Myths about Varicose Veins
Modern vein therapy, like many medical therapies and procedures, has become minimally invasive. Procedures are most often performed in a clinic and patients go home, back to work, or even shopping or out to lunch immediately afterwards depending on the procedure and the patient. In the dark historical days of varicose vein therapy, the mainstay of vein treatment was a surgical procedure called “vein stripping” which was performed by making large incisions along the length of vein to be removed.
The surgery of vein stripping was performed in a hospital, required general anesthesia, and was followed by a hospital admission for pain control and then a prolonged recovery. The surgery resulted in large incisional scars where the vein had been and unfortunately incited new vein growth. Unfortunately, vein stripping is the procedure most people associate with varicose vein therapy although largely abandoned in the modern era.
Two of the three main treatment modalities for treatment of varicose veins in the legs require no incisions. Endovenous thermal ablation (termed EVTA) uses some variation of heat energy to close the large caliber and straight source veins that are usually the source for additional varicose veins with a single 3mm access site low in the leg with additional injections for local anesthesia. After the larger straight veins have been treated with EVTA, sclerotherapy with ultrasound guidance is performed by injecting medication with very small caliber needles directly into the varicose veins closing the veins. Sclerotherapy is utilized to treat veins that are either too tortuous or small to treat with EVTA. Cosmetic sclerotherapy can also be used to treat spider and reticular veins with direct visual access by incredibly small needles, ambulatory phlebectomy, which does require very small incisions, is reserved for remaining visibly bulging veins that remain after the other therapies that might cause skin staining if not removed as part of the treatment. Ambulatory phlebectomy (abbreviated AP) requires a series of very small incisions 1-3mm in length which allow a phlebectomy tool to reach the vein and pull it to the skin surface. A significant portion of patients do not require AP at all by the time the other procedures have been done. AP is done in the clinic with local anesthesia supplemented by an oral anxiolytic medication such as Valium or nitrous oxide gas. The procedure is well tolerated and most patients watch an overhead TV or play on their phone while we work. The large majority of patients are back to regular activities quickly. The incisions are so small that they leave minimal, if any, scars.
Most patients are pleasantly surprised about their gentle recovery following vein procedures. Patients are encouraged to walk and stay active after treatment although strenuous activities such as running and weight lifting are discouraged. Most patients return to work and household duties the day after and occasionally the day of treatment.
Exercise such as running and weightlifting can be resumed one week after treatment. Pain is typically controlled using over-the-counter medication such as ibuprofen and acetaminophen. Mild bruising is usually seen at the treatment sites with more moderate bruising following AP. Ice packs and heat are very helpful for treating focal discomfort such as bruising.
Wearing a compression stocking, essentially a prescribed medical grade compression garment, continuously for 48 hours following treatment and then 5 days while awake is a requirement following almost all therapies to ensure treated veins remain closed. An alternative to EVTA is available that does not have the compression therapy requirement and only requires one local anesthetic injection to access the treatment vein but currently has to be paid for out of pocket.
Crossing your legs does not cause varicose veins. When people cross their legs, it can temporarily obstruct venous flow and exacerbate symptoms producing the false assumption that crossing your legs is the cause of the varicose veins. There are risk factors that contribute to the development of varicose veins that are mentioned below, but first we need to go over what really causes varicose veins.
Varicose veins are caused by an intrinsic problem within the valves of the vein that normally facilitate movement of blood back to the heart leading to valve failure which results in inefficient return of venous blood back to the heart and reversal of blood flow, “venous reflux.” For lack of a better description, blood pools within the leg veins. The disease process is termed “venous insufficiency.” Veins enlarge over time causing even more vein valves to fail leading to additional varicose veins. The process is self perpetuating and the disease progresses. The enlarged veins under abnormal venous pressure cause a local inflammatory response and leakage of fluid into the tissue resulting in the symptoms of venous insufficiency; namely, pain, aching, pressure, itching, leg heaviness, leg swelling/edema and even restless legs. Long standing venous disease can lead to permanent skin thickening and discoloration. In extreme cases, ulceration or a vein bursting can occur. Risk factors for vein valve failure and varicose veins include genetics (the most significant), aging, obesity, and pregnancy. Occupations requiring standing or sitting for long periods of time tend to have more people who suffer from varicose veins as well.
Varicose vein patients come in all ages, shape, size, race, and gender. Admittedly when most people think of someone with varicose veins, they think of their grandmother or great aunt who had “bad veins” or who never wore shorts or shorter skirts because they were embarrassed about their bulging, rope-like varicose veins.
Even though it is true that the prevalence of venous insufficiency increases with age, patients can suffer from varicose veins at any stage of life. There are more than 40 million people in the United States with varicose vein disease and not all of them are elderly grandmas. A large number of patients report they first had vein problems in high school or during their first pregnancy and their vein problems have progressed since then. The severity of vein disease usually increases with time unless the course is altered by some intervention or modification. In our particular population where we appreciate lots of children and big families, we see young women with advanced vein disease following multiple pregnancies. Although women are the largest portion of patients, up to 30-40% of patients are men in a given year and some studies actually show men are more likely to have chronic venous insufficiency and mild varicose veins than women but less likely to seek treatment. The kindly grandma with bad veins and sagging support hose does not necessarily reflect the reality of varicose vein disease.
'Should I wait?' is one of the most common questions we are asked at the Varicose & More by young mothers hoping to have another kid or two. Our answer is an emphatic no.
First of all, suffering through pregnancy and bad venous disease is miserable. Treatment now can significantly limit suffering during subsequent pregnancies. Second, if a woman already has venous disease, the disease will progress during pregnancy and may require even more treatment than needed otherwise. Additionally, some long term changes that develop may not be completely reversed or treatable. Treating before the next pregnancy will slow progression during the pregnancy although there will likely be some new disease regardless. Lastly, we see patients who have been told they shouldn’t have more children because of their venous disease. This may not be true. If you have been told this, come and see us before you give up on having more children. We can help.
Additionally, women can have venous insufficiency in their pelvis, sometimes called ‘pelvic congestion syndrome’ – essentially varicose veins around their ovaries and uterus due to venous insufficiency in their ovarian and iliac veins that may extend into the their vulvar regions or legs. The symptoms can include back and pelvic pain or heaviness often worse at the end of the day, during strenuous activity, and during menstruation. Pain may be associated with sexual intercourse which can make getting pregnant less enjoyable. There may be associated disfiguring vulvar and labial varicose veins. The pain can be lifestyle limiting and severe. It can be unbearable during pregnancy. The disease is oftentimes not diagnosed or misdiagnosed; however, we can diagnose and treat pelvic venous insufficiency. The treatments are minimally invasive and require minimal downtime. If you have symptoms that you suspect are because of venous problems in your pelvis, call us. We can help make your next pregnancy much more tolerable.
We cannot treat during pregnancy due to risks to the baby but we can make recommendations and prescribe compression stockings to help with symptoms during pregnancy. We can see you in consult, facilitate treatment and preauthorize with insurance after your child is born.
Varicose veins and cosmetic probably should not be used in the same sentence. Varicose vein treatment is medically necessary and improves lives. Fortunately, years of medical research and insurance companies agree.
The cosmetic appearance of the leg does improve with treatment especially for patients with bulging varicose veins, unless the patient makes it to us after ulceration and significant skin changes have occurred. Treatment will improve symptoms, allow ulcers to heal, and slow or even arrest progression of the disease process.
Varicose veins are not always visible. While visible bulging veins are most often an obvious sign of venous insufficiency, studies have shown that although half of the adult population have minor signs and symptoms of venous disease (women 50-55%, men 40-50%), fewer than half of these patients will have visible varicose veins (women 20–25%; men 10–15%). There are specific symptoms that indicate there may be underlying vein disease, termed chronic venous insufficiency. These symptoms include leg pain, aching, pressure, itching, leg heaviness, leg swelling, skin changes, superficial venous blood clots, ulceration and restless leg syndrome.
Because other disease processes may cause similar symptoms, the Varicose & More offers free screening ultrasound exams for vein disease that can tell you if the symptoms you are experiencing are due to venous insufficiency and varicose vein disease. There is no obligation to proceed with consultation or treatment and we routinely see patients who are having symptoms who do not have vein disease on ultrasound. We also see a large percentage of patients who have been suffering with venous disease too long get life altering treatment due to a brief screening ultrasound.