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. Radiofrequency Thermal Ablation or Chemical Ablation 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. Radiofrequency Thermal Ablation or Chemical Ablation 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 Radiofrequency Thermal Ablation or Chemical Ablation 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 solution do you use for sclerotherapy?
We use Polidocanol which is a highly effective and safe solution for sclerotherapy. It is less painful with lower risk of skin discoloration than other solutions. Polidocanol can also be used as "foam sclerotherapy."
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.
Radiofrequency Thermal Ablation / Chemical Ablation
20. What is Radiofrequency Thermal Ablation procedure?
Radiofrequency Thermal Ablation 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. Radiofrequency Thermal Ablation uses gentle and careful applications of heat through a small catheter placed inside of the vein. Radiofrequency Thermal Ablation 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, Radiofrequency Thermal Ablation involves risks and potential complications, but risks are much less likely and results are more effective than with traditional surgery and vein stripping.
21. What is Chemical Ablation?
Chemical Ablation closure treats symptomatic venous reflux disease in the lower extremity superficial venous system, often the underlying cause of painful varicose veins. This procedure uses an adhesive to close the vein. The catheter is advanced into the diseased vein under ultrasound guidance. It is the only non-thermal, non-tumescent, non-sclerosant procedure approved for use in the U.S. that uses an advanced formulated medical adhesive that closes the diseased vein.
22. How is Radiofrequency Thermal Ablation or Chemical Ablation 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 Radiofrequency Thermal Ablation procedure or Chemical Ablation, 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 Radiofrequency Thermal Ablation or Chemical Ablation is performed on an outpatient basis, typically using local or regional anesthesia. Three randomized trials of the Radiofrequency Thermal Ablation or Chemical Ablation vs. vein stripping, including the most recent multi-center comparative trial, show very similar results. In the multi-center comparative trial, Radiofrequency Thermal Ablation or Chemical Ablation procedure was superior to vein stripping in every statistically significant outcome. In the study, 80.5% of patients treated with the Radiofrequency Thermal Ablation or Chemical Ablation returned to normal activities within one day, versus 46.9% of patients who underwent vein stripping. Also, Radiofrequency Thermal Ablation or Chemical Ablation patients returned to work 7.7 days sooner than surgical patients. Patients treated with the Radiofrequency Thermal Ablation or Chemical Ablation had less postoperative pain, less bruising, faster recovery and fewer overall adverse events.1
23. How long does Radiofrequency Thermal Ablation or Chemical Ablation take?
The procedure typically takes about 45-60 minutes, including the normal pre-procedure preparation and post-treatment evaluation.
24. Is Radiofrequency Thermal Ablation or Chemical Ablation painful?
Patients report feeling little, if any, pain during the procedure. Local or regional anesthetic will be administered to numb the treatment area.
25. Will Radiofrequency Thermal Ablation or Chemical Ablation require any anesthesia?
The procedure can be performed under local, regional, or general anesthesia.
26. How quickly after Radiofrequency Thermal Ablation or Chemical Ablation 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.
27. How soon after Radiofrequency Thermal Ablation or Chemical Ablation will my symptoms improve?
Most patients report a noticeable improvement in their symptoms within 1-2 weeks following the procedure.
28. Is there any scarring, bruising, or swelling after Radiofrequency Thermal Ablation or Chemical Ablation?
Patients report minimal to no scarring, bruising, or swelling following the procedure.
29. Are there any potential risks and complications associated with Radiofrequency Thermal Ablation or Chemical Ablation?
As with any medical intervention, potential risks and complications exist with the Radiofrequency Thermal Ablation or Chemical Ablation procedure. Potential complications can include: vessel perforation, thrombosis, pulmonary embolism, phlebitis, hematoma, infection, paresthesia (numbness or tingling) and/or skin burn.
30. Is the Radiofrequency Thermal Ablation or Chemical Ablation suitable for everyone?
Experience has shown that many patients at any age with superficial venous reflux can be treated with the Radiofrequency Thermal Ablation or Chemical Ablation procedure.
31. Is age an important consideration for Radiofrequency Thermal Ablation or Chemical Ablation?
The most important step to determine if Radiofrequency Thermal Ablation or Chemical Ablation is appropriate involves a complete ultrasound examination by a qualified clinician. Age alone is not a factor. Radiofrequency Thermal Ablation or Chemical Ablation procedure has been used to treat patients across a wide range of ages.
32. How effective is Radiofrequency Thermal Ablation or Chemical Ablation?
Published data suggests that three years after treatment, over 91% or more of the treated veins remain closed and free from reflux, the underlying cause of varicose veins.
33. 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. Majority of treated veins become indistinguishable from other body tissue within approximately one year after the Radiofrequency Thermal Ablation or Chemical Ablation was performed.
34. Is Radiofrequency Thermal Ablation or Chemical Ablation covered by insurance?
Many insurance companies are paying for the Radiofrequency Thermal Ablation or Chemical Ablation procedure in part or in full. Most insurance companies determine coverage for all treatments, including Radiofrequency Thermal Ablation or Chemical Ablation, based on medical necessity. Radiofrequency Thermal Ablation or Chemical Ablation has positive coverage policies with most major health insurers. We can discuss your insurance coverage further at the time of consultation.
35. What are patients saying about Radiofrequency Thermal Ablation or Chemical Ablation?
98% of patients who have undergone the Radiofrequency Thermal Ablation or Chemical Ablation procedure are willing to recommend it to a friend or family member with similar leg vein problems.
Other
36. 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.
37. What is EVLT?
EVLT stands for EndoVenous Laser Therapy. Laser companies have developed a system and a catheter to treat varicose veins similar to Radiofrequency Thermal Ablation or Chemical Ablation. 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 of it’s speed. The new Radiofrequency Thermal Ablation or Chemical Ablation is as fast or faster than laser, but with the advantage of less discomfort.
38. 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.
39. 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 in regards to our appointments . If you need to cancel, you must let us know within 2 business days before the appointment. Reschedule or cancellation fees are the following: Consults or follow ups - $25.00. Ultrasounds or procedures - $50.00. Obviously, if a family emergency arises, let us know.
40. What are your office hours?
Sierra Vein & Vascular Institute is open Monday through Friday, 8:00 a.m. to 5:00 p.m.
41. What type of medical insurance do you accept?
We are participating providers for Medicare, Medical, all PPO plans, and many other insurance plans.
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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: 1190-1196.
4. 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: 1-46.
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: 451-459.
7. Morrison N, Kolluri R, Vasquez M, Madsen M, Jones A, Gibson K. Comparison of cyanoacrylate closure and radiofrequency ablation for the treatment of incompetent great saphenous veins: 36-Month outcomes of the VeClose randomized controlled trial. Phlebology 2018; 34:6: 380-390.
