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Treatment Options

The most commonly asked questions are: "Do veins require treatment?" and "What treatment is best?" Veins that are cosmetically unappealing or cause pain or other symptoms are prime candidates for treatment. There are two general treatment options: conservative measures, such as compression stockings, and corrective measures such as sclerotherapy, surgery and light source/laser treatment. In some cases, a combination of treatment methods works best.

Sclerotherapy

Sclerotherapy is a common treatment for small (spider veins) and medium size (reticular) veins. A tiny needle is used to inject the veins with a solution (called a sclersant) that irritates the lining of the vein. In response, the veins collapse and are reabsorbed. The surface veins are no longer visible. Depending on the size and location of the veins, different types and strengths of sclerosants are used. With this procedure, veins can be dealt with at an early stage, helping to prevent further complications.

You may need anywhere from one to several sclerotherapy sessions for any vein region. Depending on the type and number of veins being treated you may have one to many injections per session. Generally, normal activities can be resumed after sclerotherapy. Medically prescribed support hose and/or bandages may need to be worn for several days to several weeks to assist in resolution of the veins. The procedure, performed in the doctor's office, usually causes only minimal discomfort. Bruising and pigmentation may occur after sclerotherapy. Bruising typically disappears within 1-2 weeks. Although pigmentation almost always fades, it can last for several months.

Varicose veins before and after sclerotherapy.
Varicose veins before and after sclerotherapy. Individual results may vary.
Photos courtesy of S. Zimmet, MD

Possible complications of sclerotherapy include inadvertent intra-arterial injection, skin ulceration, hyperpigmentation (dark spots), telangiectatic matting (blush spots), superficial phlebitis, deep vein thrombosis (blood clots), and allergic reaction. Scarring and other complications are rare.

 

Endovenous Procedures

There are three types of endovenous procedures: Endovenous laser treatment, Endovenous radio frequency ablation and Ultrasound guided sclerotherapy (sometimes called echo-sclerotherapy).

Endovenous Laser Treatment

Endovenous laser treatment is a minimally invasive, in-office treatment alternative to surgical stripping of the great saphenous vein. Instead of removing the saphenous vein, it is sealed closed in place. The skin on the inside of the knee is anesthetized and a small laser fiber is inserted through a needle stick into the damaged vein. Pulses of laser light are delivered inside the vein, which causes the vein to collapse and seal shut.

This procedure is done in-office under local anesthesia. Following the procedure a bandage or compression hose is placed on the treated leg. Patients are able to walk immediately after the procedure and most individuals are able to return to work the next day. Endovenous Laser Treatment is FDA-approved for the treatment of the greater saphenous vein.

Possible complications of endovenous laser treatment are thermal skin burns and transient numbness.

Schematic of endovenous laser treatment.
Schematic of endovenous laser treatment.
Image courtesy of Diomed, Inc.
 

Endovenous Radio Frequency Ablation (Procedure)

Endovenous radio frequency ablation (Closure® procedure) is a minimally invasive, in-office treatment alternative to surgical stripping of the great saphenous vein. Instead of removing the saphenous vein, it is sealed closed in place. The skin on the inside of the knee is anesthetized and a radio frequency catheter is inserted into the damaged vein through a needle stick in the skin. The catheter delivers radiofrequency energy to the vein wall causing it to heat. As the vein warms, it collapses and seals shut.

Schematic of Closure® procedure.
Schematic of Closure® procedure.
1. Catheter inserted, 2. Vein warmed and collapses, 3. Catheter slowly withdrawn, closing vein
Image courtesy of VNUS Medical Technologies, Inc.

The procedure is generally done in an outpatient or in-office setting. It may be done under local anesthesia.

Following the procedure, the catheter is removed and a bandage or compression stocking is placed on the treated leg. Patients are able to walk immediately after the procedure and most individuals are able to return to work the next day. Endovenous radio frequency ablation (Closure® procedure) is FDA approved for the treatment of the greater saphenous vein.

Possible complications of endovenous radio frequency ablation are thermal skin burns and transient numbness.

 

Ultrasound Guided Sclerotherapy (Echo-Sclerotherapy)

Ultrasound Guided Sclerotherapy (Echo-Sclerotherapy) is an in-office treatment alternative to surgical stripping. With this technique and based on the clinical judgment of the doctor, sclerotherapy is done with either a liquid or "foamed" sclerosant, while the doctor visually monitors the vein on an ultrasound screen. This enables treatment of veins that can't be seen because they are below the surface of the skin and would otherwise require surgical removal. Ultrasound imaging is used to guide a needle into the abnormal vein and deliver medication to destroy the lining of the blood vessel and seal it shut. Ultrasound guided sclerotherapy is primarily used to treat large veins beneath the surface of the skin.

Possible complications of ultrasound guided sclerotherapy include: Inadvertent intra-arterial injection, skin ulceration, hyperpigmentation, telangiectatic matting, superficial phlebitis, deep vein thrombosis, and allergic reaction.

 

Surgery

There are several surgical options for the treatment of varicose veins. Surgery may be performed using local, spinal, or general anesthesia. Most patients return home the same day as the procedure. Surgery is generally used to treat large varicose veins.

Traditional Ligation & Stripping

Traditional ligation & stripping of the great saphenous vein is usually performed in a hospital operating room or outpatient surgical center under general anesthesia. An incision is made in the groin and the saphenous vein is tied off at its’ origin. Then a series of incisions are made in the leg and a wire “stripper” is inserted into the abnormal veins, which are then stripped out.

Possible complications of vein stripping are damage to surrounding nerves leading to numbness, damage to lymphatic tissue leading to chronic leg swelling. Incision scars. Reaction to general anesthesia is an additional risk.

PIN stripping

PIN stripping is an updated method of vein stripping. This technique is performed in a hospital operating room or outpatient surgical center but can be done using either general anesthesia or local anesthesia with IV sedation. A small incision is made in the leg and the “PIN stripper” is inserted and advanced through the vein. The tip of the PIN stripper is sewn to the end of the vein and as the PIN stripper is removed, the vein is pulled in on itself and is “stripped” out.

Possible complications of PIN stripping are local numbness, incision scars, and allergic reaction to the local anesthetic (if used).

Ambulatory Phlebectomy

Ambulatory phlebectomy is a method of surgical removal of surface varicose veins. Ambulatory phlebectomy is usually performed in a doctor’s office using local anesthesia. The area surrounding the varicose vein clusters is flooded with anesthetic fluid. A needle is then used to make a puncture next to the varicose vein and a small hook is inserted into the needle hole and the varicose vein is grasped and removed. The punctures typically leave nearly imperceptible scars.

Varicose veins before and after ambulatory phlebectomy. Individual results can vary.
Varicose veins before and after ambulatory phlebectomy. Individual results can vary.
Photos courtesy of S. Zimmet, MD

After the vein has been removed by phlebectomy, a bandage and/or compression stocking is worn for a short period.

Ambulatory phlebectomy is often performed in conjunction with minimally invasive endovenous catheter procedures or PIN stripping.

Possible complications of ambulatory phlebectomy are allergic reaction to the local anesthetic and local numbness.

 

Light-Based Treatments

Laser and intense pulsed light (IPL) can be used to treat small spider veins and facial redness. A light beam is pulsed through the skin and onto the veins in order to seal them off and cause them to dissolve. Light-based treatment is generally used only to treat small veins. Treatments may be combined with sclerotherapy. Multiple treatments are usually required.

Possible complications of light based treatments are skin burns, blistering, purpura (bruising), and scarring.

 

Conservative Treatments

Conservative treatments include compression stockings and herbal treatments.

Compression Stockings

Graduated compression stockings are a mainstay of initial/conservative management of venous disease. Graduated compression stockings are tighter around the foot and ankle and the compression decreases as it goes up the leg. This "graduated compression" promotes the normal flow of blood up the leg.

Possible complications of graduated compression stockings are obstruction of venous or arterial blood flow due to improper sizing or undiagnosed peripheral vascular disease.

Herbal Treatments

In the area of herbal remedies, horse chestnut extract is the most commonly recommended herbal preparation for venous disease. Although there is no documented evidence of its efficacy, there are many anecdotal reports of beneficial effects on the symptoms of vein disease.