Risk Factors

1. Heredity is the single most important risk factor.
2. Female Sex because of the effects of female hormones on the vein wall. Nonetheless, 15 to 25% of patients are men.
3. History of Pregnancy
4. Increasing Age is important but varicose veins occur at any age.

Symptoms of Varicose Veins

1. Pain: aching, throbbing or burning
2. Swelling of the legs
3. Tiredness or heaviness
4. Itching
5. Visible varicose veins
6. Telangectasias or spider veins
7. Superficial thrombophlebitis

Severe Cases In Which Skin Changes Can Occur

1. Eczema
2. Pigmentation
3. Ulceration
4. Bleeding

The Primary Cause of Varicose Veins is a rise in pressure and blood volume in the communicating veins of the superficial system. When these veins are close to the surface of the leg they will bulge and become visible.

Blood is only supposed to flow in one direction. Blood leaves the heart and courses all the way to the toes through the arteries. Blood then returns to the heart through the veins. There are two systems of veins, the deep system which drains the blood from the muscle and bones--this handles 90% of the blood that leaves the legs&emdash;it is this system which can give rise to the clots that can threaten your life&emdash;and the superficial system which drains the skin and fat envelope around the leg. These systems are parallel and independent of each other except for two locations, a minor junction behind the knee where the Lesser Saphenous Vein drains into the popliteal vein and a major junction at the groin where the Greater Saphenous Vein drains into the femoral vein. All of the veins have one-way check valves which prevent reverse flow through the vein. When these valves fail, blood flows backwards into the veins. This is called venous reflux and is the principle cause of varicose veins. Blood refluxes into the superficial system by gravity and whenever pressure is increased by coughing or bearing down.

Symptoms arise from the increased pressure of blood in the veins. They can be localized over the area of the varicose veins such as burning or itching or generalized for the entire extremity such as aching, fatigue and swelling. Often symptoms of varicose veins are worse at the end of the day especially after prolonged periods of standing. It is an interesting aspect of varicose vein disease that there is no correlation between the severity of the varicosities or the size of the veins and the severity of symptoms.

Treatment of varicose vein disease should always be directed at the source of the reflux. Any effort to treat the veins themselves that leaves the reflux uncorrected is doomed to fail. The varices will recur, oftentimes worse than they originally were, or in the case of spider veins, they will not go away with sclerotherapy.

Traditionally, the treatment of venous reflux in the greater saphenous vein, the predominant location for valve failure, has been surgical stripping and ligation. This involved a trip to the hospital, general anesthesia, a prolonged and painful recovery and lost time at work. Additionally, the varices themselves required removal through multiple incisions in the skin. The challenge for the surgeon treating varicose veins has always been balancing low incidence of recurrence of varicose veins with a cosmetically acceptable result. This often lead surgeons to do spot ligations, the removal of veins through small incisions, and leave the refluxing saphenous vein untouched. Almost invariably the varicose veins would return.

There are instances where EVLT has not entirely eliminated the varicose veins, this is usually apparent by the 6 week follow up visit, or EVLT is not applicable. This occurs when the saphenous veins is very tortuous, "twisty" and convoluted, and the catheter and laser fiber cannot negotiate these twists and turns. Also there may be such longstanding destruction of the valves further down the leg that blood under pressure remains and the enlarged veins persist. Lastly, there are cases where the greater saphenous vein is not refluxing but the reflux is occurring at a direct connection between the deep and superficial system called a perforator. Perforators are naturally occurring connections that direct blood from the superficial system to the deep system so that the muscular pump of the calf muscles can return the blood upward toward the heart. These perforators have valves, too. If these valves fail reflux occurs. This can result in localized or persistent varicose veins.

These veins can be removed with a procedure called Ambulatory Phlebectomy. This procedure is performed under a local anesthetic utilizing a small puncture wound about the size if a pencil lead through which a small hook is placed. The hook catches the vein and it is teased out through the tiny incision. The wound is then closed with a Steri-strip and the leg is wrapped. We prefer patients stay off there feet as much as possible for 24 hours following this procedure but can resume normal activities thereafter.

Sclerotherapy

Sclerotherapy is a tried and true method of dealing with smaller bluish veins under the skin called reticular veins and tiny telangectasias commonly known as spider veins. Many chemicals, called sclerosants, have been used and they all work by causing irritation of the inner lining of the vein. This causes the vein to close and, over time, the destroyed vein is eliminated by the body. For many years, "saline injections" were the standard sclerosant and used virtually everywhere. Unfortunately, saline injections had significant drawbacks. They were painful and could damage the skin and even cause an ulcer to develop. At The Vein and Laser Center, we have never used saline for these reasons. Instead, we use two widely used sclerosants which have become the industry standard for sclerotherapy. These are Sodium Tetradecyl Sulfate, STS for short, and Polidocenol, or Pol. These agents are extremely safe with allergic reactions very rare. They are used in various concentrations and are injected directly into the vein with a tiny needle about the size of a hair. This feels like a mosquito bite and most patients find this relatively painless. Compression is used immediately after the treatment and the compression stocking should be worn for several days but as a general rule the longer they are used, the better the result. Forty-eight hours is best but certainly not more than a week. It commonly takes several weeks for the spider veins to start to disappear. For this reason we do not retreat the same area sooner than four to six weeks.

For those rare patients who are phobic to needles or feel they cannot tolerate sclerotherapy, we have successfully used the Lyra laser to eliminate these surface veins. It is also safe and effective for veins up to 4 millimeters in diameter.

Foam Sclerotherapy is a technique gaining increased acceptance as an adjunct to standard sclerotherapy. This technique has actually been around for many decades but has only recently been found to increase the effectiveness of sclerotherapy in closing larger veins. Sclerosant is simply mixed with air and injected into a vein. The microscopic bubbles thus formed allows increased contact between the chemical and the vein wall without being washed away and diluted by the blood inside the vein. We have used foam sclerotherapy with great success, closing even large, bulging varices.

In addition, sclerotherapy can be used to treat more deeply situated veins not visible from the surface that are not amenable to ambulatory phlebectomy. Ultrasound can be used to guide the injections into the underlying diseased vessels. This procedure, known as Ultrasound-Guided Sclerotherapy, or USG, allows sclerosant to be administered safely and accurately to the problem veins hidden from view.

A Few Comments About Sclerotherapy

The first principle is that the smaller the vein to be eliminated, the greater the success. Secondly, varicose veins treated by sclerotherapy will recur if venous reflux through the greater or lesser saphenous vein is not controlled first. Most importantly, disappearance of the veins takes time and is rarely 100%. The majority of patients undergoing sclerotherapy will see their veins cleared or at least significantly improved (85% improvement is generally accepted as the "industry standard"). The number of treatments required is quite variable and cannot be predicted at the beginning of treatment although an estimate can be made. Unfortunately, there is no guarantee that sclerotherapy will be effective for you. About 10% of patients undergoing sclerotherapy will have fair to poor results. In very rare cases they may actually be worse. Once reflux, if present, has been treated, there is no way to predict who will have less than satisfactory results. Lastly, they may come back in new locations. This cannot be prevented because any treatment for varicose vein disease is treating the outward manifestation of an underlying abnormality of the veins for which there is no cure. All of this having been said, the vast majority of our sclerotherapy patients have seen excellent results.