Vein Treatment

The dilated, ropey looking veins seen at the skin surface are caused in most patients by a failure (incompetence) of one-way valves within the great saphenous vein (GSV) of the leg to prevent the backflow of blood after each heartbeat. The GSV runs in a shallow channel from the groin to the ankle and when this failure occurs, essentially over time, the overall venous congestion and pressure increases within this vein, and by extension, into the tributary vessels from the surface flowing into it. These tributary veins at the surface that become dilated are the actual varicose veins that are so noticeable. Patients usually complain of heavy, aching legs that feel fatigued that are worse after prolonged standing. The pain is often improved with walking or by elevating the legs.

There are multiple factors that can contribute to the appearance of varicose veins, but heredity seems to be the most common reason for this primary valve failure. You are twice as likely to have problems with varicose veins when one of your parents had them. Occupations that require prolonged standing such as hairdressers can lead to venous dilation and resulting valve failure over time.

Important to remember is that varicose veins are a sign of the real problem that exists in the great saphenous vein or other saphenous veins that ordinarily cannot be seen. Only an ultrasound exam can determine where the underlying source of reflux in these incompetent veins exists. If varicose veins are simply removed without treating their underlying cause, they will recur.

Without effective treatment, venous insufficiency is progressive, with symptoms ranging over time from pain and swelling, to skin discoloration, infection and ulceration. Appearance of symptoms can be confusing because the severity of symptoms don’t correlate well with the size and extent of visible varicose veins. Often, the smallest varicosities are the most painful. Leg cramps can be a common symptom, often triggered as venous pressure rises to a high enough level, and the ensuing muscle contraction effectively moves blood out of the leg, momentarily lower the pressure. Restless leg syndrome is often a symptom of lower extremity venous disease for a similar reason.

The most conservative option used to treat varicose vein disease is the use of graduated compression socks and hose. Compression works by enhancing the ability of calf muscle contractions to propel venous blood up and out of the leg, thereby relieving venous congestion and reducing symptoms. Compression can temporarily relieve symptoms of venous insufficiency, but long term consistent use is difficult to maintain and does not address the underlying problem at its source. The most comprehensive and effective approach used to treat varicose veins is the targeted elimination of their underlying source of reflux using laser energy (endovenous laser ablation or EVLA) followed by removal of the varicose veins at the skin surface through micro incisions (micro phlebectomy).

As sedation is provided for EVLA and microphlebectomy, patients must have a driver accompany them to the clinic. After arrival, they are checked in and brought to one of our treatment rooms where a small intravenous catheter is placed for administration of a sedative (versed), and the course of any varicose veins are marked on the skin. Supplemental nasal oxygen is given and monitors for blood pressure, EKG and pulse oximetry are applied. Once the leg to be treated is prepped with hibiclens and draped, the vein access point for placement of the laser fiber is identified with ultrasound guidance.

In addition to sedation, local anesthesia is used for placement of a small iv catheter in the target leg vein and the thin laser fiber is positioned and confirmed also with ultrasound guidance. Around 500 cc of tumescent anesthesia is placed circumferentially along the entire course of the vein to receive laser treatment. This tumescent anesthesia should prevent any sensation of pain while the laser is firing and its presence also serves to prevent the heat of the laser from being transmitted to surrounding skin, muscle or nerves.

Once the tumescent anesthesia is in place, the fiber position is then reconfirmed and the laser firing engaged with the fiber pulled back with a device at a constant rate. The typical laser run is around 10 minutes. Patients are comfortably sedated throughout the entire procedure. The treated vein is the underlying cause of the varicose veins at the surface and it is not removed, the body simply resorbs it over time.

Microphlebectomy is then performed on the previously marked dilated ropey, varicose vein at the skin surface through tiny micro incisions which leave little to no mark on the skin. Occasionally, if there is a large burden of varicose veins present, to prevent excessive swelling, a portion of the varicosities will be removed at the time of endovenous laser ablation, with the remainder removed after several days.

It is preferred that the first sclerotherapy treatment be done simultaneously to clear any associated spider veins in order to achieve the best possible result. Additional sclerotherapy sessions can be scheduled at follow up as described in the sclerotherapy section above.

Only steri-strips are applied over the micro incisions and the leg is wrapped with an ace bandage. This is left in place overnight and can be removed the next day. After the ace bandage is removed, normal activities can be resumed and compression hose should be placed and worn for two weeks to achieve the best results. The hose can be removed to shower and sleep and any post procedure pain is easily managed with motrin or aleve. Patients typically return to work the following day.

Some temporary skin numbness above the course of the treated vein is common and resolves with time. For 2 or 3 weeks following the procedure, a pulling sensation can be felt in the upper thigh which is part of the normal healing process and should not keep the patient from normal activity. Follow up ultrasound examinations are performed at 2 weeks and 3 months to confirm the veins treated by the laser remain closed. Recurrence of varicose veins following treatment with endovenous laser ablation and microphlebectomy is less than 1%.

Modern endovenous treatment techniques have minimal side effects and a very low complication rate. The one potential complication that most people are concerned with when talking about vein treatment, is the potential for the formation of a deep venous blot clot or “DVT”. The procedures described here directed at the treatment of varicose veins are confined to the superficial venous system and the occurrence of DVT following endovenous laser ablation is less than 1%. One reason the risk is so low is because by nature, the very post procedure instructions given to produce the best results after treatment, namely resumption of normal activities (walking) and the strict wearing of compression hose, are also extremely good preventative measures against the formation of DVT. The typical presentation for a deep vein thrombosis is a red, swollen hot and painful leg. Even though it is a very rare occurrence, because it can be a dangerous situation, it is very important for every patient to recognize the signs. If this rare situation presents itself, call our after hours number, Arabella or Dr. Barlow immediately and they will handle the problem.

Problematic leg veins cause physical symptoms but they also result in emotional symptoms as well. Although men have a lower risk of developing varicose veins overall, these symptoms can be just as debilitating and greatly detrimental to quality of life. Often times, after treatment for long standing venous disease, patients are astonished to realize how much discomfort they had been experiencing for so long and once treated, often reporting it as a life changing experience for the better.
There is absolutely no reason patients should have to endure the pain and discomfort of problem leg veins anymore. At Precision Vein Therapeutics, we are focused on providing comprehensive and results-focused care as well as a world class overall patient experience using the most advanced techniques available.