Spider and Varicose Veins - The Bottom Line - Dr. Landi

In the United States hundreds of thousands of both men and women are affected by spider and varicose veins.  Initially, it was thought that the only treatment for varicose veins was a procedure called stripping of the veins which involved multiple stitches and a long recovery and downtime.  For spider veins, in the past, the only treatment was injection of the veins (sclerotherapy) with saline solution.  This was a painful treatment with multiple potential complications including brownish discoloration, failure to eradicate the veins, pain with injection and even the potential for ulceration of the skin.  The treatment for both spider and varicose veins has evolved to what is now considered the current state of the art therapies.  For varicose veins, laser or radio frequency closure is the procedure of choice and for spider veins injection sclerotherapy with a foamed solution.

Before beginning with any treatment of spider or varicose veins it is absolutely mandatory that a detailed venous ultrasound be done of the lower extremities.  This ultrasound includes evaluation of the greater and lesser saphenous veins, all deep and communicating veins, as well as any ancillary veins such as communicating veins, perforating veins and even a vein behind the leg called the Vein of Giacomini.  Any or all of these veins can be malfunctioning.  The ultrasound which takes about thirty minutes, should be performed by a Registered Vascular Technologist (RVT) who is a person certified and trained to perform ultrasonic examinations.  The veins are evaluated to check for something called reflux.  What this does is essentially look to see if valves in the veins are leaking.  The basic principal with varicose veins is that blood normally flows from the feet to the heart through two mechanisms.  One is the contraction of the muscles in the legs working to squeeze the blood through the veins pushing it towards the heart.  Secondarily, the valves in these veins open and close so as to push the blood from the feet to the heart.  If the valves do not close properly then the blood goes backwards through the valves, leaks around the valves and is then pushed superficially through the skin to form the varicose veins and spider veins.  Therefore, unless a detailed ultrasound is done, the exact location of the refluxing (incompetent valves) will not be known.  This is important when considering not only spider vein treatment but also varicose vein treatment.  Very frequently patients will have their veins injected without any assessment of the valves.  If the patient does have an incompetent valve then usually the injection treatment will not work and, in fact, more veins will usually occur.

In addition to looking at these valves in the superficial veins a detailed evaluation is also done of the deep veins in the leg to look for clots or obstruction, as well as the connecting (perforating veins).  The perforating veins connect the superficial system to the deep system of veins.  Realistically, there could be problems with any of the three various layers of veins, the superficial system consisting of the greater and lesser saphenous veins, or the connecting veins or the deep system.  Once this detailed ultrasonic evaluation is done it should be then interpreted by a physician who is adequately trained and certified to evaluate the ultrasound.  This should be done by a physician who is certified as a registered vascular technician or certified as an RPVI (Registered Physician in Vascular Interpretation).

Following a thorough ultrasonic evaluation decisions can then be made as how to best treat the spider and varicose veins.  If the patient simply has spider veins and there is no reflux then these veins can be treated by injection sclerotherapy alone with a high success rate.  Injection sclerotherapy involves the injection of a solution into the spider vein to close or seal the tiny vessels.  There are several solutions that are commonly used currently to inject veins.  One is a foam solution, which is a mixture of liquid with air and which sort of looks like a shaving cream.  The foam then is  injected into the spider veins to help to eradicate them.  A second solution called glycerin is  slightly stronger then foam and is primarily used for very tiny spider veins.  One sclerotherapy treatment usually will not eradicate all spider veins.  As a general rule of thumb about a third of veins will be eradicated immediately, a third will require a second or third treatment and a third may require multiple treatments.  In general, approximately 90% of most spider veins can be eliminated with sclerotherapy.  However, depending on how many spider veins a patient has, multiple treatment sessions may be necessary.  It should be noted that although spider veins are treated by many people including dermatologists, plastic surgeons, podiatrists and even cardiologists, nurses and P.A.’s, the most qualified person to treat these veins is a vascular surgeon.

For varicose veins current state of the art for the treatment is a closure technique.  This could be done with either a radio frequency (VNUS) or a laser.  Both of these function in a very similar manner.  The end result is that the vein treated is closed by inserting a laser filament or radio frequency catheter into the vein and then firing the catheter which then heats the vein to seal it.  In effect, think of  this as a process that seals the leak in the vein.  This entire procedure is done usually in the office setting with either minimum sedation or no sedation at all and with a process called tumescent anesthesia.  This kind of anesthesia is a very dilute anesthesia injected along the course of the vein which serves two functions:  one is to buffer the laser of radio frequency from the skin so as not to burn the skin and secondly to bathe the vein in an anesthetic solution so as to shrink the size of the vein and to give long lasting anesthesia after the procedure.  The closure procedure is done on an outpatient basis and in most instances, by the next day, the patient is back to most routine activities.  Following the closure procedure the patient will need to wear compression stockings for a variable amount of time, usually at least two weeks.  The closure technique is performed by many kinds of physicians including plastic surgeons, cardiologists, radiologists and vascular surgeons.  However, the physician with the most expertise in the treatment of veins is the vascular surgeon.

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