The modern treatment of varicose veins is very successful. There are multiple tools in our armamentarium to treat both large painful varicosities and small ugly dilated veins on the legs. We can even treat such veins around the eyes and on the back of the hands successfully.
The treatment of varicose veins should be multifaceted. A combination of treatments after a very careful exam by an experienced clinician using duplex ultrasound scanning leads to the best treatment outcomes.
Without this multipronged approach, and only simple treatment of the visible veins, patients often ends up with short-term improvements with recurrence of the unsightly veins down the road.
Why Patient’s Get Varicose Veins?
Varicose veins are often an inherited trait; they occur in both men and woman, but are more common in woman as estrogen contributes to the formation of new vessels. In addition, pregnancy increases the incidence of varicose or “broken” veins due to pressure on the great veins.
Varicose veins are the result of faulty valves in the superficial venous system. The superficial venous system occurs just under the skin and is linked to the deep venous system, which is the main route to return blood from the toes and feet back to the heart. Nearly every patient can live without the superficial venous system and rely upon the deep venous system to return blood to the heart. That is why cardiothoracic surgeons will often strip the saphenous vein and its tributaries to use for cardiac bypass surgery, which rarely results in poor venous return postoperatively.
On the other hand surgery, trauma, obesity, and again pregnancy can separate the one-way valves in the veins leading to what is called reflux or regurgitation where the blood flows backwards down towards the feet. This causes the system to back up just like a faulty pump, which dilates the veins in the skin. These one-way valves are throughout the superficial venous system and are clinically important. Without them the blood flows back to the feet because the veins do not have any muscles to contract and pump the blood back up towards the heart. The veins rely upon the muscles in the legs to compress them squeezing the blood up while the one way valves prevent it from going backwards towards the feet. These valves can break for various reasons. The most important reason is a genetic tendency or predisposition. The technology does not quite exist to repair these valves yet; the treatment of varicosities at this point in time involves destruction or removal of the visible or symptomatic veins.
The main valve and the source of much of the problem in many patients is in the groin. It is called the saphenofemoral junction. This is where the saphenous vein meets the large femoral vein, i.e. the main connection between the superficial venous system and the deep venous system. When this valve is refluxing or leaking, the entire network can backup and create a host of problems. Varicose veins are not just a cosmetic issue; they cause cramping, pain and swelling in the lower legs and feet particularly when standing for long periods of time. In addition, they can lead to serious disease as one ages creating a condition in the skin called stasis dermatitis where patients get chronic rashes, miserable itching and eventually they can get non-healing wounds or ulcers and rock-like thickening of the skin called lipodermatosclerosis.
Stasis ulcers are a major source of problems in the elderly in this country resulting in hospitalizations, tremendous expense, and even amputations and death from infections.
All of this disease can be prevented by repairing the leaky superficial venous system and using adequate compressive therapy.
Treatment of Varicose Veins
The mainstay of treatment of varicose veins is compressive therapy. Compressive stockings particularly ones that are custom fitted to a particular patient’s leg and are graduated in compression from the toes to the knees or sometimes all the way to the groin. This will keep the superficial venous system compressed and avoid dilatation or varicosities and can help prevent stasis dermatitis and stasis ulcers as well as improve patient’s symptoms, i.e. pain and swelling in the lower legs and feet.
After compression there are various surgical interventions which can improve varicose veins dramatically.
Treatment of the Saphenofemoral Junction
As mentioned above treatment of the saphenofemoral junction, which is the main valve connecting the superficial and deep system, is critical for the successful treatment of varicose veins distal or below this junction. Duplex ultrasound technology is critical to measure retrograde or backwards flow of blood at the junction to determine whether or not this valve needs to be sealed. When a patient presents with venous symptoms of the lower legs, or obvious varicosities the first step would be ultrasound evaluation, Duplex ultrasound testing in experienced hands accurately maps out the main points of reflux or retrograde flow of blood.
Once the venous anatomy has been mapped by duplex sonography, the doctor can decide how best to proceed. If the sapheno-femoral junction is in fact refluxing, which means the valve is broken, this has to be sealed before any of the veins “down-stream” can be fixed. If this is not done properly then most of the treatments for varicosities on the rest of the leg will fail eventually because the sapheno-femoral junction is often the main source of varicose veins patients can see and feel. If this main valve is sealed sometimes the rest of the venous disease in that leg markedly improves without further treatment.
Not too long ago sealing the sapheno-femoral junction was a difficult and painful surgical stripping procedure where the patient was put to sleep, the junction was tied off with stitches and the rest of the main vein was “stripped” out. “Stripped” meant pulling the vein out with essentially a long wire from a “cut down” procedure at the knee. This resulted in two surgical scars one in the groin and one at the knee. What is worse is that studies over the years found that this did not often result in permanent cure; the body would heal the veins around the stitched area in the groin and the problem would recur both there and “down-stream”.
Modern vein specialists like Dr. Serena Mraz of Solano Dermatology Associates use lasers to solve this problem. Using local anesthesia only and just a puncture wound at the knee the laser (which is a small sterile flexible catheter or tube) is passed all the way up from the knee to the groin. It is turned on at the sapheno-femoral junction using Duplex ultrasound guidance and the entire diseased vein is sealed as the tube is slowly withdrawn. In this way the entire problem vein is sealed resulting in a much higher cure rate and a smaller recurrence rate than older stripping procedures. In addition it is a relatively minor outpatient procedure done in the office with local anesthesia resulting in much less expense and risk than stripping under general anesthesia.
Once the sapheno-femoral junction and the attached diseased vein are sealed attention can be directed to any varicosities below the junction.
Sclerotherapy or Injection Therapy
After the sapheno-femoral junction has been sealed, if Duplex sonography proved it was needed, then smaller varicose veins can be treated with injections. Various caustic agents and detergents are used by the sclerotherapist to inject the diseased veins. These agents irritate the inside of the veins and cause them to become red and a little swollen, then they slowly disappear over weeks to months. Usually a series of treatments are needed for optimal results.
Phlebectomy or Surgical Removal of Veins
For larger varicosities phlebectomy is often more effective than sclerotherapy though it is more invasive. In this procedure the phlebologist maps out the targeted veins and uses dilute local anesthesia to numb the areas. Small puncture wounds are made with needles over the numbed targeted veins then small specially made vein hooks are used to literally fish out the varicose veins. The diseased veins are then avulsed (pulled out) or sometimes tied off with absorbable suture material. This surgical method in skilled hands is very effective at removing large varicose veins with minimal to no scarring when compared to standard old-fashioned stripping where surgeons would make relatively large cuts over the veins to expose them. Standard stripping rarely if ever needs to be done anymore since these more modern techniques are more effective, produce less scarring, and can be done in the office easily.