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Q: How do normal veins work?
A: Veins are responsible for returning blood to the heart. It
can be helpful to compare veins and arteries to get a clear picture
of how veins work. Consider the following chart:
| Arteries |
Veins |
| Carry blood rich in oxygen |
Carry blood low in oxygen |
| Carry blood away from the heart to the hands and feet |
Carry blood back to the heart from the hands and feet |
| Have thicker elastic walls that are designed to handle
higher pressures |
Have thin walls that do not handle high pressures |
| The heart pumps to move blood through |
Blood is moved through veins by action of muscle contraction |
| Arteries do not have valves |
Veins have one-way valves |
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Q: Are all leg veins the same?
A: No, there are three major systems
of veins in the leg:
1) The superficial system: just like the name implies, veins of
this system are fairly close to the surface of the skin. Blood in
these veins should flow into the veins of the deep system. Examples
of important superficial system veins: the greater saphenous vein
(GSV) and the lesser saphenous vein (LSV).
2) The deep system: Veins in this system are again, as the name
implies, deep beneath the skin. These veins are usually quite large
compared to superficial veins and are the veins involved with the
condition called deep vein thrombosis (DVT). The deep vein system
contains much higher pressures than the superficial veins. Important
examples of deep system veins: the femoral vein.
3) The perforator veins: Perforator veins connect the deep and superficial
systems of veins at four or five places down the leg. In addition
to connections between the deep and superficial systems that the
perforators provide, the saphenofemoral junction provides a direct
connection between the two systems.
Q: The previous chart noted that the blood in veins is traveling
back toward the heart. Doesn't that mean that blood is traveling
against gravity?
A: Yes, blood does travel against gravity,
but remember, veins have one-way valves that are supposed to prevent
blood from traveling with gravity.
Q: So if that is the way veins are supposed to work, what can go
wrong?
A: Valves are the most common source
of vein problems. As previously noted, vein valves are supposed
to permit one-way only flow of blood, but sometimes valves don't
work properly and permit blood to flow backwards (the wrong direction).
This causes blood to "stand" in veins instead of returning
to the heart as it should. Fluid and other components of the blood
are thereby allowed to leak out into the surrounding tissue potentially
causing spider veins and varicose veins and all the problems associated
with such conditions (listed in answer a few sentences away from
here). Up to 60% of all men and women have a vein disorder such
as varicose veins or spider veins.
Q: What causes vein valves to malfunction?
A:There are many possibilities. The most
common factor is a family history of vein problems. Other common causes
are pregnancy, hormonal changes (pregnancy or menopause), obesity
and history of trauma. Interestingly, many very athletic men and women
can develop vein disease. Standing for long periods of time can make
problems worse probably because of the added stress placed on vein
valves.
Q: Can vein valves be fixed or even mend themselves?
A: No. Unfortunately, once a vein valve malfunctions it cannot repair
itself and there is no other way to repair it. Valves are very delicate
flaps of tissue.
Q: My vein problems all started with pregnancy.
Will they go away once the baby is delivered?
A: Many women first experience vein problems with pregnancy. Use of
compression stockings during pregnancy is usually advised-ask your
obstetrician. Pregnancy not only causes increases in hormone levels
and blood volume. An enlarging fetus also puts pressure on the largest
vein of the body, the vena cava. Pressure on the vena cava also in
turn causes increased pressure on the veins of the legs. Normally,
within 3 months after delivery, improvement in varicose veins can
be seen. However, as stated above, once venous valves are damaged,
they do not repair themselves, and varicosities can worsen with subsequent
pregnancies, or even just with the passage of time. The foregoing
is especially true if damage has occurred at the saphenofemoral junction
or in perforating veins.
Q: How would I know if my vein valves weren't working properly?
A: The possible problems range from spider veins to varicose veins
and you could also have many physical symptoms such as leg swelling,
fatigue, throbbing, pain, burning, itching, heaviness, aching, restlessness
that seem most pronounced after standing your feet for a long time.
Discoloration in the ankle area and even leg ulcers (see chronic venous
insufficiency) may also be present.
Q: What are varicose veins?
A: Varicose veins are visible on the skin surface of the leg as ropey,
twisted elevations that can appear to be isolated or connected to
one another. They form as a direct result of vein valve malfunction.
By definition they occur in the veins of the superficial venous system
(most typically in the greater saphenous vein and its branches). A
malfunctioning vein valve allows blood to flow from an area of higher
pressure into an area designed to handle only lower pressures. Remember,
veins have thin walls, unlike arteries. Veins tend to inflate quite
easily, and over time under increased pressure their walls become
thickened, ropey, and unsightly. In addition, they can occasionally
bleed easily because, as part of the superficial vein system, they
are near the surface of the skin.
Q: Can varicose veins get worse over time?
A: Yes. A condition called chronic venous insufficiency can develop.
Discoloration of the skin in the ankle area (venous stasis discoloration)
occurs in some people and painful venous ulcers can develop that are
usually very difficult to heal and tend to reoccur even when they
do heal. Not everyone with chronic venous insufficiency develops venous
ulcers. Superficial thrombophlebitis (a condition in which a vein
close to the surface of the skin becomes inflamed and develops clot)
may also occur.
Q: I don't have varicose veins. I have smaller,
colored veins that look like the legs of a spider. What causes those?
A: The veins you are describing are
called spider veins or telangiectasias. Spider veins can occur singly
or in large numbers. Spider veins are often considered to be unsightly
and can cause leg pain and/or a feeling of heaviness. There is not
always a correlation between amount of discomfort felt and the number
of spider veins present; e.g. a person may have only a few spider
veins and feel a fair amount of pain. Conversely, a person may have
many spider veins and feel little or no pain. Just like the larger
varicose vein counterparts, spider veins are a result of increased
pressure and vein valve malfunction, only on a much smaller scale
than varicose veins.
Q: What is chronic venous insufficiency?
A: Chronic venous insufficiency refers to a condition in which there
is ongoing venous valve malfunction resulting in venous reflux.
Symptoms can include edema (swelling), skin discoloration (stasis
discoloration) that occurs specifically in the ankle area, and possible
venous ulcer formation. Chronic venous insufficiency can also occur
as a result of post-phlebitic syndrome.
Q: Does it make a difference what's causing
my vein problems?
A: Yes, it is very important to determine exactly what is causing
your vein problems, otherwise you can end up with a lot of expensive,
ineffective treatment. At Vein Specialists of Augusta we are very
aware of how important a correct diagnosis is. Therefore, at your
first visit we take a history, do a focused physical exam, and very
importantly, we do a non-invasive ultrasound and Doppler examination
that shows exactly what type of problem exists, and where. We look
at the junctions between the deep venous system and the superficial
veins that can have great importance in determining the appropriate
treatment. We also look at perforator junctions. Dr. Zumbro will
then make treatment recommendations based on the result of your
history, physical and ultrasound examination.
Q: I just have spider veins. Do I need an ultrasound
examination, too?
A: Yes. We have found that about 15% of people who come in with
just spider veins also have problems with their larger veins (which
could have caused the spider veins in the first place). We believe
it is important for you to know if larger vein problems are present
mainly because if they are, the large vein problem should be addressed
before the smaller vein problems are. Sometimes the smaller veins
go away by themselves after larger veins are treated. Most times,
however, treatment of larger veins makes treatment of smaller veins
much more successful.
Q: What kind of treatment is recommended if I only have small vein
problems?
A: Treatment of spider veins has for
many years included injection sclerotherapy. At Vein Specialists
of Augusta we use tiny needles to inject a solution (called a sclerosant)
into the veins that cause the vein to change and stop working and
eventually fade away. We use a new technique called foam sclerotherapy
in which the fluid is mixed into a foam before injection allowing
more of the sclerosant to come into contact with the vein wall.
Using the foam technique also is thought by some to make lower volumes
of sclerosant effective at lower concentrations. At VSA we also
use a device called a vein light to aid in locating the larger veins
that often "feed" a spider vein complex or even single
spider veins. Use of a vein light allows us to potentially treat
a large area of spider veins with just one or two injections. After
the injection we cover the area of veins injected with cotton balls
held in place with tape. Compression stockings are then worn for
at least 48 hours, but the cotton balls and tape are removed the
next day.
Q: Does treatment for my spider veins hurt?
A: Minimally. For injection sclerotherapy, we use micro needles.
One of the sclerosants we use is called Polidocanol, (aethoxysclerol)
which was developed as a local anesthetic, so it doesn't burn or
sting as some other sclerosants do, (in particular, hypertonic saline).
Polidocanol is in a class of sclerosants called "detergent"
sclerosants. The advantages of using a detergent sclerosant include
the fact that they are painless, have a low (to non-existent in
the case of Polidocanol) incidence of allergic reaction, are tolerated
well by the body if an inadvertent injection occurs outside the
vein and have low to moderate rates of causing pigmentation changes
or matting. We also use other sclerosants, such as STS (sodium tetradecyl
sulfate), and glycerin. The sclerosant used is dependent on the
specific needs of each patient.
Q: Is it safe to treat my spider veins?
A: Sclerotherapy is a technique that has been practiced since the
1930's. Problems are infrequent and very minor in an overwhelming
number of patients.
Q: How many treatments will it take?
A: Since everyone is different, we'll need to see you in order to
give you our estimate of how many treatments you will need. Usually
it takes 2-4 treatments.
Q: How soon will I see results?
A: Results are visible usually after about 3-6 weeks.
Q: How long will results last?
A: The actual veins that are treated should not ever come back.
However, the same condition that led to development of spider veins
in the first place is on-going if a larger source of the problem
is not detected and treated. Other spider veins can develop. Therefore
it is a good idea to think of sclerotherapy as a program of maintenance
that will need to be undertaken every year or two (or three or four
or five), depending on the individual.
Q: What is the success rate for sclerotherapy?
A: About 80-90%, when done by experts.
Q: Is sclerotherapy safe for everyone?
A: People with clotting disorders, who are pregnant, have an inability
to walk, or who are unwilling to follow directions should not have
sclerotherapy. We are as anxious for you to have good results as
you are to have them. Therefore, we ask you to refrain from vigorous
exercise or hot baths for a few days, and to wear your compression
stockings for 48 hours.
Q: I have varicose veins, will sclerotherapy
help me or will I need surgery?
A: As stated before, ultrasound examination is important to determine
the cause of varicose veins. Conservative therapy with compression
stockings and leg elevation (feet above your heart) can be effective
in relieving the symptoms and progression of varicose veins and
chronic venous insufficiency. Many people, however, do not want
to wear compression stockings for the rest of their lives. We have
a very effective new approach for treating varicose veins that takes
the place of surgery. For thirty to forty years, the answer to the
question "will I need surgery?" would have been yes. Even
now, some physicians will tell you that you need surgery to correct
the problem of varicose veins, and that usually means "vein
stripping" or "high ligation of the saphenous vein",
and/or occasionally it means "excision of varicose veins".
Q: Could I have had the invasive surgeries
you describe and still have a problem with my veins?
A: Yes. We frequently see people who
have had both vein stripping and high ligation of the GSV and still
have problems.
Q: Why can't there be a more effective treatment
that doesn't cause as much pain and wouldn't require general anesthesia
and an operating room?
A: There is such a treatment. It's called saphenous vein ablation.
There are two kinds: one uses radiofrequency energy and the other
uses laser energy. Vein Specialists of Augusta offers both, done
in our office (avoiding costly hospital charges). The radiofrequency
version we do is called "VNUS Closure" and the laser version
is called "CoolTouch CTEV". VNUS Closure and CoolTouch
CTEV are quite similar in many ways: In our office, the vein to
be treated is accessed under ultrasound guidance. A tiny wire is
threaded through the needle and using this wire, a catheter or a
flexible laser filament is then placed in the vein. After several
injections of an anesthetic mixture the energy (radiofrequency or
laser) is turned on and the vein is treated as the catheter or filament
is withdrawn. The leg is wrapped in a bandage (mainly to supply
compression), and a compression stocking is applied. The bandage
is removed the next day and the compression stocking should be worn
for 3 weeks. These procedures are both designed to "shut the
treated vein down" so that it cannot reflux and cause its problems.
(In fact, two years after Closure, the treated vein cannot be seen
by ultrasound 94% of the time).
Q: Isn't the greater saphenous vein the one used in heart bypass
surgery? What if I need it for that?
A: It is true that many times the greater saphenous vein is used
in cardiac surgery; however, if the vein is diseased, as is the
case with varicose veins and chronic venous insufficiency, it is
typically unusable for heart surgery. In addition, there are other
possible sources of veins or arteries in the body to use for that
purpose.
Q: Is there any restriction in activities following
saphenous vein ablation?
A: A few. We request that patients limit activities that require
contraction of the abdominal muscles because that causes an increase
in venous pressure in the legs for 7-10 days. Such activities include
jogging, heavy lifting, sit-ups, crunches and excessive stair climbing.
Since we want the treated vein to close, we want to subject it to
as little pressure as possible till it has a chance to heal. Walking
is encouraged. You'll be back to your more strenuous activities
in ten days to two weeks.
Q: How long do these procedures usually take?
A: The actual procedure takes about 45 minutes. Sometimes they can
take a bit more time depending on vein diameter and whether the
path of the vein includes many branches or is excessively twisting.
Q: I'm not pregnant now, but I plan to have
more children. Should I wait to have saphenous vein ablation until
no more pregnancies are planned?
A: There's no need to wait. While we certainly do not advise treatment
during pregnancy, treatment between pregnancies is desirable, and
makes subsequent pregnancies much more comfortable for those who
suffer from varicose veins and other kinds of venous disease.
Q: You mentioned sclerotherapy before. Why
can't you just use sclerotherapy on the greater saphenous vein?
A: Well, many people have tried that approach; however, results
shown in medical literature does not support the effectiveness of
such a practice. Treating very large veins with sclerotherapy can
be problematic. Many times when patients come to us who have had
sclerotherapy attempted on their greater saphenous vein, only a
few portions of the vein have closed, if indeed any of the vein
has closed at all. This can make it much more difficult or impossible
to thread a catheter or filament into the vein to complete the job.
Q: I've heard of something called "ultrasound-guided
sclerotherapy. Is this the same thing as sclerotherapy used on the
greater saphenous vein?
A: "Ultrasound-guided sclerotherapy" refers to sclerotherapy
done using the ultrasound for guidance. In other words, ultrasound
is used to locate any vein that cannot be seen on the surface of
the skin in order to inject it with a sclerosant.
Q: Will my insurance or Medicare pay for saphenous vein ablation
or ultrasound-guided sclerotherapy?
A: In most cases, yes. Also, remember, there are no separate hospital
charges to pay because these procedures are done in our office.
One of our services is to obtain pre-certification from your insurance
company.
Q: Does insurance or Medicare pay for sclerotherapy?
A: Usually no, because they consider sclerotherapy to be a cosmetic
procedure (ultrasound-guided sclerotherapy can often be an exception
to this rule).
Q: Doesn't my body need the veins that are
treated with any of the procedures you have described?
A: No. For every visible vein in your leg, there are many more beneath
the skin. Remember, even the tiniest spider vein has appeared as
a result of its not doing its job. In truth, the body does much
better without veins that malfunction. Healthy veins help to return
venous circulation back to normal.
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