The Treatment of Varicose Veins and Spider Veins

Introduction

The treatment of varicose veins and spider veins has become more advanced in the last several years. Venous insufficiency previously received little attention in medical training. Treatments were more invasive and associated with significant discomfort. Patients were underdiagnosed and undertreated. They spent years with discomfort and disability, and later the disease progressed to chronic swelling, leg ulcers, and infection. Now the problem has received much more attention. The treatments are less invasive and performed in the office and include endovenous laser therapy, ambulatory phlebectomy, and sclerotherapy. The use of ultrasound guidance has made much of this possible.

The following is an introduction to the anatomy and physiology of venous disease in the lower extremities, a review of the symptoms and physical findings, diagnostic testing, and treatment. Treatments covered include endovenous laser therapy, ambulatory phlebectomy, and sclerotherapy.

Anatomy and physiology

The heart pumps blood to the feet through vessels called arteries. The blood is then returned to the heart through blood vessels called veins. There are two systems of veins in the legs, the deep system and the superficial system. The deep system is located inside the leg muscles. They are represented in the figure by the dark blue vessels. When a person walks, the muscles squeeze the blood inside the veins back toward the heart. As the blood moves up the leg with each muscular contraction it cannot fall back down the leg because of the presence of several one way valves located along the blood vessel column. As long as these valves remain intact, the blood can be pushed upward even against gravity in a standing individual back toward the heart. When these valves become damaged by age, trauma, or blood clots, the blood can fall back through a leaking valve and the leg can become congested with extra blood volume. This is referred to deep vein insufficiency.

The other system of veins is the superficial system. This is a network of vessels outside of the muscles under the skin. This system drains into the deep system through multiple connections. The reason the blood does not travel the other way is because of more one way valves between the two systems. As long as these valves remain intact, the blood will move from the superficial system into the deep system where the muscular pump can squeeze the blood back to the heart. As people age, have children, gain weight, and stand on their feet for prolonged periods of time, these valves start to break down and start to leak. The blood then gets held up in the superficial system where it gets stuck. As more blood gets congested in the legs, the legs start to retain more fluid volume. They may come to feel heavy. They may begin to ache, throb, or cramp especially with prolonged standing. They may tire easily. These are the first signs of venous insufficiency. As time goes on and as more blood builds up in the superficial system, the veins may begin to become visable under the skin or even pop out and become manifest as unsightly varicose veins or spider telangiectasias. As more time passes more blood and fluid volume is retained in the legs, and the legs may begin to swell resulting in lower extremity edema. Old blood retained in the skin can start to turn the skin in the legs brown and later purple. The skin later becomes more friable and begins to break down resulting in ulcerations. At first they may heal but later they may persist, become weeping and get infected. So if this problem is ignored for years the patient can end up with a swollen, achy leg with chronically draining infected sores.

Looking at the Veins of the Leg diagram again, there are several major veins in the superficial system. The largest is the greater saphenous vein. It runs from the inside of the ankle to the groin. The lesser saphenous vein runs from just above the heel, up the back of the calf to behind the knee. Referring to the Vein Anatomy – Perforator and Reticular Veins diagram, you can see that these superficial veins run parallel to the deep veins that run inside the muscles. As you can see in the diagram, the two systems are connected by numerous perforator veins that direct blood flow from outside to inside through the one way valves contained in them.

The next slide shows where the greater saphenous vein ends at the level of the groin. It connects to the deep femoral vein and also contains a valve that keeps blood flow going from the superficial vein into the deep system. This area is called the saphenofemoral junction. The key to understanding venous insufficiency is the valves. They allow blood flow in one direction, then close and prevent blood from leaking backward. This assures blood and fluid move out of the leg back toward the heart. As the valves get older or are damaged, the valve leaflets may not close properly. This allows blood to leak backwards. As the leg becomes congested with the extra volume of blood that is retained in the leg the veins themselves become enlarged. This makes the valve leaflets separate even more resulting in more leakage, more retained blood and fluid in the leg, and more vein enlargement.

Examples of Varicose Veins and Spider Telangiectasias

The next several slides show examples of these enlarged veins that have become so big that they protrude out of the skin and course up and down the leg. These are what are commonly known as variose veins. They can be large veins, as large as your finger. Or they can be a patch of tiny vessels spread out in a tree like fashion, called spider telangiectasias. Finally, as the congestion continues, the legs can become swollen with all the extra retained fluid that cannot be drained from the legs. This is called edema. With the prolonged swelling, the old blood can collect in the skin and leave a diffuse brownish rash across the feet, ankles, and shins, called venous stasis dermatitis. This rash can later turn purple. As the skin becomes more damaged from the congestion, it can start to break down and form ulcers. These can weep, become painful, cease to heal or enlarge, and become infected requiring hospitalization at times for intravenous antibiotics.

A venous stasis ulceration on the leg

Venous Insufficiency: The Signs and Symptoms

The next table shows the classification of varicose veins and demonstrates the natural progression of this disease.

Classification of Varicose Veins

C0 No visible venous disease

C1 Telangiectatic or reticular veins (spiders)

C2 Varicose veins

C3 Edema (swelling)

C4 Skin changes without ulceration (brownish or purplish rash)

C5 Skin changes with healed ulceration

C6 Skin changes with active ulceration

The varicose veins can become more swollen, twisted, and unsightly. But they can also become painful. The veins can itch and burn. The area around them can become sore and tender. But because of the entire blood volume that has become congested in the leg, much of the leg can feel heavy, achy, and throbbing. It can cramp easily. These discomforts can occur mostly with prolonged standing. It can interfere with routine activities such as housework, yard activities, exercise, and shopping. It can also limit work activities that require standing for long periods of time, such as waitressing, teaching, nursing, and factory work. They can also cause night cramps and restless legs.

Clinical Effects of Varicose Veins

Twisted and swollen veins

Swelling, throbbing, or cramping at night

Difficulty walking

Itching and burning

Venous ulcers

Venous Insufficiency: The Incidence and Causes

As the population ages, more cases of varicose veins are being seen. 40 million people in the United States have varicose veins. This is four times more prevalent than peripheral arterial disease which also causes leg discomfort. Varicose veins is not just a women’s disease, affecting 25% of the women and 15% of the men. Over one million people in the United States seek treatment yearly. Over 150,000 surgical vein strippings are done yearly as well.

Incidence of Varicose Veins

40 million in U.S. have varicose veins

Four times more prevalent than arterial disease

Varicose veins affect 25% of women and 15% of men

Over 1 million people in U.S. seek treatment yearly

Over 150,000 surgical vein strippings yearly

There are several causes of varicose veins. They can be genetic, associated with pregnancy, from obesity, or ambulatory occupations. 70% of patients with varicose veins have parents with varicose veins. 80% of women develop varicose veins in the first trimester of pregnancy (progesterone related). Obesity strains the valves as well as prolonged standing.

Causes of Varicose Veins

Genetics - 70% of patients with varicose veins have parents with varicose veins

Pregnancy - 80% of women develop varicose veins in the first trimester

Obesity - strains the vein valves

Ambulatory occupations - requiring prolonged standing

Venous Insufficiency: Diagnosis and Testing

The extent of venous insufficiency is evaluated by ultrasound. A venous duplex study is performed on the deep and superficial systems. The deep system is evaluated to check for blood clots. Blood clots in the deep system can be life threatening. If they grow and break off, they can travel up through the heart and plug up the blood vessels in the lung causing lung tissue damage. The valves in the deep system can leak, inhibiting draining of blood and fluid from the leg causing swelling or edema. However, deep system vein problems are difficult to treat and may require surgical therapies such as valve replacements. The majority of the vein treatments today involve the superficial system. Ultrasound examination of this system takes much longer, probably twice as long as the usual venous Doppler exam of the deep system. A complete venous duplex study of the deep and superficial systems takes from 45 to 90 minutes. It identifies as of the areas of leaking from the deep into the superficial systems. A typical exam will visualize the entire greater saphenous vein and record the amount of leaking in the upper, mid, and distal segments of the above the knee segment, and the same for the upper, mid, and distal segments of the below the knee segments. The upper, mid, and distal segments of the lesser saphenous vein is also examined. The amount of leaking, or reflux, is recorded in seconds. It reflects the number of seconds that blood flow leaks backwards into a vein segment after the leg is squeezed. Significant reflux is considered to be greater than 1 second. The location of leaking perforating veins (the connections between the deep and superficial veins) are recorded. Large varicosities and branches off of the main superficial veins can be tracked and noted to be originating from the major superficial veins. This may give the physician an idea about the treatment effects of treating the main superficial vessels which may collapse the other branches or large varicosities as well. It is important to identify reflux in all of the major superficial veins before treating any of the varicosities or vein spiders. The major superficial veins often feed the visible varicosities, spiders, or even ulcers. If the major superficial veins are not treated first, then the visible varicosities and spider veins are more likely to recur early after they are treated. The venous Doppler examination thus creates a map of the venous system. From this, targets for treatments are identified, and a strategy for treatments can be formulated. Significant leaking in the greater saphenous vein is usually treated by laser techniques. The greater saphenous vein below the knee is usually treated with sclerotherapy as is the lesser saphenous vein. Larger visible varicosities can be treated with minor surgical stripping techniques such as ambulatory phlebectomy or sclerotherapy.

Varicose Vein Treatments

Compression stockings - relief of symptoms

Sclerotherapy for small vessels

Surgical vein stripping (phlebectomy)

Ambulatory phlebectomy

Endovenous laser therapy

The treatment of varicose veins and spider veins include the following: conservative therapy including compression stockings, sclerotherapy of small vessels, ultrasound guided sclerotherapy of larger vessels, surgical vein stripping (phlebectomy), ambulatory phlebectomy, and endovenous laser therapy.

Varicose Vein Treatments: Conservative Therapy

The foundation of treatment of varicose veins is conservative nonoperative therapy. This includes exercise, avoiding prolonged standing, leg elevation, and compression stockings. Exercise activiates the muscular pump to squeeze blood in the deep veins back toward the heart. Avoiding prolonged standing and elevating the legs helps to negate the effects of gravity that help hold blood and fluid in the legs. Compression stockings put pressure on the superficial system of veins to promote movement of blood from the superficial system into the deep system where it can be squeezed by the muscles back to the heart. These stockings are very tight and difficult to get on. They require a doctors prescription to get the proper ones. Some offices carry them but often they are dispensed by medical supply companies. They must be fitted according to a person’s height, weight, and leg measurements. They should be at least thigh high to put pressure on the entire superficial system of the leg. Just below the knee hose although more comfortable and easier to deal with will not suffice. The recommended amount of pressure is 30 – 40 mm. Some insurance companies like Blue Cross Blue Shield require 40 – 50 mm of pressure. The reason for compression hose is threefold. One, if the leg discomfort is venous in origin, then it will often improve with use of the stockings. Two, if any procedures are done on the leg veins, then the patient will be immediately be placed in the stockings. This will put pressure on newly treated veins to prevent them from popping back open again and ending up as a treatment failure. Third, insurers will not pay for any of these vein procedures unless patients have failed what they have called a “trial of conservative, non-operative therapy” for from 6 weeks to 6 months. This therapy includes a program of exercise, leg elevation, avoiding prolonged standing, and wearing compression stockings with at least 30 – 40 mm of pressure.

Varicose Vein Treatments: Sclerotherapy


A common vein procedure is sclerothrapy. It involves the injection of a chemical through a needle that damages the blood vessel wall so that the vessel clots off and scars shut. The agent can be injected into spiders, small and large varicose veins under direct visualization. Or it can be injected into larger superficial veins that are not visable by using ultrasound guidance. Two chemicals are primarily used for sclerotherapy, polidocanol and sodium tetradecol sulfate (STS). They are fatty acid alcohol detergents. Polidocanol is considered the safest of these agents and is used widely in the United States and in Europe. However, it is not approved by the FDA. Both are very effective in eliminating unsightly veins with a minimum of side effects. Possible side effects include staining, especially where large veins have been present for a long period of time. Others include skin ulceration and “freckle” scar formation, telangiectatic matting, allergy to medications, blood clots, and phlebitis (inflammation in the treated vein presenting as a red, warm, swollen, tender area along the vessel). Skin ulceration is the most dreaded complication of sclerotherapy. With more caustic agents injected inadvertently outside of the vessel into surrounding tissue there can be a large amount of skin necrosis with damage to large patches of skin. This may require skin grafting for treatment. If the chemical is injected into an artery even larger amounts of tissue damage can occur. If a large amount of sclerosant is injected into the deep system blood clots occur and potentially travel to the heart and lung where it can be potentially life threatening. Fortunately, these more serious complications are very rare especially with the newer agents used today.

Varicose And Spider Veins -Sclerotherapy, Expanded Description and Example Treatment Protocol

Sclerotherapy is an injection treatment used to eliminate "spider" veins and small to medium-size varicose veins. A solution is injected into the problem vein with a very fine (31 gauge) needle. The vein wall becomes irritated. Subsequent application of external compression with dressings and prescription-gradient compression hose seals the vein wall together. The body breaks down the damaged vein and absorbs it, ultimately eliminating the problem vein. No pre-treatment client preparation is needed and most clients describe minimal discomfort. After treatment clients resume normal activities, but are asked to avoid prolonged sitting and standing for 3 days and heavy exercise (weight lifting, running and high impact aerobics) for two weeks. Walking is encouraged after the treatments. Prescription-gradient compression hose are worn for 3 days after each treatment.

Sclerotherapy is an injection treatment used to eliminate small to medium size varicose veins and "spider" veins. "Spider" veins are superficial telangiectases, tiny vessels that are red, blue or purple in color. The majority of these veins present as a cosmetic problem. A very small needle is used to inject a sclerosing solution into a varicose or "spider" vein. Different solutions are used depending on the type of vein. Different strengths of the solutions are used based on the size of the vessel. Once injected, the cells that line the vein wall (endothelium) will become irritated, inflamed and damaged. External compression is applied using cotton balls, tape and support hose. The compression causes the vein walls to seal together and the vein no longer can transport blood. The body will then break down and absorb the damaged vein. When healing is complete the vein is no longer visible. The process is very similar to how your body heals a bad bruise. "Spider" veins do not have any useful function and eliminating them will not affect your circulation. Reducing or eliminating varicose veins can improve one's circulation and symptoms of heaviness, aching and fatigue.

The number of treatments needed varies from client to client depending on the type, size and quantity of veins to be treated. Varicose veins and "spider" veins may require multiple injection sessions. Subsequent treatments are usually scheduled every four to six weeks to allow time for the body to respond to the treatment. It is important to realize that the best results require patience. It takes time for one's body to respond to the injections. It is important to follow the post-treatment instructions to optimize the results. The body will continue to heal and "fade" at injection sites for months after treatment.

After the initial screening exam the doctor will give an estimate as to the number of treatments that may be required. This is based on the doctor's assessment, history and expectations. The client may end up needing fewer or more treatments than estimated.

Photographs will be taken before treatment is initiated. This helps to monitor progress. The legs will look worse before they look better. After the vein is damaged, the body needs time to heal. Most people will notice a dramatic improvement approximately four weeks after their initial treatment. Maximal improvement often takes several months and several treatments. There is no guarantee sclerotherapy will be effective in every case. Some veins and areas will need to be retreated. Recurrence of the same vein treated rarely occurs with proper injection technique and compliance with post treatment instructions. New varicose veins or "spider" veins may form requiring subsequent treatment. Periodic re-evaluations are encouraged so that any new veins that develop can be injected before they become too large or too numerous.

COMMON SIDE EFFECTS

ITCHING- the client may experience itching around the area injected. If this occurs, it is usually mild and lasts for one to two days.

HYPERPIGMENTATION- a light brown discoloration of the skin may develop along the vein in the area injected. Approximately 20-30% of clients treated note the discoloration, which is lighter and less obvious than the vein being treated. The hyperpigmentation usually fades in a couple weeks, but may take several months to a year to totally resolve. There is a one-percent incidence of hyperpigmentation continuing after one year.

A small amount of blood may become trapped and hardened in the vein when injecting varicose veins or some "spider" vein complexes. This may feel like a knot or cord and it may look dark blue or bruised. This is a common occurrence. The client may need to return before their next treatment so this area can be drained to remove the trapped blood. This will reduce the hyperpigmentation that can occur. The chance of this occurring can be decreased with proper compression of the vein and use of compression hose after your treatment.

TELANGIECTATIC MATTING- the formation of new, fine "spider" veins in the area injected occurs in less than 1% of clients injected. The exact reason for this occurring is unknown. If untreated, the matting usually resolves in three to twelve months, but very rarely it can be permanent. If the matting does not fade it can be re-injected or treated with a laser/light source.
PAIN-it is common to have some tenderness or stinging at the injection site. Injection of the sclerosing agent can be uncomfortable, but is usually well tolerated by most clients. The discomfort is temporary, lasting one to at most seven days. Acetaminophen (Tylenol) can be used if needed, according to product directions.

BRUISING- may occur at the injection site. Bruising may be minimized by avoiding Aspirin and Ibuprofen products for ten days before and after each treatment session.

RARE SIDE EFFECTS

ULCERATION AT IN-JECTION SITE- very rarely a small ulcer will occur at the site where the vein is injected. An ulcer can take four to six weeks to completely heal. A small scar may result.

ALLERGIC REACTION- there is a very rare incidence of an allergic reaction to the solution injected. You should observe for such reaction and treat appropriately should it occur.

PULMONARY EMBOLUS/DEEP VEIN THROMBOSIS- a blood clot to the lungs/a blood clot in the deep vein. In the medical literature there is an extraordinarily low incidence of this complication.

Compression hose promote venous blood return to the heart. If support hose are worn faithfully symptoms such as aching, heaviness and tiredness are often alleviated. They also may help prevent the progression and formation of varicose and "spider veins". Vein stripping and/or ligation may be appropriate to treat some clients with larger varicose veins. Laser/light source therapy may be an option if you have spider veins. You will need to discuss these alternative choices.

SCLEROTHERAPY PRE AND POST TREATMENT INSTRUCTIONS

PRE TREATMENT INSTRUCTIONS:
COMPRESSION HOSE- are required to be worn immediately after each injection treatment or if you have had aspiration of trapped blood from an injected vein. Hose can be purchased from our office or you may request a prescription to purchase at a pharmacy or medical supply store. We use pantyhose style hose with 20 to 30mm Hg compression. You cannot be injected without your compression hose. The hose must be worn continuously for 48 hours after your treatment. Then they may be removed and worn daily, during the waking hours, for seven more days. Your doctor may adjust the length of time to wear your hose. The compression hose are critical to the success of the treatment.

LEG PREPARATION- do not apply oil, lotion or powder to your legs the night before or the day of your injections. Use of these toiletries will not allow the cotton balls and tape to adhere to your skin.

CLOTHING- bring a pair of loose, comfortable shorts to wear during your treatment. Dress in loose clothes and comfortable shoes to accommodate the cotton balls, tape and hose after your treatment.

MEDICATIONS- discontinue Aspirin (Bufferin, Anacin etc.) and Ibuprofen (Motrin, Advil, Aleve etc. ) .for 10 days before and after injections to reduce bruising. Acetaminophen (Tylenol) is allowed.

TIME ALLOTTMENT- a sclerotherapy treatment should last approximately 30 minutes. You should arrive 10-15 minutes early for your first sclerotherapy treatment to allow time for photographs and to sign your consents. You should then allow 15 to 30 additional minutes to apply your support hose, get dressed and to check out of the office. If you need to cancel or reschedule your sclerotherapy treatment, please give our office at least 72 hours notice.

PHOTOGRAPHS-photographs will be taken before your first treatment to document progress and/ or for the purpose of medical education, research, scientific publication or educational presentations. You will not be identified in your photographs and informed consent will be obtained before you are photographed

POST TREATMENT INSTRUCTIONS:

COMPRESSION- cotton balls or 4x4's and tape provide local compression over each area injected. Before standing, you will put on your compression hose. Proper compression is very important because it minimizes the blood re-entering the injected vein, decreases the incidence of post sclerotherapy hyperpigmentation and telangiectatic matting and improves venous blood flow. The cotton balls and tape can be very uncomfortable and may even irritate and blister sensitive skin. After the first 48 hours the hose, cotton balls and tape may be removed. If tape blisters occur, keep clean with soap and water, use Neosporin or Bacitracin ointment and cover with a dry non-adhering dressing. These heal within seven to ten days. After the initial 48 hours you should continue to wear your hose for one week, during the waking hours. If larger varicose veins are injected, you may be advised by your doctor to wear them for two to three weeks.

BATHING- a shower is allowed after the first 48 hours. Hot baths, hot tubs and saunas should be avoided for two weeks after sclerotherapy to avoid venous dilatation.

HYPERPIGMENTATION- if you develop hyperpigmentation after sclerotherapy you should apply sun block to those areas when sun exposure is anticipated to avoid increasing the hyperpigmentation. Continue to use sun block until the hyperpigmentation has resolved.

DRIVING- you may drive immediately after your treatment. If your trip home is longer than art hour we recommend you stop hourly to stretch your legs.

ACTIVITY -in most cases, you may return to work and resume normal activity after treatment. Please take a 15-minute walk immediately following your treatment. This will help circulate the solution that was injected. Walking is encouraged; it promotes efficient venous circulation. Avoid sitting and standing for extended periods and elevate your leg(s) above the level of your heart when possible for the next two to three days. If large varicose veins were injected, your doctor may recommend you stay off your feet with your leg(s) elevated for the rest of the day. Avoid high impact aerobics, jogging, running, leg weight lifting and sit-ups for one to two weeks after each injection treatment.

MEDICATIONS- do not use Aspirin or Ibuprofen products for ten days after each treatment to reduce bruising. Acetaminophen (Tylenol) can be used if you experience arty discomfort from sclerotherapy.

FOLLOW-UP- subsequent treatments are usually every week. Your doctor will advise you when you should return. If you notice dark knots or cords at your injection sites please call our office; you may need to return sooner to have these areas aspirated. Remember it is important to call our office if you have any questions or concerns before or after your sclerotherapy treatment. Please keep your follow up appointment after treatment. It is important for the physician to assess the results you achieved from each treatment. If you need to cancel or reschedule your sclerotherapy treatment or follow up appointment, please give our office at least 72 hours notice.

Varicose Vein Treatments: Ambulatory Phlebectomy

Another treatment is called ambulatory phebectomy. Where as before surgeons would make longer incisions and dig out the varicose veins, then suture the wounds shut. Some wound care and suture removal were then required. Now the technique of ambulatory phebectomy is used. This involves the use of a scapel that instead of making one long incision, makes 10 – 20 very small incisions each of about 2 – 3 mm in diameter, less than the size of a small paper cut. These cuts are made along and around the varicose vein. Then hooks that look like crochet hooks are used to go into the small incisions and snag the varicose veins. They are then pulled out and removed in pieces. This is done with a fair amount of local anesthesia around the veins to make the procedure relatively painless. Because the cuts are so small, they do not require any sutures to close them. They close and heal on their own. The patient is merely bandaged, wrapped, and put back into his or her stockings. Possible complications include bleeding and infection but these are rare.

Varicose Vein Treatments: Surgical Vein Stripping

Stripping of the greater saphenous vein used to be accomplished surgically, in an operating room, under general anesthesia. It involved making an incision in the groin and at the level of the ankle which represented both ends of the greater saphenous vein to be stripped. Then a wire was passed through the vein. One end of the wire was attached to the end of the vein and then the wire was pulled from the other end essentially ripping the vein out of the leg. This created a painful recovery process and larger wounds to heal. Complications included infection, nerve damage, and bleeding. This procedure has been largely replaced by endovenous laser therapy.

Varicose Vein Treatments: Endovenous Laser Therapy

Endovenous laser therapy is the new less invasive treatment for treating reflux in the greater saphenous vein. It is done under local anesthesia in the doctor’s office. An IV is placed into the vein under ultrasound guidance. A laser fiber is advanced up the leg. Local anesthesia is administered to surround the laser fiber with a cuff of fluid and anesthetic. The laser is then activated with the tip heating up to several hundred degrees. This is not felt because of the cuff of anesthetic all around the laser fiber. The laser is dragged back causing heat damage to the vein making it clot off and close. Again, the reason for going after the greater saphenous vein first is to treat the source of the problem not just the symptoms. In many cases, the visible varicosities and spiders feed off of a badly leaking greater saphenous vein. To treat the varicose veins or spiders first would be like cutting the head off of a dandelion and expecting the whole weed to die. No, the root of the problem should be treated first. If the varicose veins or spiders are treated first then they will ofter recur early within months resulting in a treatment failure. Often, closing the great saphenous vein will result in collapse of the varicosity it feeds.

The next several slides illustrate the endovenous laser therapy process. Patients are often given Valium by mouth before the procedure for sedation. No IVs are put in for this procedure. When a patient first comes into the office a brief repeat ultrasound examination is done to confirm abnormalities in the vein to be treated. The leg is then marked denoting the location of the vein on the surface of the skin. The entry point of the laser is then marked on the leg. Under ultrasound guidance a long IV catheter is placed into the vein and the laser fiber is inserted with its tip positioned at the level of the groin. Then additional anesthetic is administered surrounding the laser fiber with fluid and lidocaine. The lidocaine anesthetic is buffered with sodium bicarbonate to decrease the burning sensation as the anesthetic is injected and it makes the anesthetic effect last longer, up to 6 – 8 hours. The laser is activated, the tip heats up, and the fiber is dragged backwards to essentially burnout the length of the vessel. Immediately afterward the catheter is removed and the leg is bandaged and the compression stocking is put back on. The patient then gets up and walks out of the office.

Endovenous Laser Therapy of the Left Greater Saphenous Vein

Step 1

An ultrasound of the leg is done to confirm abnormalities in the vein to be treated. The patient is then prepped and draped to create a sterile field.

Step 2

Using the ultrasound as a guide, the target vein course is marked on the patient's skin and the entry site for the laser is also marked.

Step 3

A local anesthetic injection is given. Then under ultrasound guidance, the vein is stuck with a needle and a wire is passed through it into the vein. The needle is removed and over the wire a long catheter is advanced into the target vein.

Step 4

The laser fiber is then inserted into the catheter or sheath. The tip of the laser is placed up near the groin were the greater saphenous vein originates. The positioning is all confirmed with ultrasound imaging.

Step 5

Then a fair amount of anesthetic solution is injected up the leg to fill the area around the laser fiber with a cuff of fluid and lidocaine (the anesthetic). This way when the laser is turned on and the tip heats up to several hundred degrees, the patient feels nothing.

Step 6

Once the anesthetic is in, the laser is turned on and heat destruction of the vein begins. The laser is slowly pulled back to burn out and permanently close the entire length of the vein being treated. The laser fiber is then removed along with the sheath or catheter. Light pressure is held over the entry point to stop the bleeding.

Step 7

The entry site is bandaged. The patient's compression stocking leg is put back on. The leg is wrapped. And the patient can immediately walk out of the office and go home.








Varicose Vein Treatments: Follow Up

There is no recovery time. Patients are not confined to bedrest for any period of time. In fact they are encouraged to walk at least 20 minutes a day. They are required to wear the compression stockings constantly day and night for three days straight. On the third day they can remove the stockings to shower but need to replace them right away. They must wear them for a total of three weeks removing them only once a day to shower only. The leg feels pretty good until the anesthetic wears off by the next day. Then they often experience some soreness and tenderness along the laser track. The area because of the tissue damage can become bruised and swollen. It can be somewhat uncomfortable but not excruciatingly painful. Patients can return to work if they have to, but many people opt for a couple days off because of the discomfort. We typically see patients about two weeks after the procedure for reevaluation. At that time a repeat ultrasound of the vein is done to confirm a successful closure. Patients can take Tylenol for pain. If a lot of inflammation develops with any vein procedure, signaled by redness, pain, swelling, and tenderness, then an anti-inflammatory is used like ibuprofen. Some times narcotics by mouth are used for the short term. The patients are then seen 3 – 6 months later and rescanned to detect late failures. Late failures can be treated with injections of sclerosants to the open segments of vein. Some examples of successes are shown on the subsequent slides.

Varicose Vein Treatments: Laser Therapy Results

The results of laser results have been published. Navarro et. al. followed 200 patients with greater saphenous vein laser treatments. 97.5% were found to be successfully closed an average of 23.6 months later. There was a 1% incidence of superficial phlebitis. Min et al. studied 389 greater saphenous vein treatments and found a 98.0% complete occlusion rate at 1 week to 36 months. There were no significant complications.

Varicose Vein Treatments: Summary

Improvements over vein stripping

One hour treatment time

Immediate ambulation

Performed in the physician's office

Much less expensive

Clinical results are established

Two and three year follow up: 97 - 98% long term success rate

Complications are mild and infrequent

Reimbursement through most insurance companies for medically necessary procedures

In summary, the benefits of endovenous laser treatments include a one hour treatment time, immediate ambulation, performance as an office procedure, and much lower expense. The procedure is reimbursed by most insurance companies as long as certain guidelines are met. The patients have to be symptomatic. They must have pain or discomfort and the symptoms must interfere with activities of daily living. For example, it must interrupt working duties, household activities, yard work, shopping, or exercise routines. Patients who develop superficial phlebitis, bleeding from a ruptured varicose vein, or leg ulcers also qualify. Insurers will not pay for cosmetic reasons only. They require a consultation with the treating physician who documents all of the above. The patient then must undergo formal venous duplex ultrasound examination of the deep and superficial systems documenting the location and severity of all of the refluxing areas. Pictures of the varicose veins are often requested (in color). Then depending on the insurer, patients must undergo a trial of conservative non-operative therapy to include compression stockings with 30 – 40 mm of pressure, exercise, leg elevation, and avoiding prolonged standing for 6 weeks to up to 6 months. The patient is then required to revisit the treating physician so that he can document that the symptoms persist and still interfere with activities of daily living. The patient’s compliance with medical therapy is also recorded and the failure of medical therapy is documented. The venous duplex study is reviewed and a procedure is recommended. All of this is then submitted to the insurance company. They often deny it once or twice, but if the same information is resubmitted repeatedly the procedure is almost always eventually approved. The patients should be forewarned that the whole process takes weeks to months to accomplish. If multiple procedures are required, the insurers often make patients wait up to 3 months between them and make them resubmit in between as well.