Frequently Asked Questions
Varicose veins are abnormally enlarged superficial veins usually seen in the thigh and leg. In many patients they are a sign of a more serious underlying problem of the venous system. These veins often are branches of the superficial set of veins (long and short saphenous veins), which have leaking valves. As many as 30 million adults in the USA are affected by significant superficial venous insufficiency (saphenous vein and branches) and may have an easily treatable problem. Venous insufficiency is more of an ” umbrella” diagnosis, which refers to leakiness of the one-way valves within the veins that results in increased pressure in the veins. The increased pressure may cause bulging varicose veins, leg swelling, cramps or achiness of the calves, restless legs, spider veins, discoloration and thickening of the skin of the lower leg, and eventual bleeding or ulceration.
Without treatment, varicose veins worsen with time. However, rather than focus on the varicose veins, it is probably more important to focus on the fate of the skin of the lower leg in this group of patients. Venous insufficiency may manifest itself in other ways as well, such as swollen, achy legs, discolored and thickened skin over the lower leg around the ankle area and purple, painful feet.
Normally there is a series of one-way valves in the leg veins that allow for blood flow through the veins back toward the heart during muscle contraction. When functioning properly, these valves open and close in sequence, preventing blood from refluxing back down the leg. When the valves become leaky and open in the opposite direction venous blood begins to pool in the leg and the pressure rises in the veins below the knee. Since veins are thin walled, components of the blood eventually may leak out of the veins into the surrounding tissues.Initially this may be limited to water and protein, causing swelling, which worsens as the day progresses and is usually more significant with standing or sitting. Over time, red blood cells and white blood cells may also leak out of the veins into the skin and fat around the ankle leading to discoloration of the skin and eventually, scarring of the skin and fat to the underlying muscle. This condition is known as stasis dermatitis or lipodermatosclerosis (fat and skin scarring), and is a significant risk factor in the development of venous ulcerations and recurrent skin infections. Many unsuspecting patients may seek the advice of a dermatologist for this condition and be unsuccessfully treated with a variety of creams. Thus, it is of paramount importance to investigate varicose veins not only to determine the presence and severity of underlying venous insufficiency, but also to perform treatment earlier in the disease process and reduce the risk of future complications.
Heredity is the most significant risk factor in developing significant venous insufficiency and varicose veins. The second most important risk factor is the history of full term pregnancy. The more full term pregnancies a woman experiences, the higher the risk of vein related problems. Other conditions that may contribute to the development of varicose veins and venous insufficiency include morbid obesity, prolonged standing or sitting, focal trauma to a vein (sports injury) and deep vein thrombosis. Varicose veins are more common in females due to their childbearing status as well as the presence of estrogen. Despite this fact, males account for approximately 20-30% of patients who present for evaluation of varicose veins or other complications of venous insufficiency.
Varicose veins and venous insufficiency may cause symptoms less obvious than the commonly noted spider veins, bulging lumps, bleeding veins or leg ulcers. Other symptoms may include swollen achy legs, a feeling of heaviness or fatigue of the legs, or itchy and discolored legs. Patients usually complain of increased swelling and aching toward the end of the day and often note improvement with elevation of the legs or after a night of sleep. Other patients may be under treatment for conditions thought to be related to the heart(congestive heart failure), kidneys(renal failure or diabetic kidney disease), excess salt intake, lymphedema (swelling after leg incisions) or for neurologic conditions such as neuropathy or restless leg syndrome (RLS). Restless leg syndrome has been strongly correlated with venous insufficiency, so patients who have been diagnosed with RLS are encouraged to seek further vein evaluation.
Aside from the obvious signs of external varicose veins found at physical examination, the most accurate method of diagnosing underlying venous insufficiency is duplex ultrasound. When performed by a qualified registered vascular technologist, one can precisely determine the location of the leaky veins and formulate a logical and effective treatment plan to cure the problem. In addition to evaluating the superficial set of veins (saphenous system), the veins within the muscles (deep veins) are also examined to determine their status with respect to valve function and presence of clots. In addition, there are a variety of other types of leg veins which may be leaky and which less experienced technologists may overlook. These veins include the posterior thigh vein of Giacomini, the anterior and posterior medial saphenous veins and a number of perforating or connecting veins (Hunter’s, Dodd’s and Cockett’s). The importance of the role of an experienced registered vascular technologist in performing the venous insufficiency study cannot be overstated. This is an outpatient examination, which takes approximately 30 minutes per leg, and is best performed at the direction of the Physician Vein Specialist who will be responsible for making the treatment decisions.
Until the year 2000, the treatment options for varicose veins and venous insufficiency were limited to compression stocking therapy on the conservative end of the treatment spectrum or saphenous vein ligation and/or stripping on the surgical end of the spectrum. Since the Venefit™ Procedure was introduced the (radiofrequency catheter based) in 1999 (originally called Closure or ClosureFAST, endovenous closure technique in 1999, an estimated 30-40 million adults in the USA with significant superficial venous insufficiency now have an effective, outpatient treatment for their swollen achy legs, varicose veins and venous leg ulcers. In the days of vein stripping, more advanced skin changes or ulcerations were required to justify the invasive procedure. With endovenous techniques of sealing the leaky veins from within with a small catheter, under local anesthesia, these patients can now be treated at a much earlier stage of their disease, more effectively preventing more advanced complications from occurring in the future. Since a number of patients may also have arterial blockages, endovenous closure should be performed by a surgeon familiar with arterial and venous disease. Performance of the procedure in the office setting under local anesthesia offers the advantages of a less stressful environment, avoidance of exposure to hospital related risks (infections and IV medications) as well as avoidance of general or regional anesthetic risks. The procedure should be performed in a sterile operating room, under standard surgical protocol and precautions, using local anesthesia with a mild oral relaxant. The procedure usually takes less than one hour to perform, either as an isolated procedure or in conjunction with removal of varicose veins through small incisions (microphlebectomy).
Under local anesthesia, a small catheter is inserted into the leaky vein through a needle stick in the mid calf. Either radiofrequency (The Venefit Procedure) or light (Laser) energy is delivered through a small catheter to the inside of the leaky vein, which heats and seals the abnormal vein closed. The catheter is inside the vein only long enough to seal the vein and is removed upon completion. The treated vein is gradually reabsorbed by the body and causes no harm. Over time, most varicose veins will resolve and limb swelling will improve within weeks.
The function of the leg veins is to return blood from the feet to the pelvis. This occurs through the pumping action of the muscles and properly functioning valves. Ninety percent of blood return from the feet to the pelvis normally occurs through the deep veins (inside the muscles). As long as the deep set of veins are working properly, the effect of closing a leaky superficial vein is actually beneficial. The leg circulation will be better off with the leaky vein closed rather than left open and leaking.
The natural history of untreated severe venous insufficiency is that of progression to larger varicosities, clotted varicosities, bleeding varicosities, progressive leg edema and disability, and brownish discoloration and thickened skin, with potential for future ulceration. Prior to the introduction of endovenous closure techniques, it made sense to be conservative when considering “surgical” treatment of varicose veins and venous insufficiency. Although compression stockings offer some symptomatic relief from venous insufficiency, their use in no way constitutes a definitive treatment. The underlying problem persists after removal of the stocking and the process will progress in even the most compliant of patients. Just as an astute Internist would not wait for a complication of diabetes, high blood pressure or high cholesterol to occur before offering definitive medical therapy for these conditions, we should be equally proactive in objectively establishing the diagnosis of venous insufficiency and offering definitive therapy when appropriate. In this era of preventative medical care, it makes logical sense to investigate venous problems, institute a conservative trial of therapy, and when appropriate, offer definitive treatment prior to the occurrence of irreversible complications.
The local anesthetic will wear off within the first 2-3 hours after the vein closure and only a mild to moderate amount of discomfort is usually noted with the Venefit™ Procedure. Laser endovenous closure results in a similar pattern of minimal postoperative discomfort.
Although the Venefit™ Procedure (radiofrequency based) has enjoyed excellent patient comfort ratings, both techniques are very effective in achieving successful long-term closure of the saphenous vein trunks and its branches. Laser endovenous closure may be more appropriate in cases where there are segments of veins less than 7 cm in length that need to be closed, or when the diameter of the vein to be treated exceeds the recommended limit for radiofrequency closure. Treatment decisions should be individualized based on clinical and anatomic factors.
In instances where a patient is experiencing leg swelling, pain or inflammation related to bulging varicose veins, or skin changes predisposing ulcers or superficial clots, insurance companies may determine a medical condition in need of care. Generally, a three-to-six-month conservative trial of therapy, including elevation, anti-inflammatory medications and compression stocking therapy, will be required to satisfy Medicare and most commercial insurance carriers’ inclusion criteria. Some carriers will also require certain training requirements of the type Vein Specialists satisfies, and most require a detailed letter of medical necessity predetermination. It is thus of paramount importance to keep detailed records of any treatment and history of vein issues.Injection sclerotherapy is rarely covered by insurance unless there has been a history of recurrent hemorrhage or pain directly related to the varicosities in question or in cases of refractory venous ulcers despite previous closure procedures.
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Restless legs syndrome (RLS) is a constellation of symptoms of jumpy legs, and discomfort in the legs which is worse in bed and often relieved with ambulation. It is often worse in the third trimester of pregnancy and relieved after delivery. Many medical therapies have been employed, most of which make the patient drowsy thus allowing sleep to occur. Many of the symptoms of RLS are seen in patients with venous insufficiency. In patients with symptoms of RLS, one should consider the diagnosis of venous insufficiency as a contributing factor. Many patients with severe venous insufficiency and RLS symptoms experience partial or complete relief of their RLS symptoms after successful treatment of their venous problem. Patients who experience improvement or complete relief of their RLS symptoms after a trial of compression hose should have a good response to endovenous ablation of their severely insufficient superficial veins.
Yes, many patients with venous insufficiency also have these symptoms after they go to bed. The cramps are thought to be secondary to fluid shifting out of the muscles as gravity is no longer playing a role when patients are lying flat. What liquid leaks out of the insufficient veins during the waking hours when patients are upright standing or sitting (due to increased pressure in the leg veins) returns from the muscles at night. This may also result in frequent trips to the bathroom to urinate (see next question).
As in the previous question one can understand that what leaks out of the veins during the day when upright has to return to the circulation at night, or the legs will continue to swell and burst. So when the legs are even with the level of the heart at night in bed, the liquid in the soft tissues can return to the circulation through the lymphatic system and the kidneys will turn this extra liquid into urine. The more swelling there is the more urine is made and the more trips will be made to the bathroom at night. Fix the leaky veins, stop the leaking of fluid from the veins and stop the nighttime leg cramps and urination.
Water, protein and other cells may leak through the walls of the abnormal veins into the skin and fat around the distal calf and ankle regions. Initially this leads to swelling and eventually discoloration of the skin(due to red blood cells(RBCs) releasing their pigment) and finally hardening of the skin and underlying fatty tissue related to enzymes from the white blood cell (WBC)being released after the WBCs die. The same enzymes contained within WBCs and normally are released to kill bacteria and viruses, are released into the soft tissues and nonspecifically damage the tissues. If left alone, this scarred tissue will worsen and eventually ulcers may occur. After successful treatment of the underlying problem veins, these changes may reverse over time. The discoloration and scarring of the skin around the ankles in the lower leg are often confused with complications of diabetes when venous insufficiency is the most likely cause. So, if you have been told you have diabetic discoloration in the legs, stasis dermatitis or lipodermatosclerosis(fat-skin-scarring) you deserve a venous evaluation.
Varicose veins are a sign of underlying venous insufficiency and are not as benign as once thought. The most common complication of varicose veins is achiness and inflammation or heat. Another complication which may occur is thrombosis (clotting) which can lead to deep vein thrombosis (DVT) and this is usually precipitated by local trauma or long periods of inactivity (auto or plane rides). Compression hose may reduce the incidence of thrombosis but do not address the underlying problem. Bleeding from varicose veins may also occur secondary to direct trauma or erosion and thinning of the overlying skin (usually below the knee) due to prolonged high venous pressure. At the minimum, varicose veins should be a red flag and lead to ultrasound evaluation of the affected leg. If correctable venous insufficiency is discovered, definitive therapy should be strongly considered. The goal in any medical disease (which venous insufficiency is as much as hypertension, high cholesterol and diabetes) is to prevent the end complications of the respective disease and in the case of venous insufficiency these are bleeding, clotting, skin changes and persistent pain and achiness.
My initial response to this question was going to be “one” but after reconsidering I believe the answer should be “none”. Many patients who I have seen for external bleeding from varicose or spider veins had veins which I would consider to be “ripe” for bleeding for many months or years prior to their first bleed. One must take a defensive approach here and be able to identify which veins are likely to have bleeding complications prior to the actual bleeding episode. Professional vein evaluations and treatments to should be offered earlier in the disease process and minimally invasive treatments performed as appropriate. The record for maximum number of bleeding episodes prior to seeking my assistance is 14. The final episode resulted in an ulcer and after endovenous ablation of the great saphenous vein the ulcer healed within 2 weeks and the patient has not bled since, now more than 2 years.
Venous insufficiency often results in high venous pressure in the veins in the lower legs. The pressure can exceed 80 mm of mercury resulting in the seeping of water and protein(serum) out of the vein walls into the soft tissues(skin, fat and muscles). This leads to symptoms of achiness, heaviness, swelling and leg cramps. When patients lie down in bed at night the accumulated fluid returns through the lymphatic system to the left internal jugular vein at the level of the left collar bone. As this serum returns to the circulation it is the job of the kidneys to remove this “extra” water resulting in the formation and storage of urine in the bladder. The more swelling during the day with dependency, the more frequent the nighttime urination. Thus, after sealing of the leaking veins, and resolution of the leg edema, cessation of night time urination often occurs.
Heart failure, kidney failure, excess salt intake and obesity are typically at the top the list of causes of swollen and achy legs. However, when one looks across the spectrum of patient ages, the most common cause and most treatable cause of lower extremity swelling and achy legs is venous insufficiency, or venous reflux disease. For many years venous insufficiency was typically referred to as “varicose veins” and if no varicose veins were present the possibility of venous insufficiency was not further considered. Unfortunately for many patients this is often still the case today. The diagnosis of venous insufficiency as the potential cause for patients’ swollen and achy legs should not be dismissed based solely on the absence of visible varicose veins. Many patients with venous insufficiency may not have any evidence of varicose veins and may just have swelling as their main complaint.
Iron stain is the discoloration of the skin in the region of the lower leg and ankle area related to long term venous hypertension and the leaking of red blood cells out of the veins into the skin where the pigment is then released causing pigment deposition in the skin. Over time, white blood cells may also leak out and cause further damage to the skin resulting in hardening and scarring of the tissue. The eventual result is a minor traumas leading to an opening in the skin which turns into a “venous ulcer”. Treatment of the underlying cause of the venous hypertension (sealing of the leaking vein) will stop further progression of the changes and with time, as new skin cells replace the older, diseased and pigmented cells, the changes will begin to reverse, sometimes completely.
Vein Gogh is the latest non invasive treatment of spider veins of the face and nose, as well as for cherry hemangiomas and other small vascular lesion of the trunk and head and neck. Small skin tags also respond well to this treatment. Under topical anesthesia, a very small needle is used to penetrate 1-2 mm into the lesion and electric heat is applied immediately treating the lesion.