Venous Insufficiency is used to describe a spectrum of problems ranging from the appearance of spider veins, to the actual failure of veins to maintain forward flow of blood, allowing pooling to occur in the legs with resulting excessive venous pressure, and the subsequent appearance of varicose vein veins, and at the worst, venous ulceration.
We treat front and back of both legs with liquid or foam Sclerotherapy. Most patients require two treatment sessions, with each clearing about 70% of the spider vein burden.
We first treat the underlying cause of varicose veins with the CoolTouch endovenous laser system. The varicose veins at the surface are then removed through tiny incisions that leave little to no mark on the skin.
SCLEROTHERAPY TREATMENT FOR SPIDER VEINS
All new patients undergo a lower extremity venous ultrasound examination in our clinic to rule out the presence of underlying venous reflux. The reason this is so important is because sclerotherapy alone is ineffective in treating spider veins in patients with reflux in the underlying veins.
The good news is that most patients who only have spider veins without the presence of dilated varicose veins will not have reflux and can be treated simply with sclerotherapy alone, but an ultrasound examination is the only way to know for sure.
Modern, effective Sclerotherapy works by displacing the blood in these tiny vessels and producing a disruption in the lining with eventual fibrosis and closure of the vein. Don’t be surprised if the injected veins actually look worse in the first few days after treatment. This is a result of an inflammatory response and is expected. Additionally, you may notice small areas of dark red or bluish appearing blood clots within the injected veins. These are not the type of blood clots that are life threatening and should resolve over time on their own. If these small clots cause discomfort, we can make a small pin prick puncture over it after using a local anesthetic and express it from the vein. The discomfort should quickly resolve.
We know that some spider veins are more resistant to Sclerotherapy than others. We adjust the strength of the Sclerotherapy agents judging from the success of previous sessions.
Pre-treatment instructions will have been given to maximize success. We start with photographs of all areas of concern. Alcohol is used to prep the skin and tiny needles are used for the injections. Most patients tolerate this very well, however sedation is available if preferred. It is necessary that a driver be present with the patient at check-in if sedation is desired.
We use the “vein light”, a device that effectively illuminates larger reticular veins that often-feed clusters of spider veins. Injections of these feeder vessels, when present are essential to eliminate spider veins at the skin surface.
Injections are carefully performed using a combination of Sodium Tetradecyl Sulfate (STS) and/or Glycerin. These agents are quite effective and produce remarkably less pain on injection that older sclerosant agents. Not uncommonly, patients may experience minor red whelping at injection sites, similar to a fire ant bite, that will last for several hours and is not a cause for concern. Bruising may also occur with sclerotherapy and would be expected to resolve in one to two weeks. Arnica cream, an effective homeopathic agent is available for purchase in the clinic to limit bruising.
The number of Sclerotherapy sessions needed depends on the severity and extent of the spider veins. Most patients require 2-3 sessions spaced 1 month apart and our goal is to eliminate 70% of the spider vein burden with each treatment. We expect that the spider veins we treat will not recur, but as the years go by, other spider veins may appear. Many patients will stop by every year or so for a maintenance session to keep their legs looking in tip top shape.
The success of our treatment is very much a function of faithfully following the instruction of wearing compression hose after treatment. Patients are fitted with thigh high compression hose that they wear for two weeks following a Sclerotherapy session. They dramatically increase the number of spider veins that can be cleared with each session. These are available for purchase at our clinic but you may bring your own if you have them. We recommend at least Class I (20-30mmHg) compression. The absolutely essential importance of wearing compression hose after Sclerotherapy cannot be emphasized enough. Compression hose work by keeping the walls of the treated spider veins compressed together which helps them to sclerose and disappear.
The compression hose may be removed to shower and sleep, however, we recommend that if you can tolerate them to sleep in, do it! The more you can stay in them, the better the success of each treatment. Hot baths are discouraged for the first week after a Sclerotherapy session as soaking in hot water tends to dilate the veins around treated areas, making it harder for the sclerosing agent to eliminate the spider vein. Otherwise, aside from driving for the remainder of the day (only if sedation was given), immediate return to normal activity is recommended.
VARICOSE VEINS AND 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.
VENOUS ULCERATIONS AND TREATMENT
Venous ulcerations are the most severe class of chronic venous disease. The formation and management of venous ulcers is complex and the subject of much research and debate. The core issue however is the same problem that results in painful varicose veins already detailed above. Increased venous pressure from associated incompetent (refluxing) superficial veins or the connections (called perforator veins) between these superficial veins and the deep veins of the leg, has to be addressed.
Venous ulcers are also effectively treated with a combination of endovenous laser ablation and ultrasound guided sclerotherapy. Complete duplex ultrasound examination is performed to determine the appropriate treatment plan, using either modality. Most treated venous ulcers with identifiable associated abnormal veins typically heal within 1 or 2 months. Patients are kept in compression until the ulcer fully heals.
The procedure for treatment of venous ulcers with endovenous laser ablation is essentially the same as that described above for that of varicose veins. For active ulcers, there are Velcro compression devices available for purchase at our clinic that are particularly suited for the application issues with open venous ulcers.