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Griffin R. Coates, MD, FACS

Coates Vein Clinic, pllc


15920 S. Rancho Sahuarita Blvd • Suite 150 Sahuarita, AZ 85629

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Phone: 520.849.VEIN (8346)

Fax: 888.849.8354


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Venous Insufficiency


Chronic venous Insufficiency/venous reflux affects approximately 20% of the adult population and 50% of women over age 50. It is among the most common chronic conditions in North America with an estimated 75-80 million Americans suffering with varicose veins. The management of this disorder has undergone enormous advances in recent years.

Your legs are made up of a network of veins. Healthy leg veins contain valves that open and close to assist the return of blood back to the heart.

Venous Insufficiency refers to a failure of the one-way valves in the veins. This can occur in any of the veins in the leg, abdomen or pelvis. In the leg veins this can involve the small ones near the skin surface or the larger ones surrounded by the muscle. The veins will enlarge in diameter over a period of time due to increasing age, weight gain, pregnancy, genetic predisposition or injury from prior venous clots.

Mild cases of venous insufficiency include development of spider veins, which are less than 1 millimeter (mm) in diameter, or smaller varicose veins, which are usually 2 or 3 mm in diameter. Other signs may include swelling of the ankles or dull aching pain after prolonged standing. More severe problems include progressive enlargement of varicose veins, worsening of swelling and discoloration of the skin or even open wounds near the ankle.

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Diagnosing the venous problem relies on a good clinical examination and a detailed ultrasound of the veins by an experienced technologist or physician. The principles of treating the leaking veins involve either shutting the veins chemically or with heat, and/ or removing larger abnormal veins through tiny incisions. This will improve the circulation by stopping the leaking or backward flow of blood in the larger veins and allowing blood to return to the heart more efficiently through the properly functioning deeper veins. Recommended procedures depend on the size of the veins involved. Compression therapy, usually with support stockings, is an important component of managing venous problems and can be used for varying lengths of time before and after treatment depending on the patient’s specific condition.

Symptoms of venous disease vary considerably from one patient to another.  Because venous disease can start at an early age and slowly progress, some patients may actually have very minimal symptoms even with advanced problems while others may experience much more pain and discomfort with only very small venous abnormalities. 

Even though venous insufficiency is more common in women, because of hormonal influences and pregnancies, it is also a common problem in male patients. Men often ignore or dismiss their symptoms for a long time as just getting older, a long day at work or overexertion in sports. They often wait until they have more serious pain or skin complications than female patients. Often it is the spouse who encourages the husband to come in for evaluation.

In addition, some of the symptoms of venous disease may be confused with arterial problems, nerve abnormalities or back issues. Therefore some venous problems may not be properly diagnosed or maybe minimized as simply a cosmetic issue by primary care providers.

Venous insufficiency is not normally life-threatening and can often be treated with simple lifestyle adjustments in mild cases. There is currently no oral medication available to provide a cure. Left untreated, venous insufficiency will worsen over time.

 If you have any symptoms of leg pain, tired aching heavy legs, discolored skin on the lower legs, bleeding from varicose veins, a poorly healing wound on the lower leg, contact us for an evaluation.


Leg swelling (edema)


Swelling in the legs can be caused by many factors, either individually or in combination with other factors. Sometimes the swelling is equal in both legs or sometimes it is more on one side than the other.

Swelling can occur due to local injury, prior surgery, inflammatory changes, obstruction of blood or lymphatic fluid returning from the legs, infection, obesity, pregnancy, cardiac problems, endocrine problems, renal problems, liver problems, or as a side effect of medications, just to name a few causes.

However, sometimes the cause may be leaking valves (reflux) in the venous system which is often not discovered by most routine ultrasounds. These may be focused only on if there is a clot present instead of all other vein problems such as incompetent veins .If this reflux is treated, often patients can reduce or eliminate diuretic requirements and also get more energy in their legs.

Evaluation of leg swelling is often initially done by a primary care provider or a specialist such as a cardiologist. As is evident from the above discussion, swelling in the legs must be addressed individually and by someone with experience to consider the entire differential diagnosis, not just the diseases within their own specialty. Communication between the health care providers is important to achieve the best results.


Leg swelling should not be ignored especially if it is sudden, just in one leg or associated with chest pain or shortness of breath.


Leg cramps and restless legs


Tired, achy, heavy legs at the end of the day are often thought be just a part of getting older. However, we now know that this can be a sign of chronic venous insufficiency. 

Cramps in the legs at night or after exercise can often be due to the pooling of blood with metabolic byproducts in the muscles. Sometimes elevation and compression socks help, but a more permanent solution is to stop the venous reflux by closing the leaking veins.

Restless leg syndrome affects about 10% of the United States population. It often interferes with sleep and patients may complain of a tingling, creeping or crawling sensation.


Sometimes, the syndrome can be caused by medications such as antidepressants, antihistamines, calcium channel blocking medications, pregnancy, diabetes or arthritis. There is no specific test for restless leg syndrome. A duplex ultrasound can often identify if there is some associated venous reflux.


Some patients notice improvement of their symptoms after wearing graduated compression stockings for a few months. If this does provide symptom relief, patients might obtain longer-term relief with treatment of any abnormal veins.


Spider veins


Spider veins are the very tiny red or blue veins near the surface of the skin that often appear like a spider web. They usually are not dangerous but they are very common. About 40% of people have some significant spider veins by the age of 55. The development of spider veins is associated with a family history of spider veins, local trauma, some hormone replacement medications, pregnancy, or an occupation that involves sitting or standing for long periods of time. 

Some older people have very significant spider veins on the foot or lower part of leg. Occasionally as the wall of the vein gets weaker, there can be a rupture of the vein and bleeding which can be very significant and anxiety producing. The best thing to do is to lie down, elevate leg and push firmly over the area that is bleeding until it stops. This vein can then be treated so that it won’t bleed again.

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If you have spider veins, you will probably continue to develop new ones throughout your life. The treatment, while it is effective in causing visible veins to disappear, does not keep new spider veins from forming. Some people like to have their spider veins treated on a regular basis, while others prefer to wait until they have lots of spider veins or some bothersome symptoms (itching, tingling, and burning).


Varicose Veins


The veins are the blood vessels through which blood returns to the heart. In the leg, this blood has to come back against the force of gravity. The calf muscles are the primary pump to push blood back to the heart.

Veins in the leg are categorized either as superficial or deep. The superficial veins are close to the surface of the skin and drain blood from the skin and underlying tissue while the deep veins are close to the arteries, deep in the muscle. In the superficial system, the great saphenous vein is the one most commonly diseased and associated with varicose veins. It begins at the inside of the ankle and extends up to the groin. Varicose veins are blue, bulging, ropelike blood vessels that protrude beneath the skin and often look like a cluster of grapes. There are often found on the inside part of the thigh, calf or on the back of the leg; however they can form anywhere from the groin to the ankle.

Usually, the failure of valves within the trunk of the great saphenous vein or small saphenous vein is the primary source of the problem and it is just the bulging branch veins that are visible under the skin.

Many factors, such as genetics, age, gender, weight and lifestyle contribute to the development of weakened vein walls and varicose veins. Unfortunately, varicose veins cannot be completely prevented but there are ways to improve vein health. Any physical activity which activates the calf muscle will help pump blood up to the heart. Wearing graduated compression socks or stockings will also improve venous return and help relieve symptoms. Avoiding obesity or a sedentary lifestyle is very important.

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Pregnancy and varicose veins


Several factors contribute to the development of vein problems during pregnancy. 

There are hormonal changes which expand the total volume of blood and also allow the veins to stretch in order to accommodate this increased volume. There is also compression of the abdominal and pelvic veins because of the enlarged uterus and baby. This compression may cause partial obstruction of blood return from the legs and pelvis. The varicose veins which develop during pregnancy may be in the legs or in the groin area.

Using   elastic compression stockings during pregnancy will often relieve some of the symptoms and reduce complications of varicose veins during pregnancy. The stockings are available either in calf length, thigh length or pantyhose with an abdominal support panel.

The hormonal changes may also cause patients to have clotting problems either in superficial veins or in deep veins during their pregnancy and for a few months following the delivery.

Varicose veins that developed during pregnancy will sometimes improve after the baby is delivered. Often, they will return in subsequent pregnancies and will often be worse with each pregnancy. For this reason, it is usually best to treat the varicose veins between pregnancies in order to avoid recurring discomfort and reduce risk of blood clots.


Venous clots (thrombosis)


A clot, or also called a thrombus, within a vein can vary in location and in size. Therefore the symptoms associated with them and the potential problems also vary.

A clot in a vein near the skin or fatty tissue is called a superficial venous thrombosis. Often it is tender, slightly reddened and feels hard to the touch. Clots in the superficial veins usually resolve without problems and only require compression, moist heat and analgesic medications. These clots are seldom life-threatening because the veins involved are very small and usually do not connect to the deep venous system. However, about 20% of these superficial clots may extend into the deep system and create a more serious problem. Duplex ultrasound is the best way to diagnose this condition.

Deep venous thrombosis (DVT) refers to a clot within the deeper, intramuscular veins in the leg or in the veins of the pelvis and abdomen. Because these veins are larger, a clot within them is more serious because not only do they obstruct larger organs but also they can break loose, pass through the heart and obstruct blood flow to the lungs (a pulmonary embolus). Duplex ultrasound can diagnose these clots within the leg. There are different anticoagulant medications that can be used to treat these clots. Sometimes, it is necessary to place a filter within the veins to prevent the clots from going to the lungs.

Some blood clots originate from inherited disorders or genetic mutations. Usually there is a family history of these types clotting problems. These disorders can often be identified with blood testing. Other clotting disorders may develop due to various medical conditions such as lupus, cancer, surgical procedures involving either spinal or general anesthesia, prolonged bed rest or sitting, smoking, oral contraceptive use or estrogen replacement medications.


Venous stasis dermatitis


Pooling of blood in the legs caused by venous reflux can result in several symptoms:

  • Irritated and inflamed skin

  • Redness

  • Itching

  • Dryness

  • Oozing fluid

  • Scaling

  • Open sores

  • Crusting or scabbing


In some people with advanced venous reflux from varicose veins, skin discoloration symptoms become more severe. In such cases, an area of very painful skin can develop, the skin typically turns red or brown, and the skin becomes hardened like a scar. Severe symptoms normally result from years of untreated venous disease. However, in some people they can occur suddenly.

Because skin discoloration results from the advanced stages of venous disease, the condition will take some time to heal after the cause of venous reflux is treated.

Possible treatments for the underlying venous disease that causes skin discoloration include endovenous ablation therapy, foam sclerotherapy, and ambulatory phlebectomy.

Once the underlying venous disease has been addressed, fresh, oxygenated blood will return to the damaged tissues, preventing further skin discoloration and repairing the tissues over time. Repair of damaged tissues is gradual. We do not expect the natural skin color to return. Our goal is to keep the damaged skin from worsening.

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Venous stasis ulcers


Venous stasis ulcers are areas of skin breakdown resulting in an open wound which may involve loss of skin or sometimes loss of tissue all the way to the muscle and bone. Usually they occur on the inner (medial) aspect of the ankle but sometimes on the outer (lateral) aspect. Often there is surrounding stasis dermatitis and hardening of the skin and fatty tissues. They may have also had large varicose veins for many years.

Patients often have been referred to a wound center for treatment. This may involve weekly visits to the wound center with debridement, compression wrappings and work restrictions. Care at a wound center in the United States may cost over $100,000- $200,000 for each episode and there may be a 50 or 70% chance of recurrence within a year if nothing else is done. This has become an extremely expensive part of the healthcare budget in Western countries. 

Proper diagnosis and definitive treatment of any underlying venous reflux will heal the vast majority of these ulcers at a substantial savings of patient discomfort, time and money. Unfortunately, many facilities that perform ultrasounds may only be looking for deep vein thrombosis and do not find the venous reflux disease which is leading to the ulcers. Referral to an experienced phlebologist is important for any wound on the lower leg that does not heal within four or six weeks.

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Ulcer - Before Treatment
Ulcer - Before Treatment
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Ulcer - 3 Months after treatment
Ulcer - 3 Months after treatment
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