INDICATIONS FOR EVALUATION

Symptoms(Click to Watch Video Clip)
Many patients with superficial varicosities complain of cramping, aching, burning, itching, soreness, or tired legs. Studies have found that more than 90 percent of true varicosities are symptomatic, and that the vast majority of patients experience relief of their symptoms after treatment for the varicosities. Swelling of the ankles and feet may be due to retrograde flow though varicosed superficial veins or it may be completely unrelated.

Phlebitis
Prolonged stasis in superficial varicosities and telangiectasias frequently does lead to recurrent superficial thrombophlebitis. Although active phlebitis is a contraindication to treatment for superficial varicosities, a history of phlebitis is a strong indication that the amount of reflux and of stasis is enough to warrant treatment.

Stasis Dermatitis
If the fraction of blood involved in a local-flow circuit through the superficial varicosities is large, stasis dermatitis may be seen. Part of the discoloration, skin thickening, and tendency toward ulcer formation will be reversible and part will be irreversible. At the very least, interruption of the retrograde flow pathways will prevent the progression of disease caused by that retrograde flow.

Cosmetically Disfiguring Vessels
Regardless of the medical indications for treatment of diseased superficial vessels, the most common reason for patient concern is the cosmetic appearance of varicosities or telangiectasias. Even a single small starburst on the posterior calf may be of great concern to a young patient who must endure the comments of friends and the glances of strangers. Surgical treatment of varicosities is very successful at addressing the medical problems caused by retrograde flow through a dilated superficial venous system, but patients know it as a relatively poor solution from a cosmetic point of view. Vein stripping can cause significant scarring, particularly in a patient with compromised local tissue perfusion due to chronic stasis. Stripping of varicosities also fails to address associated telangiectasias which, from a patient's point of view, may be even more disfiguring.

EVALUATION MODALITIES

Our center is equiped with a complete vasclar laboratory under supervision of two board certified radiologists. 
Doppler studies with 7 to 10 MHZ and 3.5 MHZ trasducers permit the evaluation of flow through both the superficial and the deep peripheral venous systems. Bidirectional doppler is capable of detecting the direction of flow as well as its magnitude, and permits the demonstration of retrograde flow in superficial varicosities. If the deep venous system is intact, deep retrograde flow should not be observed. Treatment of superficial varicosities is rarely indicated when the deep venous system is incompetent.

QUESTIONS

Does removing, tying off, or injecting superficial branches of the saphenous vein prevent the patient from having bypass surgery in the future?

No. A diseased varicose vein is of no value for coronary artery bypass, and could not be used in any event. If the greater saphenous vein is healthy, it may still be used after more superficial veins have been treated.

Aren't these veins an important path for venous return?

No. Once retrograde flow and chronic venous stasis are established, the venous pathway is permanently pathologic. Venous blood is actually flowing backwards through the diseased surface system, preventing normal circulation in the extremity. Treatment of these diseased veins interrupts this reverse circulation of blood to improve peripheral oxygenation and venous return.

Is there a risk of deep vein thrombosis when injection sclerotherapy is performed?

No. Studies of many thousands of patients being treated with injection sclerotherapy have shown that the incidence of deep vein thrombosis is no higher than in the general population. The mild, FDA-approved sclerosing agents used today can only cause vessel wall irritation if they remain in contact with the wall in high concentrations for a fairly long time. Venous stasis in diseased vessels, along with good injection technique, help these conditions to be met, but as soon as the sclerosant leaks across into normal vessels, the normal velocity of blood flow dilutes it and carries it away from the vessel wall. This has been proven by clinical experience, by downstream blood sampling in vivo, and by histologic studies of vessel walls both in vivo and in vitro.

What are the complications of treatment?

Fortunately, neither laser therapy nor injection sclerotherapy are associated with any serious complications when properly performed. Anaphylactic reactions to modern sclerosing agents are so rare that many practitioners doubt their existence. Common minor complications include bruising at the site of an injection, itching along the course of a treated vessel, and mild inflammation. Patients may rarely develop a small local ulceration of a varicosity being treated, and superficial phlebitis is sometimes seen. Scarring or hyperpigmentation may occur with laser treatments. Treatment of a large number of vessels may lead to local edema. Healthy superficial microscopic vessels within an area of treatment may dilate slightly to become temporarily more visible to the patient.

Aren't most varicose veins asymptomatic?(Click to Watch Video Clip)

Unfortunately, studies have shown that the vast majority of patients with varicosities do complain of aching, swelling, cramping, and other clinical symptoms. A survey reported in the Mayo Clinic Proceedings actually found symptoms in more than 97 percent of those with varicose veins.

What are the contraindications?

Patients should wait approximately 3 months after pregnancy or major surgery before starting therapy for varicosities or telangiectasias(spider veins). Immunocompromised patients and others with poor expectations for healing should not be treated. Patients who cannot ambulate should not be treated. A past history of superficial phlebitis is a good indication that the patient has a medical need for treatment, but a history of deep vein thrombosis or deep venous incompetence is a relative, or in some cases an absolute contraindication to stripping or sclerotherapy