21st Century High-Tech Treatments for Varicose Veins

Over the last several years, many exciting high-tech treatments for managing venous diseases have emerged. These treatments can be performed on an outpatient basis, so patients can return to normal activity almost immediately. One of the conditions which these new treatments can be used for is varicose veins.

Varicose veins are dilated veins in the legs that bulge under the skin surface when the valves in the main superficial leg veins (the great and small saphenous veins) do not function normally. Veins are responsible for carrying the blood back to the heart. In a functioning vein system, this happens when three mechanisms work together: breathing, the calf muscle pump, and the valves. When the valves stop functioning, blood does not flow through veins efficiently; the blood pools in the veins and causes them to enlarge. The medical term for this problem is "saphenous venous insufficiency."

Although varicose veins may cause no symptoms, many people with varicose veins experience leg pain and heaviness, especially at the end of the workday when they have been walking or standing for a long time. Symptoms can become more serious and include chronic leg swelling, skin infection (cellulitis), clotting in the veins (phlebitis), brown skin discoloration, and skin ulcers.

Mild symptoms from varicose veins can be controlled by limiting prolonged standing, elevating the legs when possible, and wearing support stockings. Special support hose prescribed by a physician are available if over-thecounter stockings do not improve symptoms. Until recently, more severe symptoms could be helped only by major surgical procedures. The most well- known surgery for varicose veins is "vein stripping" where the saphenous vein, the major branches, and varicose veins are surgically removed through multiple leg incisions. This operation is effective but causes significant bruising and has a recovery time of at least two weeks. Over time, symptoms can recur. Vein stripping today is typically reserved for persons with fairly severe symptoms.

New advances make it practical for persons with mild to moderate saphenous venous insufficiency to be treated with little risk or interruption in their lives. A combination of three treatment approaches is used. These are venous ablation, sclerotherapy, and micro-phlebectomy.

Venous ablation uses an energy source to close the malfunctioning saphenous vein. This has the same effect on the venous blood flow as surgical removal of the vein without the incisions, pain, and bruising. The energy used to close the vein can be laser energy or radiofrequency (RF) energy. To do venous ablation, a small plastic tube (similar to a long IV) is inserted into the saphenous vein. When the tube is in the proper spot, it is connected to a laser or RF generator and the unit is turned on to allow the energy to close the vein. At the end of the procedure, a support stocking or compression wrap is put on the leg. This procedure is done using local anesthesia. Once the saphenous vein is closed, symptoms of pain and heaviness decrease significantly and may go away entirely. Since many of the varicose veins are branches of the saphenous vein, they may become smaller or even disappear.

Venous ablation may be the only treatment needed for some people. However, others may still experience symptomatic varicose veins even after successful saphenous ablation. This is particularly true if the veins are extremely large or have been dilated for a long period of time— they may be so stretched out that they cannot shrink down after the reason for the blood pooling has been removed. In such cases, the other treatments are used.

Microphlebectomy is the actual removal of specific varicose veins. Local anesthesia is put in the skin over the vein to be removed. A small incision is made (about one-fourth inch or smaller). The vein is removed using an instrument that looks like a small crochet hook. After the vein is removed, a small adhesive bandage is applied and a support stocking is put on the leg to prevent bruising. This procedure can be done at the same time as venous ablation or during a second visit.

Sclerotherapy is used to close up varicose veins or "spider veins" instead of removing them. During sclerotherapy, a small needle or plastic tube is inserted through the skin directly into a varicose vein. Then a medication is injected that irritates the vein lining and causes the vein to close. This can cause a stinging sensation. At the end of the procedure, a small adhesive bandage is sometimes applied to the site of injection. The area is also wrapped tightly or a compression stocking is placed on the leg. This is done to minimize bruising and to help close off the vein with compression.

All of these procedures are very safe and effective, but they are not appropriate for everyone. Before having any of these procedures, the patient should consult with a vein-specialist physician and have an ultrasound test to examine all the leg veins and to plan the best treatment.

Complications do occur occasionally, as with any medical procedure, which include bleeding, infection, blood clots in the legs or the lungs, and skin ulceration.

Once the veins have been closed or removed, the blood can continue to circulate. The legs actually have two main sets of veins. One is just under the skin and is called the "superficial system." The other set is deep in your leg muscles and is call the "deep system." All the treatments described in this article refer to treating problems with the superficial system. If the superficial veins are closed up or removed, your blood will circulate in the deep veins. People with deep- vein problems typically are not able to have these treatments for superficial venous insufficiency.

About the Author: M. Victoria Marx, MD , is a professor and Vice Chair for Education, Dept of Radiology USC Keck School of Medicine in Los Angeles, where she has been on faculty for over eight years.