The normal function of leg veins – both the deep veins in the leg and the superficial veins – is to carry blood back to the heart. During walking, for instance, the calf muscle acts as a pump, contracting veins and forcing blood back to the heart.
To prevent blood from flowing in the wrong direction, veins have numerous valves. If the valves fail blood flows back into superficial veins and back down the leg, known as venous reflux. This results in surface veins enlarging and becoming varicose. The process is like blowing air into a balloon without letting the air flow out again- the balloon swells.
To succeed, treatment must stop this reverse flow at the highest site or sites of valve failure. In the legs, veins close to the surface of the skin drain into larger veins, such as the saphenous vein, which run up to the groin. Damaged valves in the saphenous vein are often the cause of reversed blood flow back down into the surface veins.
Gravity is the culprit. The distance from the feet to the heart is the furthest blood has to travel in the body. Consequently, if the vein valves fail, those vessels experience a great deal of pressure. The backflow of blood causes the surface veins to become swollen and distorted.
Conditions contributing to varicose veins include genetics, obesity, pregnancy, hormonal changes at menopause, work or hobbies requiring extended standing, and past vein diseases such as thrombophlebitis (i.e. inflammation of a vein as a blood clot forms.) Women suffer from varicose veins more than men, and the incidence increases to 50% of people over age 50.
Varicose veins may cause legs to ache, feel heavy, and tire easily. Feet and ankles may swell towards day’s end, especially in hot weather. Varicose veins may be itchy, and the veins themselves may ache. Leg cramps can be caused by varicose veins. Varicose veins can get sore and inflamed, causing redness of the skin around them. In some cases, patients may develop venous ulcerations.
Venous ulcers are areas of the lower leg where the skin has opened and exposed the flesh beneath. Ulcers can range in size from less than a quarter inch to completely encircling the leg. They are painful, odorous open wounds which weep fluid and can last for months or even years. Most leg ulcers occur when vein disease is left untreated. They are most common among older people but can also affect individuals as young as 18.
Typical advice for treating varicose veins is summed up by the letters ESES (pronounced SS). It stands for Exercise Stockings Elevation and Still. Exercising, wearing compression hose, elevating and resting the legs will not make the veins go away or necessarily prevent them from worsening because the underlying disease (venous reflux) has not been addressed. However, it may provide some symptomatic relief. Weight reduction is also helpful. Insurance companies often require some time in use of compression stockings, anti-inflammatories (aspirin, ibuprofen, naproxen), and leg elevation before authorizing treatment. This may seem to reflect a conservative approach to treatment, but actually demonstrates an outdated understanding of vein disease, since these measures will not change the underlying problem. At best, they may slow the advances of the complications of chronic vein disease, but will not reverse them. Hopefully, one day the insurance companies will update their knowledge of vein disease and drop these requirements. In the meantime, it serves as a delay tactic in patients getting timely treatment.
A solution is injected into a vein causing a chemical injury resulting in the vein closing through a scar-like reaction. It is most effective when underlying sources of venous reflux have been treated. Leg wrapping or stockings are used following the injections, depending on the size of vein injected.
We use the only two FDA approved solutions for sclerotherapy, sodium morrhuate and sodium tetradecyl sulfate (sotradecol). Saline has been used in the past for sclerotherapy. It is very painful. It is not more effective than other solutions. Many physicians used it because it was cheap. Others still use it in order to avoid allergic reactions which were reported in the past in association with other solutions. These were probably not true allergic reactions. Some physicians are now using “foam sclerotherapy.” The solution is turned into a foam by injecting it with air back and forth between two syringes. This is not FDA approved. Informed consent for foam sclerotherapy should include this fact, as well as the fact that there are disturbing side effects (e.g.,dry cough, blindness), which are transitory. The long-term effects are not documented. For these reasons, we do not use foam sclerotherapy at Vein Surgery and Treatment Center.
Ambulatory phlebectomy is a surgical procedure for treating surface veins in which multiple small incisions are made along a varicose vein and it is “fished out” of the leg using surgical hooks or forceps. The procedure is done under local or regional anesthesia, in an operating room or an office “procedure room.”
When the source of the reverse blood flow was due to damaged valves in the saphenous vein, the vein was removed by a surgical procedure known as vein stripping. Under general anesthesia, all or part of the vein was tied off and pulled out. The legs were bandaged after the surgery but swelling and bruising lasted from days to weeks. Now that ablation has been proved to be effective, vein stripping should be regarded as a procedure of the past. It carries higher risk, greater pain, greater disability, longer recovery, greater cost, and, historically, less effectiveness than modern treatment.
VNUS Closure is used, instead of vein stripping, to eliminate reverse blood flow in the saphenous vein, but without physically removing the vein, and can be performed in the office with local anesthesia. With Closure, or Radiofrequency Ablation, the vein is closed using radiofrequency energy through a catheter to heat the inside of the vein. Ultrasound is required to make the diagnosis and indicate whether a patient is a candidate for the procedure. Like other venous procedures, the Closure procedure involves risks and potential complications, but these are much less likely than with traditional surgery.
In simplest terms, arteries pump oxygen-rich blood FROM the heart, veins return oxygen-depleted blood TO the heart. Especially with regard to the legs, arteries bring the blood down to the legs, and veins return blood up the legs back to the heart.
Deep leg veins return blood directly to the heart and are in the center of the leg, within the muscles, near the bones. Superficial leg veins are just beneath the skin, above the muscles. They have less support from surrounding muscles and bones than the deep veins and may thus develop an area of weakness in the wall. When ballooning of the vein occurs, the vein becomes varicose. Perforator, or communicating, veins serve as connections between the superficial system and the deep system of leg veins.
Spider vein are enlarged tiny veins in the skin (remember, varicose veins are under the skin). They may be hair-thin, or as large as a spaghetti noodle. They may be associated with underlying vein disease. An ultrasound exam may be advised to assess this. Not recognizing underlying vein disease is the most common reason for unsatisfactory results. This is why even spider veins should be treated by a physician with formal expertise in vein disease.
Before treating surface spider veins, any underlying vein disease must be evaluated and treated or else unsatisfactory results are likely. At Vein Surgery and Treatment Center we use sclerotherapy to treat spider veins. This involves using a tiny needle to inject a small quantity of a solution that will shut the vein down. It is nearly painless, and even patients who say they are afraid of needles have done very well with treatment. We first treat the surface feeder veins (called reticular veins) associated with the spider veins. A few weeks later, the spider veins are treated. After treatment sessions, a compression stocking is worn for a week. Treatment is not magic. There is a healing process that is required. Most spider veins look better within a few weeks, but continued improvement usually occurs over many months. Depending on how large the spider veins are to begin with, more sessions to inject the spider veins may be necessary.
Lasers have a definite place in medicine, but, in my opinion, treating leg veins is not one of them. Lasers have been used to treat spider veins of the legs. Unfortunately, because the procedure is so easy to do, it is often done by physicians who are not experts in vein disease, and underlying vein abnormalities may be overlooked. So, treatment often is less than satisfactory. In addition, lasers hurt more than injection. Many people are surprised to hear this. I’m not sure why – think of Star Wars. Lasers painless? And, finally, lasers are much more expensive than simple injection. Some people have said lasers are good to treat veins that are too small to inject. If you talk to a vein expert, you’ll find no vein is too small to inject. So, why use a therapy that is more painful, more expensive, and no more effective? We don’t use lasers at Vein Surgery and Treatment Center.
EVLT stands for EndoVenous Laser Therapy. After radiofrequency ablation (Closure) became available, laser companies developed a laser system designed for the same purpose. Unfortunately, laser is a less controllable source of heat and there is generally more bruising and pain with the procedure because of damage to tissues around the vein. It was attractive to surgeons because it was faster than the original Closure procedure. The new ClosureFAST catheter, however, is as fast or faster than laser, but with the advantage of less tissue trauma. We don’t use EVLT at Vein Surgery and Treatment Center.
a Roman goddess, who has nothing to do with veins
flow in the wrong direction – in veins, blood pooling down, rather than flowing up
veins not functioning normally, either because of reflux or obstruction in the vein; in either case, there is pooling and increased back pressure in the veins below
an 8-legged insect that is not the cause of spider veins
a device which emits pulses of sound waves and then picks up their reflection from underlying tissues and blood vessels to create an image of those tissues and vessels
Occasionally patients fail to come for their appointment and don’t notify us. This leaves a large gap in our schedule that someone else might have used. We therefore have a policy that consultation appointments will be held with a $100 deposit. If you need to cancel, you must let us know within 2 working days (remember, we’re not in the office Fridays). Failure to show without notice results in forfeit of the deposit. Obviously, if a family emergency arises, let us know and the deposit will not be forfeited. It is not that we want to keep your deposit – it’s just that we don’t want to be left in the lurch.
Your medical history will be reviewed and your legs and abnormal veins examined. An ultrasound examination will be performed if necessary – and essentially everyone with varicose veins needs one. A treatment plan will then be described.
If you are being seen for simple spider veins, treatment may begin at that first visit if you let us know that is what you would like at the time you make your appointment.
We are participating providers for Medicare, Sutter Health system HMO, UC Davis system HMO, and many PPO plans.