Vein Teacher

Treating Varicose Veins

Varicose veins develop for a reason. And when they start to develop, the reason has already been present for a long time. It has finally done enough damage to cause varicose veins to begin to appear and now many more are going to be appearing without such a long wait.

The venous system can be likened to an upside down tree with the blood flowing up the branches towards the trunk. Unlike a tree, the venous system has cross branches that interconnect all of the limbs. This is a very important fact. Normally the blood pressure in leg veins is very low - only about 15 - 20 cm of water pressure. When we stand, gravity is pulling down on the blood all the way from the heart to the floor with a total force of about 150 cm of water pressure. There are valves about every 10 - 20 cm along the veins, which only allow the blood to go uphill. When the muscles of the legs are used, the veins are squeezed. The pressure inside the veins rises dramatically, sometimes as high as 300 cm of water pressure transiently. Then the blood flows towards the heart, because the valves will only let it go in that direction. Note that this pressure is pushing from the outside of the vein, towards the inside - it is not a force that would dilate the vein

Over time the valves fail. There are many reasons for this, but they all amount to wear and tear. When the valves fail, the column of blood in the vein is now uninterrupted when standing and the pressure at the bottom rises. It can reach 150 cm of water pressure. Note that this pressure is inside the veins, pressing outward! The veins are thin-walled and not equipped to handle this kind of internal pressure. When subjected to these pressures over a long period of time, the veins dilate. This is the origin of varicose veins. Since all the veins are connected by cross branches, when the pressure in one vein rises, it rises in all the veins in that leg. The varicose veins you see are the ones with the weakest walls that have dilated first. Eventually they will all dilate! This elevated pressure is transmitted into the capillary beds where it causes excess fluid to leak out of the capillaries. This is the cause of the swelling of the leg commonly seen with varicose veins.

Most of the trouble with varicose veins occurs in the superficial venous system in the leg. The deep veins are not usually involved except in the worst cases. The superficial system has some fairly large veins in it. The usual culprit is the Greater Saphenous Vein which is on the front of the thigh and calf. Sometimes the Lesser Saphenous vein is also bad. It is on the back of the calf. These are usually too deep for you to see, but the varicose veins you can see are branches of these larger veins. Only one of these large superficial veins needs to have its valves stop working for you to develop a large number of varicose veins. Remember, the cross branches transmit the elevated pressure into the whole system. However, the cross branches also mean that we can eliminate a bad segment of vein without isolating the veins below it. There are always cross branches that allow the blood to flow from these lower veins into a different vein and continue up the leg.

The essence of treatment is to find the segments of vein that contain the bad valves and simply eliminate them. We use ultrasound to identify the bad veins. The ultrasound can detect the direction of blood flow and the technician examines the veins to see which major veins allow the blood to go backwards. When you have bad valves in a vein, this is exactly what happens. You stand up and the blood in the bad vein flows backwards, down the leg, until the vein and its branches are filled to capacity and bulging - due to increased pressure. The circulation is impaired. And when this vein is eliminated, the blood will no longer flow backwards when you stand. The circulation will be substantially improved.

The best way to eliminate these bad veins is to destroy them right where they are and leave them there. We do this using a procedure called Endovenous (inside the vein) Ablation (destruction). We insert a needle into the vein near the bottom of the segment we want to eliminate. Through this needle we introduce a catheter into the vein and thread it up the vein to the top of the segment we want to eliminate. When we turn it on, the tip of the catheter gets hot, and the inside of the vein is cauterized. We then slowly withdraw the catheter down the entire length of the vein segment, so the entire segment ends up being cauterized. The energy we use to heat the catheter is either radiofrequency (RF) or laser. When we use RF, the procedure is called the Closure® procedure and when we use laser the procedure is called EVL. Both work great. The vein is irreparably damaged and clots. This blood clot in a superficial vein is perfectly safe. It will not harm you and it will not impair the circulation. Remember, by destroying this vein, the circulation is actually improved. Your body will absorb the blood clot in a month or two, and the vein will shrivel up into a small fibrous cord and never carry blood again. Of course, before we do all of this we make the entire length of the vein numb by giving it several injections of lidocaine along its length. We also often give each patient a small amount of IV sedation to make the procedure more relaxing.

What about those varicose veins that you can see. They are still there. When the bad vein is destroyed, the underlying cause of the varicose veins and the spider veins is corrected. The pressure in the system is dropped substantially and you should no longer be developing new veins on a regular basis. The varicose veins you already have should also be smaller, because there is not as much pressure in them. However, they have become overstretched and will not return to their normal size. The photos of the man below show the result after an Endovenous Ablation alone. His Greater Saphenous Vein, which you cannot see, was treated. The large varicose veins which were branches of the treated vein became much smaller, but they are still somewhat visible. Because they can go on to cause continuing symptoms of tenderness and intermittent phlebitis, it is a good idea to treat them. We do this as a separate procedure called Microphlebectomy. We anesthetize the veins with lidocaine and then make a small stab wound next to each vein with a pointed scalpel, usually only about 3mm in size. Through this stab we insert a micro vein hook and extract a section from the vein. We make a stab every three inches or so along the vein and remove the vein in pieces. Sometimes if the vein is fragile, it doesn’t actually come out, but is simply divided in two. This has the same effect. The separated pieces no longer carry blood. They stay in the leg in a collapsed state and are no longer visible. Over time they too shrivel up into small pieces of fibrous tissue. The stab wounds we make are so small that we do not even stitch them. They are pink for a few months as they heal, but eventually fade to a neutral color and are no more visible than a freckle.

The photo below is of the same leg as the photo at the beginning of this paper. This woman had both an Endovenous Ablation AND a Microphlebectomy. She has a near perfect result. Here is what she had to say about here treatment:

"After Ablation, they removed the veins in my leg. I was biking in four days, horseback riding in six! You can’t see the tiny marks without getting within two feet of my leg after only five weeks, and the marks are fading and getting smaller all the time."

Kori Jo S.

If you have spider veins or smaller varicose veins that you desire to have treated, we do this with injections of sclerosing agents and with external beam laser. The results are very satisfactory. We do this about a month following the Microphlebectomy of the larger varicose veins.