FAQs About Vascular Disease,Varicose Veins, and Treatments Plan

Venous Disease

1. What is the difference between arteries and veins?

Arteries pump oxygen-rich blood away from the heart to different parts of body. Veins return oxygen-poor blood from various parts of the body back to the heart. With respect to the legs, arteries bring the blood down to the legs, and veins return blood up the legs back to the heart.

2. What are functions of normal veins?

The normal veins in the legs (both deep and superficial veins) carry blood back to the heart. During walking, calf muscles contract and act as a pump to force the blood back to the heart. All veins have one-way valves to prevent blood from flowing in the wrong direction back toward the feet. In the legs, surface veins drain into larger veins which run up to the groin.

3. What are the three main categories of veins in the leg?

Deep veins are in the center of the leg, within the muscles and near the bones. They act as the main highways to return blood back to the heart. Superficial veins are just beneath the skin, above the muscles. They act as the side roads to return blood back to the heart. Perforator or communicating veins serve as connections between the deep and superficial veins. Blood flows from superficial veins into the perforator veins in order to connect with the deep veins and return to the heart. VNUS Closure procedure concentrates in the treatment of superficial and perforator veins to treat varicosities.

4. What are varicose veins?

Varicose veins afflict 10% to 20% of all adults. Varicose veins are swollen, twisted, blue veins that are beneath the surface of the skin and occur in bunches like grapes, or in snakelike curves. Failing valves in the leg veins allow blood flow down into feet. This condition is known as venous reflux. Venous reflux causes surface veins to enlarge and becoming varicose. The force of blood traveling the wrong way to the foot causes the fluid to leak into the surrounding tissues, making the affected leg swell and feel heavy. Unsightly and uncomfortable, varicose leg veins can cause aching, heaviness, and tiredness in the legs. They may occur in almost any part of the leg. Left untreated, patient symptoms are likely to worsen. Patients may develop black discolorations of skin or ulcers (open non-healing sores) around ankles.

5. How can superficial venous reflux be treated?

Since vein valves cannot be easily or effectively repaired, the only alternative is to re-route blood flow through healthy veins. Traditionally, this has been done by surgically removing (stripping) the troublesome vein from legs. The VNUS Closure procedure provides a less invasive alternative to vein stripping by simply closing the problem vein instead of stripping it. Once the diseased vein is closed, other healthy veins take over and empty blood from legs.

6. Why do varicose veins occur in the legs?

Gravity and failing valves in leg veins are the cause. The distance from the feet to the heart is the furthest blood has to travel in the body. Consequently, if the vein valves fail, the backflow of blood causes the surface veins in legs to be under pressure, become swollen, enlarged and distorted.

7. Who is at risk for varicose veins?

Conditions contributing to varicose veins include genetics/hereditary, pregnancy, hormonal changes at menopause, work or hobbies requiring extended standing, obesity, trauma and injury to legs, and past vein diseases such as thrombophlebitis (inflammation of veins) or previous history of blood clots. Women suffer from varicose veins more than men, and the incidence increases to 50% of people over age 50. Since females usually have multiple risk factors for the development of varicose veins, about 75% of the persons who have varicose veins are women and 25% are men.

8. What are the symptoms of varicose veins?

Varicose veins may cause legs to ache, feel heavy, and tire easily. Feet and ankles may swell at the end of day. Varicose veins may itch or burn. Leg cramps can occur at any time, but more often at night. Varicose veins can get inflamed and cause redness of the skin. As skin and tissue damage progresses, ankles and feet can develop brown or black discolorations. In some cases, patients may develop ulcers and open painful sores.

9. What are the consequences of varicose veins?

Oxygen and nutrients are depleted from blood that pools in the varicose veins. The veins also do not tolerate high pressure well and begin to allow red blood cells and fluid to leak into the tissues of the leg. The fluid leak causes ankle swelling. The red blood cells in the tissues cause chronic inflammation and the skin becomes dark and discolored. The medical term for the dark discoloration is hyperpigmentation. When the skin and the fat under the skin are inflamed for years, the tissues become woody, firm, and unhealthy. The medical term for this woody, hard tissue is lipodermosclerosis.

10. How are blood clots formed in varicose veins?

The blood flow in varicose veins is slow enough to encourage blood to sit still and coagulate. The medical term, superficial thrombophlebitis, refers to the occurrence of blood clots in superficial veins. Superficial thrombophlebitis rarely causes death or a blood clot that travels to the lungs. However, progression of a superficial phlebitis to involve the deep veins may have fatal consequences.

11. What are the short term treatments for varicose veins?

Exercise, compression stockings, and elevation of legs during rest may improve symptoms. However, these regimens will not treat varicose veins or the underlying disease (venous reflux) and will not prevent varicose veins from worsening. Weight reduction is also helpful. Insurance companies often require some time in use of compression stockings, exercise, trial of anti-inflammatory drugs (Aspirin, Ibuprofen, Motrin, Advil, Naproxen), and leg elevation before authorizing treatment. This approach provides an initial conservative measure and attempt at symptom control, however, will not change the underlying problem. At best, they may slow the advances of the complications of chronic vein disease, but will not reverse them.

12. What are the effects of varicose vein treatment on blood flow?

Patients at times are concerned that the loss of the varicose veins will have a negative effect on their circulation. They ask: "How will the blood get back to my heart if these veins are gone?" The answer is that varicose veins are non-functional and do not help the circulation. Blood does not flow effectively through varicose veins back to the heart and instead, sits in the legs. Varicose veins can actually harm the body. Their treatment improves circulation by allowing blood to pass through the remaining normal functioning veins back to the heart.

13. What is phlebectomy?

Phlebectomy is a surgical procedure used for the treatment of varicose veins. Multiple small incisions are made along the varicose vein and veins are pulled and removed from the leg using surgical hooks or forceps. The procedure is done under local or regional anesthesia, in an operating room or an office "procedure room."

14. What is vein stripping?

Vein stripping is a surgical procedure used for the treatment of varicose veins. This is a more extensive procedure than phlebectomy and is used in treatment of larger surface veins. Under general anesthesia, all or part of the vein is tied off and pulled out. The legs are bandaged after the surgery, however, swelling, bruising, and pain can last from days to weeks. Vein stripping should be regarded as a procedure of the past. It carries higher risk, greater pain, greater disability, longer recovery, greater cost, and less effective results than VNUS Closure procedure. Vein stripping causes a lot more bruising and pain which results from tearing the side branch veins while the saphenous vein is pulled out.

15. What are spider veins?

While varicose veins are located deeper under the skin in fat, spider veins are hair-thin, much smaller and superficial and are located in the skin. They may be blue or red color and frequently look like a spider. The medical term for a spider vein is telangiectasia. They may or may not be associated with other underlying vein disease, such as varicose veins. Therefore, an ultrasound exam may be advised since unrecognized underlying vein disease is the most common reason for unsatisfactory results.

16. How are spider veins treated?

Before treating surface spider veins, any underlying vein disease must be evaluated and treated first. Sclerotherapy is used to treat spider veins. This involves using a tiny needle to inject a small quantity of a solution that will shut down the vein. It is nearly painless, and even patients who are afraid of needles do very well with treatment. First, larger varicose veins are treated. Second, medium size surface feeder veins (called reticular veins) which are connected to spider veins are treated. Lastly, spider veins are treated within a few weeks. After treatment sessions, a compression stocking is worn for three weeks during the day. Injection sites may initially appear bruised or red. Within a few weeks, once the healing process in complete, most spider veins look better, although, continued improvement usually occurs over many months. Depending on the size and surface area of spider veins, multiple treatment sessions may be necessary.

17. What is sclerotherapy?

A solution is injected into a vein to cause a chemical injury of the cellular lining within the vein. This process results in the vein closing through a scar-like reaction. It is most effective when underlying sources of venous reflux have been treated. Leg wrapping and stockings are often used following this procedure.

18. What solutions do you use for sclerotherapy?

We use two different solutions for sclerotherapy. Sodium Morrhuate is an FDA approved agent which is very effective, however, is painful to inject and can cause skin discoloration. We also use Polidocanol which is also FDA approved and very effective. It is less painful with lower risk of skin discoloration. Polidocanol can also be used as "foam sclerotherapy." Informed consent for sclerotherapy includes side effects (e.g.,dry cough, or visual changes) which are transitory, allergic reactions, and skin changes or discoloration.

19. What are venous leg ulcers?

A skin ulcer is caused by a venous reflux disorder or chronic leg venous hypertension that is not treated. Venous stasis ulcer or sores are areas of the lower leg where the skin has opened and exposed the flesh beneath. Early signs that a venous stasis ulcer may develop include darkening of the skin in the area of the ankle. Gradually, the skin may become leathery or waxy in appearance. Without treatment of the venous disease, the skin may breakdown and bleeding may occur. Ulcers can differ in size or appearance. They are painful, odorous open wounds which weep fluid and can last for months or even years. Most leg ulcers occur when vein disease is left untreated. They are most common among older people but can also affect individuals as young as 18.

VNUS Closure™ Procedure

20. What is the VNUS Closure procedure?

VNUS Closure is a new revolutionary treatment used instead of vein stripping. It eliminates venous reflux and treats varicose veins without physically removing the vein. It is performed as an outpatient same-day procedure in the office with local anesthesia. VNUS Closure or Radiofrequency Ablation uses gentle and careful applications of heat through a small catheter placed inside of the vein. VNUS Closure causes the vein to close off and empty of blood. Ultrasound is required to make the diagnosis and to indicate whether a patient is a candidate for the procedure. Like other procedures, VNUS Closure involves risks and potential complications, but risks are much less likely and results are more effective than with traditional surgery and vein stripping.

21. How is VNUS Closure different from vein stripping?

During vein stripping, the surgeon makes an incision in the groin and ties off the vein. A stripper tool is then threaded through the saphenous vein and is used to pull the vein out of leg through a second incision. Other additional incisions may also be needed to get a complete result. In the VNUS Closure procedure, there is no need for groin surgery. Instead, the vein remains in place and is closed using a special catheter placed in the vein through the skin. This method eliminates lots of the bruising and pain often associated with vein stripping. Vein stripping is usually performed in an operating room, under a general anesthetic, while VNUS Closure is performed on an outpatient basis, typically using local or regional anesthesia. Three randomized trials of the VNUS Closure vs. vein stripping, including the most recent multi-center comparative trial, show very similar results. In the multi-center comparative trial, VNUS Closure procedure was superior to vein stripping in every statistically significant outcome. In the study, 80.5% of patients treated with the VNUS Closure returned to normal activities within one day, versus 46.9% of patients who underwent vein stripping. Also, VNUS Closure patients returned to work 7.7 days sooner than surgical patients. Patients treated with the VNUS Closure had less postoperative pain, less bruising, faster recovery and fewer overall adverse events.1

22. How long does VNUS Closure take?

The procedure typically takes about 45-60 minutes, including the normal pre-procedure preparation and post-treatment evaluation.

23. Is VNUS Closure painful?

Patients report feeling little, if any, pain during the procedure. Local or regional anesthetic will be administered to numb the treatment area.

24. Will VNUS Closure require any anesthesia?

The procedure can be performed under local, regional, or general anesthesia.

25. How quickly after VNUS Closure can I return to normal activities?

Many patients can resume normal activities immediately. For a few weeks following the treatment, we recommend a regular walking regimen and suggest you refrain from very strenuous activities (for example, heavy lifting) or prolonged periods of standing.

26. How soon after VNUS Closure will my symptoms improve?

Most patients report a noticeable improvement in their symptoms within 1-2 weeks following the procedure.

27. Is there any scarring, bruising, or swelling after VNUS Closure?

Patients report minimal to no scarring, bruising, or swelling following the procedure.

28. Are there any potential risks and complications associated with VNUS Closure?

As with any medical intervention, potential risks and complications exist with the VNUS Closure procedure. Potential complications can include: vessel perforation, thrombosis, pulmonary embolism, phlebitis, hematoma, infection, paresthesia (numbness or tingling) and/or skin burn.

29. Is the VNUS Closure suitable for everyone?

Experience has shown that many patients at any age with superficial venous reflux can be treated with the VNUS Closure procedure.

30. Is age an important consideration for VNUS Closure?

The most important step to determine if VNUS Closure is appropriate involves a complete ultrasound examination by a qualified clinician. Age alone is not a factor. VNUS Closure procedure has been used to treat patients across a wide range of ages.

31. How effective is VNUS Closure?

Published data suggests that two years after treatment, 90% of the treated veins remain closed and free from reflux, the underlying cause of varicose veins.3,4,5

32. What happens to the treated vein left behind in the leg?

The vein simply becomes fibrous tissue after treatment. Over time, the vein will gradually incorporate into surrounding tissue. One study reported that 89% of treated veins are indistinguishable from other body tissue one year after the VNUS Closure was performed.6

33. Is VNUS Closure covered by insurance?

Many insurance companies are paying for the VNUS Closure procedure in part or in full. Most insurance companies determine coverage for all treatments, including VNUS Closure, based on medical necessity. VNUS Closure has positive coverage policies with most major health insurers. We can discuss your insurance coverage further at the time of consultation.

34. What are patients saying about VNUS Closure?

98% of patients who have undergone the VNUS Closure procedure are willing to recommend it to a friend or family member with similar leg vein problems.7

Other

35. What about lasers?

Lasers are used in medicine, however, are not always the best modality in certain treatment regimens. Lasers have been used to treat spider veins of the legs. Unfortunately, it can be performed by those who are not experts in vein diseases. This can lead to overlooking underlying vein abnormalities and less than satisfactory outcomes. Lasers are also more painful than sclerotherapy. Lastly, lasers are more expensive than simple sclerotherapy injection. Some have said lasers are good to treat veins that are too small to inject. Most vein experts, however, find no vein is too small to inject.

36. What is EVLT?

EVLT stands for EndoVenous Laser Therapy. Laser companies have developed a system and a catheter to treat varicose veins similar to the VNUS Closure radiofrequency technique. Laser produces more heat during the procedure and as a results, patients have reported more discomfort post-procedure with laser. Initially, laser was attractive to physicians because it’s speed. The new radiofrequency ClosureFAST™ catheter, however, is as fast or faster than laser, but with the advantage of less discomfort.

37. What can I expect at the first appointment?

Your medical history will be reviewed. Your legs and abnormal veins will be examined. You will be scheduled for an ultrasound examination if needed. Ultrasound examination will be performed at a later time and almost everyone with varicose veins needs one. Following completion of the above, a treatment plan will then be prescribed. If you are being seen for simple spider veins, treatment may begin at that first visit if you let us know that is what you would like at the time you make your appointment.

38. What is the cancellation policy?

Occasionally patients fail to come for their appointment and don't notify us. This leaves a large gap in our schedule that someone else might have used. We therefore have a policy that consultation appointments will be held with a $100 deposit. If you need to cancel, you must let us know within 2 working days. Failure to show without notice results in forfeit of the deposit. Obviously, if a family emergency arises, let us know and the deposit will not be forfeited.

39. What are your office hours?

Sierra Vein & Vascular Institute is open Monday through Friday, 8:00 a.m. to 5:00 p.m.

40. What type of medical insurance do you accept?

We are participating providers for Medicare, Medical, all PPO plans, and many other insurance plans.

1 Lurie F, Creton D, Eklof B, Kabnick LS, Kistner RL, Pichot O, et al. Prospective randomized study of endovenous radiofrequency obliteration (Closure) versus ligation and stripping in a selected patient population (EVOLVES study). J Vasc Surg 2003;38:207-14. 2 Goldman, H. Closure of the greater saphenous vein with endo radiofrequency thermal heating of the vein wall in combination with ambulatory phlebectomy: preliminary 6-month follow-up. Dermatology Surg 2000; 26:452-456.
3 Merchant RF, DePalma RG, Kabnick LS. Endovascular obliteration of saphenous reflux: a multicenter study. J Vasc Surg 2002;35:1190-6.
4&7 Weiss RA, et al. Controlled Radiofrequency Endovenous Occlusion Using a Unique Radiofrequency Catheter Under Duplex Guidance to Eliminate Saphenous Varicose Vein Reflux: A 2-Year Follow-up, Dermatologic Surgery, Jan 2002; 28:1: 38-42
5 Whiteley, MS, Holstock JM, Price BA, Scott MJ, Gallagher TM. Radiofrequency Ablation of Refluxing Great Saphenous Systems, Giacomini Veins, and Incompetent Perforating Veins using VNUS Closure and TRLOP technique. Abstract from Journal of Endovascular Therapy 2003; 10:I-46.
6 Pichot O, Sessa C, Chandler JG, Nuta M, Perrin M. Role of duplex imaging in endovenous obliteration for primary venous insufficiency. J. Endovasc Ther 2000;7:451-9.

Sierra Vein & Vascular Institute

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Manteca, CA 95337
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Modesto, CA 95355
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Associations

American Medical Association

Society for Vascular Surgery

American Medical Association

Society for Vascular Medicine

American College of Surgeons

American College of Surgeons

Society of Thoracic Surgeons

Society of Thoracic Surgeons

American College of Cardiology

American College of Cardiology

American Board of Thoracic Surgery

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Thoracic Surgery

American Board Surgery

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Surgery

American Society for Laser Medicine and Surgery

American Society for
Laser Medicine and
Surgery

American College of Phlebology

American College of
Phlebology

American Heart Association

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American Medical Association

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California Medical Associations

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