A patient before (left) and after (right) varicose vein treatment.
By Richard L. Feinberg, MD, FACS
Varicose veins can range from tiny, thread-like red or blue “spider veins” to large bulging veins exceeding 1 cm in diameter. They are a manifestation of chronic lower extremity venous insufficiency and are one of the most common conditions prompting patients to seek medical attention. Approximately 1 in 4 adults in the United States have varicose veins in one form or another. Over the age of 50, the prevalence rises to approximately 1 in 2.
Ligation and stripping of the great saphenous vein, the gold standard for managing patients with symptomatic venous insufficiency for over a century, is now seldom performed. Advances in vascular ultrasonography and the rise of endovascular surgical techniques have ushered in a new era of minimally invasive varicose vein treatment.
Watch a video of Dr. Richard Feinberg discussing the treatment of varicose veins.
PATHOPHYSIOLOGY
The return of venous blood from the lower extremities is uniquely hampered by gravitational effects. After passing through the capillaries and into the venous circulation, blood has lost most of the kinetic energy and propulsive force of cardiac contraction. Consequently, venous return to the heart is greatly affected by the pull of gravity, whose influence is proportional to the distance from the right atrium. As gravity traps venous blood in the legs, venous pooling leads to increased pressure and, ultimately, varicose dilatation. The two primary mechanisms countering these effects are: (1) the massaging action of calf muscle contraction (i.e., the “calf pump”), which milks venous blood back toward the heart; and (2) an intricate system of delicate, bicuspid valves within the lower extremity veins. These valves are oriented to allow antegrade blood flow back toward the heart, while “competency” of the valve leaflets resists the retrograde pull of gravity. If these valves become incompetent, increased venous pooling will lead to varicose vein formation.
MANIFESTATIONS
For a long time varicose veins had been considered strictly a cosmetic nuisance, but it is now recognized that the venous insufficiency underlying varicose veins often produces unpleasant symptoms and under-appreciated disability, adversely impacting quality of life. Symptoms commonly reported by patients include:
- throbbing
- aching
- itching
- swelling
- heaviness
- fatigue
- nocturnal “restlessness” of the legs
In more advanced stages of venous disease, inflammatory skin changes and even ulceration may occur. Separate and apart from this, the desire for cosmetic improvement also remains a large motivation for patients seeking varicose vein treatment.
NON-INVASIVE MANAGEMENT
While non-invasive measures such as weight loss, ambulatory exercise, leg elevation, and graduated compression stockings can help improve symptoms of venous insufficiency, many patients will still require some form of venous intervention in order to achieve optimum results.
CLINICAL EVALUATION
The evaluation of all patients with venous disease begins with a thorough evaluation by an experienced specialist who is fully trained in all aspects of venous treatment. In addition, a detailed assessment of venous valvular function with high-resolution duplex ultrasonography is mandatory and provides the information necessary to formulate a specific, individualized treatment plan in each case. If significant valvular incompetence is identified within the axial veins, then endovenous intervention may be helpful.
MINIMALLY INVASIVE SURGERY
Traditional “ligation and stripping” of the saphenous vein has essentially been supplanted by endovenous thermal techniques for eradicating valvular reflux within the saphenous veins. Endovenous ablation (EVA) is a minimally-invasive catheter-based procedure which utilizes heat (in the form of either laser or radiofrequency energy) to “close” the incompetent vein — eliminating reflux and restoring normal venous hemodynamics. EVA is an ambulatory, office-based percutaneous technique performed under local anesthesia, and is highly effective in eliminating the symptoms of venous insufficiency with minimal morbidity. An additional benefit is that varicose veins frequently regress following EVA, although to achieve maximum cosmetic enhancement some patients may elect to pursue additional minimally invasive treatment options afterward. Recently, several newer modifications of endovenous ablation have become available which are even less invasive and promise even lower risk of complications. Techniques such as mechanochemical vein ablation or the use of cyanoacrylate “glue” may prove to be equally effective at “closing” the faulty vein(s) with yet an even lower incidence of potential minor side effects.
SCLEROTHERAPY
An important treatment adjunct, sclerotherapy involves the injection of dilute irritant solutions directly into varicose veins, leading to endothelial adhesion, inflammation, and involution of varicosities. It is essential that axial vein reflux be completely eradicated by EVA prior to sclerotherapy for best results. In recent years, the introduction of newer sclerosing agents and techniques (including foam sclerosants) has led to markedly improved results.
AMBULATORY PHLEBECTOMY
For patients with veins too large or extensive to be successfully treated with sclerotherapy alone, several techniques of vein excision (phlebectomy) are available. Recent innovations now enable more veins to be extracted through fewer and smaller incisions, all on an ambulatory basis and with minimal scarring. Transilluminated powered phlebectomy (TIPP) combines a high-speed mechanical resector with fiberoptic transillumination to allow extensive resection of veins through just two or three micro-incisions with excellent results.
FOR MORE INFORMATION
At the UW Vein Center, we have over 25 years of experience treating patients with venous disease. Individual treatment plans are formulated following comprehensive assessment by a board certified vascular surgeon and on the basis of detailed duplex ultrasound vein mapping. We offer the full range of treatment options, including: endovenous laser ablation, radiofrequency ablation, ambulatory phlebectomy, transilluminated powered phlebectomy, foam sclerotherapy, injection sclerotherapy of spider veins, and cutaneous laser therapy. You can contact us at (608) 287-2210.