What can I do to treat Varicose and Spider veins?

Vein Treatments:

Treatment of varicose and spider veins is best approached with a comprehensive plan.

1. Identify the cause of the varicose and spider veins.
2. Treat the underlying “feeder” or causative veins first.
3. Treat all varicose veins.
4. Treat spider and reticular veins.
5. Follow up treatments to assure the target veins are under control.

 

1. Identify the cause of the varicose and spider veins:

Diagnosis:
For patients with varicose veins, spider veins, and advanced vein disease, the first step is diagnosing the underlying problem.

History and Physical Exam:
You will have a history and physical exam performed by the doctor. Questions about your lifestyle (prolonged standing, job, exercise, etc.), your family history, prior vein treatments, conservative management (stockings, etc.) will be reviewed.

The physical exam will include an examination of your legs or problem area. The doctor will be looking at the pattern of your varicose and spider veins, signs of swelling, skin changes and other signs of disease. The appearance of your legs, and the degree of problems help the doctor to assess the appropriate investigation and treatment.

If the doctor determines that the cause of your vein concerns may be the result of abnormal veins hidden below the skin, an ultrasound mapping we will performed. An ultrasound mapping is a detailed 3 dimensional road map of your veins.

With the mapping of your veins, the doctor can determine the appropriate treatment. Typical causes include reflux of the great or small saphenous veins, that lead to back flow into skin veins that are now varicosed. There are numerous veins that are hidden under the skin that can give rise to varicose veins.

An ultrasound may be performed to create a 3 dimensional image of your leg veins. Modern ultrasound allows the doctor and technician to look right through your skin and see a “map” of your underlying veins. We actually refer to this comprehensive ultrasound investigation as a “mapping” as it gives the doctor a complete road map to your veins, shows invisible passages, detours, and road blocks, as well as alternate routes. The vascular technician documents the anatomy of your venous system, points of valve failure, signs of obstruction, as well as all normal and abnormal aspects of your veins.

After the mapping, the results, and various treatment options will be reviewed with you. The ultrasound may show that the veins are associated with venous insufficiency, in which case the treatment is initiated with the intention of correcting this first. In general, if the varicose veins are associated with venous insufficiency, and the varicose vein is removed without correcting the underlying problem, they will have a high tendency to recur. In other situations, if there is no venous insufficiency we then use the ultrasound to guide specific varicose vein treatments.

2: Treat the underlying “feeder” or causative veins first:

The causative veins are typically not visible to the eye, although they may be felt through the skin. Typical feeder veins are called the “great saphenous” and “small saphenous” veins. Click here to view Vein Anatomy diagram.

Old Treatment Option:
Surgical stripping was once the gold standard of vein treatment. In the case of stripping, multiple incisions are made and the vein snipped and pulled out. While this procedure is safe and effective, it involved heavy sedation, significant recovery, and scars. Additionally, there is a fair incidence of new vein growth off the left over vein. Much like when you cut down a tree, there are new branches that grow off the base, the same thing can happen after stripping.

New Treatment Options:
Because this is such a common problem, and the surgery for correction was fairly dated, newer techniques that are more non-invasive have emerged.

Currently the best technologies to treat this feeder or root veins are laser and radiofrequency.

Laser:
A catheter (like an IV) is placed in the target vein, the vein is surrounded by numbing fluid to make the vein smaller and protect the surrounding skin and tissues, and the device heats up and destroys the vein. A laser fiber is then placed inside the vein through the catheter and destroys the vein from the inside. This is done with local anesthetic, no downtime, and very little discomfort. This procedure is commonly referred to as Endovenous Laser Therapy or EVLT™ by one manufacturer, or CTEV™ by another. There are several manufacturers and wavelengths. Currently, evidence shows that the wavelength of 1320nm (which is CTEV™ by Cool Touch™) is probably the best laser available. This is one of the laser technologies we use.

Radiofrequency:
A catheter (like an IV) is placed in the target vein, the vein is surrounded by numbing fluid to make the vein smaller and protect the surrounding skin and tissues, and the device heats up and destroys the vein. A radiofrequent fiber is then placed in the vein through the catheter just like the laser and the vein in destroyed. This is known as VNUS® Closure®, and VNUS® Closure® Fast. The difference is the second one is faster, and it may work a little more effectively. There is only one manufacturer of radiofrequency in the US for veins, and we use the VNUS® Closure Fast™.

Our office uses both laser and radiofrequency. Neither has clear superior benefits, and we have performed a scientific study to compare the two. The bottom line is they are the best devices available in the world, have the least discomfort, best success rate, and a proven track record. We tend to use the laser more than radiofrequency as it is more versatile.

3: Treat all varicose veins:

After treating the feeder veins most commonly the saphenous veins and perforating veins the varicose veins need treatment. The best treatment options are Ultrasound Guided Sclerotherapy and Microphlebectomy.

Ultrasound Guided Sclerotherapy involves locating the vein with ultrasound, and injecting a microfoam medication that destroys the vein in place. The medicine then passes harmlessly out of your body. The advantage of this procedure is that any vein can be treated, the entire vein can be treated, and it is nearly painless. The disadvantage is that when the vein is destroyed, there is pigment in the skin (iron staining) that can last any amount of time, typically a few months.

Microphlebectomy is performed with the tiniest incision and the vein is teased out and removed. In our office we make the incision with a needle, the type you do a blood test with, so the mark is so small, it is unlikely to leave a scar. This is a time consuming way to do the procedure (through a needle hole) but gives by far the best cosmetic outcome. This is done with local anesthetic and is nearly painless. The reason to do this is to reduce the amount of vein left in the skin after Ultrasound Guided Sclerotherapy and associated discoloration. The advantages of this procedure are that it removes the vein without skin staining. The disadvantage is that you cannot get all of the vein out this way.

In most cases we use a combination of Microphlebectomy and Ultrasound Guided Sclerotherapy to get the best combination of both procedures. This allows a scarless, complete vein procedure with the least amount of treatment failures and complications.

4: Treat spider and reticular veins:

Spider veins are the little purple to red-branched veins that tend to occur in bunches or clusters. Reticular veins are the blue ones that are a little deeper and create a web pattern under your skin.
There are two ways to treat these, and we use both.

Sclerotherapy uses a sclerosant solution that destroys the wall of the vein. This makes the vein useless, and your body clears it up like a bruise. A variety of medications are used for this, and we find that Chromated Glycerin has the best profile of rapid response, little discomfort, and the least side effects.

Skin lasers (not the type placed inside the vein), these shoot the laser energy through the skin and into the vein. This also destroys the vein, and it is cleared out by the body. The laser chosen is based on your skin type (color), and the depth and size of the vein. We have a variety of lasers available.

5: Follow up treatments to assure the target veins are under control:

Varicose and spider veins are essentially a chronic disease. Return of some degree of veins are common. Right now, this technology gives the best long-term success in history, but by their nature, veins want to regrow. Prevention such as weight maintenance, avoidance of prolonged standing, and physical fitness is indicated to reduce recurrence. We also request that if you feel you are having some vein regrowth, that you contact us for evaluation, as it is best to get these taken care of early on.

What can I expect after the procedure?

While it would be wonderful to get rid of your veins, and have no visible proof that you ever had them in a week or so, this is not possible. Generally, it takes weeks, if not months for the signs of veins to fade away. Satisfaction with these procedures is very high, but you must have patience.

We require that you do plenty of walking after the procedure for the benefit of your normal veins. There are no restrictions.

Compression stockings are worn for a minimum of 2 days. Longer use of stockings is recommended in some cases.

For spider veins, there will be some discoloration that will typically last a couple of months before fading away. It doesn't matter if they are treated by a laser or injection, there is a process that your body undergoes to clear out the blood left over after the vein treatment. Typically, more than one spider vein treatment is needed, as with each treatment, a percentage of the spider vein cluster will fade away.

Following treatment of varicose veins, you may feel small “knots” and see brownish discoloration in your skin, perhaps even in areas where you don't have varicose veins. This is because the veins that feed the varicose veins were treated, and it is like a slowly resolving bruise, and sometimes takes months to fade away.

Swelling may occur after varicose vein treatments. If this occurs, notify us, and we will evaluate you. In most cases it resolves with regular use of knee high support stockings for a couple of months.

Numbness after treatment of varicose veins can occur. Wherever there is a vein, there is a nerve nearby. The nerves can get “stunned” for any amount of time, but typically a few months. While this is something you are aware of, it doesn't cause any functional impairment.

New vein growth can occur after treatment of varicose veins and spider veins. This is known as “neovascularization” or “matting”. This type of growth is generally temporary, but may require treatment for cosmetic reasons if it doesn't go away on it's own.

Return of the varicose veins can occur. With stripping it can be about a 50% return rate. With these more modern procedures, it is less than 10%, and if there is some recurrence, it is generally minor and usually very easy to re treat.

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