It is estimated that over 50 million Americans are bothered by the appearance of veins on their thighs, calves and ankles. Nearly half that number has symptoms associated with their veins. These symptoms include pain and tenderness, swelling, a feeling of leg heaviness or fatigue, itching, and inability to perform the daily tasks that most people take for granted. When the venous disease gets more severe, the symptoms also get worse, and there may also be bleeding, ulceration, or a dark discoloration of the lower leg and ankle. For many years, the progressive severity of varicose vein disease has been under appreciated, leading for many to a decreased quality of life. When treatment was given, it was usually vein stripping, which was frequently worse than the disease. Fortunately, recent technology advancements, as well as a better appreciation of the nature of venous disease, have led to more effective treatment options. Many of these treatments may be covered by your health insurance. The following information discusses normal and abnormal vein function, the nature of the treatments available, and how we can tailor a treatment plan to meet your specific needs.
How Leg Veins Work
Blood flows through a system of blood vessels, also known as veins and arteries. The job of the veins is to carry blood from the organs and limbs to the heart. The job of the arteries is to carry blood from the heart to the rest of the body. The blood then drains back into the veins, and the cycle begins again. In healthy legs, there is a large network of veins to handle the blood flow. The tiny skin veins drain into the reticular veins, which drain into the larger superficial veins. The main superficial veins are the greater and lesser saphenous veins. This system runs parallel to the deep veins, which drain blood from the muscles and other deeper tissues in the leg, and return the blood to the heart. These two systems are connected by perforator veins.
To get from the feet and legs to the heart, blood has to flow upward. This means that it must work against gravity. The action of the calf and thigh muscles helps pump blood upwards. Valves (small flaps inside the veins) open to let blood through, then close to keep it from flowing backward. The root of most vein problems is venous insufficiency, or veins not functioning well in carrying blood back to the heart. This condition occurs when veins dilate (widen and stretch) and valves become incompetent (unable to close properly). Spider veins are tiny dilated blood vessels just under the surface. Varicose are large or small veins that have become dilated and may have valves that don’t work.
Spider veins are tiny blood vessels just below the surface of the skin that become enlarged and look like red or blue threads on the skin. Clusters of spider veins can even look like a bruise. Spider veins can form due to heredity, pregnancy, hormone changes, or injury. These veins are usually not painful, but their appearance can make you self-conscious.
Varicose veins are a similar process, but in a larger vein. When a vein is dilated or its valves are damaged, blood flows in the wrong direction. This is called reflux. Blood “backs up” in the leg veins, which may cause aching, tiredness, swelling and feelings of heaviness or fullness. The veins stand out from the skin and can appear rope-like or twisted. Problems with the saphenous veins can harm the veins that drain into them, causing these smaller veins to dilate and become varicose. Potential problems caused by varicose veins include bleeding, ulcers, skin discoloration, and blood clots.
Evaluation and Treatment Plan
When you come in for an evaluation, we will discuss your medical history, including any previous vein treatments you may have had. We will want to know about your symptoms, such as pain, swelling or fatigue, if there is a family history of vein problems, the duration and symptoms of the problem, current medications, and your level of activity. We will want to know if you have worn any type of compression hose, and if you have to rest and elevate your legs to get relief. We will also do a physical exam, and likely get a duplex Doppler to evaluate your legs. This is a non invasive test that uses sound waves to create pictures, and can give us detailed information about the venous system. It shows blood flow, and can determine where reflux is occurring. This test can also rule out other more serious vein conditions, such as blood clots. After your evaluation is complete, we will discuss your individual needs, and what treatment options are available to you. All treatments destroy or remove veins. The remaining veins then take over the workload, carrying blood where it needs to go.
It is important to have realistic expectations. Varicose vein treatments can decrease or eliminate symptoms, can improve your appearance, and can reduce the number of new problem veins that may form. Varicose vein treatments can not guarantee that problem veins won’t develop in the future, and can not make your legs look perfect, though we do strive for the very best result.
There are some nonsurgical options to reduce the chance of getting varicose veins, or to reduce the symptoms once they are present. This is often the best choice when there are only a few veins, or few symptoms present. Medical grade compression stockings are the first line of treatment, and a trial of compression therapy is usually required by most medical insurance companies before they will approve further treatments. These come in many levels of compression, and many different styles. Compression stockings help move the blood upward and prevent pooling in the legs. Exercise of the thigh and calf muscles promotes good tone, and also helps move the blood upwards in the leg. Weight loss may help relieve symptoms, and elevation of the legs to relieve pressure is also a good way to relieve symptoms.
Laser Spider Vein Removal
This is an effective treatment for spider veins. A laser is used to damage the thread-like veins, causing them to seal shut. Detailed information about this is available under the laser portion of the web site. This is considered a cosmetic procedure and therefore is not covered by medical insurance.
This involves the injection of a chemical, called a sclerosant, directly into the small varicose veins. This causes irritation of the inner lining of the vein resulting in closure of the vein. External compression is used in the form of compression hose for one week after treatment, to help the vein walls seal together. The body will then break down and absorb the damaged vein. When healing is complete the vein is no longer visible. These veins do not have any useful function and eliminating them will not affect your circulation. The majority of persons who have had sclerotherapy performed have satisfying results. Unfortunately, there is no guarantee that sclerotherapy will be effective you. In rare instances, the condition may become worse after sclerotherapy treatment. The number of treatments needed caries from patient to patient, depending on the extent of the problem and your body’s response to the injections, but several sessions are usually required. It is important to realize that the best results require patience. It takes time for your body to respond to the injections. It is important to follow the post-treatment instructions to optimize your results. Again, this is a cosmetic procedure, and therefore is not covered by medical insurance.
This is also known as stab phlebectomy or microincisional phlebectomy, and is the removal of undesired varicose veins through a series of very small skin incisions, or cuts, along the path of the enlarged vein. Prior to this procedure, the vein is evaluated by ultrasound to mark its path, and determine how best to approach its removal. The procedure is done under local anesthesia in the office. Afterward, the leg is wrapped with a compression bandage. This is a good choice if there are only a few larger veins that need to be removed.
Transilluminated Powered Phlebectomy
This is also known as the Trivex procedure. This is a minimally invasive type of ambulatory phlebectomy, and is performed in the operating room under anesthesia. In this procedure, small incisions are made in the skin, and thin metal instruments are placed below the skin. These consist of a light source, called an illuminator, to identify the varicose veins, and a rejector, which sucks the vein into it and chops the vein into small pieces, which are then sucked out. Fluid is used to help separate the veins from the fatty tissue, and to help control bleeding. The legs are then wrapped in compression bandages, and compression hose are work for two weeks to help minimize bruising and swelling. This procedure is a good option if there are many veins to be removed. There are few cuts to the skin, but a much wider area of treatment than with standard ambulatory phlebectomy.
This is a minimally invasive alternative to vein stripping, and is a good treatment for saphenous vein reflux. We use a procedure call Endovenous Laser Treatment, or EVLT, to perform this technique. The laser fiber is inserted into the saphenous vein through a small puncture or incision, and then under ultrasound guidance, is advanced up the vein to its end. The laser is activated, causing damage to the saphenous vein. The laser fiber is slowly withdrawn, to treat the entire segment of the sephenous vein. Damage to the vein wall leads to its collapse and ultimately its obliteration. The varicose veins associated with this vein then disappear from sight. The leg is then wrapped in a compressive bandage, and compression hose are worn for two weeks to ensure proper closure of the vein, and to minimize bruising and swelling.