Frequently Asked Questions

Here are some commonly asked questions for your reference

What causes varicose veins?

Varicose veins are engorged veins with malfunctioning valves. There are many factors that can contribute to varicose vein formation, such as inherited vein wall weakness, hormones (eg. progesterone), pregnancy, obesity, hormone therapy and standing occupations. Varicose veins are very common in women but also in men.

What are the typical symptoms?

Varicose veins are typically signs of venous insufficiency: the veins cannot adequately return blood back up the leg. This results in pooling of blood in the lower legs particularly with standing. This can result in aching, swelling, leg tiredness, darkening of skin around the ankles, restless legs and even leg ulcers.

Can varicose veins be treated?

In most cases, yes. In the past, surgical options such as ligation or vein stripping were commonplace. Now, a number of minimally invasive, minimal discomfort options are available, such as thermal ablation, mechanochemical ablation and sclerotherapy.

Are there any nutraceutical or medical treatments for varicose veins?

Certain compounds have shown some benefit. They include the saponins (horse chestnut seed extract) and flavonoids (such as hesperidin, diosmin, micronized purified flavonoid fraction and rutosides).

Horse chestnut seed extract (aescin) can reduce swelling, discomfort and itching. Typical dosages are 50mg of the active compound aescin, twice daily. Formulations sold are often 250mg horse chestnut (20% being aescin), twice daily.

The flavonoids appear to have anti-inflammatory effects and may reduce swelling. Flavonoids can be found in grape seed, blueberry, cranberry, hawthorn and pine bark.

The drug pentoxifylline appears to help with venous ulcer healing, particularly at the higher dose of 800mg three times a day (but has a high rate of gastric upset).

Do I need compression stockings?

Graduated compression stockings, when properly fitted, can provide some symptom relief for people with venous insufficiency. They cannot cure spider or varicose veins. However, they can help heal venous leg ulcers. Some form of compression after sclerotherapy and ablation can help reduce leg discomfort and swelling. As a general guide Dr. Attaran recommends up to 2 weeks of compression after radiofrequency ablation (during waking hours) and 2-7 days after sclerotherapy.

Most insurance companies require a trial of stocking use before paying for definitive therapy.

What is a venous ulcer?

Venous insufficiency can lead to venous hypertension and inflammation. The effects are seen particularly in the lower legs, above the ankles. The skin darkens, thickens and can develop a shiny, leathery appearance. Ultimately ulcers can develop. Venous ulcers require aggressive treatment including compression stocking therapy, treatment of any venous insufficiency or venous outflow obstruction.

What is radiofrequency or laser ablation?

RF1When veins such as the great saphenous vein have incompetent valves and are dysfunctional, instead of the traditional surgeries such as vein stripping or ligation, thermal energy can be delivered through a thin fiber to eliminate them. This can be from a laser or a radiofrequency device. Dr. Attaran favors radiofrequency because it works very well but causes less bruising and discomfort.

Radiofrequency ablation is an outpatient procedure. Using local anesthetic and ultrasound guidance the small fiber is positioned inside the target vein and the treatment is delivered. The whole procedure typically takes 45 minutes. The treated leg is wrapped afterwards and most people drive themselves home.

What is sclerotherapy?

Sclerotherapy is the treatment of varicose or spider veins by injection with chemicals that cause steady elimination of the unwanted veins. The treatments used have a good safety record. Local irritation with the injection is common but allergies, deep vein thrombosis or ulceration are rare. It typically takes a few weeks to months for the injected veins to disappear. Larger treated veins can leave behind some pigmentation that usually dissipates over time. Many patients favor sclerotherapy because it’s minimally invasive and typically a tiny needle is used. Most return to normal activities immediately.

What is mechanochemical ablation?

Clarivein1Clarivein2

An alternative way to eliminate dysfunctional large veins with thermal ablation is so-called mechanochemical ablation (Clarivein). In this technique a small fiber is inserted into the vein under local anesthetic. Its tip rapidly spins while releasing a sclerotherapy drug to the vein. There is no heat required. The technique appears to act by scratching the inner layer of the target vein whilst allowing the sclerosant drug to create a reaction that eventually seals the vein.

What is the superglue (VenaSeal) treatment?

Veneseal1For years medical grade cyanoacrylate superglue has been in use, for example in Dermabond, as tissue adhesive for wounds. The FDA has approved a device called VenaSeal, that using ultrasound guidance, delivers cyanoacrylate adhesive into a vein, sealing it. The advantage to this technique is that there is no need to give tumescent anesthesia or to wear compression stockings afterwards.

What is Post-Thrombotic Syndrome (PTS) and is it treatable?

PTS can occur in 30-50% of people after a DVT. It is a result of venous hypertension and inflammation associated with venous obstruction and/or reflux. It can lead to leg heaviness, swelling, varicosity, itching, skin pigmentation and ulceration. It’s a chronic condition. PTS can be more severe in cases of recurrent DVT, obesity, or if occurring higher up in the leg. While it is not curable, it can, in cases, be treated by minimally invasive techniques aimed to reduce venous obstruction. Research suggests that PTS may also be prevented in many cases by prompt catheter-based removal of clot if a DVT occurs.

What is Deep Vein Thrombosis (DVT) and how can it be managed?

Blood clots can sometimes form in the deep veins, obstructing venous drainage out of the affected leg. In some people this occurs spontaneously. In others, it is provoked by immobility or surgery, for instance. It may lead to pulmonary embolism (clots traveling to the lungs) that can be fatal. It can also lead to venous inflammation, permanent vein valve damage and venous hypertension. The standard of care is anti-coagulation (blood thinners) but in many cases anti-coagulants do not relieve the obstruction quickly enough. Permanent damage in the form of post-thrombotic syndrome (PTS) can occur. One treatment that can be offered for a new DVT is to use a small catheter to disrupt and suck out clot directly. Any venous outflow obstruction can also be treated at the same time, with stents. Early research suggests that this leads to better outcomes than just taking anti-coagulant medicines.

What is venous outflow obstruction?

Blood leaves the legs through the femoral and iliac veins. Some individuals are born with iliac vein compression, which makes it harder for blood to flow out. This can result in venous insufficiency, leg discomfort, swelling and possibly deep vein thrombosis (DVT). Sometimes a DVT can result in inflammation and scar tissue in the femoral and iliac veins that can lead to venous outflow obstruction (see “post-thrombotic syndrome”). Low risk treatment options exist such as minimally invasive iliac vein stenting that can relieve the obstruction, improving symptoms.

What if I need the vein for a bypass? Won’t the ablation eliminate a vein that I may need for surgery some day?

It is true that portions of the great saphenous vein can be used for coronary artery bypass or leg arterial bypass. However, an incompetent and dilated saphenous vein is not a good bypass conduit and surgeons do not favor them. In those cases, alternative bypass conduits such as the internal mammary (which cardiac surgeons prefer) and radial arteries are available. Dr. Attaran will only ablate the parts of the saphenous veins that are diseased and refluxing, leaving the healthier portions intact.

If my legs ache or fatigue with walking, what could it mean?

Whilst venous insufficiency (and varicose veins) may result in aching, particularly when standing, leg discomfort from walking can be the sign of an arterial problem, such as obstruction. Dr. Attaran performs a comprehensive evaluation of circulation. Arterial and venous disease can be diagnosed by ultrasound imaging, in addition to a number of other modalities available at Yale University.

Have More Questions

Please feel free to contact us directly and we will be glad to assist you.