4, 5, 2022

What are Non Healing Ulcers & Wounds?

2022-04-28T17:17:13-07:00

Non-Healing Ulcers &  Wounds

 

We might all be familiar with non healing ulcers & wounds in a general manner, but certain types of ulcers behave quite differently due to various contributing factors. These are non healing ulcers or non healing wounds, and if not treated with care and in good time, such wounds can pose a serious risk to the patient’s health. Severe cases may lead to amputation of the affected limbs or loss of life in the most extreme circumstances. The nonhealing ulcers cases we treat here at La Jolla Vein & Vascular fall under peripheral arterial disease (PAD) and a subcategory of arterial disease.

Non-healing wounds or ulcers do not follow the usual healing process and are referred to as chronic wounds should they persist beyond 3 weeks. Such wounds can be a heavy burden to live with for anyone. Still, the board-certified vascular surgeons and specialists at La Jolla Vein & Vascular are dedicated to administering effective treatment and management solutions to all patients so they may resume a healthy, productive, and pain-free life.

foot ulcer

Types of Non-Healing Ulcers

In general, patients will present with one of three categories of non-healing ulcers, with these categories being broadly defined by the major causative factors allowing for their development. These are:

Arterial or Venous Ulcers

 

These are found to account for between 70% up to 90% of non-healing wounds or non-healing ulcers. Mostly occurring in elderly patients, they are believed to come about as a result of a failure of the valves in a person’s blood vessels of both arteries and veins. These valves are responsible for preventing the backflow of blood as it passes within them. The consequent outcome is a lack of nutrient and oxygen-rich blood from reaching the affected tissues and sets up the conditions favoring non-healing wounds.

 

Pressure Ulcers

 

These are ulcers that are brought about by the restriction of blood flow to certain regions of the body due to the persistent and prolonged application of pressure upon them. It is mostly encountered among patients with full or partial paralysis and those who are bedridden for extended periods.

 

Diabetic Ulcers

 

These are also highly prevalent chronic wounds, and are on the increase among patients owing to the ever-increasing cases of diabetes among the population. In fact, the prevalence of chronic wounds among diabetics makes this demographic 15% more likely to have to undergo limb amputation as a complication of the condition.

The high amputation rate among diabetics is attributable, in part, to the neuropathic effects of the ailment. Neuropathy leads to a lack of pain perception in the affected individual, meaning that they may be entirely unaware of minor wounds on their feet and legs in good time, allowing for their infection or repeat injury. It is also made more likely by the immunosuppressive effects of the condition, which makes the patient more vulnerable to infection.

foot ulcer2

What are Non Healing Ulcers & Wounds?2022-04-28T17:17:13-07:00

26, 4, 2022

La Jolla Vein and Vascular welcomes Jodi Hirsch, PA-C

2022-04-23T14:24:17-07:00

La Jolla Vein and Vascular welcomes Jodi Hirsch, PA-C

jodihirsch

Jodi Hirsch PA-C is a board-certified physician assistant who has spent her career specializing in the field of peripheral vascular disease and venous disease.  She gained her undergraduate degree in chemistry and pursued her degree in Physician Assistant Studies from Touro University in NY in 2006. She has spent her professional career in San Diego, previously working in the Department of Vascular Surgery at Scripps. When not at work, she enjoys spending time with her husband and two little boys.

For more information please watch Jodi’s video here.

La Jolla Vein and Vascular welcomes Jodi Hirsch, PA-C2022-04-23T14:24:17-07:00

La Jolla Vein & Vascular welcomes Dr. Elliot DeYoung, M.D.

2022-04-23T14:16:23-07:00

La Jolla Vein & vascular welcomes our newest doctor at the La Jolla location, Dr. Elliot DeYoung, MD.

new doctor

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 is excited about joining La Jolla Vein & Vascular team to continue its renowned venous care. 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 treatments for peripheral arterial disease, may thurners, and uterine fibroids.

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.

Dr. DeYoung is looking forward to treating your vascular needs at La Jolla Vein & Vascular.

Dr. DeYoung is a vascular specialist with focus on aortic and peripheral vascular disease, pelvic congestion syndrome, and interventional oncology. His skills include varicocele embolization, venous interventions, uterine fibroid embolization, prostate artery embolization, and genicular artery embolization.

Please check out Dr DeYoung’s video for more information.

La Jolla Vein & Vascular welcomes Dr. Elliot DeYoung, M.D.2022-04-23T14:16:23-07:00

Spider Veins Before and After Patient Transformation

2022-04-13T11:56:42-07:00

What are spider veins?

They are the fine, thread-like reddish veins at the surface of the skin, and 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. They may also be a sign of underlying venous insufficiency. For example, they are usually 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.

What are the symptoms?

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

What are the causes?

They 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. Spider 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.

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 modern solutions such as Asclera, allow for spider veins to be treated with minimal discomfort and immediate return to activities.

 

Below are La Jolla Vein Care patient transformations before and after vein treatment for spider veins. 

spider veins

spiderveins2

spider veins

Spider Veins Before and After Patient Transformation2022-04-13T11:56:42-07:00

What is Asclera?

2022-12-13T13:07:15-08:00

What is polidocanol (Asclera)? 

 

A variety of sclerosant medications can be used for veins, but at La Jolla Vein Care, we prefer polidocanol (brand name Asclera), because it is the most comfortable for the patient and has the lowest risk of side effects. It is a detergent-type medication that injures the inner lining of the veins. This causes the vein to stop flowing, then eventually close down completely. Polidocanol has been well-studied and has been approved by the FDA since 2010 for the treatment of varicose veins and has been used in Europe for decades. Polidocanol is turned into a foam to treat larger veins. This is an off-label use of the sclerosant but very effective and well tolerated. Asclera (polidocanol) Injection is a prescription medicine that is used in a procedure called sclerotherapy to remove unwanted veins on your legs. It is administered by a healthcare provider to treat two types of veins:

 

  • Uncomplicated spider veins (very small varicose veins ≤ 1 mm in diameter)
  • Uncomplicated small varicose veins (1 to 3 mm in diameter) known as reticular veins

Asclera has not been studied in varicose veins more than 3 mm in diameter. La Jolla Vein Care providers have extensive experience with foam sclerotherapy. 

 

ADVERSE REACTIONS: 

 

  • injection site hematoma
  • injection site irritation 
  • injection site discoloration 
  • injection site pain 
  • injection site itching 
  • injection site warmth 
  • neovascularization 
  • injection site clotting

 

How often do I need treatment to see results?

The number and frequency of treatments depends on the size of the vessels and their location. Ask your provider about an individualized treatment approach that is right for you.

How does Asclera work?

Asclera is a sclerosing agent that is injected into the vein. It works by damaging the endothelium, the inside lining of blood vessels. This causes blood platelets and cellular debris to attach to the lining of the vessels. Eventually, cellular debris and platelets cause the blood vessel to clot. Over time, the clotted vein will be replaced with tissue.

How satisfied are patients who use Asclera?

88% of clinical study patients were satisfied or very satisfied with their Asclera treatment after 12 weeks.

How long is each Asclera session?

A typical session lasts 15 to 45 minutes. Generally, 1 to 3 injections may be necessary to treat a given spider or reticular vein. Repeat treatment sessions may be necessary. Any additional treatment sessions are usually separated by 1 to 2 weeks.

What should I expect after being treated with Asclera?

Following treatment, you’ll need to wear compression stockings day and night for 2 to 3 days, then for 2 to 3 weeks during the daytime, as directed by your provider. Compression stockings are designed to apply pressure to your lower legs, helping to maintain blood flow, and reduce discomfort and swelling. Compression helps your legs heal and is necessary to reduce the risk of deep vein thrombosis.

 

Are there activities I should avoid after receiving an Asclera Injection?

For 2 to 3 days following the treatment, avoid:

  • Heavy exercise
  • Sunbathing
  • Long plane flights
  • Hot baths, hot tubs, or saunas

Possible side effects to Asclera treatments:

Temporary side effects may occur at the site of the injection, including:

  • Bruising
  • Raised red areas
  • Small skin sores
  • Darkened skin in the form of lines or spots
  • Multiple tiny red blood vessels

These side effects usually go away within a few days to several weeks. Some side effects may take months or years to resolve.

For more information or to book an appointment for Asclera therapy, please call our office at 858-550-0330.

You can visit the Asclera website here.

 

What is Asclera?2022-12-13T13:07:15-08:00

31, 3, 2022

Physical Activity and Vascular Health

2022-03-31T11:45:50-07:00

Physical activity helps to burn calories, increase the heart rate, and keep blood flowing at a healthy rate. All of these contribute to vascular health. 

If your doctor has diagnosed you with vascular disease, or if you have concerns about your vascular health, starting some good habits can help keep vascular complications at bay. Daily exercise has been found to have a significant positive effect on vascular health, along with other good lifestyle choices, such as not smoking, eating heart-friendly foods and maintaining a healthy body weight.

Your Vascular Health

Exercise can impact several artery diseases. A regular exercise routine may reduce the risk of stroke, the fourth leading cause of death in America according to the CDC’s 2010 National Vital Statistics Report. In 2010, 137,000 Americans died of stroke. Studies show that patients with peripheral arterial disease (PAD) may be successfully treated with exercise therapy and possibly avoid interventions. Regular exercise also decreases the growth rate of abdominal aortic aneurysms (AAA), research has found.

The United States Centers for Disease Control and Prevention (CDC) recommends 150 minutes of physical activity per week for adults ages 18 to 64. The activity can be a combination of moderate intensity aerobics and strength training, and should continue for at least 10 minutes at a time.

Moderate-intensity aerobic activities that increase the heart rate and cause sweating which are great for vascular health:

  • Riding a bicycle at a casual pace 
  • Playing doubles tennis
  • Actively playing with children
  • Mowing the lawn
  • Gardening, raking, or bagging leaves
  • Light snow shoveling
  • Water aerobics
  • Ballroom dancing

Vigorous activity that increase the heart rate that are great for vascular health:

 

  • Hiking uphill or with a heavy backpack,  race walking, jogging, running
  • Riding a bicycle fast or riding hills, more than 10 miles/hr
  • Rollerblading / inline skating at a brisk pace 
  • Playing basketball, football, soccer, etc.
  • Cross-country skiing
  • Jumping rope
  • Aerobic dancing
  • Heavy gardening continuous digging and hoeing
  • Swimming laps
  • Playing singles tennis

Twice weekly strengthening activities include:

  • Sit-ups, push-ups
  • Weight lifting
  • Heavy gardening such as digging and shoveling 
  • Yoga

The lack of regular physical activity results in 250,000 deaths annually, according to a 2003 report in the medical journal, Circulation. People who are the least physically fit have a mortality risk 4.5 times higher than physically fit people.

To add physical activity into your daily schedule:

  • Select enjoyable activities 
  • Work out with a friend
  • Encourage family members to participate
  • Measure progress through a daily exercise journal

 

Physical activity is not just good for your veins and arteries, just about every part of your body can benefit. According to the CDC, exercise also helps your vascular health and in addition helps:

  • Maintain healthy weight
  • Reduce the risk of cardiovascular disease; can lower blood pressure and improve cholesterol levels
  • Reduce the risk for type 2 diabetes; can help control glucose levels
  • Reduce the risk of colon and breast cancer
  • Strengthen bones and muscles – can increase or build muscle mass and strength; can slow the loss of bone density that comes with age; can help with arthritis and other joint conditions
  • Keep thinking, learning, and judgment skills sharp 
  • Reduce the symptoms of depression and anxiety
  • Improve the ability to complete daily activities and prevent falls for older adults
  • Increase the chances of living longer by reducing the risk of dying from heart disease and some cancers

 

Physical Activity and Vascular Health2022-03-31T11:45:50-07:00

What is Peripheral Arterial Disease?

2022-03-29T11:41:41-07:00

What is Peripheral Arterial Disease?

You probably are familiar with the terms angina and heart attack, which are related to a blockage of blood flow to the heart. That same sort of blockage can occur elsewhere in the body, depriving the limbs (the peripheral parts of the body) of oxygen and nutrients. Left untreated, the disease can lead to amputation.

Healthy peripheral arteries are smooth and unobstructed, allowing blood to freely provide the legs with oxygen, glucose and other nutrients. As we age, peripheral arteries build up plaque, a sticky substance made up mostly of fat and cholesterol. Plaque narrows the passageway within the arteries and causes them to become stiff, which then leads into peripheral arterial disease. 

A moderate blockage in one of arteries in a major leg muscle, such as the calf or thigh, can cause pain when walking.This pain can be temporarily decreased with rest, but will act up again with more walking or activity.

Lower extremity pain, similar to angina, is called claudication by medical providers. The pain itself is not limb-threatening but it is a sign that the person should make lifestyle changes and see a doctor. 

Examples of possible treatments for peripheral arterial disease include: 

  • Smoking cessation 
  • Daily exercise
  • Medical management

If the disease becomes more severe, the limb can be starved of basic nutrients and the patient begins to suffer pain at rest (especially at night). Sores that won’t heal may develop on the feet. This is a very concerning sign for losing toes or even amputation of the leg. An urgent referral to a vascular surgeon is necessary to prevent limb loss in this situation.

Causes and risk factors of Peripheral Arterial Disease:

  • Age
  • Gender—males are more prone to the condition than females
  • Hypertension (high blood pressure) 
  • Diabetes
  • Smoking
  • High cholesterol
  • Obesity
  • Lack of exercise
  • Family history of vascular problems

Leg pain does not always indicate PAD, but older patients, especially those who are at risk, should see a physician. A simple, noninvasive ultrasound and leg blood pressure examination can diagnose peripheral arterial disease and determine its severity.

If you experience symptoms of peripheral arterial disease, ask your primary care physician to refer you to a vascular surgeon. Vascular surgeons can perform any necessary treatments, including medication management, minimally invasive endovascular angioplasty and stent procedures, and open bypass surgery.

 

Treatment for Peripheral Arterial Disease:

Depending on the severity of your condition, treatment options may include lifestyle changes, medications, minimally invasive angioplasty/stenting, or open bypass surgery.

 

What is Peripheral Arterial Disease?2022-03-29T11:41:41-07:00

Asclera: A New Treatment For Spider Veins and Small Varicose Veins

2022-12-13T13:26:40-08:00

What is polidocanol (Asclera)?

A variety of sclerosant medications can be used for veins, but at La Jolla Vein Care, we prefer polidocanol (brand name Asclera), because it is the most comfortable for the patient and has the lowest risk of side effects. It is a detergent-type medication that injures the inner lining of the veins. This causes the vein to stop flowing, then eventually close down completely. Polidocanol has been well-studied and has been approved by the FDA since 2010 for the treatment of varicose veins and has been used in Europe for decades. Polidocanol is turned into a foam to treat larger veins. This is an off-label use of the sclerosant but very effective and well tolerated. Asclera (polidocanol) Injection is a prescription medicine that is used in a procedure called sclerotherapy to remove unwanted veins on your legs. It is administered by a healthcare provider to treat two types of veins:

Uncomplicated spider veins (very small varicose veins ≤ 1 mm in diameter)
Uncomplicated small varicose veins (1 to 3 mm in diameter) known as reticular veins
Asclera has not been studied in varicose veins more than 3 mm in diameter. La Jolla Vein Care providers have extensive experience with foam sclerotherapy.

Patient Results before and after at 26 weeks after last treatment

asclerabeforeascleraafter

The patient was treated for uncomplicated spider veins (≤ 1 mm)
Treated with 0.5% Asclera

ADVERSE REACTIONS:

-Injection site hematoma
-Injection site irritation
-Injection site discoloration
-Injection site pain
-Injection site itching
-Injection site warmth
-Neovascularization
-Injection site clotting

How often do I need treatment to see results?

The number and frequency of treatments depends on the size of the vessels and their location. Ask your provider about an individualized treatment approach that is right for you.

asclerabeforeafter

How does Asclera work?

Asclera is a sclerosing agent that is injected into the vein. It works by damaging the endothelium, the inside lining of blood vessels. This causes blood platelets and cellular debris to attach to the lining of the vessels. Eventually, cellular debris and platelets cause the blood vessel to clot. Over time, the clotted vein will be replaced with tissue.

How satisfied are patients who use Asclera?

88% of clinical study patients were satisfied or very satisfied with their Asclera treatment after 12 weeks.

ascleragraph
How long is each Asclera session?

A typical session lasts 15 to 45 minutes. Generally, 1 to 3 injections may be necessary to treat a given spider or reticular vein. Repeat treatment sessions may be necessary. Any additional treatment sessions are usually separated by 1 to 2 weeks.

What should I expect after being treated with Asclera?

Following treatment, you’ll need to wear compression stockings day and night for 2 to 3 days, then for 2 to 3 weeks during the daytime, as directed by your provider. Compression stockings are designed to apply pressure to your lower legs, helping to maintain blood flow, and reduce discomfort and swelling. Compression helps your legs heal and is necessary to reduce the risk of deep vein thrombosis.

Are there activities I should avoid after receiving an Asclera Injection?

For 2 to 3 days following the treatment, avoid:
-Heavy exercise
-Sunbathing
-Long plane flights
-Hot baths, hot tubs, or saunas

Possible side effects to Asclera treatments:

Temporary side effects may occur at the site of the injection, including:

-Bruising
-Raised red areas
-Small skin sores
-Darkened skin in the form of lines or spots
-Multiple tiny red blood vessels
-These side effects usually go away within a few days to several weeks. Some side effects may take months or years to resolve.

For more information or to book an appointment for Asclera therapy, please call our office at 858-550-0330.

Asclera: A New Treatment For Spider Veins and Small Varicose Veins2022-12-13T13:26:40-08:00

What to expect when you receive Foam Sclerotherapy

2022-03-25T12:49:38-07:00

Ultrasound-Guided Foam Sclerotherapy

 

Ultrasound-guided foam sclerotherapy works well for treating surface varicose veins and veins that are not visible to the naked eye. The foam medication can be seen on ultrasound, which allows us to administer it precisely and direct it towards nearby varicose veins. Foam sclerotherapy can be safely used for veins that travel close to the skin or nerves. It also travels easily through veins with many twists and turns. 

 

Foam treatment of varicose veins is not as new as people think. It was originally described as early as 1944.  Foam sclerotherapy is a method for treating varicose veins. It involves injecting a foamed sclerosant medication into unhealthy varicose veins, causing them to eventually dissolve.

image of foam sclerosant

Colleagues in Spain attracted attention of some vein specialists and interest in the use of foam technology in treating venous insufficiency was reawakened. Administration of foamed sclerosant was reintroduced in the early 1990s by Cabrerra, who summarized a broad experience in 1997. By the 1990’s, broad use of diagnostic ultrasound imaging made it possible to monitor foam distribution with ultrasound scanning. Some 40 years earlier, and before the development of ultrasound scanning, foam had been used in Germany to treat varicose veins.  At that time, foam was made by special syringes and its distribution was assessed by touch, instead of ultrasound scanning.

foam

How many treatments will I need?

 

The number and frequency of treatments depends on a patient’s anatomy, how well the veins respond to each treatment, and the patient’s treatment goals. The national average is 2 to 5 treatment sessions to achieve 80% improvement. Some larger or resistant veins require two or more treatments to respond completely. 

 

What should I expect on my treatment days?

You will sign your consent form then change into shorts provided by the office. We will clean your skin with alcohol, then use ultrasound to localize the veins. The foam medication will then be injected into your veins with a fine needle. You will elevate your legs on a wedge pillow for approximately 15 minutes. After your foam sclerotherapy treatment, we will help you into your compression stockings, then you will walk for 30 minutes prior to getting in your car. This is normal for your legs to be achy and tender to the touch after treatment. 

For more information on foam sclerotherapy, read this article.

 

What to expect when you receive Foam Sclerotherapy2022-03-25T12:49:38-07:00

What is an abdominal aortic aneurysm (AAA)?

2022-03-24T11:15:19-07:00

What is an abdominal aortic aneurysm (AAA)?

The aorta, the largest artery in your body, runs from your heart, down through your chest, and into your abdomen. The abdominal region of the aorta is responsible for delivering blood to your legs, GI tract and kidneys.

An abdominal aortic aneurysm (AAA) occurs when the wall of the aorta progressively weakens and begins to bulge. An AAA may continue to enlarge and eventually rupture if left untreated, causing severe internal bleeding and possibly death. Nearly 200,000 people in the United States are diagnosed with A A A annually; approximately 15,000 die each year from a ruptured AAA.

In addition to concerns about rupture, clots or debris may also develop within an AAA. These substances can be carried to other areas in the body and block circulation, causing severe pain or possibly limb loss if blood flow is cut off for too long.

AAA can be safely treated with early diagnosis; however, most patients have no symptoms.

Causes and Risk Factors:

Most aortic aneurysms are caused by a breakdown in the proteins that provide structural strength to the wall of the aorta. Some risk factors that contribute to this structural breakdown include:

  • Age—individuals over 60 years are most likely to develop the condition
  • Gender—males are more prone to the condition than females
  • History of atherosclerosis (hardening of the arteries) • Family history of AAA
  • Smoking
  • High blood pressure

Symptoms:

Most people feel no symptoms, and an abdominal aortic aneurysm is often detected when tests are conducted for other unrelated reasons. Those who do have symptoms commonly describe back pain, pulsations in the abdomen, groin pain or sometimes sores on the feet.

Diagnosis

If an abdominal aortic aneurysm is suspected, you likely will be referred for an abdominal ultrasound, a painless, safe test that can screen for and measure the size of an AAA. Computed tomographic angiography (CTA) can assess aneurysm size, location and the extent of impact. This study requires exposure to radiation and injection of an intravenous contrast agent. However, a CTA provides valuable anatomic information and can help your vascular surgeon determine the optimal type of repair.

Medicare Screening Benefit

Medicare offers a free, one-time AAA ultrasound screening for qualified seniors as part of their Welcome to Medicare physical during the first 12 months of their enrollment. Men who have smoked sometime during their life and men and women with a family history of AAA are eligible for this benefit.

Treatment

Vascular surgeons can determine the best procedure for you, based on the size of your aneurysm and other factors. For smaller AAAs, you may need to make lifestyle changes, such as quitting smoking and lowering blood pressure. You may be prescribed medication. Your surgeon will have you come back for regular checkups to see if the AAA has changed.

For large AAAs, or those that have been increasing in size over time, repair may be carried out either by placement of an endovascular stent graft or by open bypass grafting.

Be sure to see a board certified vascular surgeon. They have specific training in both minimally invasive and traditional open repairs. The type of repair conducted is very important to long term durability and freedom from rupture.

 

What is an abdominal aortic aneurysm (AAA)?2022-03-24T11:15:19-07:00
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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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