Trust Your Legs To Northern California's Most Experienced Vein Specialist
Sebastian Conti, MD, FACS
Advanced Vein Care
6450 Coyle Avenue, Suite 1
Carmichael, CA 95608
Answers To Questions About Varicose Veins
WHAT IS THE FUNCTION OF LEG VEINS?
Veins return blood from the legs to the heart. There are both superficial and deep leg veins. The deep veins have excellent support because they are surrounded by muscle whereas the superficial veins have relatively little support, surrounded as they are by just fat and skin. When the muscles of the legs contract the veins are compressed and blood is propelled upwards towards the heart.Vein valves function to keep blood flowing in one direction only - up toward the heart. When the pressure above a valve becomes higher than the pressure below the valve, the valve snaps shut. This one way check valve action prevents regurgitation down the vein, empties the vein and thereby reduces vein pressure.
WHAT CAUSES VARICOSE VEINS? People with varicose veins usually inherit a weakness in the structure of the leg veins so that over time and with the stresses of ordinary living (including pregnancy, standing, etc.) susceptible veins gradually dilate, and as they dilate the valves stretch. Stretching of the valves damages them and prevents them from closing tightly. As a consequence blood regurgitates through the leaky valve and the vein emptying which normally occurs does not occur. As a consequence vein pressure remains elevated. It is this sustained increase in pressure that causes most of the problems that people with varicose veins have.
HOW DO BODY POSITION AND ACTIVITY AFFECT VEIN PRESSURE?
The vein pressure at the ankle level with an individual standing erect is proportional to the distance from the ankle to the heart. This hydraulic pressure is caused by the effect of gravity on the column of liquid (your blood) extending from the ankle to the heart. In the average height individual that pressure is about 90 millimeters (mm) of mercury (the same units as when your arm blood pressure is measured with a cuff). When the leg muscles contract during walking, this pressure falls to about 20 mm because the muscles empty the veins. After you stop, the pressure returns to 90, then falls again to 20 mm when you walk again. If an average of these pressures for the day were taken the average pressure would be about 50 mm.
In a patient with varicose veins the pressure reduction which normally occurs does not occur and the pressure may only go down to about 50 mm; therefore the average pressure would be higher or about 75 mm. It is this increase in average pressure from 50 to 75 mm that accounts for most of the problems encountered. This sustained increase in pressure causes the vein to swell. In response to this increased pressure the vein wall gets bigger and thicker, and of course this is what a varicose vein is - a big thick-walled tortuous vein which can be tender to the touch and cause aching and pain. Increased pressure inside the vein also forces fluid outside the vein causing the leg to swell and feel heavy and tired. After a while the vein walls become more porous and this results in a leakage of chemicals from within the blood stream out into the fat and skin. Inflammation occurs which impairs oxygenation and nutrition of these tissues, and eventually, staining and ulceration of the skin can develop.
HOW ARE VARICOSE VEINS TREATED?
As explained above, the underlying cause of all problems that occur with varicose veins is a sustained increase in vein pressure (venous hypertension). It follows then that for effective treatment and prevention of varicose veins, measures to counteract this increased pressure must be used. This can be done by remembering "The Four 'E's of Treatment and Prevention."
1. Elastic support stockings - stockings designed for this purpose provide the superficial veins what muscles provide for the deep veins - counter pressure. One never sees varicose veins in the deep system because the muscles give them such good support. Clearly your body is telling you something. It is very important for both treatment and prevention to wear a pair of good quality elastic stockings. These are available by prescription. They range in price from $15 to as much as $120 depending on the manufacturer and whether one desires a "designer" line, and are available at a discount at Advanced Vein Care. Stockings should be worn as much as possible, especially if you are going to be up on your feet for a long time. Obviously when the weather is extremely hot wearing elastic stockings is not comfortable. On days like this it is important that other measures are taken.
2. Elevation of the legs - leg elevation is the most important part of treatment and prevention. Remember that while you are standing, the pressure in your veins is proportional to the distance from your ankle to the heart. When you lie down flat your ankles and heart are at the same level; therefore the pressure is zero. Still better is elevating your legs as high above your heart as possible. In this position gravity works with you rather than against you and the vein pressure becomes negative; if done enough times during the day the average vein pressure is substantially reduced. This of course helps control your symptoms and more importantly can prevent problems in the future. It is important to lie down at least four times a day with your legs elevated above your heart and to keep them elevated for at least 15 minutes each time. Obviously the more you can elevate them, the better. It's also a good idea to elevate the foot of your bed (on concrete blocks) or place a foam wedge under the mattress. Many people place pillows underneath their legs but this is not effective because the weight of the leg compresses the pillow so that there is little elevation if any.
3. Exercise - any activity that causes contraction of the leg muscles is good. Therefore walking, running, aerobics, bicycling, stair steppers are all good ways to reduce the pressure in your veins. The best exercise for this condition is swimming because the body is horizontal (for a zero vein pressure), the muscles are exercising, and the water pressure adds additional counter pressure. Many people with severe varicose veins report marked relief when they go swimming or merely sit in a spa. It is not a good idea to lift heavy weights because this increases the pressure in your abdomen that in turn is transmitted to your veins.
There are other simple activities to temporarily reduce vein pressure; for example if you are standing in line at the grocery store, step up an down on your toes. This effectively reduces the pressure in your leg veins, compared to if you just stand. Develop a habit of moving your ankles, feet and legs while you are sitting or standing. Remember whenever your muscles are active, the pressure in your veins is reduced. Avoid crossing your legs.
4. Elimination of excess weight - extra body weight may put additional pressure on veins and exacerbates symptoms. If you are overweight you are less likely to exercise, which can also make your leg veins hurt more. It is therefore important to maintain a reasonable body weight.
If all of the above recommendations are followed you will be doing everything you can possibly do to alleviate your vein symptoms and to prevent problems in the future. If you understand the relationship between pressure and leg position, and what can be done to counteract this pressure, the more effective you will be in relieving your symptoms and preventing future problems.
WHEN SHOULD INJECTION TREATMENT BE CONSIDERED?
If the above measures are not effective in controlling your symptoms, you may wish to consider either injection treatment or surgery. In the hands of an experienced physician, injection treatment can be quite good. For smaller varicose veins, injections are the preferred method of treatment. Injections are done in the office using a special saline/local anesthesia solution. There is no need to take any time off from work. Elastic stockings are worn for about one week. Most patients require two or three sessions about one month apart. Improvement occurs in 80% - 90% of patients treated. The cost depends on how many veins need to be treated. An cost estimate will be provided at the initial consultation. The consultation is free.
WHEN IS SURGERY RECOMMENDED?
When varicose veins are larger (over 1/2 inch in diameter) a surgical approach is preferred because the recurrence rate is much lower than with injections. Surgical treatment is also more efficient - the problem is taken care of in just a few hours instead of over the weeks and months it may take with injections. The extent of surgery depends on the location of your varicose veins and the status of the vein valves and deep veins. In order to select the best operation a vein ultrasound examination is done. This noninvasive test will determine whether your major superficial veins (long saphenous vein and short saphenous vein) have abnormal valve function.
If the valve function of the major superficial veins is normal, then the varicose veins can be removed with a minor surgical procedure. Many people have heard horror stories about painful, disfiguring surgery that was done to remove varicose veins. Certainly in the past many surgeons were unconcerned about the cosmetic results and large incisions were made without regard to healing. Hospital stays were frequently as long as a week.
However with modern techniques surgery is done without hospitalization and can be done under local anesthesia. The veins are marked with ink before surgery to enable the surgeon to do a thorough job. In a technique called “Microphlebectomy,” tiny incisions are made, the underlying veins are pulled out with forceps and removed. Usually about 20 or 30 of these little incisions are needed to completely remove the involved veins. The incisions are closed with butterfly tapes or tiny sutures. The cosmetic result is very good because the incisions are made so that there is very little tension on their edges when they are closed. The leg is wrapped with elastic bandages that are kept in place for about one week at which time a return office visit is scheduled for removal of the bandages and tapes. Pain medicine is prescribed but most patients take it only for the first few days after surgery. Normal activities and most kinds of work can be resumed in one or two weeks or sooner if desired. Elastic support is advisable for one or two months after surgery and sometimes for an indefinite period of time.
WHEN IS "VEIN STRIPPING" DONE?
Vein stripping is an operation that was done in the past If the ultrasound examination showed severe valve leakage in the saphenous vein (the main superficial vein in the thigh), or if the saphenous vein is dilated to more than one half inch. This was done by making an incision in the groin, disconnecting the saphenous vein from its attachment to the femoral vein and then removing the vein down to the knee or sometimes below the knee through separate small incisions. However, newer, less invasive ablation treatment is now available and nowadays vein stripping is rarely performed.
WHAT ALTERNATIVES ARE THERE TO VEIN STRIPPING?
The best alternative to vein stripping is a relatively new technique called “Endovenous Ablation” (employing radiofrequency or laser energy) of the saphenous vein. Endovenous ablation is an excellent alternative treatment for individuals with symptomatic varicose veins. It is associated with fewer complications, less postoperative pain and enables return to work sooner than with conventional vein stripping. Studies have shown that the results achieved with endovenous ablation are as good if not better than with vein stripping.
“ENDOVENOUS ABLATION” TECHNIQUE
Modern technology now permits treatment of serious vein problems to be performed in the office using mild sedation and just local anesthesia. General anesthesia is NOT required. A small catheter is inserted into the saphenous vein just below the knee and the tip advanced to groin level. The catheter delivers radiofrequency (RF) to the vein wall, causing it to collapse, and seal shut. Once the diseased vein is closed, other healthy veins take over and empty blood from your legs. Your symptoms should also improve noticeably following the procedure. After the catheter is removed, a bandage is placed over the insertion site and your leg is wrapped to aid healing. Oftentimes any bulging varicose veins in the thigh or calf will shrink after closure. if this does not occur, the bulging varicose veins can be removed using the microphlebectomy technique described above, or with an injection technique known as "foam sclerotherapy."
If you'd like to know more about endovenous ablation, go to this Web Site: http://www.vnus.com/
VNUS Closure VNUS Closure
WHAT IS FOAM SCLEROTHERAPY ?
Foam sclerotherapy is a specialized injection technique in which a small amount of air is mixed with sclerosing solution, and then injected into the varicose veins. Published reports describe excellent reults in terms of immediate and primary closure of the injected varicose veins. In experienced hands it can be done with less discomfort and fewer complications than conventional injection treatment with saline.
WILL THE VARICOSE VEINS COME BACK?
Vein stripping, endovenous closure and sclerotherapy are effective in eliminating varicose and spider veins. However no treatment can eliminate an individuals susceptibility to venous insufficiency. The liklihood of recurrence is related to: 1. How strong the family history of varicose veins is - if both mother and father were affected then the recurrence rate is higher. 2. Whether a proper evaluation and the appropriate treatment was done in the first place. if vein treatment is carried out by a non – qualified physician, results will not be as effective. For best results, an accurate diagnosis with ultrasound must first be made. A qualified physician is one who can provide whatever treatment is best for the patient, whether it’s surgery, laser or injection, and who will provide the necessary follow up support and care that is needed. The recurrence rate after varicose vein surgery is less than after injection treatment of similar veins. With injection treatment of large varicose veins, the recurrence rate may be as high as 50 % after five years, if the underlying valve abnormalities are not corrected first with surgical treatment.
WHAT ARE THE RISKS OF VEIN SURGERY?
As in any operation there are certain risks associated with varicose vein surgery, these include infection, bleeding, the possibility of nerve damage, skin burns, and a poor cosmetic result. The risks of any of these occurring are very low and generally under five per cent. Phlebitis is a rare complication, seen in approximately one of every 1,000 patients treated for larger varicose veins. The dangers of phlebitis include the possibility of pulmonary embolism (a blood clot to the lungs) and the development of chronic pain and swelling in the affected leg.
Both traditional and newer techniques to treat varicose veins are effective when performed by qualified physicians. if vein treatment is carried out by a non – qualified physician, results will not be as effective. Again, a qualified physician is one who can provide proper diagnosis with ultrasound and whatever treatment is best for the patient, whether it’s surgery, laser or injection, and who will provide the necessary follow up support and care that is needed.
If you have any questions regarding vein problems or other circulation problems, please call the office at 916-965-5050to speak to our exceptionally well informed staff.
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