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.
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.
