Assessment and Diagnostic Ultrasound
On your first visit to Vein Care Solutions, Dr. Lorenzo will review the pertinent aspects of your medical history and perform a physical exam. This may be complemented by imaging studies of the affected leg. Fortunately, assessment of the symptomatic patient is usually non-invasive.
A vascular technologist (also known as an ultrasound technologist) will use an ultrasound machine to document the anatomy and flow characteristics of the veins in the leg. The duplex scan can determine if there are flow abnormalities such as those caused by valve dysfunction or vein thrombus.
Radiofrequency ablation is durable treatment for reflux of the saphenous veins or perforator veins and can be performed in an office setting. A catheter is inserted in the dysfunctional vein via a small puncture site in the skin. Duplex imaging is used to guide the catheter into position. Ultrasound waves are then absorbed by the vein walls causing the vein to close. Many varicose veins will decompress once the larger refluxing saphenous veins supplying flow to them are ablated.
Some varicose veins are too large to be treated by other means. In these cases, the best treatment option is microphlebectomy. This treatment is best suited for bulging, enlarged veins which are very close to the surface and are significantly dilated.
During a microphlebectomy, local anesthetic is used to remove a segment of the vein from each side of the incision via a small (approximately 1/8 to ¼ inch) incision at the skin surface. Most skin incisions do not require a stitch, but, when necessary, a suture will be placed and will need to be removed in 48 to 72 hours. A compression wrap is applied to the leg that can be removed in 2 to 3 days.
If there are few veins to be removed, microphlebectomy can be performed in the office. For larger veins or when multiple areas are to be treated, the procedure is performed in the operating room on an outpatient basis at an ambulatory surgery center. The risks for microphlebectomy include superficial bruising, hematoma formation (collection of blood under the skin surface) and infection.
Since the affected tissue is so superficial, patients do not have much pain after this procedure. Pain can be well-controlled with anti-inflammatory medication; such as ibuprofen or naproxen (Motrin, Advil, Aleve). Patients are able to return to work and normal activities in 2 to 3 days.
Vein Ligation and Stripping
On occasion, a patient may have vein anatomy that is not conducive to treatment with a minimally invasive approach. Ligation and stripping may be a more appropriate technique to manage reflux in these patients. This is a procedure whereby the saphenous vein is removed via a small incision in the groin crease or the crease behind the knee and a smaller counter incision made lower on the extremity. This procedure is performed under general anesthesia on an outpatient basis. Recovery is typically less than 4 to 5 days.
Sclerotherapy (Liquid and Foam Options)
Sclerotherapy is intended to irritate the lining of a vein causing it to close and eventually disappear. The chemical, polidocanol, in foam consistency is a product known as Varithena and is used to treat large veins while a liquid version, Asclera, is used for smaller veins. Treatment varies from patient to patient depending on the type of vein, size, and flow characteristics of the veins being addressed.
Treatment sessions take approximately 30-45 minutes. In some cases, compression hosiery is used as an adjunct to therapy while some sessions require only a wrap that is worn for one day.
Some visible veins are smaller than the diameter of the needles used for sclerotherapy. These small spider veins are better addressed with laser treatment. Laser therapy relies on there being color or pigment inside the vein. A narrow beam of light is delivered to the target. This pulse penetrates the skin to be absorbed by the pigment in the vein; thus, generating heat which causes the vein to close. The wavelength and strength of the pulse may be limited by the amount of color in the skin as well as allergic response to intense light (“sun allergy”). These same parameters as well as the extent of the veins and their flow characteristics determine how many sessions are required. Sessions are typically at monthly intervals to prevent injury to the skin.
Graduated compression hosiery may be prescribed for those patients without arterial disease or decompensated heart failure. The hosiery provides pressure to redirect blood away from the skin surface. This is intended to overcome the back pressure effect of venous reflux. This type of hosiery is intentionally designed to provide relatively more compression at the ankle than at the calf or upper part of the leg. This enhances the return of flow toward the heart.
The compression provides relief of pressure for many patients, but will not result in correction of the function of otherwise damaged valves in the veins. Compression hosiery must be fitted to the appropriate size of the patient in order for it be effective and comfortable. Dr. Lorenzo takes your measurements at your initial visit and compression hosiery can be purchased through our office
Compression Wrap Application
In cases of venous ulcer formation, wound care consists primarily of cleaning the skin surface of any dead cells and applying pressure to the foot, ankle, and leg. This serves to redirect the excess fluid and blood away from the skin to decrease inflammation of the underlying tissue and thereby promote wound healing. It must be performed precisely to avoid trauma to the tissue and exacerbation of tissue swelling.
Some patients with venous reflux present with severe swelling without varicose veins or ulcers. In the decompensated state this swelling may be severe and may be mistaken for infection. Surgical expertise is necessary to discern between infection and hyperemia (excess amount of blood flow), as well as ruling out other medical conditions that may complicate the condition. Compression wraps may be applied in the acute phase to relieve swelling and prepare the patient’s leg for compression hosiery and use of compression pumps.