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What are varicose veins?
Varicose veins appear as twisting, “rope like” cords of bulging veins under the skin, anywhere along the legs from the ankles to the thighs. If you close your eyes and can feel your veins by running the back of your hand along your legs, these are varicose veins. The smaller, red and blue thin lines on legs are commonly known as spider veins; a subset of varicose veins.
What are some of the causes of varicose veins?
Occurring in about 40% of women and 25% of men, varicose veins have a multitude of causes including age, hereditary, pregnancy, hormonal imbalances, weight fluctuations, age, prolonged standing, and trauma. It is not surprising to have only one leg affected. Unfortunately, it is almost impossible to identify any one reason as to why you have or do not have varicose veins.
What are some of the common symptoms?
Heaviness, ache, swelling, fatigue, itching, tingling, tenderness around a visible vein are some of the more common symptoms. Pain is usually described as a dull fullness, ache, or cramping sensation. Varicose veins do not routinely cause sharp, stabbing pains.
What are some of the potential serious complications?
If one is experiencing symptoms and does not seek treatment, varicose veins have the potential to get worse and cause such things as inflammation (phlebitis), blood clots (DVTs), bleeding, discoloration/hardening of the skin (stasis dermatitis) and ankle or calf sores (ulcers).
How do varicose veins occur?
In the body, arteries carry blood from the heart to the feet. Veins are responsible for returning blood from the feet back to the heart. Veins have to work against gravity. Because of this, veins have one way valves in them that normally only allow blood to travel toward the heart. These valves close and prevent blood from “reversing flow” back down the leg. There is a deep venous system, within the muscles and a superficial venous system, outside the muscle, deep to the skin. When valves in the superficial system start to malfunction, blood does not completely empty out of the veins and start to “collect” or “pool” in your leg. In other words, blood that should be moving toward your heart start to move backwards or simply remaining your leg. The path of least resistance for this flow reversal is through branches of the superficial system, in essence the varicose veins which develop in one’s legs. Think of a freeway system. The superficial venous system is the freeway and when flow starts to “back up” or be impeded, it starts to back up onto the on-ramps, the varicose veins.
Can varicose veins be prevented?
Unfortunately, “curing” varicose veins is usually not possible because of the underlying conditions described above. One can try to “control” or relieve symptoms by various things such as wearing compression stockings, avoiding standing and sitting for long periods of time, controlling your weight, and elevating your legs about 10 to 20 minutes every few hours above the level of your heart. Because these measures do not treat the underlying cause, varicose veins have the propensity to enlarge and worsen over time.
What test can be done to evaluate the venous system?
Historically, a good physical exam and history was all that was necessary. Plethysmography had been used in the past but is not in much use today. The best, objective test is a full venous duplex evaluation of the legs looking at the deep system, the superficial system, the perforators for not just thrombus (clots) but also the function/integrity of the one way valves and whether or not flow reversal is identified within the veins.
What treatment options do I have for varicose veins?
As mentioned, varicose veins can’t necessarily be cured, but they can be controlled. Conservative measures mentioned above can be tried with compression stockings and leg elevation being the most effective in “controlling” the symptoms of the varicose veins. The elastic compression stockings squeeze the veins and attempt to prevent blood from reversing flow and pooling within the veins.
If despite these maneuvers, one still continues to experience the symptoms mentioned above, there are a few invasive techniques to be considered.
If it can be identified that the cause of the varicose veins is “reflux” or “incompetency” of the valves in the superficial system (the freeway) then treatment should be aimed at the superficial system first before treatment of the actual varicose veins (the on ramps). This is because the cause is the superficial system while the “effect” are the visible varicose veins.
Historically, surgeons have tried to repair the faulty valves with delicate surgery. There has also been attempts at transplanting a valve from the arm or inserting a tissue valve grown in a lab or a man made valve. Unfortunately, these have not had promising long term results; sometimes the patient is even worse off within a few years then if they had nothing done.
Then there was “vein stripping”. This is when the superficial vein (greater saphenous vein) is removed in the leg by making small incision in the groin and calf and running a wire inside the vein and literally “pulling it out”. This required a general anesthetic and treatment in an operating room.
Recently, minimally invasive technology has replaced vein stripping. This is known as endovenous ablation. This can be done either with a laser or high speed radio frequency.
The general principle is that this can be done in the office with only local anesthetic. With the assistance of an ultrasound, the superficial vein is located within the leg. A needle is introduced into the vein to “cannulate” the vein. This is followed by a guide wire and laser fiber and advanced toward the groin.
The portion of the vein be treated is then “anesthetized” with an anesthetic that is injected into the surrounding tissue of the leg. The laser fiber is then activated and causes a general “destruction” of the vein wall, forcing the vein to seal off and prevent further flow within it. This prevents “flow reversal” or pooling of blood in the leg. The circulatory system “resets” or “re routes” the blood to your heart through the remaining good veins in the leg that do not have faulty valves within them.
The procedure is done in an office setting. Takes roughly 20-40 minutes. One can walk out of the office and resume normal activity immediately. It will feel as if one were “kicked” really hard in the thigh. There will be some bruising along the thigh that will resolve with time. One has to wear a compression stocking for thirty days after the procedure to help with the bruising and swelling.
What is the success rate and some potential complications?
The physicians of Las Vegas Surgical Associates have performed over 1100 of these procedures. We have a 97% success rate where the vein closes and within six weeks patients have relief of their heaviness, ache and discomfort. Pre existing sores (ulcers) on the calves also now have a chance to heal and not recur because the”pressure” from excess blood within the veins has been removed.
Additionally, 80% of the time, the varicose veins that were present on one leg’s will disappear to the client’s satisfaction. 20% of the time, despite resolution of heaviness, ache and discomfort, the client may still have some unsightly veins, of which a second procedure can be offered to help remove the remaining unsightly veins.
The most serious potential complication is a deep venous thrombosis or DVT. This is when a vein in the deep system clots in addition to closure of the vein that was treated in the superficial system. There is a theoretical 2% chance of this happening. Fortunately at LVSA, our personal experience has seen a less than 0.5% chance. If this were to happen to you, you would have to be placed on a blood thinner such as “coumadin” for three months.
Some less dangerous and usually temporary adverse effects of laser vein treatment include a tightness or pulling where the vein is, bruising, scarring, redness in the overlying skin (ecchymosis), hematoma, tingling, or numbness. Fortunately, these are usually temporary and short lived (a few days to a few weeks)
Don’t I need my superficial veins?
When the superficial veins have valves that malfunction or become faulty, they actually interfere with normal return of blood to the heart. By closing or removing these veins, blood is diverted to other veins in the leg that have good, functional valves. This results in improved circulation and relief of symptoms.
Yes the superficial vein could be used as a vein for future heart bypass surgery or lower leg bypass surgery. However, since faulty valves usually cause the superficial vein to become “hard” or “scarred”, they are no good to the vascular or cardiac surgeon and an alternative “conduit” would be used for bypass surgery if one were to need it.
What options do I have to treat my varicose veins if they are still present after treatment of the malfunctioning superficial vein?
If you fall in the 20% of patients that still have varicose or spider veins that have not resolved to your satisfaction, options include sclerotherapy and stab phlebectomy.
For very small spider veins, sclerotherapy is an in office procedure where using small needles, a sclerosing agent or detergent is injected directly into the vein causing the vein to collapse on itself. The same effect can be done with a different type of laser from the one used to treat the superficial vein where the laser is used directly on the vein, causing the vein to collapse.
For remaining varicose veins that you can still feel, phlebectomy can be considered. This is done in an operating room where many small, 0.5 cm incisions are made over the veins and the veins are removed under direct vision.
A newer technique of phlebectomy is done similar to “liposuction”. But rather than remove fat, it is done to remove the veins. It involves fewer incisions and has an overall better result than traditional phlebectomy. This newer technique is called transilluminated powered phlebectomy.
Your physician at Las Vegas Surgical Associates can work with you to develop a thorough treatment plan to help you achieve the best resolution of symptoms and cosmetic results.
Eddy H. Luh, MD, FSVS, RPVI, FACSVascular Surgeon
Dr. Eddy Luh graduated from Cornell University. He then received his medical degree from the University of Vermont College of Medicine. Dr. Luh completed his General Surgery residency here in Nevada at the University of Nevada Affiliated Hospitals. He then trained at the world renowned ...