Varicose veins and venous insufficiency is the most common vascular problem in the United States, affecting more than 60 million people. Often people are told that this is a natural part of aging and that they should just live with their painful or aesthetically unpleasing legs. Although this problem is rarely life or limb threatening, it is certainly something that can affect a patients daily life and activities.

What are varicose veins?
Varicose veins are abnormal veins that enlarge in a patient’s leg because of leaky valves in the veins. Veins work to return blood from the legs to the heart. In order to work against gravity, they contain one-way valves to help with the “uphill” movement to the heart. When the valves are leaky or “incompetent” the superficial veins can become varicose.

What types of veins are there in the leg?
The leg containes three types of veins: superficial, deep, and perforators-connecting veins between the superficial and deep systems. All of these veins have one-way valves to help with the transport of blood but only the superficial ones can become varicose. When valves in the deep system do not work it is called deep venous insufficiency. The deep system carries the majority of blood back to the heart. The main deep veins are called the popliteal and superficial femoral veins. The main superficial veins are the greater and lesser saphenous veins. Superficial veins are sometimes used to perform heart or leg bypass operations. However, if they are varicose, they are not usable.

What kinds of problems can varicose veins cause?
Many people with varicose veins have no symptoms at all. However, many people have symptoms of heaviness, itching, aching, pain, or throbbing, especially at the end of the day or after prolonged standing. Varicose veins can also cause swelling that usually resolves with elevation or with overnight rest. In a small percentage of patients with varicose veins , changes in skin color at the ankle/calf (hyperpigmentation), changes in the skin texture (excema-like) and even open wounds (ulcers) can occur. This is generally associated with longstanding venous insufficiency (leaky valves in the veins).

What kind of problems can deep venous insufficiency cause?
Leaky valves in the deep system can often cause more problems than leaky valves in the superficial system. These patients have often had a blood clot in the past that damaged the deep valves. They often have persistent swelling and are more likely to develop the hyperpigmentation, skin changes, and ulcers than people who just have problems with superficial leaky valves.

How are varicose veins diagnoses?
Much of the diagnosis of varicose veins is done simply by examining the patient. However the diagnosis of venous insufficiency or leaky valves in the veins can best be done by duplex ultrasound. Before any treatment plan is undertaken for varicose veins, it is mandatory that an ultrasound is done by a trained vascular technologist. This looks not only for leaky valves in all three vein systems but also looks for evidence of prior blood clots. It is very important in providing a “roadmap” for treatment.

How are varicose veins treated?
Almost all treatment of varicose veins is elective as having varicose veins is not a dangerous condition. This does not mean, however, that one must live with unsightly or achy legs. Treatment can consist of either medical or more invasive methods.

Medical therapy involves :

• walking to increase blood flow
• Wearing compression stockings
• Keeping legs elevated as much as possible (ankles above knees)
• Maintaining a normal weight

All the above temporarily help the symptoms and generally do not help the appearance. More definitive treatment of varicose veins can be done by:

• SURGERY - Saphenous vein stripping: A technique where an incision is made at the groin and at either the knee or the ankle of the affected leg. A small tube is placed through the whole length of the vein and the vein is pulled out. This is usually done under general anaesthesia in an outpatient or hospital setting. Patients go home the same day, but often do not return to their normal activities for 7-14 days.

• Phlebectomy: Used for removal of the seconday varicosities-branches of the main veins that are usually the unsightly ones. A small incision or needle poke is make under local anaesthesia over the varicose vein and a small hook is used to remove the vein. This can often be done in the office. It is usually not covered by insurance because it is used to treat cosmetically unappealing varicosities.

• VNUS Closure: A newer technique than vein stripping that is also used on the main superficial veins. A small catheter (tube) is placed through a needle hole generally near the knee into the vein and radiofrequency energy is used to seal the vein as the catheter is pulled through it. This can be done in the office under local anaesthesia. Most patients have minimal discomfort afterwards and return to normal activities in 48-72 hours. Please see the VNUS Brochure for more information.

• Endovenous Laser treatment: Another treatment option for the greater saphenous vein where a small laser fiber is inserted through a needle stick in the skin into the vein. Pulses of laser light are delivered inside the vein which causes it to seal shut. This can also be done in the office under local anaesthesia. We have not found that there is adequate data to recommend this treatment over vein stripping or VNUS Closure.

• Sclerotherapy: Smaller varicosities and spider veins can be treated by sclerotherapy or laser treatments. We find that sclerotherapy is more effective and less painful than laser treatments. It involves the injection with a tiny needle of an irritating solution into the vein that causes collapse of the vein walls. Surface veins thus are no longer visible. Treatment of these veins often requires 2-4 treatments and results in an improvement of 50-90%. Our sclerotherapy session are generally spaced about 4-6 weeks apart in order to allow for resolution of any bruising. Compression hose are necessary for optimal results after sclerotherapy and we recommend using them for two weeks after an injection session.Sclerotherapy is done in the office and generally causes minimal discomfort. No anaesthesia is used. Normal activities can be resumed immediately after sclerotherapy. All sclerotherapy is considered cosmetic and not covered by insurance.

• Ultrasound-guided sclerotherapy: This is a treatment for bigger and deeper veins (ie perforators). Under ultrasound, sclerotherapy solutions are injected into the vein. This is done in the office and as an alternative to ligating or removing these veins.

• SEPS: This is a surgical treatment of the perforator veins that is done in the hospital, usually under general anaesthesia. It is almost always used to treat patients who have non-healing ulcers in their legs. Laparascopic equipment is used to ligate the perforator veins with clips.