Frequently Asked Questions

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Varicose veins are the prominent, bluish bulges frequently seen in the legs. It is estimated that 20 to 25 million Americans have varicose veins. These unsightly veins are non-functional and are no longer contributing to the circulation of the leg. Varicose veins are usually caused by a problem in an underlying deeper vein. These discolored, ropey veins are the result of stagnant blood caused by faulty valves, making the blood back up instead of returning to the heart. This problem can be easily diagnosed with a simple, painless sonogram (ultrasound) study. Not only are varicose veins a major cosmetic concern, but as they enlarge, they can produce symptoms such as pain, itching, heaviness, bleeding, skin ulceration, discoloration, and swelling. Early diagnosis can prevent all of this. Varicose veins often restrict a person’s activity, alter one’s choice of clothing and can even cause personality changes.
The most common cause of varicose veins is an inherited weakness of the vein wall. This is called Venous Insufficiency. Leg veins contain one-way valves that facilitate the flow of blood back to the heart from the legs against the force of gravity. These valves frequently become weak under so much pressure, and blood pools in the legs, causing swelling and eventually varicose veins. Varicose veins are visible on the skin, but the underlying cause is a vein below the skin. Risk factors include obesity, pregnancy, increasing age and prolonged standing (a universal problem). Early diagnosis is key to prevent permanent skin damage.
Varicose veins are associated with a variety of symptoms including pain, swelling, itching, restlessness, heaviness, cramping, skin discoloration, rashes and skin ulceration. The symptoms are due to venous congestion (pooling of blood) within the legs. This can lead to inflamed veins (red, tender, knotty veins), hyperpigmentation (dark staining of the skin), and even bleeding. The symptoms of varicose veins are progressive with time. The risk of a life-threatening blood clot is very low, unless there is an associated inherited clotting disorder or a problem with a deeper vein.
Varicose veins tend to become gradually worse. As the varicose veins become larger, the risk of associated complications increases. The speed of progression of the disease will be determined by many factors including genetics, occupation, body weight and use of compression hose. Compression hose do help with the symptoms of venous disease and tend to slow progression of the disease, but do nothing for the underlying cause of the varicose veins. I am often asked if varicose vein procedures are cosmetic. Vein procedures typically make a leg look better, feel better, but more importantly, it keeps the problem from becoming worse. Vein procedures are a little different from typical cosmetic procedures in that you also make symptoms go away, and varicose veins are one cosmetic issue that tends to become worse and worse if it is not fixed.
A person with varicose veins may have cosmetic or medical (symptomatic) concerns, or frequently both. I recommend that anyone with visible veins at least have a simple evaluation to clarify the source and extent of the problem, as well as treatment options and prognosis. Remember, early diagnosis is the key. If diagnosed and treated appropriately in an early stage, irreversible skin changes can be avoided. The longer a spider or varicose vein remains untreated, the greater the chance of permanent skin discoloration.

It is my belief that a patient with varicose veins or venous disease in general needs to be evaluated by a vascular surgeon experienced with the surgical and medical management of venous disorders. As a vascular surgeon with a practice and staff totally dedicated to the treatment of varicose veins, I can formulate a treatment plan and appropriate followup for the simplest to the most complex venous disorder. We diagnose the problem, give treatment recommendations and provide long-term followup.

The goal of varicose vein treatment is to address the underlying source and then approach the existing visible varicose veins. Endovenous ablation with laser or radiofrequency is a minimally invasive procedure that targets the vein just beneath the skin responsible for bulging varicose veins and swelling. This is done in the office using a combination of local and oral anesthesia. Microphlebectomy (ambulatory phlebectomy) involves the use of tiny needle incisions to remove visible bulging varicose veins. Endovenous ablation and phlebectomy can be done together or with a staged approach as recommended by the physician. Visible varicose veins and spider veins are easily treated with a combination of microphlebectomy and sclerotherapy (injections).
The symptoms associated with varicose veins are from venous congestion (blood pooling) in the legs. Compression hose work by facilitating the flow of blood from the legs to the heart, relieving this congestion. The best compression hose to use for this problem are “graduated” hose. This means that the hose has more compression (tighter) at the ankle with gradually diminishing compression as the hose ascends to the top of the leg. This pushes the blood upward against the force of gravity. Compression hose are obviously a non-invasive option to help relieve some of the swelling and discomfort associated with varicose vein disorders. Compression tends to slow the progression of the disease, though the veins will still tend to gradually become worse. Symptoms from abnormal veins (aching, heaviness, restlessness, burning, itching, swelling) will typically improve while compression hose are on. This will not correct the underlying malfunction of the veins, but is an option for the patient who does not want procedures.
A venous ultrasound is a painless, noninvasive method to thoroughly assess the venous circulation of the legs. The study does more than simply rule out a “blood clot”. It will reveal the source of your varicose veins. The ultrasound (sonogram) shows us abnormal veins and reversed flow (reflux), which are the cause of your varicose veins. This information is essential to allow the physician to formulate a customized plan for you. The accuracy of the ultrasound is dependent on the quality of the equipment and the expertise of the technologist. An ultrasound should be done by a Registered Vascular Technologist (RVT) at a credentialed facility certified to do venous studies by the IAC (Intersocietal Accreditation Commision). Check to see if the facility has an IAC-certified vascular lab.
Varicose veins are not a life or limb threatening problem; therefore, treatment is not “absolutely” required if the patient can tolerate the symptoms and the appearance. Varicose veins will eventually cause symptoms such as discomfort, itching, rashes, discoloration, swelling, skin sores and bleeding. If a patient elects not to have a procedure, I advise that they diligently wear compression hose and call me if they should develop one of the above-mentioned complications. I strongly recommend at least annual routine followup with me. Most patients eventually decide to proceed with treatment as their discomfort and skin discoloration worsens. I do recommend that a patient with varicose veins at least come in for an evaluation to see what their treatment options are.
Spider veins are the tiny red and blue veins most of us eventually get. These veins are often evidence of a more significant vein problem beneath the skin, and it is recommended that the patient with spider veins at least have a formal evaluation. They occasionally cause burning, stinging, itching and bruising, but usually are totally asymptomatic though a significant cosmetic problem. Spiders may, however, be the first evidence of venous reflux (abnormal valves in the legs). Spider veins do not have to be treated unless cosmetic concerns are present, though they do typically worsen with time and often eventually cause permanent staining (discoloration) of the skin. The longer the veins go untreated, the greater the incidence of skin staining. Spider veins do not become large, bulging varicose veins. They just become more numerous. The best treatment for spider veins at this point in time remains sclerotherapy (injections). We do recommend early treatment of spider veins before they become extensive.
The first step is to determine the underlying source of the visible veins with a proper physical examination and sonographic survey of the deep and superficial venous circulation. If visible veins are treated without first eliminating the source, the results will be poor. Options to treat poorly functioning non-visible superficial veins causing varicose veins include Endovenous Laser Ablation, Radiofrequency Closure, Ultrasound-Guided Sclerotherapy and at times various surgical techniques for more complicated situations. “Surface” varicosities are best addressed with either injections (sclerotherapy) or Ambulatory Phlebectomy (removing large bulging varicose veins through tiny punctures). Advanced sclerotherapy techniques work better than laser treatments for spider veins. Vein “stripping” is rarely needed with the new technology available to us today.
Endovenous ablation with either laser or radiofrequency is used to correct the underlying cause of varicose veins. The procedure prevents additional varicose veins from emerging. Existing bulging varicose veins may or may not diminish in size with these procedures. Correcting the underlying problem with endovenous ablation allows the surgeon to remove visible bulging varicose veins through tiny needle incisions (ambulatory phlebectomy). This can be done at the time of endovenous ablation or at a later date, depending on circumstances which will be discussed by your surgeon. Smaller varicose veins may well disappear following endovenous ablation alone, or diminish in size to the extent that injections (sclerotherapy) will suffice as further treatment. The majority of varicose vein patients require endovenous ablation, ambulatory phlebectomy and sclerotherapy. Timing of the ambulatory phlebectomy and sclerotherapy depends on the extent and location of the veins.
As one would expect, it depends on the procedure. Sclerotherapy (injections) often will involve no activity limitations, or very minimal restrictions. Patients usually return to work that same day. Endovenous procedures (laser ablation and radiofrequency closure) require roughly a week of limitation regarding strenuous activity (running, biking, tennis, weight machines, etc.). Ambulatory phlebectomies necessitate about 2 weeks of heavy activity limitation. Use of compression hose is required after all of these procedures. Discomfort and bruising vary considerably from patient to patient. Most patients return to work the next day, depending on the nature of one’s job. The doctor will discuss any specific limitations depending on the extent of the procedure.
Ambulatory Phlebectomy refers to the removal of bulging leg varicose veins through tiny needle incisions without sutures. This is a totally different procedure from the traditional vein stripping operation, which refers to surgical removal of the greater saphenous vein (a vein not visible on the skin surface). A vein stripping involves a hospital setting with anesthesia and is associated with significant discomfort and postoperative disability. An Ambulatory Phlebectomy is usually done in the office under local anesthesia, and most patients return to work the next day with very little discomfort. Endovenous procedures have made vein stripping almost obsolete in the United States, though are still commonly done in other countries.
Sclerotherapy is the injection of a “sclerosant” solution into an abnormal vein utilizing a tiny needle to destroy the wall of the vein. Sclerotherapy is the “gold standard” treatment for spider veins. Most solutions used in the United States are FDA-approved. The injection turns the vein into an invisible fibrous structure which cannot fill up with blood. This makes the vein disappear. Sclerotherapy does not adversely affect one’s circulation because varicose and spider veins are not part of our main circulation. There are several commonly used sclerosant agents. These medications can be injected as a liquid or foam solution, dependent on the size and location of the vein.
Venous ulcers are areas of the ankle where the skin has died and exposed the tissue beneath. Ulcerations can range from the size of a penny to completely encircling the lower leg. They are painful, odorous, open wounds, which weep fluid and are prone to infection. We frequently see ulcerations that have been present for months or even years. Most of these skin wounds are the result of poorly-treated venous disease. Frequently the patient has venous “reflux” in a superficial vein causing pooling of blood at the ankle, which causes the skin ulcer. This reflux can be corrected with endovenous laser or closure. Veins have a series of valves that allow one-way flow of venous blood back toward the heart. When these valves break down, gravity pulls the blood in the opposite direction toward the feet. This is called “reflux”. Correcting this reflux can prevent recurrence of skin ulcerations.
Most insurance companies do not cover spider vein treatment but our insurance personnel strive to utilize your insurance benefits as much as possible to cover any of your procedures. The “out of pocket” cost of sclerotherapy is, however, quite reasonable. The results of sclerotherapy are much more obvious than that seen with a multitude of other more radical and much more expensive cosmetic procedures. The patient will also frequently get symptomatic relief, the problem will not become progressively worse and the risk of complications (side effects) is very low. All of this makes sclerotherapy a much more practical expense relative to other cosmetic procedures.

The average female new patient will spend more in a year with their beautician working on their hair than they will spend getting their spider veins treated (with 3-5 sessions). Keep in mind that the hair appointments continue whereas the spider veins just need occasional touchups over the years. Keep in mind also how important it is to have a well trained experienced sclerotherapist working on you. This is not a procedure that can be learned at a seminar. It takes years of experience to develop the skills required to get good results. Don’t let your spider veins wait too long. They can lead to skin discoloration. Remember, the average patient with spider vein issues who pursues appropriate long term maintenance care will spend much more on her hair than on her veins. Given the extensive training of the personnel rendering these treatments, the low cost of sclerotherapy is quite remarkable.

Peripheral arterial disease (PAD) occurs when there is inadequate blood flow from the heart to the legs due to blockages in arteries (“hardening” of the arteries). Smoking and elevated cholesterol are risk factors. PAD causes leg cramping with walking and sores on the feet and toes (not calves and ankles). Veins, on the other hand, carry blood from the legs back to the heart. PAD can lead to gangrene, strokes, and heart attack. Bad “veins” can cause a lot of problems but obviously PAD is a much more serious disorder. A vascular surgeon will be able to diagnose PAD as well as a vein problem.
Lower extremity “blood clots” (Thrombosis) can be in the deep or superficial circulation. Deep Venous Thrombosis (DVT) can be very serious with the potential risk of a clot floating to the lungs (Pulmonary Embolus), which can be fatal. DVT may also permanently damage leg veins, producing chronic pain, swelling, and skin ulceration. It can be difficult to differentiate DVT from the more benign superficial vein thrombosis, which rarely progresses to a life threatening situation. Symptoms of both include leg pain, swelling (with or without pain) and redness. If you develop such symptoms, you should urgently seek medical attention. Predisposing factors include immobilization (travel, recent surgery, illness), injury, pregnancy, a family history of clotting problems, birth control pills and other hormone replacement medications.
Swelling of the legs is a frequent complaint from patients of all ages. A common cause is venous insufficiency (poorly functioning valves of the lower extremity veins). This allows blood to pool in the legs with resultant swelling. Quite commonly, this is the result of an abnormal superficial vein, which can be corrected with an outpatient endovenous procedure. Another common cause of swelling is fluid retention from Lymphedema (insufficiency of draining lymphatic channels) which is frequently congenital, but can be secondary to injury (such as surgery) or obstruction (tumors), as well as obesity. Heart and kidney disease can also produce severe lower extremity swelling (edema). An acutely swollen leg is of urgent concern because it could represent a potentially life threatening blood clot (Deep Vein Thrombosis). Any patient with leg swelling should seek medical attention to prevent long term complications (skin ulcerations, etc.). Remember, patients with leg swelling should be wearing good compression hose.
Superficial thrombophlebitis is caused by inflammation due to a clotted varicose vein just below the surface of the skin. This is to be differentiated from deep venous thrombosis (DVT), which is a clot in the deeper vein, which is a more dangerous condition requiring treatment with blood thinners. Superficial thrombophlebitis is typically a short-term condition (1-4 weeks) that does not lead to serious, life threatening complications. Symptoms include redness, tenderness, and firmness of the visible vein. The skin may become permanently discolored. Treatment includes wearing compression hose, taking anti-inflammatory agents and application of heat to the area. Often, superficial thrombophlebitis is caused by underlying venous reflux, which is a correctable condition. Occasionally, there may be an associated genetic clotting tendency. Evaluation by a vein specialist is advised. Superficial thrombophlebitis is one of the many potential complications related to varicose veins.
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