Discussion of Varicose Veins and Faq’s About Treatment Options

What are varicose veins, spider veins, and reticular veins?
Varicose veins are ropy, swollen veins that are close to the surface of the skin. Reticular veins are the smaller, fine blue veins that are under the skin. Spider veins are smaller, red or blue veins that are in the skin layer.

What causes varicose veins?
The normal function of leg veins is to carry blood back to the heart. During walking activity, the calf muscle acts as a pump, compressing the leg veins and forcing blood back towards the heart.To prevent blood from going in the wrong direction, veins have one-way valves valves that prevent blood from flowing backwards down the leg. If the valves are faulty (a condition known as valvular incompetence), blood flows back into superficial veins and down the leg. This process is known as reflux. Reflux results in veins enlarging and becoming varicose. Once veins become varicose, they lose their ability to snap back into their correct shape, and become more plastic rather than elastic. Varicose veins unfortunately cannot heal themselves, and this condition is either stabilized with compression hose, or managed with one of the vein treatment plans. The greater saphenous vein is one of the most frequently damaged veins that leads to varicose veins in the leg.

Who is at risk for varicose veins?
There are numerous risk factors for varicose veins. These risks include a family history of varicose veins, obesity, pregnancy, hormonal changes at menopause, work that requires prolonged standing or sitting, and past vein diseases such as phlebitis (inflammation of a superficial vein) or deep venous thrombosis (blood clot in the deeper veins). Women also tend to suffer from varicose veins more than men. In addition, varicose veins can appear after trauma to the area.

What are the symptoms of varicose veins?
Varicose veins may cause aching of the legs. The ankles, calf and feet may swell towards day's end, especially in hot weather. Varicose veins can become sore and inflamed, causing redness of the skin around them. Skin changes from long standing vein problems include thickening of the skin, a brown discoloration, red rashes, and skin infections. Some patients with severe vein problems can develop sores on the ankles, known as venous ulceration. These are often difficult to heal, and can be helped by treating the underlying vein problem to prevent the reflux that led to the ulceration.

How can varicose veins be treated?
There are several ways to treat varicose veins, depending on the symptoms and types of veins present:
1. Compression stockings: The conservative management of varicose veins is to wear compression hose, exercise, control your weight, and elevate your legs above your waist as much as possible in order to drain the vein blood out of your legs. Compression hose will assist the vein in pumping blood up the leg and back to the heart. However, this technique will not make the varicose veins go away. Nevertheless, the use of compression hose is very important in not just preventing worsening of varicose veins, but also in preventing recurrent problems after treatment.
2. Sclerotherapy: This technique is used for the treatment of smaller varicose veins, as well as reticular veins and spider veins. A small amount of a medication (sclerosant) is injected directly into the diseased vein. The medication irritates the inner lining of the vein and causes it to seal shut. The newer types of sclerosants are not painful when injected using a very tiny needle, and multiple sites of injection are typically needed. In addition, one usually needs anywhere from 2-6 treatments to obtain 70-80% clearance of the spider veins. The procedure is performed quickly and easily without the need for anesthesia. Sometimes, we use ultrasound guidance for sclerotherapy. The number of treatments required will vary with each individual, depending on the extent of visible varicosities and spider veins. A range of 2-6 treatments can be expected in order to achieve a 70-80% clearance of the spider veins. We also use a Lyra 1064 nm YAG laser to treat stubborn spider veins.
3. Surgical Stripping: In the past, surgical removal or “stripping” of the diseased vein out of the leg was the best treatment we could offer patients with vein problems. This procedure required an operating room, general or spinal anesthesia, and recovery times that varied from 2-6 weeks. Vein stripping is an antiquated procedure and should be very rarely used in the management of varicose veins with the newer techniques that are currently available.
4. Microphlebectomy: This procedure involves the use of several, 1 mm, tiny incisions along the course of the leg veins in order to remove the diseased vein in segments. These tiny incisions heal well with minimal discomfort. Microphlebectomy can be performed by itself or in combination with another type of vein treatment.
5. Endovenous Laser Therapy: The use of lasers in the management of vein problems is replacing the standard surgical approach to treating large varicose veins. With Endovenous Laser Therapy (EVLT) a very thin fiber or catheter is inserted into the diseased vein through a small needle puncture in the leg, requiring only local anesthesia. The laser delivers energy directly to the inner lining of the vein, causing the vein to close. The procedure can be performed in the physician’s office in approximately one hour. Patients are usually able to resume their routine activities immediately after the procedure.

How Does Endovenous Therapy Work?
Endovenous Laser Therapy (EVLT) treats the incompetent greater saphenous vein (GSV). The GSV vein courses along the inside part of the leg from the groin to the ankle, and is frequently the underlying cause of varicose veins.
The procedure is done in the office under local anesthesia using ultrasound guidance. A laser fiber is passed through a small sheath inserted into the GSV. As the laser is activated, the resulting heat treats the inner lining of the vein causing it to seal. The whole procedure is performed through a tiny skin incision, so there is no post-operative scarring. Pressure is applied to the treated veins using compression hose or other compressive dressings.
The recovery time from EVLT is rapid as there are no large surgical incisions or side effects of general anesthesia. Normal activities can be resumed the net day. Vigorous physical activity such as weight lifting and aerobics are not advised during this time, and we advice that patients do not take plane flights for at least one week after the procedure.
Why Endovenous Laser Therapy Instead of Other Treatment of Varicose Veins?
The benefits of EVLT are the following:
1. A simple procedure
2. Performed under local anesthetic
3. Minimally invasive, so minimal risk of scarring and postoperative infection
4. The procedure takes about one hour and avoids surgery in the operating room with its associated costs
5. Rapid recovery with reduced postoperative pain
6. Normal activities can be resumed almost immediately
7. Excellent clinical and aesthetic results
8. Covered by most insurance companies including Medicare after failure of conservative medical management

What Are The Complications Of Vein Management?

Sclerotherapy and EVLT have rarely been associated with any serious complications. Minor complications of these procedures include bruising, mild itching, tingling, tenderness and tightness in the treated leg for up to two weeks after the treatment. Allergic reactions to the sclerosant have been reported, but are extremely rare. Ulceration of the skin after sclerotherapy can rarely occur. If they occur, the usually heal in 2-3 months and leave a small scar. Deep Vein Thrombosis is a very rare complication following sclerotherapy of larger varicose veins or EVLT. Other potential complications include:
1. Staining or brown pigmentation at the site of treatment. This occurs in about 30% of patients. In most cases the staining resolves but it may take many months.
2. Clots under the skin. These clots may affect the treated veins. These are not dangerous and can be removed through a small incision if necessary. Most of these clots dissolve by themselves.
3. Bruising at the injection sites usually resolves within one to two weeks.
4. Capillary matting is an increase in the number of fine red vessels around the injection site. This problem may disappear on its own, or can be treated by further injections.

What Is Involved In The Care After Treatment?

We recommended compression hose or some other type of compression dressing after treatments. These dressings are usually worn for one day following sclerotherapy and 1-2 weeks after EVLT. Compression stockings come in different styles, sizes and colors. We advise return to a normal physical activity routine after the procedure, but vigorous aerobic exercise is not recommended for 2 weeks after ELVT. Sclerotherapy patient can resume normal exercise the day after treatment.

Will Abnormal Veins Come Back After Treatment?

After sclerotherapy for spider veins, a small number of patients who have a natural tendency to form spider veins will need yearly treatments or “touch-ups”. Larger varicose veins can also recur, especially if one gains weight, or does not wear compression hose. These recurrences are usually not as severe as the initial episode, and can be treated with sclerotherapy or microphlebectomy.

Will My Health Insurance Cover My Care For Vein Problems?

Most insurance companies will cover treatments for varicose veins that are causing problems despite conservative management. Conservative management means a trial of compression hose for 3-6 months. If you continue to have pain or swelling despite wearing compression hose, then most insurance carriers will cover EVLT or microphlebectomy. Insurance does not usually cover the treatment of spider veins, and these treatments are paid for by the patient.

Will Getting Rid Of Varicose And Spider Veins Hurt My Circulation?
The varicose veins that are being treated are not doing their job, and therefore are not missed when they are treated. The body has numerous other veins that are taking blood back towards the heart, and they take over the role of the varicose veins after treatment.

How Long Will It Take For Me To See Results After Treatment?
You will see some immediate results after treatment for varicose and spider veins. The best results will be seen after 3-6 months, when the swelling and bruising has completely resolved.

For more questions about all things venous, including deep venous thrombosis (DVT) and the latest management techniques such as thrombolysis of DVT’s and pulmonary emboli, please visit my vein website at www.my-varicose-veins.com.