In short Dr. Erika Mendoza, general practitioner with her own vein practice in Wunstorf near Hannover, Germany, relies on class 1 and 2 compression stockings to treat spider veins and varicose veins: “If the patient doesn’t suffer from any complaints, we keep monitoring the legs for a few years and adjust the compression stockings if necessary.” Here, the phlebology specialist highlights the following: All physicians and medical retail employees should take advantage of every patient visit to check their legs and make sure any abnormal conditions can be treated early. The wellbeing of the patient is what matters most. Healthcare professionals should always be ready to refer patients if they don’t offer a treatment option themselves. That was also the motto of the DGP 2022 Annual Meeting: “Choosing Wisely in Phlebology.” If surgery cannot be avoided, Dr. Mendoza prefers to use the gentle CHIVA method, which corrects blood flow and preserves the vein.
Compression stockings/ Venous disorders
“Compression stockings are my most important tool”
Standard cases in phlebological care
From Bauerfeind Life Magazin
When does the patient need to have surgery for varicose veins? When is it sufficient to wear compression stockings? With over 25 years of experience in treating venous conditions, Dr. Erika Mendoza knows the answers to these questions and advises taking a closer look at the patients’ legs.
For Dr. Mendoza, the mere existence of a varicose vein is no reason to treat it surgically right away. “If the patient is not in pain and has no further symptoms, we can also wait and monitor this condition for three or four years,” states the general practitioner, who runs a vein practice in Wunstorf, Lower Saxony. “They don’t have to undergo surgery and instead, I recommend wearing compression stockings at work, for example.” Yet she does not want to trivialize vein problems in any way: “However, as soon as a patient feels the need to elevate their legs because they feel heavy or due to swelling, it goes without saying that surgical intervention should be considered.” This also applies if they develop itching or eczema along the vein, or if they simply find the varicose veins unsightly. For the physician, other reasons that indicate surgery include superficial vein thrombosis or if examinations show that the vein in the groin area has a diameter of more than ten millimeters. “In this case, the risk of thrombosis may be slightly increased,” she warns.
Taking a closer look at the legs
In her many years of professional practice, the physician has observed two categories of patients who come to see her for the first time: on the one hand, there are people with harmless spider veins who are very worried. “And on the other hand, there are increasingly more patients who ignore swelling and skin discoloration for far too long and only come when they already have a venous leg ulcer – that is especially true for men,” Dr. Mendoza states with much regret. That is why she appeals to doctors and professionals who see their patients’ legs – gynecologists, dermatologists or family doctors, but also employees in medical retailer stores when customers try on compression stockings or knee braces: “Despite all the time constraints, they should take every opportunity, every check-up, every screening to verify the following: does a leg increase in volume, does it show discoloration? Are there any other changes?” This also applies to patients who have been wearing compression stockings for a long time. This way, you can make sure that the compression class is still appropriate. “Physicians cannot rely solely on what their patient tells them. An individual check-up should not be omitted for any reason,” emphasizes Dr. Mendoza. After all, venous disorders are much more common than diabetes, affecting 70 to 80 per cent of the adult population, with 18 per cent in CEAP classes C3 to C6, which associated with swelling, skin discoloration and ultimately non-healing wounds, which means they suffer from conditions that require urgent treatment. Corresponding abnormalities always call for referring the patient to a specialist.
Selecting the right compression class
Swelling in the leg can also be triggered by other causes in addition to venous disease. Many people get vein problems after receiving a different medication to lower their blood pressure or for Parkinson’s disease. “If it’s not possible to switch to a different medication, I recommend class-1 compression stockings,” Dr. Mendoza explains. Compression class 1 is also often sufficient for people who sit a lot at work. A metal worker, on the other hand, would be better served with a firmer stocking in class 2, as would people with a body mass index (BMI) of 40 or more. Obesity has increased substantially in recent years, which aggravates venous disorders, as the physician emphasizes. For patients with some excess pounds, she also recommends walking more and definitely losing weight, in addition to compression stockings. Dr. Mendoza also prescribes compression class 2 after surgery. “For patients, this highlights the seriousness of having to wear them. In terms of length, it is important to ensure that the stockings extend beyond the treated area that is affected by the insufficiency,” advises the devoted physician, and it is also important to her that, “in case of thrombosis, there is no way around wearing stockings. I can get very serious and firm with my patient in this regard. As a medical doctor, you have a vital role when it comes to convincing patients.” It also helps if you wear a compression stockings yourself in the practice or at least have a nice sample at hand.
“Following surgery, it is essential for a patient to wear compression stockings.”Dr. Erika Mendoza
When surgery cannot be avoided, Dr. Erika Mendoza also performs it in her practice. If the patient find the spider veins extremely bothering, but the truncal vein behind them is still in good condition, sclerotherapy may be a viable option. She uses the gentle CHIVA method1 if a truncal vein is affected that has not been operated on before. In this case, the truncal veins in the leg remain completely intact and are still available to the circulatory system. Dr. Erika Mendoza was among the first in Germany to perform this surgical method in the late 1990s. “Studies have shown that the smaller the portion of the truncal vein that is destroyed, the less likely recurrences occur.”
The doctor summarizes: “Compression stockings are my most important tool.” It is critical to take exact measurements for the stocking and to ensure that the patient is instructed on how to put them on correctly in the medical retail store or in the doctor’s office. And she reiterates her call to all health care professionals: “Becoming aware of venous disorders only takes a glance. So keep your eyes open and take note of any changes. We have to see the person from a holistic point of view. If we do that, we can achieve a great deal of reaction with just
a little action!”
“Choosing wisely” – focusing on the patient’s well-being
life: Dr. Mendoza, you were president at the Annual Conference of the German Society of Phlebology (DGP) in Hannover. How should the motto “Choosing Wisely in Phlebology” be understood?
Dr. Erika Mendoza: ‘Choosing wisely’ is an established concept for having the courage not to perform a medical service, and if you do not offer a certain treatment in your practice, not to be afraid to refer the patient to a colleague. The motto is meant to promote smart decisions about what will best help the patient.
How can a conference support this concept?
Dr. Erika Mendoza: The conference is an opportunity to meet: for members of various relevant disciplines, such as dermatology, angiology, vascular surgery and radiology, but also family medicine. You get to know each other, meet experts from neighboring fields and have the chance to exchange ideas and discuss new procedures.
Why is there not enough exchange in day-to-day practice?
Dr. Erika Mendoza: This is because phlebology is no longer represented in hospitals, which I consider to be a good thing in general, but this means there are fewer touch points with others compared to the way it used to be. There are no more group discussions as had been initiated by the owners, and there are by far not enough round tables on vascular disorders. However, it is so important that we all work together, abandon our tunnel vision and start looking to the right and left.
Versatile helpers: VenoTrain micro, VenoTrain soft & soft S
VenoTrain micro offers relief for mild vein problems and is the perfect choice for work and travel as well as for preventive care during pregnancy. The extra-smooth compression stocking has a microfiber content of over 50 per cent, making it particularly soft and skin-friendly. It comes in many colors, with patterns, and in funky tie-die versions.
VenoTrain soft is a versatile unisex compression stocking. The robust stocking can withstand plenty of wear, yet it is very soft and pleasant on the skin. It offers gentle massage action with every movement, which can be very beneficial for post-operative care or for patients with weak veins.
VenoTrain soft S
caters for the special requirements of people who spend prolonged periods of time sitting down and features a generous heel area and comfortable instep region. The stocking stimulates circulation using gentle massage action with every movement. The robust knitted fabric can withstand plenty of wear, and can also be easily put on by
1 CHIVA stands for “cure conservatrice et hémodynamique de l’insuffisance veineuse en ambulatoire”, which means: “office-based vein-conserving hemodynamic correction of venous insufficiency.”
Images: Steffi Behrmann, Bauerfeind