Q: How do normal veins work?
A: Veins are responsible for returning blood to the heart. It can be helpful to compare veins and arteries to get a clear picture of how veins work. Consider the following chart:
|Carry blood rich in oxygen
||Carry blood low in oxygen
|Carry blood away from the heart to the hands and feet
||Carry blood back to the heart from the hands and feet
|Have thicker elastic walls that are designed to handle higher pressures
||Have thin walls that do not handle high pressures
|The heart pumps to move blood through
||Blood is moved through veins by action of muscle contraction
|Arteries do not have valves
||Veins have one-way valves
Q: Are all leg veins the same?
A: No, there are three major systems of veins in the leg:
1) The superficial system: just like the name implies, veins of this system are fairly close to the surface of the skin. Blood in these veins should flow into the veins of the deep system. Examples of important superficial system veins: the greater saphenous vein (GSV) and the lesser saphenous vein (LSV).
2) The deep system: Veins in this system are again, as the name implies, deep beneath the skin. These veins are usually quite large compared to superficial veins and are the veins involved with the condition called deep vein thrombosis (DVT). The deep vein system contains much higher pressures than the superficial veins. Important examples of deep system veins: the femoral vein.
3) The perforator veins: Perforator veins connect the deep and superficial systems of veins at four or five places down the leg. In addition to connections between the deep and superficial systems that the perforators provide, the sapheno/femoral junction provides a direct connection between the two systems.
Q: The previous chart noted that the blood in veins is traveling back toward the heart. Doesn't that mean that blood is traveling against gravity?
A: Yes, blood does travel against gravity, but remember, veins have one-way valves that are supposed to prevent blood from traveling with gravity (i.e.backwards).
Q: So if that is the way veins are supposed to work, what can go wrong?
A: Valves are the most common source of vein problems. As previously noted, vein valves are supposed to permit one-way only flow of blood, but sometimes valves don't work properly and permit blood to flow backwards (the wrong direction). This causes blood to "stand" in veins instead of returning to the heart as it should. Fluid and other components of the blood are thereby allowed to leak out into the surrounding tissue potentially causing spider veins and varicose veins and all the problems associated with such conditions. Up to 60% of all men and women have a vein disorder such as varicose veins or spider veins. Illustration of normal vein with intact valve vs abnormal vein with malfunctioning valve pictured above.
Q: What causes vein valves to malfunction?
A: There are many possibilities. The most common factor is a family history of vein problems. Other common causes are pregnancy, hormonal changes (pregnancy or menopause), obesity and history of trauma. Interestingly, many very athletic men and women can develop vein disease. Standing for long periods of time can make problems worsen due to added stress placed on the vein valves.
Q: Can vein valves be fixed or even mend themselves?
A: No. Unfortunately, once a vein valve malfunctions, it cannot repair itself and there is no other way to repair it. Valves are very delicate flaps of tissue.
Q: My vein problems all started with pregnancy. Will they go away once the baby is delivered?
A: Many women first experience vein problems with pregnancy. Use of compression stockings during pregnancy is usually advised-ask your obstetrician. Pregnancy causes an increased level of hormones and blood volume. Additionally, an enlarging fetus also puts pressure on the largest vein of the body, the vena cava. Pressure on the vena cava also, in turn, causes increased pressure on the veins of the legs. Normally, within 3 months of delivery, improvement in varicose veins can be seen. However, as stated above, once venous valves are damaged, they do not repair themselves, and varicosities can worsen with subsequent pregnancies, or even just with the passage of time. The foregoing is especially true if damage has occurred at the sapheno/femoral junction or in perforating veins.
Q: How would I know if my vein valves weren't working properly?
A: The possible problems range from spider veins to varicose veins and you could also have many physical symptoms such as leg swelling, fatigue, throbbing, pain, burning, itching, heaviness, aching, restlessness that seem most pronounced after standing on your feet for a long time. Discoloration in the ankle area and even leg ulcers (see chronic venous insufficiency) may also be present.
Q: What are varicose veins?
A: Varicose veins are visible on the skin surface of the leg as ropey, twisted elevations that can appear to be isolated or connected to one another. They form as a direct result of vein valve malfunction. By definition they occur in the veins of the superficial venous system (most typically in the greater saphenous vein and its branches). A malfunctioning vein valve allows blood to flow from an area of higher pressure into an area designed to handle only lower pressures. Remember, veins have thin walls, unlike arteries. Veins tend to inflate quite easily, and over time under increased pressure their walls become thickened, ropey, and unsightly. In addition, they can occasionally bleed easily because, as part of the superficial vein system, they are near the surface of the skin.
Q: Can varicose veins get worse over time?
A: Yes. A condition called chronic venous insufficiency can develop. Discoloration of the skin in the ankle area (venous stasis discoloration) occurs in some people and painful venous ulcers can develop that are usually very difficult to heal and tend to reoccur even when they do heal. Not everyone with chronic venous insufficiency develops venous ulcers. Superficial thrombophlebitis (a condition in which a vein, close to the surface of the skin, becomes inflamed and develops a clot) may also occur.
Q: I don't have varicose veins. I have smaller, colored veins that look like the legs of a spider. What causes those?
A: The veins you are describing are called spider veins or telangiectasias. Spider veins can occur singly or in large numbers (spider vein complexes). Spider veins are often considered to be unsightly and can cause leg pain and/or a feeling of heaviness. There is not always a correlation between the amount of discomfort felt and the number of spider veins present; e.g. a person may have only a few spider veins and feel a fair amount of pain. Conversely, a person may have many spider veins and feel little or no pain. Just like the larger varicose vein counterparts, spider veins are a result of increased pressure and vein valve malfunction, only on a much smaller scale than varicose veins.
Q: What is chronic venous insufficiency?
A: Chronic venous insufficiency refers to a condition in which there is ongoing venous valve malfunction resulting in venous reflux. Symptoms can include edema (swelling), skin discoloration (stasis discoloration) that occurs specifically in the ankle area, and possible venous ulcer formation. Chronic venous insufficiency can also occur as a result of post-phlebitic syndrome.
Q: Does it make a difference what's causing my vein problems?
A: Yes, it is very important to determine exactly what is causing your vein problems, otherwise you can end up with a lot of expensive, ineffective treatment. At VEININNOVATIONS we are very aware of the importance of a correct diagnosis. Therefore, at your first visit we take a history, do a focused physical exam, and very importantly, we do a non-invasive ultrasound and Doppler examination that shows exactly what type of problem exists, and where. We look at the junctions between the deep venous system and the superficial veins that can have great importance in determining the appropriate treatment. We also look at perforator junctions. Your VI physician will then make treatment recommendations based on the result of your history, physical and ultrasound examination.
Q: I just have spider veins. Do I need an ultrasound examination, too?
A: Yes. We have found that about 15% of people who come in with just spider veins also have problems with their larger veins (which could have caused the spider veins in the first place). We believe it is important for you to know if larger vein problems are present mainly because if they are, the larger vein problems should be addressed first. Sometimes the smaller veins go away by themselves after larger veins are treated. Most times, however, treatment of larger veins makes treatment of smaller veins much more successful.
Q: What kind of treatment is recommended if I only have small vein problems?
A: Treatment of spider veins has for many years included injection sclerotherapy. At VI, we use tiny needles to inject a solution (called a sclerosant) into the veins that cause the vein to change and stop working and eventually fade away.
At VI, we also use a device called a vein light to aid in locating the larger veins that often "feed" a spider vein complex or even single spider veins. Use of a vein light allows us to potentially treat a large area of spider veins with just one or two injections. After the injection, we cover the area of veins injected with cotton balls held in place with tape. Compression stockings are then worn for 48 hours, but the cotton balls and tape are removed the next day.
Q: What about laser treatment of spider veins?
A: At VI, we commonly use a combination of injection sclerotherapy and laser treatment of spider veins.
Q: How do you decide which to use, injection sclerotherapy or laser?
A: Size of the vein to be treated is the biggest determinant. At VI, we try to do as much as we can first with injection sclerotherapy. This method is much more efficient and less expensive than laser alone because you can treat many more veins in a shorter period of time. Also, the laser is effective only when it is used on the tiniest of veins. Depth of skin color is another determinant. Our laser works best with medium and lighter skin tones.
Q: Does treatment for my spider veins hurt?
A: Minimally. First, for injection sclerotherapy, we use micro needles. The sclerosant we use is called Polidocanol, (aethoxysclerol) which was developed as a local anesthetic, so it doesn't burn or sting as some other sclerosants do, (in particular, hypertonic saline). Polidocanol is in a class of sclerosants called "detergent" sclerosants. The advantages of using a detergent sclerosant include:
- the fact that they are painless
- have a low (to non-existant in the case of Polidocanol) incidence of allergic reaction
- are tolerated well by the body if an inadvertent injection occurs outside the vein and have low to moderate rates of causing pigmentation changes or matting.
Laser treatment feels a bit like being popped with bacon grease or like being snapped with a very small rubber band.
Q: Is it safe to treat my spider veins?
A: Sclerotherapy is a technique that has been practiced since the 1930's. Problems are infrequent and very minor in an overwhelming number of patients.
Q: How many treatments will it take?
A: Since everyone is different, we'll need to see you in order to give you our estimate of how many treatments you will need.
Q: How soon will I see results?
A: Results are visible usually after about 3-6 weeks.
Q: How long will results last?
A: The actual veins that are treated should not ever come back. However, the same condition that led to development of spider veins in the first place is on-going if a larger source of the problem is not detected and treated. Other spider veins can develop. Therefore it is a good idea to think of sclerotherapy as a program of maintenance that will need to be undertaken every year or two (or three or four or five), depending on the individual.
Q: What is the success rate for sclerotherapy?
A: About 80-90%, when done by experts.
Q: Is sclerotherapy safe for everyone?
A: People with clotting disorders, who are pregnant, have an inability to walk, or who are unwilling to follow directions should not have sclerotherapy. We are as anxious for you to have good results as you are to have them. Therefore, we ask you to refrain from vigorous exercise or hot baths for a few days, and to wear your compression stockings for 48 hours.
Q: I have varicose veins, will sclerotherapy help me or will I need surgery?
A: As stated before, ultrasound examination is important to determine the cause of varicose veins. Conservative therapy with compression stockings and leg elevation (feet above your heart) can be effective in relieving the symptoms and progression of varicose veins and chronic venous insufficiency. Many people, however, do not want to wear compression stockings for the rest of their lives. We have a very effective, new approach for treating varicose veins that replaces vein surgery. Feel fortunate! For thirty to forty years, the answer to the question "will I need surgery?" would have been yes. Even now, some physicians will tell you that you need surgery to correct the problem of varicose veins, and that usually means "vein stripping" or "high ligation of the saphenous vein", and/or occasionally it means "excision of varicose veins".
Q: What is excision of varicose veins?
A: Excision of varicose veins is often a surgical procedure involving incisions over varicose veins. The vein is then pulled out and tied off. The patient is left with many small (or sometimes large, depending on the skill of the surgeon) scars. Infrequently, those scars can become rather large and thick and/or form keloids.
Q: What is vein stripping?
A: Vein stripping is done in the operating room under general anesthesia. An intraluminal stripper is placed directly into the greater or lesser saphenous vein and the entire vein is literally pulled out of the body.
Q: Doesn't that hurt?
A: Yes it does. It can cause a lot of bruising and pain. In addition, it's not always effective.
Q: What is high ligation of the greater saphenous vein?
A: High ligation is another surgical procedure done in the operation room under local or general anesthesia. It involves a groin incision (possibly on both sides). The tissue is dissected by the surgeon down to the greater saphenous vein (GSV)/femoral vein junction. The greater saphenous vein is then clamped and tied off. The idea is to sever the connection between the superficial system (the GSV) and the deep system (the femoral vein).
Q: Does high ligation of the GSV work?
A: It might work if the only problem is at the GSV/femoral junction. It does not address the problem of perforator reflux further down the leg if it is present.
Q: Does this mean I could have the surgeries you describe and still have a problem with my veins?
A: Yes, unfortunately it does. We frequently see people who have had both vein stripping and high ligation of the GSV and still have problems.
Q: Why can't there be a more effective treatment that doesn't cause as much pain and wouldn't require general anesthesia and an operating room?
A: There is such a treatment. It's called saphenous vein ablation. There are two kinds: one uses radiofrequency energy and the other uses laser energy. VEININNOVATIONS offers both, done in our office (avoiding costly hospital charges). The radiofrequency version is called "Closure" and the laser version is called "ELVT or EVLA". Closure and EVLT are quite similar in many ways: In our office, the vein to be treated is accessed under ultrasound guidance. A tiny wire is threaded through the needle and using this wire, a catheter or a flexible laser filament is then placed in the vein. After several injections of an anesthetic mixture, the energy (radiofrequency or laser) is turned on and the vein is treated as the catheter or filament is withdrawn. The leg is wrapped in a bandage (mainly to supply compression), and a compression stocking is applied. The bandage is removed the next day and the compression stocking should be worn for 7-10 days. These procedures are both designed to "shut the treated vein down" so that it cannot reflux and cause its problems. (In fact, two years after Closure, the treated vein cannot be seen by ultrasound 94% of the time).
Q: Isn't the greater saphenous vein the one used in heart bypass surgery? What if I need it for that?
A: It is true that many times the greater saphenous vein is used in cardiac surgery; however, if the vein is diseased, as is the case with varicose veins and chronic venous insufficiency, it is typically unusable for heart surgery. In addition, there are other possible sources of veins or arteries in the body to use for that purpose.
Q: Is there any restriction in activities following saphenous vein ablation?
A: A few. We request that patients limit activities that require contraction of the abdominal muscles because that causes an increase in venous pressure in the legs for 7-10 days. Such activities include jogging, heavy lifting, sit-ups, crunches and excessive stair climbing. Since we want the treated vein to close, we want to subject it to as little pressure as possible till it has a chance to heal. Walking is encouraged. You'll be back to your more strenuous activities in ten days to two weeks.
Q: How long do these procedures usually take?
A: The actual procedure takes about 45 minutes. Sometimes they can take a bit more time depending on vein diameter and whether the path of the vein includes many branches or is excessively twisting.
Q: Do these procedures hurt?
A: Not much. There is some discomfort possible with the initial needle stick and with injections along the area of the vein to be treated. Some patients choose to take Valium and/or a mild pain pill before the procedure begins, which can be helpful. People report varying degrees of discomfort following the procedures. Most of our patients say the discomfort during and following the procedure is nothing compared to the pain they have experienced over the years with their varicose veins and chronic venous insufficiency. It's also good to keep in mind the pain caused by the alternative methods of treatment: vein stripping and high ligation of the greater saphenous vein. Both of those are surgical procedures and are much more invasive than saphenous vein ablation. This is especially true of vein stripping. Mild activity following our procedures are encouraged, especially walking, and can be very effective in reducing any discomfort.
Q: I'm not pregnant now, but I plan to have more children. Should I wait to have saphenous vein ablation until no more pregnancies are planned?
A: There's no need to wait. While we certainly do not advise treatment during pregnancy, treatment between pregnancies is desirable, and makes subsequent pregnancies much more comfortable for those who suffer from varicose veins and other kinds of venous disease.
Q: You mentioned sclerotherapy before. Why can't you just use sclerotherapy on the greater saphenous vein?
A: Well, many people have tried that approach; however, results shown in medical literature does not support the effectiveness of such a practice. Treating very large veins with sclerotherapy can be problematic. Many times when patients come to us who have had sclerotherapy attempted on their greater saphenous vein, only a few portions of the vein have closed, if indeed any of the vein has closed at all. This can make it much more difficult or impossible to thread a catheter or filament into the vein to complete the job.
Q: I've heard of something called "ultrasound-guided sclerotherapy". Is this the same thing as sclerotherapy used on the greater saphenous vein?
A: "Ultrasound-guided sclerotherapy" refers to sclerotherapy done using the ultrasound for guidance. In other words, ultrasound is used to locate any vein that cannot be seen on the surface of the skin in order to inject it with a sclerosant.
Q: Will my insurance or Medicare pay for saphenous vein ablation or ultrasound-guided sclerotherapy?
A: In most cases, yes. Also, remember, there are no separate hospital or anesthesiologist charges to pay because these procedures are done in our office. One of our services is to obtain pre-certification from your insurance company.
Q: Does insurance or Medicare pay for sclerotherapy?
A: Usually no, because they consider sclerotherapy to be a cosmetic procedure (ultrasound-guided sclerotherapy can often be an exception to this rule). You are certainly free to try to get your insurance company to reimburse you, and we will provide you with documentation; however, we ask that you pursue this on your own. It becomes prohibitively time-consuming for us.
Q: Doesn't my body need the veins that are treated with any of the procedures you have described?
A: No. For every visible vein in your leg, there are many more beneath the skin. Remember, even the tiniest spider vein has appeared as a result of it not doing its job. In truth, the body does much better without veins that malfunction. Healthy veins help to return venous circulation back to normal.