Varicose Vein

What are they? Many times people ask what the difference is between a varicose vein and a spider vein. A simple way is to look at the size and shape of the vein in question. Small, reddish or purplish veins clustered together are usually spider veins and they usually lie flat against the skin.

Varicose veins are larger( think at least the size of a garden worm), protrude from the skin surface, are squiggly, and are oftentimes blue or green. Sometimes they can look like a simple, soft bump in the skin.

As Sir William Osler, a famous surgeon, once said, varicose veins are the product of poorly choosing one’s grandparents. Another way of saying that having varicose veins is predominantly genetic; either you are lucky or you are not. Women are affected almost twice as much as men, in part due to hormones and pregnancies, and things typically only get worse with aging.

So what is actually going wrong that causes varicose veins? To answer this, you have to understand a little bit of the plumbing of the leg. What comes in must come out. In other words, arteries feed blood into the legs, and veins are built to return the used blood back to the body. Think of a circle or roundabout on the highway. When all the traffic is moving smoothly, in and out, there is no traffic jam. But what happens when cars are slow to exit the circle? There is a pileup. Varicose veins are the sign that there has been a pileup in your leg. Traffic is coming in OK, but it can’t get out fast enough because the veins inside of your leg are not working efficiently.

Looking closer into the situation, why has the outflow slowed down? Well, inside of the leg, the veins are built with little valves that typically only allow travel in one direction, that direction being up and away from your feet. They act as little turnstiles in the subway, allowing passengers(blood) to only go in one direction. What happens with varicose veins is that these valves break down over time, allowing blood to flow in both directions, up and down! Your muscles are trying to push the blood up and out, but this is being defeated by gravity, which is pulling blood back down the leg. This increase in back pressure flows into side veins which go to your skin surface and stick out as lumpy, bumpy varicose veins. Going back to the highway circle analogy, the circle(your circulation) is attempting to relieve this unexpected back pressure of traffic by allowing cars to exit out of the normal entry points.

Foam Sclerotherapy

Varicose Vein

Varicose Vein Treatments

How do we fix this? In the past, surgery would need to be performed called a “vein stripping” procedure, which physically removes the internal segments of veins with bad valves. A phlebectomy is a type of vein stripping procedure where only externally visible vein segments are pulled out. For the past decade, a procedure has been available called “endovenous laser ablation, “ which replaces the need for surgery by using laser energy to seal shut the bad vein segments with weak valves. The procedure is done in the office, takes less than 30 minutes with local numbing only, like a dental procedure, with minimal post procedure pain. Patients can return to normal activities, including work, the following day, just with no exercise for 1 week. Results of this technique are extremely effective and safe.

Vein Treatment FAQ

The first step is an ultrasound examination in our office to look at the direction of blood flow within the veins in the leg. Most times, tracking the source of the varicose veins beneath the skin surface demonstrates a root vein that has developed bad valves. Several different veins within the leg can develop bad valves most commonly.
First and foremost, for people with a valve problem, this procedure makes the leg work more efficiently. By lasering only the bad vein segment, the flow is diverted into much larger veins that are working well, thereby relieving the back pressure in the system. The leg will feel better, lighter, without the accompanying leg heaviness and fatigue that most patients describe. First line therapy is always wearing good compression stockings to alleviate some of the leg discomfort from varicose veins, although ultimately, this alone does not fix the problem. Most insurers will require 3-6 months of medical compression wear without substantial alleviation of symptoms, to qualify the patient for approval for endovenous laser ablation.

If the patient is experiencing leg swelling, restlessness, or cramps due to the vein problems, these symptoms will also typically decrease or alleviate after the flow issue has been fixed.

The larger, external veins that people see will typically decrease in size from 30-70% from the ablation procedure alone, although in most circumstances, they will still be visible. Ultimately, if complete absence of the veins is desired by the patient from a visual aspect, further adjunctive therapies such as sclerotherapy, may be required after the internal root problem is addressed. Visual external sclerotherapy performed as a “clean up” procedure after ablation is considered cosmetic, and is not covered by medical insurance. The exception to this rule is that sometimes sclerotherapy is used under ultrasound guidance, aimed at internal veins with valve problems. In this circumstance, the insurer may cover the procedure as medical necessity on a case by case basis.
Absolutely. We have many patients that have suffered with venous stasis ulcers chronically for several years, that improve dramatically after the causative bad valve is identified and addressed. In most circumstances, the ulcer will heal within 6-8 weeks of treatment if properly diagnosed.
There are two different types of sclerotherapy.
One is external, visual based sclerotherapy, where a tiny needle is inserted into a spider vein(telangiectasia), reticular vein, or sometimes even a varicose vein, in order to inject a small amount of material called a sclerosant. The job of the sclerosant is to damage the lining of the vein so that it will die and go away. Multiple injections are usually performed in a single 20-30 minute session. The needles are extremely small and although they are “pinchy”, they do not feel anything like a blood draw due to their micro size. Most people tolerate the procedure well without difficulty. After the injections, a compression stocking is worn over the injected leg for 1 week to help compress the injected veins. Normal activities are allowed with the exception of halting exercise for 2 days.

The second type of sclerotherapy is ultrasound guided sclerotherapy. This is a technique where we guide a longer needle into a vein beneath the skin surface to get rid of a “root vein” with a bad valve. This is a more frequently used procedure in people that have extensive varicose veins, rather than spider veins, and is done as an adjunctive therapy after endovenous laser ablation.
For leg spider veins, this depends on the extensiveness of the vein networks. A “mild” spider vein patient will require 1-3 sessions, “moderate” 3-5 sessions, and “severe” 5-10 sessions. Sessions are usually spaced 2-4 weeks apart. It can take up to several months for the veins to “fade” to a point where they are no longer visible. Smaller veins may take 1-3 months to go away, moderate veins 3-5 months, and large veins, up to 1 year. In the interim, the veins may change in color to a light grey or light brown, with gradual dissipation.
Although hypertonic saline, or salt water, is commonly used for sclerotherapy for spider veins, it is not an ideal sclerosant because it is relatively weak, hurts upon injection, and has an increased potential to cause an ulceration when it leaks out of the injected vein.

For these reasons, we utilize 2 different FDA approved compounds. One is Sotradecol, which is sodium tetradecyl sulfate. It has been in use since the 1920’s, and is particularly good for larger veins, especially when administered as a foam( see later comments). The second type of sclerosant is Asclera, (polidocanol), which is the most widely used sclerosant globally. It is very safe, slightly weaker than sotradecol, and can be used for both small and moderate sized veins.

Both of these sclerosants can be administered as a pure liquid or as a “foam”. A “foam” is a sclerosant comprosed of a gas and a liquid. Foam sclerotherapy can treat larger veins than standard liquid sclerotherapy. At Lumen, we utilize both liquid and carbon dioxide based foam sclerosants, because of their enhanced safety profile.
Typically, any superficial vein in the body can be sclerosed without harmful consequences due to the extensiveness of the superficial network in conjunction with the tremendous capacitance of the underlying deep venous system. This means that unsightly veins of the décolleté or breast can be injected, or other veins of the upper torso. Hand veins are the most popular region for sclerotherapy outside of the legs, and they respond very well to sclerotherapy given adequate compression. Blue reticular facial veins around the eyes and temporal region respond well to transdermal laser therapy, obviating the need to chemically inject into the head and neck circulation.

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