Varicose Veins and Treatment Options

Varicose veins (VVs) are those dilated, bulging veins close to the skin surface that affect up to 25 percent of women and 15 percent of men. Spider veins are smaller, flat, less tortuous, bluish-reddish superficial veins found in greater than 80 percent of the general population. Being a woman, advanced age, family history, pregnancy, prolonged standing, obesity and hormone therapy (birth control or hormone replacement) will all put you at risk for developing varicose veins.

VVs are not only a cosmetic problem, but may commonly produce symptoms of heaviness, fatigue, pain, swelling, restlessness, burning and itching, which interfere with daily activities and result in lost time from work. There are some complications associated with VVs, including vein rupture and bleeding, blood-clot formation and skin ulcers. Skin ulcers associated with venous disease affect approximately one percent of the population and are difficult to heal, with an estimated U.S. health care cost of $3 billion per year.

Traditional treatments for VVs include making life-style modifications, wearing compression stockings and taking some medications. Patients with VVs are encouraged to lose weight, exercise, and elevate their legs. Compression stockings are effective in reducing swelling and pain. Low-dose diuretics (water pills) reduce swelling in the short term, topical steroid creams reduce inflammation, and antibiotics treat cellulitis (skin infection). Horse chestnut seed extract is an herbal remedy shown to reduce swelling short-term, but this preparation has not been approved by the FDA.

If these traditional treatments are not successful, then surgery is recommended. Catheter-directed (endovascular) techniques have revolutionized the treatment of VVs, with reduced complications and time away from work.

Surgical treatments traditionally included vein ligation and stripping performed in the operating room under general anesthesia. The procedure involves making an incision in the groin, tying off the large vein and its branches, advancing a wire along the length of the vein, and retrieving the wire through a second incision in the upper calf to remove (strip) the entire vein. Effectiveness of vein stripping in removing the VVs is about 76 percent at five years. Tying off the vein alone results in a higher recurrence rate and is typically performed with other treatment modalities. Ambulatory phlebectomy, an outpatient alternative to vein ligation and stripping, is performed under local anesthesia and involves making multiple incisions along the leg, through which the vein is hooked and removed. Complications of surgical interventions include pain, bleeding, infection, nerve injury and blood-clot formation. Recovery time from surgery is approximately two or three weeks.

Catheter-directed procedures, including endovenous laser therapy, radio-frequency ablation (RFA) and foam sclerotherapy, have emerged as minimally invasive outpatient treatments for VVs. Laser therapy and foam sclerotherapy are also used to treat spider veins. Laser and RFA are performed under local anesthesia and involve advancing a catheter through an incision at the knee and directly heating the vein wall or affecting the blood to destroy the vein. Foam sclerotherapy involves injection of a foam substance into the VV, which irritates the inner lining of the vein and causes it to scar and disappear over time. While RFA and foam sclerotherapy are equally effective as compared to surgery in eradicating VVs (75-80 percent obliteration rate at five years), laser therapy may have a greater long-term success rate (95 percent obliteration rate at five years). Complications of laser and RFA include pain, skin burns, infection, and skin-color changes along the treated vein, bloodclot formation, bleeding and nerve injury. Foam sclerotherapy can be associated with mild post-procedure discomfort and skin-color changes along the treated vein. Other adverse events, including blood-clot formation, skin ulcers, bleeding, cough, visual changes and headaches are rare.

Currently, clinical trials are underway to definitively evaluate the role of foam sclerotherapy in the treatment of VVs. The recovery time after laser therapy and RFA is approximately three to five days and after foam sclerotherapy, recovery takes less than 24 hours.

Treatment options for VVs have greatly improved over the last decade, with less invasive outpatient catheter-directed modalities showing results as good as surgical techniques, and with the benefits of reduced complication rates, recovery time, and procedure costs. Consultation with a vein specialist who can discuss the available options is recommended prior to any vein procedure.

About the Authors:
Raha Nael, MD, is a fellow in vascular medicine at the University of Oklahoma Health Sciences Center, Department of Medicine: Cardiovascular Section.

Suman Rathbun, MD, MS, is Associate Professor of Medicine, Cardiovascular section, at the University of Oklahoma Health Sciences Center, Department of Medicine: Cardiovascular Section.