More than 80 million Americans have venous insufficiency in the legs, a condition caused by poorly functioning vein valves allowing blood to flow the wrong direction, which typically results in spider veins and varicose veins. Spider veins are the tiny veins on the skin surface that do not bulge or change the contour of the skin. Varicose veins are the large ropelike veins, which cause the overlying skin to bulge. Both can cause symptoms including leg pain, leg fatigue, throbbing, burning, or itching. Like many things, there is a spectrum of the severity of the problem and the symptoms which result. Sometimes, the appearance does not correlate well with the symptoms. For example, some patients with small spider veins can have very annoying burning, throbbing, or itching while some patients with large varicose veins may be relatively symptom free. More frequently, however, large varicose veins result in a dull ache which progresses throughout the day and worsen after prolonged sitting or standing, and is relieved with leg elevation or walking. This fact helps differentiate leg pain due to venous insufficiency from leg pain caused by peripheral arterial disease (PAD), which is exacerbated by walking and relieved by rest. This is an important distinction since they each can be treated, but have a different treatment.
What causes venous insufficiency/varicose veins?
As already mentioned, the problem with venous insufficiency is poorly functioning valves. But it is a little more complicated than that. The heart pumps your oxygenated blood throughout your body and the veins return the deoxygenated blood back to your heart. Your heart needs a hand to get the blood back because the journey of the blood is uphill against gravity, as far as your legs are concerned (unless you are standing on your head). This help comes from the muscles in your legs, which squeeze and collapse the veins within them with each muscle contraction. These “deep veins” within the muscles have valves, which when properly functioning, snap shut with each squeeze so that the blood can only go “uphill” towards the heart. This deep system of veins is responsible for getting 90 to 95% of the blood out of your legs on its way back to your heart.
The superficial veins are another group of veins within the fatty space between your skin and your muscles. These veins are on light duty carrying only about 5 to 10 % of the blood back towards the heart in the normal situation. Typically, the blood within the superficial veins passes through any of a number of “perforator” veins that connect the superficial veins to the deep veins. The leg muscles pump then squeeze and squirt the blood back towards the heart. The “perforator” veins also have one-way valves intended to only allow blood to go from the superficial veins to the deep veins.
If only the valves in the deep system fail, patients develop leg swelling but not varicose veins. This condition can be improved by wearing compression stockings. At the present time there are no other treatment options for deep venous insufficiency. Valve replacement is currently being studied and may become a reality in the future.
If the valves in the superficial veins or the perforator veins fail, patients develop leg swelling, varicose veins, and spider veins. Superficial vein valve failure causes varicose and spider veins because the leaky valves allow blood to flow the wrong direction, or reflux, back towards the feet. Perforator vein valve failure allows blood to be squirted from the higher-pressure deep veins into the low-pressure superficial veins. Either way, the blood is flowing the wrong direction, or refluxing. This results in accumulation of blood in the veins, which abnormally dilate creating the varicose, and spider veins. With further dilation of the veins, the degree of valve failure worsens and a self-perpetuating cycle is established. This is why the degree of bulging and severity of symptoms typically worsens throughout the day and with prolonged standing.
Why me?
There are a variety of factors which lead to the development of varicose and spider veins. Although the specifics have not been sorted out, it is clear that heredity plays an important role. Typically, you get your mother’s legs. Pregnancy can lead to the development or progression of varicose veins and spider veins for a number of reasons. These include hormonal factors, the normal increase of blood volume during pregnancy, and the compression by the uterus of the inferior vena cava which is the large vein into which the leg veins drain as the blood flows back to the heart. Occupations which involve prolonged standing or sitting with minimal leg muscle contraction also increases the risk of developing varicose and spider veins. Finally, the incidence and severity of varicose and spider veins increase with age due to the cumulative effects of gravity on the repetitive uphill journey of the blood from the legs back to the heart. The cumulative effect of these risk factors explains why 72 % of women and 43 % of men between the age of 60 and 69 have varicosities.
How do I know what is causing my particular pattern of varicose and spider veins?
The first step in getting treatment is a thorough ultrasound exam which evaluates the entire deep and superficial system of veins in the legs. This is done while the patient is standing, by experienced sonographers and physicians specially trained in the evaluation of venous insufficiency. This is necessary to discern the many variations on the theme which must be correctly elucidated to recommend and perform the appropriate treatment. One shoe doesn’t fit all.
How are the varicose veins and spider veins actually treated?
Physicians must treat the root of the problem before trimming the hedge. This means that physicians must first eliminate the largest source of the reflux before treating the smaller and sometimes more visible problem veins. A common scenario is varicose veins along the inside of the knee and leg. The unseen cause of this is typically reflux in the great saphenous vein (GSV) along the inside of the thigh. This must first be treated. Years ago, and still sometimes today, this would be treated by vein stripping. Vein stripping is an effective procedure, but is more painful and has a longer recovery period than newer alternatives, such as endovenous radiofrequency ablation or endovenous laser ablation.
Endovenous laser ablation (VenaCure) is the recommended option. This procedure is performed by inserting a small laser fiber inside the problem vein, frequently the great saphenous vein (GSV) or small saphenous vein (SSV). Once local anesthetic has been infiltrated into the tissue around the vein, the laser is activated and essentially welds the vein closed with laser energy. This is done while the patient is awake since it is painless. Sometimes this procedure is augmented by removing the largest and most offensive branch varicose veins with a procedure called ambulatory phlebectomy.
Ambulatory phlebectomy is also done and requires only local anesthetic. Tiny incisions which are approximately 1/8 inch in size are made in the skin and the underlying varicose vein is hooked and removed. Since the incisions are so small no suture is required. The tiny incisions are closed with Steri-strips which are essentially like tape.
Depending on the situation, injection sclerotherapy is also performed in larger varicose veins or in the tiny spider veins. Sclerotherapy is the injection of an irritating solution into the vein so that the injected vein spasms and scars shut. It has been around for many years.
How long is recovery?
Patients normally wear compression stockings for five days or up to 2 weeks, depending on the treatment. There is no down time. Walking is encouraged and actually the most important part of the recovery. The amount of pain following VenaCure is relatively mild and patients typically take only an NSAID such as Motrin or Advil for discomfort. Most people don’t take off from work at all. Recovery from ambulatory phlebectomy and sclerotherapy is even less uncomfortable.
Does insurance cover these procedures?
VenaCure and ambulatory phlebectomy are covered by insurance for treatment of varicose veins for patients experiencing symptoms. Insurance will not pay for a cosmetic procedure and typically does not pay for sclerotherapy.