Superficial Vein Disease
Lower Extremity Venous Disorders
Issues with leg veins are among the most common conditions experienced by Americans. Approximately 80 million people in the US have vein disease. For some, these veins are simply a cosmetic issue, but for others, these veins are causing symptoms affecting their daily activity. The following information will help explain the conditions and treatment options available.
What are the Functions of Veins?
Veins are blood vessels that return blood back to the heart from all parts of the body. A major challenge for leg veins is that the blood needs to get back to the heart against the force of gravity when standing. In this position, blood is pumped upward by calf muscle contractions when you walk. The leg veins have one-way valves to keep blood moving upward. When valves do not close properly, they allow blood to flow backwards and pool in the veins of the lower leg. This pooling leads to increased pressure and volume within the veins which, over time, causes them to dilate (get wider) and elongate (get longer). Significantly bulging varicose veins are often due to leaking veins higher in the leg and located beneath the skin surface; most often, this underlying vein is the saphenous vein, which is only visible with the aid of an ultrasound. These dilated and elongated veins in the skin are known as telangiectasia (or spider veins) and dilated and elongated veins below the skin are known as varicose veins. Spider veins appear as small diameter red, purple or bluish web like veins. Varicose veins are larger deeper veins that can protrude resulting in a rope-like appearance.
Treatment Options for Veins:
During your consultation, your physician will determine the best treatment plan based on your condition and health history. This may include one or a combination of the following treatments:
Endovenous Laser Treatment (EVLT) Endovenous laser treatment, (EVLT), also known as Endovenous laser ablation (ELA), is a minimally invasive technique to eliminate varicose veins. The procedure is performed in the office using local anesthetic. Our patients experience little to no pain or scarring and a short recovery period. The laser is inserted through a small IV and seals closed the vein that causes the varicose veins. The procedure takes about 1 hour and patients are instructed to immediately walk and resume most of their usual activities. EVLT is effective in more then 95% of patients. If it does not work it can often be repeated.
Non-Thermal Approaches for Saphenous Ablation
Non-thermal ablation is a method of minimally invasive vein closure utilizing glue or an irritant drug. The options include; Venaseal™, Clarivein®, and Varithena® and are procedures that are at the forefront of varicose vein care. The procedures are performed in the office. A tool is inserted through an IV in the vein and used to treat the vein that causes varicose veins. The procedure takes about 1 hour and patients are instructed to immediately walk and resume most of their usual activities. Advantages of non-thermal techniques include fewer needlesticks during the procedure and less post procedure pain and bruising.
Venaseal – Results from the clinical trial of the device demonstrates 95% vein closure at two years with very rare complications.
Clarivein – Results from the early trials of the device demonstrate 97% vein closure at 1 year post procedure.
Varithena Foam – Results from clinical trials show 95% vein closure rate at one year.
Microphlebectomy
Ambulatory phlebectomy, also known as microphlebectomy is a minor procedure that can be used to eliminate larger varicose veins. This procedure is performed in the office. The veins are removed through tiny nicks in the skin and can be done at the same time as EVLT. No stitches are necessary, the scars are barely visible and patients are extremely satisfied with the aesthetic outcomes. The procedure takes about 1 hour and patients are instructed to immediately walk and resume most of their usual activities.
Sclerotherapy
Sclerotherapy is performed as an in-office procedure to eliminate spider veins and small to medium size varicose veins. Injections with needles smaller than those used for flu-shots are performed directly into the abnormal veins. Following this 15–20 minute treatment, the patient can resume nearly all activities. A support stocking is worn during the daytime for one week after the procedure which aids in the closure of the veins.
EVLT, CLARIVEIN, MICROPHLEBECTOMY AND VARITHENA
Important Procedure Information
How Should I Prepare?
Eat a regular breakfast and/or lunch before coming to our office.
You do not need to have anyone come with you to the procedure. Unless you elect to take a light sedative.
Bring the stockings that were prescribed at the time of your consultation. You can purchase these stockings from our staff. Do not wait until the day of the procedure to purchase the stockings since we may not have your size in stock.
You may want to bring a pair of flip flops or casual sandals with you to the office and a warm sweater, as the room will be cool. Please note that we will use betadine soap to clean the area prior to the procedure, and light clothes and underwear may be stained.
If you take aspirin, Plavix, or a blood thinner, please continue to take them as normal. We generally recommend that you do not stop taking your regular medication.
The procedure may take 30 minutes to an hour, during which you will be laying down in one position.
Be prepared to walk 10 minutes each hour for four hours after the procedure.
You should be prepared to purchase Dermaka cream to apply to the legs for two weeks twice daily after the procedure. Cost is $35.
What Should I Expect During The Procedure?
In our preparation room, we will have you change into a pair of loose-fitting shorts.
An ultrasound will be performed, and the vein segment(s) to be treated will be marked on the skin with a temporary surgical marker.
The marked area will be cleaned and sterile drapes will be placed on your legs.
Important Post-Procedure Information
What Should I Expect After The Procedure?
Your leg that was treated will be wrapped for 72 hours.
You will continue walking throughout the rest of the day in smaller intervals, avoiding any long periods (30–45min) of sitting or standing.
You should continue walking throughout each day for 2 weeks, avoiding long periods of idleness. On average, you will be walking a total of at least one or two hours a day.
Should pain medication be needed on the day of the procedure and for the following days, Tylenol or Ibuprofen can be taken.
How Long Do I Need to Wear The Leg Wraps?
The leg wraps may be removed in 72 hours and you may take a regular shower after. Some secretion of numbing fluid along the area of the treated vein should be expected. After your shower, simply pat those areas dry. If the ACE bandage is too tight, you may loosen it.
After a shower, a fresh stocking should be put on and worn for a total of two weeks, except to sleep and shower.
What Are My Activity Restrictions And Recommendations?
After the procedure, you may immediately resume all of your usual activities except for vigorous gym workouts, heavy weight lifting or long hot baths for the first 2 weeks following the procedure. You may swim after the entry site of the catheter and skin nicks have closed (approximately one week).
Frequent walking is strongly recommended for at least 2 hours a day, spread out throughout the day, the first 2 weeks following the procedure.
Prolonged idleness for more than 30 minutes should be avoided. Walking around the office and standing up on your toes is recommended at work.
Regular exercise routines may be resumed 2 weeks after the procedure.
You should not fly in an airplane for a couple of weeks after the procedure. If you must fly please let us know; we will ask you to come in for an ultrasound to ensure that you can do so safely.
Avoid sun exposure until the skin nick is fully healed to prevent pigmentation Covering the skin nick with a band-aid is suggested if you decide to go into the sun before it’s fully healed. Sun-block is not sufficient to prevent skin staining.
We will want to see you for a 1 month follow-up to assess your response to treatment.
Will I Feel Any Discomfort After The Procedure?
Bruising after the procedure is expected and will last several weeks.
Some soreness over the treated vein may occur after the procedure for about 1–3 days which may require at most some Tylenol or Advil. Warm compresses can be used if necessary.
In most cases, the treated vein will develop a pulled muscle feeling, with some stiffness. This pulled muscle feeling usually develops 5 days following the procedure, and improves in about one week. The pain you will feel is normal and indicates that the vein is closing properly.
The soreness will be most apparent after sitting or lying for a period of time. Stretching the leg, wearing the stocking, and walking will be helpful. If necessary, to prevent pain, Advil or Motrin can be taken.
It is normal to have soreness, slight swelling and redness along the treated area. These symptoms will disappear within the first few weeks.
Does My Body Need The Vein That is Being Treated?
No, the vein that is being treated is an abnormal vein. The abnormal vein is causing your normal veins to work harder to return the leaking blood back to your heart. Eliminating abnormal veins enables normal veins to work more efficiently.
Varicose Veins
Painful Varicose Veins
Large ropy varicose veins are best treated by phlebectomy or removal of the vein. This is done in the office under local anesthesia. Lidocaine is used and the vein is hooked and snipped. There is no pain and takes about 45 minutes. Medicare and Insurance covers.
Final result two weeks after phlebectomy of the patient in first picture above.
However, not all varicose veins need to be removed. It depends on their size and how tortuous they are. Many we treat with Varithena Foam and some with Clarivein. I prefer not to use laser on large varicose veins because of the risk of staining the skin and pain during the procedure. Therefore I will either remove them or use a sclerosant agent in the office and our results are excellent.
Venous Wounds
Our unique approach to treating vein wounds is unlike all other Vein Centers. Our success rate is over 95%. In our method, we identify the culprit vein, perforator, or accessory vein and before intervention, drain the vein, then flush it, and intervene by any one of several methods such as Laser, Clarivein, or Varithena Foam to collapse it. This is all done in one of our two surgical suites in the office.
By treating the cause of the venous wound, the wound heals and usually does not recur.
Laser Ablation/Varithena Foam/Clarivein/Venaseal
Any of the above procedures are used to close the diseased vein and is performed in the office under local anesthesia. The procedure collapses the diseased vein, allowing blood to circulate through good veins back to the heart.
Any of the above modalities are used to treat diseased veins, varicose veins, deep refluxing perforator veins, and dilated veins causing wounds. It takes about 30 minutes and most are covered by Medicare, Medicaid, and private insurance. Some Insurance Companies do not yet cover Clarivein. Medicare does.
The above picture is Laser ablation and is used to help heal skin ulcers, vein wounds, varicose veins, stasis ulcers, venous stasis, and even sore legs.
Unlike most vein centers that treat only cosmetic or superficial vein problems, Dr. Harrison treats all vein disorders whether cosmetic, superficial, or complex. He works with wound care centers across Arkansas, Missouri, Oklahoma, Louisiana and Texas restoring circulation and reducing venous pressure to insure the healing of the skin ulcer and prevent its recurrence.
The slide below shows the possible progression of chronic venous reflux. Whether you have simply tired swollen legs or active ulcer, we can treat the underlying cause with great results.
This leg was treated with Varithena Foam of the Greater Saphenous Vein. The leg was swollen and the wound was several months old before we treated him. After treatment see below.
This picture taken approximately 3 weeks after Varithena Foam treatment of the Greater Saphenous Vein of the leg above. Note the wound is nearly completely healed. We later treated the left leg as well with excellent results.
Deep Vein Disease
Many times the cause of deep vein disease is in the deep veins within the pelvis and cannot be seen under external ultrasound. Treatment of these veins almost always require outpatient treatment in the hospital where specialized imaging and treatment equipment can be utlized. The symptoms can be different than superficial vein disease however they can overlap or even mimic superficial disease. Dr. Harrison is a specialist in all disease processes of veins whether within the deep or superficial system and has many years of experience in diagnosing and treating.
DVT
Deep Vein Thrombosis is a blood clot occurring within the deep vein system typically located above the knee. DVT typically presents with pain in the affected leg with redness and swelling. It typically occurs suddenly and places you in danger of a pulmonary embolus. A PE or pulmonary embolus is when a blood clot becomes dislodged and travels to the right heart and lungs. Depending on the size this clot may inhibit all or part of venous blood flow to the lungs and can result in death. Treatment of an uncomplicated DVT usually means starting a blood thinner and in some cases can be started in the clinic. If the blood clot is extensive and painful, in-hospital treatment may be warranted. This treatment may involve placing a catheter into the affected leg vein and removing the thrombus with a machine called Angiojet. Angiojet is also used for removal of blood clots in not only veins but also arteries in the legs, heart, and lungs. Dr. Harrison has extensive experience with Angiojet. Another treatment may be EKOS which is a catheter based device that emits a low frequency ultrasound to break up the clot and a very tiny amount of TPA or clot buster medicine is slowly infused to dissolve the clot. Another treatment may be delivering a clot buster medicine into a peripheral vein that circulates within the body. The choice of treatments should be made by someone who has experience in all possible treatment modalities so the most effective and safest can be chosen. Dr. Harrison has many years of experience with all the above treatment modalities.
Deep Vein Stenosis
Deep vein stenosis typically occurs in the deep veins of the pelvis ie in the femoral, iliac, or vena cava system. A stenosis or blockage of a vein may occur in the leg but less likely. Patients at risk for permanent blockages in the central deep vein system are patients who have a prior history of DVT. Presenting symptoms are swelling in one extremity or the other and sometimes both, leg heaviness, tired painful leg, or non-healing leg ulcers. Symptoms may mimic superficial vein reflux disease and it may be difficult to know the difference without invasive testing. Typically if a patient presents with those symptoms vein mapping is performed of the legs and if reflux is found of significance the superficial veins are treated first in the office and if symptoms persist then the patient is taken to the hospital for invasive testing. Testing usually means placing the patient under anesthesia, placing two catheters one in each deep leg vein, and injecting contrast and recording images and placing a catheter with ultrasound at the tip to look inside the vein to see if it is partially blocked. This is called IVUS (intravascular ultrasound). If significant blockages are found we then treat immediately with a balloon and stent.
May-Thurners Syndrome
This syndrome can only be diagnosed by IVUS (intravascular ultrasound) and done in a hospital or outpatient surgical lab. May-Thurners occurs when the iliac artery which overlies the iliac vein has begun to compress the vein to the point of decreasing venous flow to the heart. This typically occurs on the left side with symptoms of left leg only swelling but may occur on the right or on both. Treatment of this syndrome is done in the hospital with balloon and stenting with excellent results and relief of symptoms. It must be done by someone with experience in making the correct diagnosis and skills for treatment. Not all May-Thurners are significant enough for treatment and minor compression of the vein should not be stented.
IVC Filter Occlusion
Many patients over the years now have Inferior Vena Cava filters and many who have had filter placement have not had the filters removed. Unfortunately for a few some of these filters have become totally occluded not allowing any direct blood return to the heart. The Inferior Vena Cava is the large vein in the abdomen that brings all the blood back to the heart from the pelvis and legs. When the filter becomes blocked many times collateral veins step in to try to bring blood back to the heart but usually there are not enough collateral vessels to return adequate blood. Consequently, the patient experiences swelling in both legs as well as in the pelvis, and sometimes varicose veins develop across the abdomen and pelvis. Symptoms are variable but can range from mild chronic pain and swelling to severe non healing ulcerations, pain, and severe edema. If the filter can not be safely removed then Dr. Harrison may have to place a wire around the filter, balloon the filter crushing it against the vena cava wall, and stenting the vena cava to assure good blood flow to the heart. This is done in the hospital under anesthesia as outpatient and involves going through the leg veins up to the abdomen and making a diagnosis first by imaging the vessels with IVUS and a venogram. This typically takes between 2 and 4 hours to diagnose and treat the patient and is done as outpatient. Results are usually excellent and the risk is surprisingly very low.