Varicose Veins: What Are They?

Varicose Veins: What Are They?
Normal veins return blood to the heart. In the legs, this is accomplished by muscle contraction, such as walking, and a system of one-way valves within the veins. Valve leaflets are attached to the lining of the vein. The valves allow blood to flow in only one direction—back to the heart.  If the valves fail, blood is no longer directed back toward the heart. Instead, the blood simply follows the forces of gravity.  If you are standing or sitting, the blood will flow backwards, away from the heart. Backward flow is called reflux and is abnormal.

Do varicose veins cause any problems?
Symptoms such as leg swelling, heaviness, fatigue, restlessness, itching or burning, throbbing, and awakening with leg cramps are frequent findings in patients with varicose veins.

Because this stagnant blood is acidic from metabolic wastes, it causes inflammation and pain within the vessel.  Smaller varicose veins can cause significant symptoms but rarely cause significant problems. Large varicose veins can lead to severe and chronic problems in the legs, such as stasis dermatitis, itching, darkening of the skin, hemorrhage, or even chronic leg ulcers—open, weeping, painful sores, usually found near the ankles.

Although they occur at any age, about 4% of the population over the age of 65 suffers from a “leg ulcer”. This is a unique type of ulcer that is a direct result of varicose veins.

Ulcers are slow to develop and are usually preceded by an area of dry and progressively darkening, hard skin. Physicians and surgeons trained in the United States frequently fail to understand the relationship between varicose veins and venous stasis ulcers.

Classification of Veins
Lets keep it simple. Basically, there are three types of veins in the legs: the deep veins, the saphenous veins, and the rest (medium veins).

Deep Veins
The deep veins are large essential veins supported by bones and muscles. They serve one very important function—the deep veins return blood directly to the heart. We have only an occasional patient with deep vein problems. Generally, these patients are not treatable by today’s available treatment methods.

Saphenous Veins
Saphenous veins are superficial veins designed to carry blood to the deep venous system. The deep veins (above paragraph) return blood to the heart. The saphenous veins bring blood from the superficial structures of the leg into the deep veins.

Saphenous veins are large veins and are given names. The great (or long) saphenous vein (GSV) runs from the foot up the inseam of the leg to the groin. There are several prominent branches and tributaries of the greater saphenous vein. The second major saphenous vein is the short (or small) saphenous vein (SSV). It runs along the Achilles tendon and up the calf to behind the knee.

Medium Veins
The medium veins are small blue vessels like those found on the back of the hand. Very tiny veins are often called “spider” veins. There are thousands of medium and spider veins in the legs. They all communicate with the saphenous veins and each other and contribute to venous blood return to the heart.

Varicose Veins
Any vein can become a varicose vein (blood is moving the wrong direction). Varicose veins of the deep venous systems are very rare and difficult to manage.

However, those large, disfiguring, bulging, tortuous and ropey veins that everyone has seen are saphenous varicose veins—the great saphenous vein, the short saphenous vein, and/or their branches. These are usually seen around the knee or lower leg at first, but the origin of the problem usually starts at the top of the leg. In most people, only about 20 % of the disease of varicose veins is visible from the surface. It can take years for the veins to become dilated, twisted and tortuous. The pain and skin damage from varicose veins is not related to the appearance of the veins.

Treatment Options
Choices for treatment vary depending on which veins are diseased. Treatment of large (saphenous) veins dates back over 3000 years when the vessels were beaten with a stick. This would cause clot formation in the vein, and could cause the vessel to close off and shrink away. Injection treatment dates to the 18th century when various poisons were injected causing the veins to close. Unfortunately, there were no sterile needles and the medicines used were toxic to the patients. Surgical ‘stripping’ of these veins dates back about 60-70 years.

Medium and Small Vein Treatment
Patients suffering from medium or small vein disease have few treatment options. Compression stockings can often help the pain of varicose veins but do nothing to correct the problem. Surface Laser has proven very disappointing for small veins below the level of the heart (especially leg veins), but the new 1064 nm Nd.Yag lasers do show some promise for very tiny leg veins. However, sclerotherapy remains the only proven treatment for these smaller varicose veins.

Treatment Choices for
Saphenous Vein Disease
Graduated Compression Stockings: These medical stockings can provide symptomatic improvement in some patients. New styles are much improved over those our grandparents may have worn. New devices have been developed to help you get them on and off. If relief is not long lasting, definitive treatment is indicated.

Ligation and Stripping Surgery: In the early 1900’s, surgeons developed “ligation and stripping” of the major veins, especially the greater saphenous vein. Because of high failure rates and a prolonged and painful convalescence, many surgeons are reluctant to perform this operation today. Stripping surgery is often combined with ambulatory phlebectomy.

Ambulatory Phlebectomy (stab avulsion varicectomy): This surgical approach to varicose vein disease developed in response to the difficulties encountered with the stripping surgery. It is designed to reduce the prolonged convalescence and pain from the stripping operation. The greater saphenous vein is not “stripped out”. It is simply “tied off” at the groin with a suture. Segments of vein are then pulled out of the leg through tiny incisions that usually need little or no stitching. Like vein stripping, about 18 to 24 inches of vein segments are removed. Success rates are probably similar to that of stripping but await long-term trials. This procedure may be performed along with the stripping operation, as well.

Thermal Ablation Techniques:  Several newer methods have been developed to destroy the proximal segment of the great saphenous vein with heat. An electric catheter (tube) is inserted through an incision near the knee. It is guided up the vein to the groin under ultrasound visualization. An energy source of either radio frequency, or laser, heats the vein to induce injury and contraction. The catheter is slowly withdrawn, and the vein shrinks against the heat and seals shut. Thermal technologies are generally used for only the primary great saphenous vein from knee to groin. If your anatomy is appropriate, you may be a candidate for this treatment. However, this method cannot be used on the numerous branches and tributaries usually found in patients with varicose vein disease. Surgery (stab avulsion) or injection sclerotherapy would be necessary for those veins.

Sclerotherapy: Sclerotherapy, as developed in Europe in the 1940’s, is generally not used for treatment of large, saphenous vein disease in the United States. However, the physicians of Vein Clinics of America have been the pioneers in modernizing this treatment, and coupled with ultrasound-guidance and a thorough understanding of the pathology of venous disease, large varicose veins can now be treated most successfully by our unique treatment protocol.

Duplex Ultrasound Guided Sclerotherapy of Saphenous Varicose Veins:
The McDonagh-COMPASS Technique
Vein Clinics of America developed this treatment method. We believe this to be the most effective, thorough and safest treatment for varicose veins ever developed.
It is based on:

Sound medical principles in peer-reviewed medical literature

Detailed and comprehensive understanding of venous pathophysiology

Clear ultrasound visualization of the vascular system

Sclerotherapy uses sclerosing medicine injected into the blood vessels. This causes them to shrivel and to ultimately fade away. We use sodium tetradecyl sulfate or polidocanol. We never use hypertonic saline solution (very salty water) because of its limited efficacy and often associated severe pain and muscle cramps. Sodium morrhuate is not a recommended sclerosing medicine.

Whatever method is used, the key to effective treatment starts with a correct diagnosis, and only ultrasound visualization on a television monitor can provide that.

Ultrasound Mapping
Before starting treatment at our clinics, you will be required to complete a very detailed diagnostic evaluation of the affected leg. This is the standing ultrasound map. Only while standing can normal veins be differentiated from varicose veins.

All of the deep and superficial veins are evaluated. The ultrasonographer draws a schematic representation of the venous findings. That drawing, representing your anatomy and disease, is “the map”. Mapping has become the “gold standard” for venous diagnostics and should be done prior to proceeding with any saphenous vein treatment, whether surgical or sclerotherapy. Without mapping, there is no way to know the extent and complexity of your varicose vein disease.

The detailed venous map is then used to develop a specific treatment plan for you, and it is sent to your insurance company to verify your specific diagnosis.

Treatment Plan
Following the “Mapping”, your doctor will review your treatment options based on the ultrasound findings. We perform COMPASS sclerotherapy, Laser ablation, or a combination of both. We do not perform ligation and stripping surgery or stab avulsion surgery. If you decide on surgical treatment, we will help direct you to an appropriate surgeon.

Final treatment plans are developed based on the severity of your condition. Treatment is divided into three stages, but will vary based on your map.

Treatment Stage I – Symptom Control
Given the complexity of venous insufficiency and the chronic nature of this disease, a staged approach is employed, designed to provide both near term symptom control and long-term benefit.

Endovenous Laser Ablation: During Stage I, all large varicose veins will be treated. If you are a candidate for endovenous laser ablation, and you elect this treatment, your first large vein treatment will be done with the laser in our ultrasound suite. Total time in the clinic for the first treatment session averages between 2 and 3 hours, and 1 to 2 hours for follow-up visits.

Following treatment, you will need to return to the clinic in 72 hours for a brief ultrasound examination, and it is recommended that you wear prescription compression stockings for up to 7 days.

Laser patients will require a variable amount of traditional and ultrasound guided sclerotherapy within the first few weeks.  Just like COMPASS patients, duplex scanning is performed as needed (typically 2-3 visits) over the following twelve months to assure proper healing and to account for any new disease that may appear. (Please see “Treatment Stage II” below).

COMPASS SCLEROTHERAPY: If you elect our COMPASS sclerotherapy protocol, your first treatment will be done in the ultrasound suite while lying on the ultrasound gurney. Local anesthetic is applied before each large vein injection for comfort. Under ultrasound visualization, the physician injects the medicine into the vein. The injections are viewed on ultrasound TV monitors” (ultrasound-guided injections). You will need to go home and elevate your legs overnight and possibly up to 24 hours. The majority of routine activities are resumed on day 2 or 3.

Most patients require multiple treatment sessions over the first four to six weeks, but home leg elevation is usually required for the first duplex-guided sclerotherapy treatment session only.

Coupled with treatment of the large saphenous veins, other treatment will be directed against the small veins coming from the pelvis (called high source vein treatment). Ultrasound is not needed for the smaller veins entering the thigh from the pelvis.  The nurse usually treats the smaller surface veins.

Most patients will require sclerotherapy for both large (saphenous) and smaller veins. Surface sclerotherapy appointments are scheduled according to your needs, and involve no ultrasound guidance.  Surface treatments typically involve no more than 45 minutes of treatment and in-office elevation time.  We do encourage you not to exercise on the day of either surface or large vein sclerotherapy beyond typical walking or swimming after the session.

Treatments under ultrasound-guidance require longer clinic visits. Total time in the clinic for the first treatment session averages between 2 and 3 hours, and 1 to 2 hours for follow-up visits.

Following the first ultrasound-guided treatment, those who live within 30 minutes may drive themselves home. Once home, most patients need to elevate their legs until bedtime, then stay at “chair rest with the leg up” the next day. Strenuous activities should be avoided for 10 to 14 days. Extensive walking is encouraged starting on the 2rd day.  You may elect to wear compression stockings, but this is not required for sclerotherapy alone.

The sequence of treatment varies from individual to individual, but combining treatment of the large saphenous veins with the smaller “feeding veins” is common. For small vein treatments, elevation is always “office only”, and you may drive yourself.

Only limited leg elevation may be required after follow-up treatment sessions, however, you should always plan on light activities for that evening should more sclerotherapy of the large saphenous veins be necessary.

The large varicose veins will now start to shrink away and the bruising and discoloration from treatment will start to resolve. Symptoms should also start to improve.

Once treatment is started, with sclerotherapy or surgery, the haemodynamics of the leg begin to correct. Venous pressures normalize; veins come under new forces and may reveal themselves as varicose veins. New varicose veins may erupt from the deep venous system. Because of the often-dramatic haemodynamic evolution within the leg, we then transition into the second stage of treatment.

Treatment Stage II – Long-term benefit
Long after your leg is feeling and looking better, we must evaluate your leg for both proper healing and the beneficial haemodynamic changes of a given leg. Long-term benefit is based upon finding disease that may adversely affect the success we obtained in Stage I.  Ultrasound evaluation of the leg may be scheduled at 3, 6 and 12 months after completing Stage I, but varies patient to patient according to severity.

This protocol is based on the treatment of thousands of patients and our experience with the evolution of venous disease. Compliance with this protocol is paramount in achieving prolonged results. You will be evaluated with ultrasound at each visit, and any recurrence or progression of disease found will be treated with ultrasound-guided sclerotherapy before it has the opportunity to progress. This results in a stabilized haemodynamic system within the leg.

Treatment Stage III
During Stage III, periodic diagnostic ultrasound testing is scheduled as indicated by the individual’s response to earlier treatment and complexity of disease. Most commonly, we will see you every few years. If any new disease is discovered, sclerotherapy may be performed. Occasional follow-ups are adequate for most patients to prevent progression of disease and maintain symptom-free legs. Recurrent disease of previously treated vessels is rarely found during these visits.

There is no “cure” for the causes of varicose veins. You may find that lifetime management and occasional sclerotherapy treatments, offer a tremendous advantage over surgery, where re-do surgeries provide very limited benefit.

Risks of Treatment of Saphenous Disease
Many years ago, in response to consumer pressures, the medical profession came up with the concept of “informed consent”. This means we provide all the possible and conceivable risks of treatment before starting, in a written form for your review. Any questions you have about the treatment or its risks will be answered by the physician prior to starting treatment. The risks of endovenous laser ablation treatment and sclerotherapy are very similar.

These explanations are detailed and made for you to understand that the risks of any medical treatment, however small, are possible and could happen to you.

Having the disease of varicose veins carries risk. Nearly all the risks of treatment are the same risks as doing nothing. Saphenous veins cause darkening of the skin (hemosiderin staining) and treatment exacerbates that process. However, we hope that staining eventually resolves completely, and in 85% of patients it’s gone within 12 months.

The stagnant blood in varicose veins is prone to clot if the veins are not treated. In theory, treatment could cause a blood clot, but deep vein clots associated with sclerotherapy is rare (estimated at about 0.02%). Surgery is causally implicated in the formation of deep vein blood clots, and these can be fatal, but that is rare. It is believed that the risk for deep vein clot is slightly higher with endovenous laser treatment, and for this reason you are brought back for a quick ultra-sound scan of the deep system at 72 hours.

A severe allergic reaction to the medicine used to treat the varicose veins could be life threatening. This is called anaphylactic shock. Bee stings and Penicillin are well known for causing anaphylactic shock. However, even minor allergic reactions to our sclerosing medicines are very unusual.

Ligation and stripping surgery, as well as one very remote incident combining surgery with sclerotherapy, have been reported to result in severe leg damage requiring amputation. In this author’s knowledge, loss of leg has never been reported with sclerotherapy alone.

Any sclerosant can cause a chemical burn. Much like a heat burn, the skin can be severely damaged. Most of these are minor injuries, but they can be devastating, very painful, and can take up to a year to heal. Such severe burns are very rare and can occur with sclerotherapy or endovenous laser therapy.

New vessels can appear in response to treatment. These are actually old vessels that become congested and visible, sometimes they are so small and numerous they give a “slapped skin” appearance. Called “matting”, this typically  improves or completely fades over many months.

Rarely reported are very brief episodes of numbness, weakness, monocular vision loss, or paralysis of a hand or a limb. These events may last several minutes, and have never been reported as permanent.

To put everything is perspective– there are serious risks associated with treatment, but these risks are less than the risks of surgery, and considerably less than allowing the disease to run its course. Treatment risks are considered less than the risks of living with the condition of varicose veins.

Notes on Insurance
There are many insurance companies and each company writes many different policies. Many employers are “self-insured” and dictate to an insurance administrator what treatment is, or is not, covered. The majority of companies and policies in Indiana cover a portion of our treatment. Some provide outstanding benefits. But variability and inconsistency seems to be the rule when it comes to health insurance.

As your physician, I will write what is called a ‘Certificate of Medical Necessity’ if symptoms and findings of venous disease merit treatment. This letter does not mean that the insurance company will agree with either the necessity for treatment, or with our proposed treatment plan. A worldwide body of academic medical literature clearly supports this type of treatment as safe and effective.

Ultimately, decisions regarding your health care are your responsibility.

Frequently Asked Questions
Don’t I need these veins for my circulation?

No, once they become varicose, they no longer return blood to your heart. They actually “steal” blood away from the primary pathway back to the heart.

What if I need a coronary artery bypass?
Won’t the doctor need this vein?

The greater saphenous vein is often used for bypass surgery, but only if it is a normal vein, not if it is a damaged varicose vein. There are several good alternative vessels to use for bypass grafting.

Am I a candidate for ultrasound-guided sclerotherapy?

You must be able to tolerate standing for up to 45 minutes for your ultrasounds, you must be able to walk, and you must have a relatively normal deep venous system.

Am I a candidate for endovenous laser ablation treatment?

Based on ultrasound examination, we will advise you as to all suitable treatment options.

I am on Coumadin to thin my blood. Can I be treated?

Yes, there are no medicine related contraindications to sclerotherapy or endovenous laser treatment.

Can you test me for allergy to the sclerosant that you use?

No.

What if I am allergic to the medicine?

We would have to stop using our primary agent and use an alternative sclerosant.  We are prepared to recognize and provide treatment for any allergic phenomenon.  Given the chemical is being administered into the vein, reactions will be immediate if they occur, and promptly recognized by our team.

Do I have to keep coming back for the follow-up ultrasounds?

To acquire optimal long-term results, we will recommend periodic follow-ups based upon your medical condition and responses to treatment. The haemodynamic changes within the leg mandate follow-ups to assure success and avoid future varicose veins. This is required following any treatment of major varicose veins for optimal results.

My surgeon says sclerotherapy of the big veins doesn’t work. He wants to operate.

Your surgeon is incorrect. The COMPASS protocol has been accepted and published by a leading vascular journal. Ultrasound guided sclerotherapy, as performed at our clinics is, in my opinion, one of the safest and most effective treatment for varicose veins of any size! Because we can visualize your disease with ultrasound, we can ablate literally hundreds of vessels that would be left behind from surgery. Many patients in treatment have already failed stripping surgery. Nonetheless, surgery is an option to be considered. When stripping surgery works, patients are happy with it. Unfortunately, failure rates and recurrences are quite high.

We specialize in the treatment of extremely complex varicose veins and venous stasis ulcers. Any treatment, without first performing ultrasound diagnostics of both the deep and saphenous veins, is below the standard of care. To rely on vision to treat a mostly invisible disease is unacceptable.

Treatment of venous disorders is restorative and, like any chronic condition, often requires ongoing management. Follow-up work may be required from time to time.

I have massive, ropey clusters of varicose veins all the way down my leg. Will they actually disappear?

Yes. The leg can be significantly disfigured from varicose veins. In nearly all patients, the large, bulging veins will have vanished and the normal contour of the leg will be restored in less than 3 months.

Symptomatic improvement should begin within weeks, and typically are gone within 1 to 3 months of starting treatment.

Cosmetic improvement is the last to be realized. Bruising takes weeks to resolve, but staining may take months to years to fade. It can be permanent in some cases.

I just have the smaller type of varicose veins. What can I expect?

The average patient needs about 6 treatment sessions per leg. Symptoms typically improve after 4-5 treatments. Improvement continues for up to 6 months following treatment. Final cosmetic results take at least that long as well.

I love to exercise, I lift weights, I run and I play tennis. Do I have to limit my exercise?

Yes. Abdominal pressures can cause newly closed veins to reopen. For medium/small vein treatment, strenuous exertion is not allowed for 24 hours.  Following the first treatment, either endovenous laser or ultrasound-guided sclerotherapy, we usually restrict strenuous exercise for about 2 weeks. Fitness can be maintained with walking during this time. Following the ultrasound mapping, and your treatment choice, the doctor will discuss your restrictions on an individual basis.

Follow-up treatments will require, at most, light activities for 24 hours. This is also true for medium and small vein treatments.

You say I have large vein disease. But I just want the small veins treated. Why won’t you do that?

Large varicose veins are high-pressure veins flowing backwards. These reverse flows tend to back up into smaller vessels, enlarging them. For the majority of patients with large and medium/small vein disease, sclerotherapy of the small veins alone will likely not be able to resolve symptoms (if present) and will lead to at best short-term cosmetic benefit and ultimately unsatisfactory results.

We wish the best results for all of our patients, and do not wish to compromise your care without at least full knowledge to the extent of your disease.

I’m planning to have more children. Should I wait to begin treatment?

No! Pregnancy can cause terrible problems with varicose veins. Have them treated before your next pregnancy. Even if some veins develop again with the pregnancy, they can be easily closed following the birth of your child.

What if I become pregnant during treatment?

We would have to interrupt treatment until your child is born. There is no reason to suspect that the sclerosant medicine is dangerous to the fetus, but you want nothing that may complicate the pregnancy. Therefore, it is best to simply wait to complete treatment.

Do I have to wear compression hose following treatment?

It is highly recommended that you wear compression hose for up to 7 days following endovenous laser treatment, and there is no elevation following that aspect of treatment. Compression may be used if you prefer, and is occasionally recommended.  We do not believe that compression stockings are necessary following sclerotherapy, yet some patients use them for comfort following sclerotherapy treatment.  We are able to measure you for stockings and order your stockings if needed at a significant discount.  There is no scientific evidence, however, that compression offers any advantages for sclerotherapy outcomes.

Concepts to Consider
Any treatment for varicose veins can ‘fail’. Since there is no “cure”, how can your venous condition best be managed?  Twenty-five percent of all vein surgeries are done for recurrent varicose veins following a first vein surgery. Unfortunately, these “re-do” surgeries are clinically unsatisfactory in a majority of cases. Third surgeries are not recommended. At least 20% of our patients have already failed surgery, one or more times.

Endovenous laser ablation techniques are becoming a popular alternative to surgery. The “goal” of these treatments, ablation of the proximal great and/or small saphenous vein, is important. But this is limited and fails to address the global picture of venous disease. Nevertheless, the negative data available regarding stripping surgery, and early data in support of thermal ablation techniques, suggest thermal ablation is superior to stripping. Most patients undergoing laser ablation do require additional sclerotherapy to control the extent of his/her vein disease.

Traditional sclerotherapy is the type of sclerotherapy with which most American surgeons are familiar. Therefore, they often advise patients that our treatment will not work, without understanding our highly advanced diagnostics and treatment. Such information is misleading, if not unethical. Our treatment protocol (COMPASS) is extremely effective, even for the most severe venous disease. The best scientific study published to date supports the true efficacy of ultrasound-guided sclerotherapy. Failure rates at 10 years for ambulatory phlebectomy, or ligation and stripping surgery, are 30% and 42% respectively, with ultrasound-guided sclerotherapy failure rates reported as 8% at 10 years.

REVAS studies (Recurrent Varicosities After Surgery) reveal the true limitations of surgery.       The most recent and thorough evidence regarding surgical failures identifies 20 to 80% failure rates at 5-year evaluation.    No other traditional surgery has such poor results.

Finally, please understand: Our treatment is not a cosmetic treatment! It is considered a reconstructive treatment designed to correct a very complex haemodynamic “problem”. In achieving that goal, the circulatory health of the leg is restored, and most often a significant cosmetic result is achieved. However, cosmetic results cannot be assured for every patient.