What are Varicose Veins?

Varicose veins are enlarged, weakened, dilated veins that have permanently lost their ability to carry blood from the legs back up to the heart against the force of gravity. This occurs because the one-way valves inside the veins have worn out. As blood falls down varicose veins the wrong way (away from the heart), the veins become distended from excessive pressure, resulting in their typical bulging appearance. Once a vein is damaged by this process, it can never again function as a healthy vein. Varicose veins commonly cause many symptoms in the legs including tiredness, fatigue, heaviness, aching, throbbing, itching, burning, and swelling. Night-time leg cramps and leg restlessness (sometimes called Restless Leg Syndrome) are also very common problems caused by varicose veins (Your family doctor may not realize that leg cramps and restlessness can be caused by varicose veins!) These symptoms are typically worse at the end of the day but get better with rest or elevation of the legs. Effective treatment of these diseased veins usually eliminates the symptoms. If left untreated, however, varicose veins always worsen over time and may lead to the formation of blood clots (thrombosis), inflammation of the vein (phlebitis), inflammation of the skin (dermatitis), and finally ulceration. Leg ulcers are the most severe stage of varicose vein disease, but even patients with venous leg ulcers can be helped with appropriate treatment.

What causes Varicose Veins?

Heredity is the number one contributing factor causing varicose veins. They are not caused by crossing the legs or by standing for long periods at work. A genetic tendency causes veins to weaken and wear out over time. The greater this genetic tendency, the sooner it will happen. Even after diseased veins have been successfully treated and eliminated, patients with a strong hereditary predisposition to varicose vein disease may develop new vein problems as time goes on. Other contributing factors include pregnancy, obesity, estrogen-containing medications, and traumatic injury to the leg. In most cases, nothing can be done to prevent veins from wearing out, but if effective treatment is given early in the course of the disease, complications like phlebitis, blood clots and ulcerations can be prevented and symptoms relieved.

How are Varicose Veins treated?

The procedure or combination of procedures recommended will be based upon the nature of your specific venous problem and your overall health and age. The doctor may recommend an ultrasound examination to assess the severity and extent of your vein disease, most of which may not be visible on the surface of the leg. With an accurate ultrasound map of your veins, we can determine the exact source of your problem and treat it effectively.

Conservative Therapy

The most conservative way to treat varicose vein disease is to wear prescription-strength compression stockings, usually knee length. Compression stockings help alleviate the swelling and pain caused by varicose veins. These stockings will also help heal any skin inflammation or ulcerations which have developed. However, compression stockings do not prevent varicose or spider veins. Since the diseased veins that are causing the symptoms are not being eliminated, the compression stockings have to be worn indefinitely. Conservative treatment is usually reserved for those patients too weak or sick to undergo definitive treatment. However, some insurance companies are now requiring patients to wear prescription-strength compression stockings for 3-6 months before they will consider reimbursement for treatment. This is medically unnecessary and merely serves to delay effective treatment.

Ultrasound-Guided Sclerotherapy (Chemical Ablation)

Sclerotherapy (chemical ablation) is ideal for treating small to medium sized varicose veins. An FDA-approved solution is injected into diseased veins causing them to shrink and gradually disappear. The solution used is extremely safe and painless. Anesthesia and sedation are not needed. For deeper varicosities, ultrasound is often used to "guide" the injections into the underlying diseased veins below the surface of the skin. This allows the medication to be administered to precise locations safely and accurately. Sclerotherapy (chemical ablation) is often done during post-operative visits to eliminate any diseased veins that were too small or too deep to remove during surgery. Thus, surgery and sclerotherapy (chemical ablation) are often complementary, ensuring that all the diseased veins are eliminated with treatment.

What about Foam Sclerotherapy (chemical ablation)?

Foam is made by mixing gas bubbles with a liquid sclerosing medication, giving a consistency like shaving cream or mousse. The smaller the bubbles, the thicker and more long-lasting the foam. When injected inside a vein, foamed sclerosing medication displaces the blood rather than mixing with it creating better contact with the vein wall. Improved contact between the medication and the vein wall gives better and faster results in appropriate cases. By foaming a sclerosing medication the doctor can get good results without resorting to larger doses of stronger medications. Much research is being done on foam sclerotherapy and its use for large saphenous veins. For now, it is mainly used in small amounts on spider veins and smaller varicose veins. In large amounts, foam can cause temporary side effects like blurred vision and chest pain, but these last only 10-20 minutes. Because of these side effects we use foam sclerosants sparingly.

Traditional Vein Stripping Surgery

Surgery is used to treat large varicose veins. Traditional surgery, commonly referred to as "vein stripping," is no longer necessary. This procedure is painful and requires hospitalization and administration of general or regional anesthesia. The permanent scarring that results from "stripping" is also unacceptable, as is the lengthy recovery time. The newer endovenous catheter occlusion and micro-surgical procedures provide aesthetically, cosmetically appealing results without permanent scarring and have completely replaced the traditional vein stripping surgery.

"This is not your mother's vein surgery."

Recent advances in venous ultrasound and surgical techniques now allow treatment of most varicose veins through very small incisions that do not require stitches and provide cosmetically acceptable results (in other words...no scars). A duplex ultrasound examination is done before treatment is begun, and this provides an accurate venous map, allowing precise treatment to be directed at only the diseased veins. In this way, treatment is tailored to the specific needs of each individual patient. There is no 'one procedure fits all' approach. All of our treatments are done in a pleasant office setting using only mild, if any, sedation and local anesthesia. The patient is up and about immediately after the surgery with no need to 'take it easy' or 'stay off your feet.' The patient is encouraged to walk as much as possible right after the surgery. Driving and working can be resumed the very next day. Strenuous exercise is usually limited for a short time.

Endovenous Catheter Techniques (Endothermal Ablation)

The most dramatic advance in the treatment of varicose vein disease in the past decade has been the use of catheters. Specialized catheters use heat to close diseased veins inside the leg. The heat is delivered directly inside the diseased veins which then shrink and seal shut permanently, eventually disappearing completely. There are two types of catheters used currently: laser and radiofrequency. Catheter procedures have completely eliminated the need for old-fashioned vein stripping procedures. Catheter techniques are done in the office under local anesthesia with mild, if any, sedation. General anesthesia is not required. Patients are awake during the procedure and are up and about immediately afterwards. Walking is encouraged immediately. Most patients can return to work the following day. Only your doctor can tell you whether you have diseased internal veins and whether a catheter procedure is right for you.

The catheter techniques are sometimes advertised as a treatment for bulging varicose veins. This is somewhat misleading. The catheter technique is only used to close internal veins that in some cases cause bulging varicose veins to form, but the catheters do not eliminate bulging, diseased veins. These bulging veins may shrink down and appear to disappear, but over time they can refill with blood and begin to bulge again. Bulging varicose veins usually require removal with ambulatory phlebectomy which is oftentimes done at the same time as a catheter procedure.

Ambulatory Phlebectomy

Ambulatory phlebectomy or "hook" phlebectomy is a micro-extraction procedure used to remove lumpy, bulging varicose veins. Small instruments are used to remove these diseased veins permanently. The incisions required are so small (1/8 inch) that they are closed with Band-Aids and not stitches. These tiny incisions usually heal completely without any scarring. This technique is done in the office under local anesthesia with mild, if any, sedation. General anesthesia is not required. Patients are awake during the procedure and are up and about immediately afterwards. Walking is encouraged immediately. Most patients can return to work the following day. A compression stocking is worn over the surgical bandages. When the stocking and bandages are removed 3 or 4 days later, patients are amazed how good the leg looks without the "ropey" veins. In many cases, the symptoms of heaviness and achiness that bothered the patient for so long disappear in just a few days or weeks. Bruising does occur and will take a few weeks to go away. Remember, in many cases bulging varicose veins on the surface are actually caused by diseased internal veins. Your doctor may recommend an ultrasound examination to make sure all your diseased veins are found and treated. This will minimize the chances of recurrence of vein problems in the future.