable by treating the varicose veins, eliminating the need for pharmacologic therapy in many patients and a better night’s sleep,’ says Dr. Bunke.

 

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. 

 

Restless Leg Syndrome and Venous Insufficiency2022-07-19T17:36:34-07:00

Hemorrhages & Varicose Veins

2022-07-19T17:31:08-07:00

Complications of Untreated Varicose Veins: Bleeding or Hemorrhage Caused by Vein Rupture

 

Untreated varicose veins are at a higher than usual risk of bleeding or spontaneous rupture, hemorrhage. 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 spontaneously 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.

hemorrhage

This is a patient who experienced spontaneous hemorrhage of their varicose veins. Notice the appearance of the blue, bulging veins that we describe as, ‘blue blebs.’ These veins are dilated, weak, and are close to the surface of the skin. The pooling blood within these veins causes high pressure, ultimately resulting in a spontaneous rupture or hemorrhage. The bleeding is rapid since varicose veins are under high pressure.  This is a common condition that we see at La Jolla Vein Care.

 

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.

 

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. 

 

Hemorrhages & Varicose Veins2022-07-19T17:31:08-07:00
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CONTACT INFORMATION

La Jolla/UTC

Vista

Patient Privacy Practices

Privacy Policy

Hippa Privacy Practices
HIPAAOneTM Certified Seal 2

Use the search features below to find articles and insights for the diagnosis and treatment of vascular disease

TWO CONVENIENT LOCATIONS THROUGHOUT SAN DIEGO

La Jolla/ UTC

North County San Diego/ Vista — Endovascular Center
Now Open! Call/Text for Appointments

© Copyright 2010-2024, La Jolla Vein & Vascular | All Rights Reserved

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