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Vein Problems
Varicose Veins
What are Varicose Veins?
Varicose veins usually appear as swollen, ropey veins just under the surface of the skin most commonly occurring in the legs, ankles and feet. They are produced by a condition known as venous insufficiency or venous reflux, in which blood circulating through the lower limbs does not properly return to the heart but instead pools in the veins, causing them to become distended and tortuous.
What Causes Varicose Veins?
More than 25 million Americans suffer from venous reflux disease. Venous reflux disease, also known as venous insufficiency, is a medical condition affecting the circulation of blood in the lower extremities. Arteries carry oxygen rich blood away from the heart. Veins return oxygen poor blood to the heart, where blood is first pumped to the lungs, oxygenated, and then pumped back out through arteries to the body’s tissues. Valves in veins keep blood flowing in one direction--toward the heart. When these valves fail, the flow of blood in leg veins is influenced more by gravity, causing blood to pool in these veins, which then become stretched and dilated. Just like a balloon that never returns to its original size after it is inflated, varicose veins remain distended unless they are treated.
What is Venous Reflux?
Venous reflux means that blood is flowing the wrong way in veins, usually because valves in these veins have failed.
To see a Windows Media Player video about Venous Reflux Click Here or on the image to the left.
Who Develops Varicose Veins?
Gender and age are two primary risk factors in the development of venous reflux. An estimated 72% of American women and 42% of men will experience varicose veins symptoms by the time they reach their sixties. Women who have been pregnant more than once and people who are obese, engage in heavy lifting, have a family history of varicose veins or spend a great deal of time standing have an elevated risk for the condition, but venous reflux may occur in nearly anyone at almost any age. Varicose veins never go away without treatment and frequently progress and worsen over time.
Common Symptoms of Varicose Veins
Symptoms can include pain and fatigue in the legs, swollen ankles and calves, restless leg syndrome, burning or itching skin, skin discoloration and leg ulcers. Standing for a prolonged period of time may be uncomfortable due to blood pooling in dilated leg veins. In less severe cases, thin, discolored vessels – “spider veins” – may be the only symptom. Elevation of the legs, avoidance of prolonged standing, and wearing compression stockings usually improves symptoms. Some patients with varicose veins initially report that they have no symptoms, but after wearing compression stockings they realize that their legs feel lighter and “have more energy.” This suggests that these patients became accustomed to the heaviness in their legs, not recognizing that this sensation is abnormal.
Patient Education: Varicose Vein Slideshow
Complications of Varicose Veins
- Thrombosis (Clotting)
Because blood flow in varicose veins tends to be slower and less uniform than in normal veins, varicose veins can thrombose or clot. This usually results in a condition called superficial thrombophlebitis (SVT) in which the clotted vein becomes painful and tender. Due to the inflammatory response, the overlying skin may appear red and inflamed and may be mistaken for an infection. In a small percentage of patients a clot in a superficial vein may extend into the deep venous system, forming a deep venous thrombosis (DVT). A clot in the deep veins can dislodge and travel to the heart causing a potentially life threatening condition known as a pulmonary embolism (PE). - Ulceration
Venous ulcers indicate the most severe forms of venous insufficiency and typically involve both the deep (including perforators) and superficial venous systems. Extreme reflux and elevated pressure within veins result in changes in the microcirculation of the skin eventually leading to severe ulceration. A subset of the population has deep system-only involvement (<5%) and an even smaller portion perforator-only incompetence. Venous ulcers can be very difficult to treat and even with the best care may take many months to heal. Venous ulcers also have a tendency to recur, especially if venous insufficiency is left untreated.Severe varicose veins can have a significant impact on the lives of people who work on their feet – nurses, postal workers, teachers, flight attendants et al. Research has shown that more than two million workdays are lost each year in the US, and annual expenditures for treatment total $1.4 billion.
- Bleeding
Varicose veins may spontaneously bleed, or bleeding may occur as a result of trauma to a varicosity. Bleeding can usually be easily controlled by simply applying pressure to the bleeding vein. Elevation of the leg above the level of the heart should also help control bleeding. Occasionally bleeding from a varicose vein may require treatment at an urgent care center or an emergency room.
Prevention of Varicose Veins
Unless you live on the space station, your leg veins will be subject to the effects of gravity. The ability to prevent varicose veins is debatable, however, below are some tips that may help in the prevention of varicose veins and spider veins:- Elevate legs when possible,
- Exercise regularly. Walking, climbing stairs, cycling and swimming cause calf muscle contraction which pumps blood through the veins. This reduces pooling and venous pressure.
- Avoid inactivity. Flexing the ankles periodically will keep blood moving via the calf muscle pump. During periods of prolonged sitting or standing, flex the ankles repeatedly. If possible, avoid sitting for extended periods throughout the day.
- Compression stockings provide external graduated counter-pressure to keep veins from dilating and speed venous blood return to the heart. Compression stockings reduce blood pooling and pressure in the veins. They also may reduce the risk of forming a deep vein blood clot. Consider wearing them during long plane or car rides.
- Try to achieve an ideal body weight to reduce excess pressure on the legs.
Treatment of Varicose Veins
- Endovenous Radiofrequency Ablation (Venefit Closure)
What is Endovenous Radiofrequency Ablation?
Radiofrequency (RF) endovenous ablation is a minimally invasive treatment procedure for venous reflux, using radiofrequency energy to heat and seal diseased saphenous veins, branches of saphenous veins, and perforator veins, addressing the underlying cause of varicose veins. The Venefit ClosureFAST™ catheter and the Venefit ClosureRFS Stylet deliver radiofrequency energy to heat and contract the collagen within the vein walls and cause shrinkage and collapse of the vessel.When ablating the greater saphenous vein, the procedure involves inserting the catheter into the diseased vein through a very small incision and threading the device through the vessel up to the groin area. Radiofrequency waves are applied to the heating element in 20-second intervals to sequentially heat and ablate the vein in seven centimeter increments. After each segment is treated, the ClosureFAST catheter is manually withdrawn down the vein and the process is repeated until the entire length of the vein has been ablated. The body automatically re-routes blood flow through healthier veins, and the restoration of normal circulation relieves the distention of the surface veins. The ablated vein becomes scar tissue and is eventually absorbed by the body.
- In Vitro Study
To the left is an infrared thermal camera image of the ClosureFAST catheter heating a vein inside a block of tissue. Note uniformity and limited depth of heating; temperature decreases from 95o C to 43o C at 1.5mm radial distance from intima. -
Radiofrequency perforator ablation:
Elevated venous pressure near the ankle may cause skin changes including darkened pigment, thickened skin, and venous ulcers, affecting 7% to 9% of the population and increasing with age. Refluxing perforator veins contribute to the elevated venous pressure in over two thirds of these patients. The ClosureRFS Stylet is the only intravascular ablation device specifically cleared - by the FDA for the treatment of refluxing perforator veins. After a small incision, the tip of the stylet is introduced into a refluxing perforator under ultrasound guidance. Local anesthetic is placed around the stylet and the vein is heated to 85 degrees centigrade in four quadrants, closing the vein.
- Endovenous Laser Ablation
Endovenous laser ablation is a minimally invasive procedure frequently performed in the office of Northern Arizona Vein Center under local anesthesia for the treatment of varicose veins. A laser fiber (image to left) is inserted under ultrasound guidance through a tiny incision into the vein that is causing the bulgy, unattractive, and often painful varicose veins. Fluid is placed around the vein (tumescent anesthesia) so that the procedure is relatively painless. The laser heats the lining of the vein (the endothelium), damaging it and causing it to collapse, shrink, and eventually disappear. This technique typically is used to treat the saphenous veins and branches of the saphenous veins that are causing large varicose veins in the legs and takes about 30-60 minutes to perform.
Patient Education: What to expect during your endovenous laser ablation
What are the benefits associated with endovenous ablation?
- A reduced chance of developing stasis ulcers
- Significant relief from discomfort such as aching, fatigue, heaviness, and pain
- More efficient blood circulation
- An improved body image and confidence in one’s appearance
- A minimally invasive, quick and easy treatment option under local anesthesia
Is the loss of varicose veins a problem?
No. Varicose veins are unhealthy and actually can be detrimental to circulatory health. Varicose vein removal has no adverse affect on the body. Blood is rerouted through healthy veins with intact valves so that blood travels away from the feet and returns to the heart in an efficient manner. The greater saphenous vein is frequently obliterated during endovenous ablation. Although the greater saphenous vein is the preferred conduit harvested by cardiac surgeons during bypass surgery, a diseased and dilated greater saphenous vein makes a poor bypass conduit and therefore cannot be used for cardiac bypass surgery. A normal saphenous vein should always be preserved because it may be required in the future for open heart surgery.What is recovery like after endovenous laser ablation?
The procedure leaves nearly imperceptible scars, is associated with minimal postoperative pain, involves a rapid recovery period, and provides almost immediate relief from symptoms. Minor soreness and bruising can be treated with over the counter pain medication such as Aleve, Motrin, or Tylenol. After the procedure, patients are encouraged to walk and resume their normal activities, wearing compression stockings for about three weeks. An ultrasound is usually performed within three to five days post procedure to make sure that the treated vein has closed and to evaluate for the rare complication of a deep venous thrombosis (DVT). Another follow up appointment is typically made with Dr. Schilperoort about three to four weeks later for a final postoperative check.What are the risks associated with endovenous ablation?
As with any medical procedure, there are potential complications. These include:
- Decreased sensation in the thigh, ankle, or foot, depending on which vein is treated
- A pulling or tight sensation in the thigh which may last a week or two
- Phlebitis (redness and tenderness of the skin) is quite common but is mild in nature and easily treated with over the counter pain medications. Most cases of phlebitis resolve in 3-7 days
- Deep venous thrombosis (DVT). This is a very rare complications following endovenous ablation. The best way to prevent this rare complication is to wear a compression bandage or compression stocking and to walk right after the procedure. This keeps blood flowing in the deep venous system and reduces the chance of clot formation. An ultrasound three to five days after endovenous ablation is used to evaluate for DVT.
- Infection at an incision site is a rare complication
- Bruising is common after the procedure, but is usually mild and resolves within a week
- Other complications may occur involving improper procedures being performed or mistakes made in the execution of the procedure. These problems can usually be avoided by choosing a reputable, experienced surgeon such as Dr. Brian Schilperoort FACS.
How successful is endovenous laser ablation (EVLA)?
All data indicate that endovenous laser ablation is a safe and effective procedure. The FDA has approved it for the treatment of varicose veins. Endovenous laser ablation is minimally invasive and enjoys a 98% success rate with a recurrence rate of 7% after two years.What are alternatives to endovenous ablation?
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Vein Stripping
Before the development of endovenous ablative techniques, surgery was the standard treatment for varicose veins. Vein stripping requires the use of general anesthesia, leaves obvious scars, is more painful, and has a longer recovery time. Vein stripping usually involves making an incision in the groin and passing a long cord-like device called a “stripper” down the diseased vein. Another incision is made near the knee or ankle and the stripper is tied to the vein at the site of the second incision. In a relatively barbaric procedure, the stripper is then pulled back, ripping out the vein and tearing its branches. This procedure often results in extensive bruising that typically resolves within one to two weeks. -
Ambulatory Phlebectomy
Endovenous ablation does not remove the large varicose veins that develop as a result of venous reflux. After endovenous ablation varicose veins located just below the surface of the skin may appear slightly smaller due to the reduced pressure in the venous system. However, once reflux is corrected, these veins may clot and cause an inflammatory response known as superficial thrombophlebitis. To prevent this complication, many patients choose phlebectomy—removal of varicosities through tiny incisions. With a patient standing, the dilated veins are marked with an indelible pen. After the leg is sterilely prepped, tiny nicks are made in the skin overlying these veins. A small hook is used to deliver the vein out of the wound. The vein is clamped, divided, and rolled onto the hemostat and removed. This eliminates the varicose veins and gives an excellent cosmetic result. -
Foamed sclerotherapy
Click here for an Example of Foamed Sclerotherapy
Sclerotherapy is often used to treat varicose and spider veins. Using a small needle, veins are injected with a solution that irritates the lining of the vein wall, causing the vein to thrombose (clot). The body then breaks down the thrombosed vein and the vein gradually fades away. This procedure is performed in office and multiple treatments may be needed to reach desired results. The sclerosing agent is often mixed with air or carbon dioxide to create foam that will displace the blood in the vein. Compression stockings are worn for about two weeks post procedure. Most patients resume normal activities immediately. An allergic reaction to a sclerosant is rare, but has been reported. Staining, or brown discoloration on the skin is a possible side effect of sclerotherapy. This staining may take six months or longer to fade. Rarely sclerotherapy may result in the breakdown of a small area of skin resulting in an open wound (an ulcer).
Click here for a second Example of Foamed Sclerotherapy
Click here to see the making a Foamed Sclerosant for Sclerotherapy
What is the difference between cosmetic surgery and medical necessity?
Physicians have been debating the treatment of varicose veins for well over two thousand years. Ancient artwork depicts varicose veins and the legendary Hippocrates wrote about them in the fifth century BC. Medical necessity and health insurance are now major factors in determining the course of treatment for varicose veins.If a patient desires treatment of varicose or spider veins for the exclusive purpose of improving the patient’s appearance, such treatment is considered to be cosmetic and will not be covered by the patient’s health insurance or Medicare. Nearly all procedures addressing spider veins will fall into this category.
If varicose veins are causing symptoms that adversely affect the patient’s quality of life, ability to work and/or function normally, or if a patient manifests complications of venous reflux, such as bleeding, stasis ulcers, or blood clots, treatment will likely be recommended to restore or preserve the patient’s health and well-being, and such treatment will therefore be considered a medical necessity. Under those circumstances, most health insurance and Medicare plans will cover the procedure.
Spider Veins
What are Spider Veins?
Spider veins are tiny dilated blood vessels visible as purple, blue or red streaks, located just below the surface of the skin and sometimes occurring in web-like groups. Spider veins can occur on the face, chest, and abdomen, but are more common on the thigh, calves, and ankles. Unless treated, they are permanent and tend to increase in number over time. Although spider veins are mainly a cosmetic problem, they can be an indication of venous disease below the surface of the skin. Spider veins drain into deeper veins called reticular veins. Reticular veins may or may not be visible to the naked eye, but can be easily seen with the use of high intensity light applied directly to the skin (transillumination). Identification and treatment of reticular veins is an important aspect of the successful treatment of spider veins.
Symptoms of Spider Veins
Spider veins are usually of cosmetic concern, but may be associated with itching or burning. If spider veins are associated with leg heaviness, fatigue, and/or swelling, dilated veins below the skin surface may be to blame. Occasionally spider veins spontaneously rupture and bleed, or they may bleed with trauma such as may occur during shaving.
Patient Education: Spider Veins
The exact cause of spider veins is unknown. The presence of spider veins is sometimes an inherited trait. Spider veins may also appear after trauma or surgery. No correlation exists between crossing the legs, wearing constrictive clothing or garters and the occurrence of spider veins. More common in women, spider veins may be triggered by hormonal variations such as occur in pregnancy. Spider veins may be associated with venous hypertension due to larger diseased veins causing pressure on tiny veins which then dilate at the skin surface. If this possibility is considered, duplex ultrasound imaging can evaluate for underlying venous disease, which should be treated prior to treatment of spider veins.
Treatment of Spider Veins
To see a Windows Media Player video about Spider Vein treatment Click Here or on the image to the left.
Sclerotherapy is often used to treat varicose and spider veins. Using a tiny needle, veins are injected with a solution that irritates the lining of the vein wall, causing them to collapse and gradually fade away. This procedure is performed in office, usually lasting approximately 30 minutes. Multiple treatments may be needed to reach desired results. The sclerosing agent is often mixed with air to create foam that will displace the blood in the vein. For optimal results, reticular veins associated with spider veins also need to be sclerosed. Compression stockings are worn for about two weeks post procedure. Most patients resume normal activities immediately. An allergic reaction to a sclerosant is rare, but has been reported. Staining, or brown discoloration on the skin is a possible side effect of sclerotherapy. This staining may take six months or longer to fade. Rarely sclerotherapy may result in the breakdown of a small area of skin resulting in an open wound (an ulcer). Some patients may develop lace-like matted webs of tiny, dilated, red, blue, or purple capillaries, arterioles, or venules visible just below the skin surface after sclerotherapy.Laser ablation can also be used to eliminate tiny spider veins in fair skinned patients. At Northern Arizona Vein Center we use the state-of-the-art, high performance Dornier Medilas D FlexiPulse diode continuous wave laser with a 940 nm wavelength. Short pulses of laser energy are applied to spider veins, effectively obliterating them. The 50 milisecond pusles feel like tiny needles and are usually well tolerated by most patients. Cooling of the skin may decrease the discomfort of laser treatment. Tanning should be avoided for two to four weeks before laser treatment. Laser and sclerotherapy are frequently used to complement each other during the same treatment session.
Despite appropriate treatment, spider veins may recur later in life, possibly due to the underlying genetic predisposition that led to the development of spider veins in the first place. Treating spider veins does not keep new ones from appearing, but treating new ones every few years may be appropriate to keep them from becoming too extensive. After child bearing years, which are associated with hormonal swings, spider veins may develop more slowly.
Superficial Thrombophlebitis
Superficial thrombophlebitis results from clotting and inflammation in a superficial vein. The skin over the vein becomes red, swollen, and painful and may be mistaken for an infection. Instead of feeling like a soft normal vein, a phlebitic vein feels like a hard cord under the skin. Superficial thrombophlebitis most often affects the superficial veins in the legs but may also affect superficial veins in the groin or in the arms. Superficial thrombophlebitis in the arms usually results from having an intravenous catheter. Thrombophlebitis occurs more frequently in people with varicose veins because the blood tends to flow more slowly and with less uniformity than in normal veins. However, most people with varicose veins do not develop thrombophlebitis. Even a slight injury can cause a varicose vein to become inflamed. Unlike deep vein thrombosis, which causes very little inflammation, superficial thrombophlebitis involves a sudden (acute) inflammatory reaction that causes the thrombus (blood clot) to adhere firmly to the vein wall and lessens the likelihood that it will break loose. Unlike deep veins, superficial veins have no surrounding muscles to squeeze and dislodge a thrombus. For these reasons, superficial thrombophlebitis rarely is associated with pulmonary embolism (blood clot travelling to the lung). Superficial thrombophlebitis usually subsides by itself. Taking an anti-inflammatory agent, such aspirin, ibuprofen, or naproxen usually helps relieve the pain. The condition generally subsides in a matter of days, but several weeks or months may pass before the lumps and tenderness subside completely.
Deep Venous Thrombophlebitis (DVT)
Deep vein thrombosis is the formation of blood clots (thrombi) in the deep veins. Deep vein thrombosis occurs most often in the legs or pelvis but occasionally develop in the arms—usually due to catheter insertion. Blood clots can form in veins if a vein is injured, a disorder causes blood to clot (hypercoagulable state), or blood is flowing very slowly in a vein. Blood clots may cause a leg or arm to swell. A blood clot in a deep vein can break loose and travel to the lungs, which is called a pulmonary embolism. Ultrasonography and blood tests are used to detect deep vein thrombosis. Anticoagulants are given to prevent pulmonary embolism, which can be a life threatening complication of DVT.Deep Venous Insufficiency
When the one-way valves fail in the deep veins, deep venous insufficiency results. If a person has had a DVT, clots in the deep veins may heal by being converted to scar tissue, which damages the valves in the veins. Because the damaged valves prevent the veins from functioning normally, fluid accumulates (a condition called edema) and the ankle swells. The edema can extend up the leg and even affect the thigh if the blockage is high enough in the vein. Edema tends to be worse toward the end of the day, because blood must flow upward, against gravity, to reach the heart when a person is standing or sitting. Overnight, edema subsides because the veins empty well when the legs are horizontal. Sometimes after a DVT, the affected veins are destroyed. In people whose veins are obliterated, leg edema is always present, generally worsening at the end of the day. The skin on the inside of the ankle may become scaly and itchy and turn a reddish brown. The discoloration is caused by red blood cells that escape from swollen (distended) veins into the skin. The discolored skin is vulnerable, and even a minor injury, such as that from scratching or a bump, can break it open, resulting in a venous ulcer. In addition to aggressive wound care to heal an ulcer, lifelong compression stockings are usually recommended in such patients.