Diagnosis & Treatment of Varicose Veins

Diagnosis of varicose veins
How are varicose veins treated?
Vein Stripping
VNUS Closure Procedure
Staged Treatment
Endovenous Chemical Ablation
Sclerotherapy
Microphlebectomy
What problems can occur with treatment?

Diagnosis of Varicose Veins
Like spider veins, one aspect of diagnosis of varicose veins is simple: if you've got 'em, you've got 'em. But it is the evaluation of the cause of the varicose veins that is more important. Varicose veins occur usually according to well-known anatomical patterns. Varicose veins, in the majority of cases, are a disease of the superficial veins. The Great Saphenous Vein (a superficial vein) starts at the inner ankle, runs up the inner leg and thigh, and empties into the Femoral Vein (a deep vein) at the groin. The Short Saphenous Vein (a superficial vein) runs up the back of the calf and empties into the Popliteal Vein (a deep vein) behind the knee. In addition, there are communicating, or perforator, veins that connect the deep veins to the superficial veins in various locations of the legs. In the past, indirect methods were used to look for which veins had bad valves. Today we have sophisticated ultrasound technology that allows us to clearly view the leg veins and assess whether their valves are functioning properly or not. Rather then try to make an educated guess at which might be the abnormal vein, the ultrasound shows us exactly which vein is abnormal, and how much of its length is abnormal. Treatment can then be planned according to the ultrasound findings.

How are Varicose Veins treated?
As you can now appreciate, treatment of varicose veins must involve treatment of the underlying superficial vein whose valves are no longer working, as well as treatment of the surface varicose veins. Traditionally, this was done all at once. It has been believed for over a hundred years that treatment will fail unless all the surface veins are eradicated.

Vein Stripping involves an operating room setting and general or spinal anesthesia. First, all of the varicose veins (marked beforehand with indelible ink with the patient standing) were removed through small incisions. Some surgeons used large incisions. This could involve forty or fifty or more incisions. Then, an operation was done to tie off the Great Saphenous Vein at its junction with the Femoral Vein. The lower end of the vein was exposed at the ankle. A small cable or plastic cord was then passed up the vein to the tied off end at the groin. A bullet-shaped tip was fastened on to one end of the cable, and then the cable forcefully pulled from the other end. This resulted in the vein being "stripped" from the leg. Of course, all of its connections with other veins were sheared off and measures were taken to try to minimize the bleeding and bruising. The leg was then wrapped up tight with a heavy bandage and the patient put to bed with limited activity for a few days. Time off work varied from two to six weeks depending on the job. As you can imagine, this operation was not much fun, and people generally didn't have it done until their varicose veins were quite advanced, or they were showing signs of complications from the varicose veins.

VNUS Closure Procedure: Finally, in the late 1990's a new technique for treating the saphenous veins developed that avoided stripping. Using ultrasound as a guide, a special catheter was placed into the Great Saphenous Vein at the knee level and advanced up toward the groin. The tip of the catheter was positioned just inside the saphenous vein to avoid injury to the Femoral Vein. A fluid mixture of saline and local anesthetic was injected with a small needle around the length of saphenous vein to be treated. The catheter was connected to a radiofrequency power generator. When the power was turned on, the tip of the catheter heated up and damaged the lining of the vein. This resulted in the vein closing, and eventually scarring down. The catheter was slowly pulled out of the vein (usually taking 15 to 20 minutes), closing it from the top down. This procedure is called radiofrequency ablation or VNUS Closure. Laser companies soon found they could create a similar system with laser heat, and the term endovenous ablation was used to describe both types of ablation procedures. Quite recently the radiofrequency catheter has been modified, and the pull-back time now takes about three minutes. Patients who undergo the Closure procedure typically resume normal activities within a day.

Click here to learn more about the VNUS Closure procedure



Staged Treatment: In the past, treatment of the underlying sources of venous reflux, usually with stripping, was combined with the surgical removal of the surface veins in one long operation. It was the Big Event. I call it "The All-Out Assault" approach. It required an operating room, general anesthesia, lots of pain, and a long recovery. With the development of the Closure procedure and the elimination of stripping, some of us asked the question of whether varicose vein treatment could be brought out of the operating room entirely. Because of many misconceptions and improper use of sclerotherapy (vein injection), many surgeons believed (and still do) that surgical removal was preferable. Our surgical training told us that removal of all visible surface veins was essential to success of treatment. What many of us have observed is that the surface varicose veins spontaneously regress to greater or lesser degrees after performing the Closure procedure alone. My strategy for varicose veins is to treat the problem in stages. We first do the Closure, or treatment of other underlying veins, to treat underlying reflux, then wait for a period of time to allow the varicose veins to regress on their own. Then, when spontaneous regression has stopped, treat any remaining surface varicose veins with sclerotherapy. We have found that we inject less than one-fifth of the veins that were originally present. While definitive research for this approach has not yet been published, my experience has confirmed its efficacy. (See Physician Section) Many vein specialists now employ this approach.

Endovenous Chemical Ablation: In addition to the Great and Short Saphenous Veins there are also other veins, known as tributary and perforator veins, that may require treatment to control pooling in the leg veins. In the past these were treated with surgery, which often was extensive. Now, we can identify these veins with ultrasound, and treat them with sclerotherapy. Since they are beneath the surface, they cannot be seen except with ultrasound. So, we inject them while visualizing them with the ultrasound. This is called ultrasound-guided sclerotherapy, or endovenous chemical ablation.

Sclerotherapy: In order to avoid incisions for removal of all the surface veins, physicians have used various solutions injected into the veins to collapse them. This is called sclerotherapy. Sclerotherapy is performed in the office, of course, and requires no sedation or anesthesia. As with sclerotherapy for spider veins, the tiniest needle available is used. The veins to be treated are marked with a pen. The longer varicose veins need to be injected every 2 or 3 inches apart. The patient then lies down on the procedure table. At each marked site the needle is inserted into the vein, and a small amount of solution injected - larger veins require more solution. Cotton balls are placed over all the treated veins, and the leg is wrapped up with light cotton. Over this, a slightly stretchable second wrap is placed. For this we use Coban, which is kind of like a disposable Ace wrap. Finally, a compression stocking is put on. The wrap is left on for three days. After removal, the stocking is worn for another week. After sclerotherapy for varicose veins, the veins go through a healing, or scarring-down process. Initially the vein wall is thickened and there can be small amounts of blood trapped in the vein. The treated vein can be felt under the skin as a firm cord; not painful. This gradually goes away with time, the same time as for any wound to undergo healing and resolution. Sometimes, if the cord is especially prominent or discolored or tender, we will aspirate the trapped blood from the vein a few weeks after treatment. This results in faster resolution of the cord.

Microphlebectomy: Some surgeons perform a procedure called microphlebectomy. Phlebectomy is the term for surgically removing surface varicose veins. During the evolution of varicose vein surgery in the past century, cosmetic concerns became increasingly more important. Larger incisions were replaced with smaller ones. The ultimate end-point of this evolution has been to use very tine incisions. Of course, the cosmetic results are better than if larger incisions are used. At Vein Surgery and Treatment Center we have rarely used this technique. When done properly (some surgeons call the use of small incisions microphlebectomy, but don't actually utilize the very tiny incisions appropriate for that term) the procedure is quite tedious. There is still surgical trauma to the leg, and recovery time is still necessary. And, if many varices are removed, there is still scarring present when healing is complete. Sclerotherapy remains our preferred option, especially if done after shrinking of the veins is obtained following elimination of underlying sources of back pressure. Microphlebectomy is preferred by some surgeons because they feel they avoid the staining that sclerotherapy can leave. Both techniques require many months before the cosmetic result is final. Staining usually disappears, but scars don't, even tiny ones. So our preference is sclerotherapy.

What problems can occur with treatment? The main issues are those discussed above under treatment of spider veins. The most important concern is blood clot development in the deep veins of the legs, or deep venous thrombosis (DVT). While we continue to be vigilant in observing safety precautions to prevent DVT, and remain concerned about its potential, we have never had a case of DVT following sclerotherapy. Sometimes segments of the surface veins that were not injected become clotted. There is an associated inflammation with this clotting, and the veins become tender, firm, and often have redness of the skin over them. This is called superficial phlebitis, and is most importantly different from DVT in that these clots do not travel in the bloodstream. Superficial phlebitis, therefore, does not represent a threat, but, because of the tenderness, is a nuisance for a couple of weeks. The other possible untoward effects are discussed more fully under spider vein treatment, but the main concerns are the following. Staining is common following sclerotherapy of varicose veins. This is a light brown discoloration of the skin over the vein. Most of the time, it resolves in a few weeks or months. Occasionally, staining can take 18 months to resolve, and, very rarely, a light brown stain may be permanent, resembling a birth mark. Blushing/matting can occur following varicose vein treatment, and usually indicates the presence of an untreated source of pooling. Skin breakdown is very rare with sclerotherapy for varicose veins. Poor response is unusual, but recurrence is always a possibility.