Varicose and Spider Veins – What Are Your Options?

As I am writing this, I am on a cross-country plane trip from Seattle to New York. I do quite a bit of traveling, both regionally and internationally and have found that over the last several years, by the end of the flight, my legs often swell and feel heavy. Having just faced another birthday, I started noticing areas of large and small blue veins, as well as brown-pigmented regions developing in and around the areas of discomfort. All those years of standing on my feet for hours on end in the operating room, repeated superficial injuries from activities and sports, and the history of varicose veins that runs in my family, all spell venous disease. Sound familiar? What I am describing are the conditions referred to as venous insufficiency and varicose veins.

So, let’s start with some of the basics. What are veins? Veins, by definition, are the circuit that returns blood in the direction of the heart. It is the path thru which oxygen deficient blood is brought back to the heart and directed to the lungs in order to off-load waste and start over again. Veins, operating at lower pressure, have less muscle tissue within their walls. Venous flow is also much slower than arterial and varies in a to and fro fashion affected by one’s breathing. Veins also have a series of one-way directional valves that promote flow towards the heart while preventing flow away from the heart. This is especially important in the legs where blood basically has to flow uphill and against gravity in order to return to the heart.

Vein valve damage leads to a condition referred to as venous insufficiency (a malfunction of the efficient return of blood through the venous system). As valves fail, a larger column of blood falls onto the next intact valve, which then obstructs the backward flow of blood as it is designed to do. In halting the abnormal flow, the added weight from above causes dilation of the surrounding vein segment (like filling up a water balloon) which progressively stretches the support mechanism for the underlying valve. Stretching the valve support pulls the valve leaflets apart from each other. If the valve cusps no longer meet, this allows blood to leak through the valve. This process continues until the valve fails completely and an even larger column of blood puts greater pressure on the next lower valve. Over time, this process continues until all of the vein valves are damaged.

In the vein system near the skin, valve failure leads to greater pressure being transmitted throughout the superficial veins. Since the superficial veins are just under the skin, they become more visible as they become pressurized. These dilated superficial veins are known as varicose veins.

The evaluation of varicose veins begins with a clinical examination and documentation of the associated symptoms and areas of dilated veins. Since the vast majority of varicose veins are the result of underlying venous insufficiency, non-invasive evaluation with ultrasound is an important step in evaluating the presence of upstream obstruction, patterns of normal and reversed blood flow, and overall valve function. Proper varicose vein treatment really means treating the entire path of abnormal venous pressure from beginning to end.

Treatment for varicose veins is primarily concerned with improving or eliminating symptoms, or improving the cosmetic appearance of the affected area.

Compression Stockings

Compression stockings are really what the term implies: tight stockings which provide external compression to the legs. The idea behind compression stockings is that application of external compression will force blood out of the dilated veins, fluid out of the surrounding tissue, and resist further accumulation from happening. As you might imagine, reducing the fluid pressure within the leg will help reduce swelling and should reduce symptoms associated with venous insufficiency. The issue most individuals have with compression stockings is that they are a temporizing measure; addressing symptomatic relief rather than curing the underlying condition.

Direct Treatment

Direct treatment options are primarily dictated by the size and extent of the affected veins.

• For veins that are >4 mm in diameter, cluster removal using very small 2-3mm incisions (ambulatory phlebectomy) is the treatment of choice.
• For veins less than 4mm in diameter, injection sclerotherapy is recommended.
• For intradermal spider veins, telangiectasias that are less than 1mm in diameter, and those which persist after previous treatment, laser or light treatments are recommended.

Laser or Radiofrequency Treatment

Over the last several years, newer techniques have evolved as a substitute for vein stripping. Laser or radio-frequency ablation procedures are used to obliterate the insufficient vein channel without removing it from the body. For laser ablation, a laser fiber is inserted in the vein (just like the vein stripper) and advanced up to the groin. The laser is turned on and the fiber pulled slowly through the vein. As the laser fiber moves through the vein, the heat energy causes it to “scar” and eliminates the abnormal flow channel. The advantages of ablation techniques are less bleeding and bruising, and faster patient recovery.

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