Varicose Veins:
How to Find Relief
By Robert L. Smith, MD, MSc, FACC, FSCAI
If you are plagued by painful varicose veins, heavy, swollen, discolored legs, or any form of venous disease read on to learn more about venous insufficiency and the treatment options available at the OHI Vein Clinic.
In 2009, Oklahoma Heart Institute began performing catheter ablations of incompetent saphenous veins, which are the underlying cause of painful, ropy varicose veins, as well as most other forms of symptomatic venous insufficiency. Since then, we have successfully treated hundreds of incompetent veins, and have expanded our practice to include adjunctive therapies like microsurgical phlebectomy (surgical removal of varicose veins through tiny incisions) and foam sclerotherapy of varicose veins and spider veins.
Patient satisfaction after treatment of venous insufficiency at Oklahoma Heart has been remarkably high, and our team of vein specialists has grown to include nurses, nurse practitioners, ultrasound technicians, and physicians alike. We have a brand new, state-of-the-art vein treatment center at our OHI SouthPointe office (92nd and Mingo).
Although recent years have brought about a greater awareness of the importance of diagnosing and treating peripheral arterial disease, pathology of the venous system has received little attention. Peripheral venous disease was first mentioned in the medical literature in 500 BC, when Hippocrates described an association between leg ulcers and varicose veins1. Despite longstanding recognition, understanding of issues surrounding venous hypertension and resultant venous incompetence has lagged.
Peripheral venous disease is four to five times more common than peripheral arterial disease (reference 1), and the clinical presentation of lower extremity venous incompetence spans a broad clinical spectrum from telangiectasias (spider veins) to long-standing and recalcitrant venous stasis ulcers. This spectrum of disease manifests from cosmetically displeasing lesions on the legs to threats of serious secondary illnesses, such as deep venous thrombosis (DVT), pulmonary embolism (PE), and infection from chronic ulceration.
Venous disease has a hereditary component, and children of patients with varicose veins are more likely to develop problems related to venous reflux (reference 2). Occupations characterized by inactivity, such as standing or sitting for long periods of time, also place patients at risk (reference 3).
Until recently, the treatment of varicose veins and venous incompetence consisted mainly of surgical “vein stripping” procedures, during which large veins from the superficial collecting system of the legs are ligated and/or removed under general anesthesia. These surgical procedures, while effective, are associated with the risks of general anesthesia, infection of surgical wounds, long recovery times, and considerable patient discomfort. Perhaps for these reasons, surgical treatment of venous disease has occupied a rather small niche, and many patients have chosen to live with the condition rather than opt for surgery.
During the last ten years, outpatient, catheter based treatments have revolutionized how this disease is treated.
In order to understand the physiology of venous reflux disease, one must understand that there are two distinct venous systems in the lower extremities: The deep venous system is comprised of veins that run parallel to the arteries. These veins are surrounded by muscle and encased in connective tissue, providing them with good mechanical support. The deep veins are responsible for returning >95% of the venous blood from the lower extremity back to the heart.
The superficial system, comprised primarily of the saphenous veins, lies just beneath the skin and is without the mechanical support of the deep system. These superficial veins collect blood from surrounding tissues and, in a healthy system, route blood into the deep system so that it may be returned to the heart. It is typically incompetence of the superficial system that gives rise to the symptoms and physical manifestations of venous reflux disease.
It is widely accepted that most varicose veins and other problems from venous reflux relate to incompetence of the largest superficial vein; the greater saphenous vein. In some cases, the small saphenous vein (previously referred to as the lesser saphenous vein) is also involved. These superficial veins are located about a centimeter beneath the skin and should be less than 3mm in diameter in a healthy patient, though they can dilate to greater than 10mm in a patient with venous reflux disease. Unlike the deep venous system, where contraction of the leg muscles plays an important role in “pumping” the venous blood back to the heart, the return of venous blood in the superficial systems is passive, and depends entirely upon a series of one-way valves that aid the flow of the superficially collected blood on its route back to the deep venous system. Once in the deep system, venous blood is actively propelled against gravity back to the heart, primarily through the action of the calf muscles. In a healthy system, the superficially collected blood enters the deep venous system at two critical anatomic locations: The small saphenous vein deposits blood into the deep system at the sapheno-popliteal junc- tion (near the knee) and the greater saphenous vein deposits blood into the deep system at the sapheno-femoral junction (near the groin). If the series of one-way valves in the superficial veins become incompetent, the superficial system becomes congested, and the flow of blood into the deep system (and subsequently toward the heart) stalls, resulting in swelling, pain, and other clinical sequelae.
When valvular function in the superficial system becomes sufficiently compromised, deoxygenated venous blood flows backwards, from the deep system into the superficial system, at these critical anatomic points, resulting in a blind loop, where deoxygenated blood cycles endlessly from the deep system to the superficial system, back to the deep system, and so forth, never making it back to the heart.
Common clinical manifestations of these events are swelling, heaviness, throbbing, pain, varicosities (bulging tributaries of the overloaded superficial veins), and skin changes that occur as a result of the endless loop of oxygen and nutrient poor blood circulating throughout the lower extremity network of veins. At the extreme, refractory and painful venous ulcers develop.
Although incompetence of the one-way valves can occur at any point in the network, the most common site of incompetence is the sapheno-femoral junction. When incompetence of the sapheno-femoral junction occurs, venous blood from the deep system, en route to the heart, is diverted from the (deep) femoral vein back into the (superficial) greater saphenous vein. This is typically the starting point of the pathologic cycle, and causes the greater saphenous vein to become increasingly engorged, setting off a cascade of events where superficial valves, unaided by the pumping function of the leg muscles, fail in a top to bottom fashion until clinical manifestations develop. This is why surgical removal of a diseased greater saphenous vein has proven effective in the treatment of venous reflux disease: the most common site of retrograde flow from the deep to superficial system is eliminated and the blood has nowhere to go but up (and back to the heart).
Experience with surgical removal of the greater saphenous vein goes back many decades. During the last several years, less invasive alternatives to surgical vein stripping procedures have arisen, and have targeted treatment of greater saphenous and small saphenous veins. Endovenous laser ablation and radiofrequency ablation of diseased greater and small saphenous veins have largely replaced the more painful surgical procedures. In several trials, these minimally invasive procedures, which can be performed on an outpatient basis, have proven to be as effective as the surgical alternatives (references 7,8,9,10). While laser endovenous ablation of the greater saphenous vein and radio-frequency ablation of the greater saphenous vein are both as effective as surgery, radiofrequency ablation causes the least amount of patient discomfort, and is emerging as the minimally invasive procedure of choice (references 11,12).
During radiofrequency ablation of the greater saphenous vein, a tiny incision is made near the knee. Under ultrasound guidance, the greater saphenous vein is entered and a radiofrequency ablation catheter is advanced from the knee to the sapheno-femoral junction near the groin. Radiofrequency waves are then applied to the vein, causing the vein to fibrose and permanently close. In a matter of minutes, the vein is ablated, and the same functional outcome of the more painful surgical treatments is achieved. Although the benefit to the patients is the same as the surgical approach, patients may have this procedure performed on an outpatient basis (often in about 15 minutes) and will walk out of the office afterward, often experiencing dramatic results in hours to days after the procedure. When done properly, radiofrequency ablation of the saphenous veins is associated with little pain, speedy recovery times, and lasting results (references 11,12). Complications, which include infection, paresthesias, DVT/PE, skin burns, and lymphedema, are exceedingly rare (references 11,12).
Several clinical scenarios may lead to the recommendation of minimally invasive saphenous confirmed by ultrasound prior to consideration of any treatment. Ultrasound mapping studies are performed in order to rule out deep venous thrombosis in the deep venous system and to evaluate for dilation and reflux in the superficial system. Prior to minimally invasive saphenous vein ablation, conservative measures should be tried. These include compression with graded elastic stockings, leg elevation, exercise, and symptomatic pain management with NSAIDS. If the patient demonstrably fails a 3-6 month trial of conservative therapy, they may be considered for minimally invasive saphenous vein ablation. In cases where isolated saphenous vein ablation fails to entirely treat the problem, a host of adjunctive therapies, such as stab phlebectomy and sclerotherapy, are available.
Venous reflux disease results in painful and cosmetically displeasing derangements of normal venous anatomy. At the extreme, it leads to recalcitrant venous ulcers, which can themselves cause secondary health issues. In the modern era, this common disease can be effectively treated with a minimally invasive, office-based procedure, with pleasing results. Radiofrequency saphenous vein ablation results in less discomfort and risk to the patient than surgical alternatives, and is proven to have lasting benefit. If you are interested in learning more about the treatment of varicose veins and other forms of venous disease, please call for an evaluation in the OHI vein clinic: 918-592-0999.
REFERENCES
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2 Cornu-Thenard A et al. “Importance of the familial factor in varicose disease. Clinical study of 134 families” J Dermatol Surg Oncol 1994
3 Santler, R., Ernst G., Weiel, B. “Statistisches uber der varikosen Symptomenkomplex” Hautarzt 1956; 10: 460-3
4 Jones L et al. “Neovascularization is the principal cause of varicose vein recurrence: results of a randomized trial of stripping the long saphenous vein” EurJ Endovasc Surg 1996; 12:442-5.
5 Rutgers PH et al. “Randomized trial of stripping versus high ligation combined with sclerotherapy in the treatment of the incompetent greater saphenous vein” Am J Surg 1994;168:311-15.
6 Dwerryhouse S, Davies B, Harradine K, Earnshaw JJ. “Stripping the long saphenous vein reduces the rate of reoperation for recurrent varicose veins: five-year results of a randomized trial” J Vasc Surg. 1999 Apr;29(4):589-92.
7 Rasmussen L et al. “Randomized trial comparing endovenous laser ablation of the great saphenous vein with high ligation and stripping in patients with varicose veins” J Vasc Surg 2007;46:308-15
8 Darwood RJ et al. “Randomized clinical trial comparing endovenous laser ablation with surgery for thetreatment of primary great saphenous
varicose veins” Br J Surg 2008;95:294-301
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10 Ogawa T et al. “Endovenous Laser Ablation Compared With Stripping – Multi-Center RCT in Japan” Poster presentation at the American Venous Forum February 2008, Charleston, SC
11 Merchant et al. “Long-term Outcomes of Endovenous Radiofrequency Obliteration of Saphenous Reflux as a Treatment for Superficial
Venous Insufficiency” J Vasc Surg 2005;42:502-9.
12 Proebstle et al. “Treatment of the incompetent great saphenous vein by radiofrequency powered segmental thermal ablation: First clinical experience” J Vasc Surg 2008;47:151-6.