The Vein Center
Specializing in the treatment of the full spectrum of venous disorders.
Vein disorders vary in severity, ranging from severe chronic venous insufficiency
with venous ulcerations, to mild varicose veins, to small reticular veins,
to tiny spider veins. Accordingly, the treatment for vein disorders differs
from patient to patient, depending on the severity and stage of the vein
condition. Below is a general outline of how vein disorders develop and
how various vein conditions are usually treated. Of course, your treatment
will vary with the severity and extent of your vein condition.
Medical information found on MHMG.com or related links is provided for
general patient information only, and may not be relied upon as a substitute
for professional medical care.
These are the bulging veins that you can see with the naked eye. Varicose
veins are typically branches of the great saphenous vein or small saphenous
vein. Varicose veins are usually painful and tender and indicative of
a deeper problem of venous reflux. When varicose veins progress untreated,
a condition known as Chronic Venous Insufficiency may result. In severe
cases, the legs become swollen and a brown hyperpigmentation occurs at
the shins and ankles, and the skin can break down into ulcers.
These are the tiny (<1mm) veins just under the skin. They are typically
red or purple and have a center and several arms. They usually occur in
the thighs or legs, and cause symptoms of pain, burning, and itching.
Venous System Anatomy
The venous system consists of the deep veins and superficial veins. This
is sometimes a source of confusion for patients. Many patients are concerned
about "blood clots" in the veins and their potential dangers. It is true
that blood clots are serious, but it is the blood clots in the deep vein
system, especially those above the knee,that are dangerous and life-threatening
and require treatment with blood thinners (see
Deep Venous Thrombosis). Blood clots in the superficial system are in general not dangerous and
are usually associated with a common disorder known as phlebitis (tender,
inflamed vein). Phlebitis and blood clots in the superficial system, though
tender and painful, are usually self-limiting and not life threatening.
The superficial system is where varicose veins arise. The superficial system
is comprised of two large veins (great saphenous vein and small saphenous
vein) and all the branches that arise from these two large veins. The
great saphenous vein is a large vein that runs from your groin to your
ankle. The small saphenous vein runs from the back of your knee to your
heel. The great saphenous and small saphenous veins are encased in a fibrous
sheath and are not visible to the eye. They give rise to many smaller
veins that branch out and drain blood from the leg. Like branches of a
tree, these vein branches in turn give rise to smaller and smaller branches
that arise more superficially in the skin. The varicose veins that you
can see are typically these branches of the great and small saphenous
veins, and become varicose because of an underlying reflux problem in
the great or small saphenous vein. As a matter of definition, a vein is
considered "varicose" only if it bulges out from the skin.
The smaller, more superficial branches of these veins, found just under
the skin, are the reticular veins. When reticular veins become enlarged
and varicose, they often feed a network of spider veins.
The return of venous blood from the legs back to the heart is accomplished
by numerous valves which are located in the veins, and the leg's "muscle
pump." Normal veins contain one-way valves that permit the blood to flow
from the periphery back toward the heart. These valves are necessary because
of our upright posture, and the effect of gravity, which would otherwise
cause the blood to pool in our feet and legs every time we stand. The
"muscle pump" is made up of muscle groups in the calf. When these muscles
contract, blood is forced upward toward the heart, through the one-way
valves. The blood cannot flow "backwards" toward the feet, because of
the presence of the valves. When the muscles relax, the valves prevent
the blood from flowing back down to the feet. The empty veins in the feet
and legs can now accept new blood coming from the feet, and the process repeats.
Large varicose veins are formed when the valves in the legs malfunction.
The valves become "incompetent," and begin to leak. As a result, blood
can leak back down to the feet and legs, because of the action of gravity.
This causes the veins to become distended, which causes further valves
to leak because of the increase in size of the vein channel. Over time,
these veins become large, "ropy," and visible to the naked eye. The word
"varicose" comes from the Greek word for "cluster of grapes," which these
veins can come to resemble. Varicose veins can cause discomfort, and typical
symptoms include pain, burning, heaviness, or tingling.
Superficial, small blue or red-blue spider veins, also called telangiectasais,
are a result of reflux into tiny venules in or just below the skin. Reticular
veins, also called feeder veins, often supply such telangiectasias. Spider
veins may cause symptoms of pain--especially pain which is aggravated
by prolonged periods of standing--as well as itching or tingling sensations.
One way that varicose veins are treated is through an open surgical procedure.
In this procedure, a surgeon makes an incision and ties off or removes
("strips") the varicose vein. This is typically done in a hospital under
In this procedure, the doctor makes a small (2 mm) nick in the leg. He
then inserts a hook instrument under the skin and grabs the vein, then
excises it out of the leg through the incision, removing it permanently.
The incision is then closed using strips of tape. Stitches are not required.
This procedure is done in the office.
A more modern and less invasive technique for treating varicose veins involves
use of a laser. In this technique, known as EndoVenous Laser Ablation
(EVLA), a small laser catheter is inserted into the vein and laser energy
is applied to the inner wall of the vein, causing the vein, to close permanently.
The EVLA procedure takes about an hour and is done in a doctor's office.
After an EVLA procedure, the patient can walk immediately and may return
to work the next day. Mild bruising of the legs and mild pain are normal
after this procedure. Compression stockings must be worn for several weeks
after an EVLA procedure, in order to assure complete closure of the vein.
EVLA is usually performed on large varicose veins, such as the Great Saphenous
Vein, which runs down the inner aspect of the leg from the groin to the
foot, and the Small Saphenous Vein, which runs down the back of the calf.
Ultrasound-Guided Chemical Ablation, or Foam Sclerotherapy
Another very successful technique for treating varicose veins involves
using a liquid chemical compound known as a "sclerosant". The sclerosant,
which is mixed with air and prepared as a foam, is injected into the vein
with a small needle. This chemical interacts with the inner lining of
the vein wall and causes the vein to spasm and close. The foam property
of the chemical causes it to stay in contact with the vein wall, rather
than washing away with the venous blood flow. In the ensuing hours, the
vein channel clots and permanently closes. Foam sclerotherapy is a very
simple procedure that takes about an hour, is done in a doctor's office,
and involves minimal discomfort. Following foam sclerotherapy, the patient
must wear compression stockings for several weeks. Foam sclerotherapy
is typically performed on the small and medium sized varicose veins.
EVLA and Ultrasound-Guided Chemical Ablation are covered by Medicare and
most PPO insurance plans.
Sclerotherapy involves injection of a liquid chemical substance (sclerosant),
into the vein. This causes the vein to spasm and close. If the spider
veins are supplied by a reticular vein, successful and permanent results
will only be achieved if the reticular vein is also injected. Occasionally,
a diagnostic study using special illumination techniques, such as a vein
transillumination light or infrared Vein ViewerR, may be useful to identify
and successfully inject these deeper reticular veins. Following sclerotherapy,
the patient must wear compression stockings for several weeks. Typically,
a sclerotherapy treatment plan can be decided after a consultation and
physical exam. Note that sclerotherapy is a cosmetic procedure and not
usually covered by insurance carriers.
Graduated Compression Stockings
Graduated compression stockings are an important treatment for varicose
veins. They work by compressing the superficial veins and forcing blood
to be re-routed to the deeper, non-diseased, veins. This reduces the inflammation
in the superficial varicose veins. In this way, the stockings reduce the
pain and swelling associated with varicose veins. A disadvantage to the
stockings is that they are a temporary solution, as the symptoms of varicose
veins recur when the stocking is removed. Graduated compression stockings
are prescribed by your physician and come in various strengths or levels
of tightness. Typical strengths for treatment of varicose veins are 20-30
mmHg or 30-40 mmHg.
Graduated compression stockings are also an important step following treatment
for varicose veins. By compressing the veins after EVLA, Ultrasound-Guided
Chemical Ablation, or Sclerotherapy, they help assure complete closure
and healing of the varicose veins.
Prior to having EVLA or Ultrasound-Guided Chemical Ablation, patients typically
undergo a Vein Mapping ultrasound procedure, to study the vein anatomy
and assess the function of the venous valves.
Diagnostic studies used to evaluate venous insufficiency prior to or as
part of treatment may include the following:
- Handheld Doppler - A portable handheld device which uses Doppler ultrasound
to detect reflux flow in the veins with an audible flow signal.
- Ultasound Vein Mapping - A comprehensive study performed in the Vascular
Ultrasound Laboratory which provides a complete assessment of the vein
pattern and connections, size of the veins, valve function, direction
and magnitude of blood flow, and presence or absence of thrombus. A complete
vein mapping study takes about an hour.
- Vein Light - A handheld device which transilluminates the veins by using
a bright light held against the skin. This allows visualization of veins
up to about 5mm below the skin surface.
- Vein Viewer® - A portable device that uses an infrared signal to identify
the veins and project an image of the underlying veins onto the skin.
This allows visualization of veins up to about 8mm below the skin surface.