The first step is an ultrasound examination in our office to look at the direction of blood flow within the veins in the leg. Most times, tracking the source of the varicose veins beneath the skin surface demonstrates a root vein that has developed bad valves. Several different veins within the leg can develop bad valves most commonly.
First and foremost, for people with a valve problem, this procedure makes the leg work more efficiently. By lasering only the bad vein segment, the flow is diverted into much larger veins that are working well, thereby relieving the back pressure in the system. The leg will feel better and lighter, without the accompanying leg heaviness and fatigue that most patients describe. First line therapy is always wearing good compression stockings to alleviate some of the leg discomfort from varicose veins, although ultimately, this alone does not fix the problem. Most insurers will require 3-6 months of medical compression wear without substantial alleviation of symptoms, to qualify the patient for approval for endovenous laser ablation.
If the patient is experiencing leg swelling, restlessness, or cramps due to the vein problems, these symptoms will also typically decrease or alleviate after the flow issue has been fixed.
The larger, external veins that people see will typically decrease in size from 30-70% from the ablation procedure alone, although in most circumstances, they will still be visible. Ultimately, if complete absence of the veins is desired by the patient from a visual aspect, further adjunctive therapies such as sclerotherapy, may be required after the internal root problem is addressed. Visual external sclerotherapy performed as a “clean up” procedure after ablation is considered cosmetic, and is not covered by medical insurance. The exception to this rule is when sclerotherapy is used under ultrasound guidance, aimed at internal veins with valve problems. In this circumstance, the insurer may cover the procedure as medical necessity on a case by case basis.
Absolutely. We have many patients who have suffered with venous stasis ulcers chronically for several years and improve dramatically after the causative bad valve is identified and addressed. In most circumstances, the ulcer will heal within 6-8 weeks of treatment if properly diagnosed.
There are two different types of sclerotherapy.
One is external, visual based sclerotherapy, where a tiny needle is inserted into a spider vein(telangiectasia), reticular vein, or sometimes even a varicose vein, in order to inject a small amount of material called a sclerosant. The job of the sclerosant is to damage the lining of the vein so that it will die and go away. Multiple injections are usually performed in a single 20-30 minute session. The needles are extremely small and although they are “pinchy,” they do not feel anything like a blood draw due to their micro size. Most people tolerate the procedure well without difficulty. After the injections, a compression stocking is worn over the injected leg for 1 week to help compress the injected veins. Normal activities are allowed with the exception of halting exercise for 2 days.
The second type of sclerotherapy is ultrasound-guided sclerotherapy. This technique uses a longer needle into a vein beneath the skin surface to get rid of a “root vein” with a bad valve. This is a more frequently used procedure in people who have extensive varicose veins, rather than spider veins, and is done as an additional therapy after endovenous laser ablation.
For leg spider veins, this depends on the extensiveness of the vein networks. A “mild” spider vein patient will require 1-3 sessions, “moderate” 3-5 sessions, and “severe” 5-10 sessions. Sessions are usually spaced 2-4 weeks apart. It can take up to several months for the veins to “fade” to a point where they are no longer visible. Smaller veins may take 1-3 months to go away, moderate veins 3-5 months, and large veins, up to 1 year. In the interim, the veins may change in color to a light grey or light brown, with gradual dissipation.
Although hypertonic saline, or salt water, is commonly used for sclerotherapy for spider veins, it is not an ideal sclerosant because it is relatively weak, hurts upon injection, and has an increased potential to cause an ulceration when it leaks out of the injected vein.
For these reasons, we utilize 2 different FDA approved compounds. One is Sotradecol, which is sodium tetradecyl sulfate. It has been in use since the 1920’s, and is particularly good for larger veins, especially when administered as a foam(see later comments). The second type of sclerosant is Asclera, (polidocanol), and the most widely used sclerosant globally. It is very safe, slightly weaker than sotradecol, and can be used for both small and moderate sized veins.
Both of these sclerosants can be administered as a pure liquid or as a “foam”. A “foam” is a sclerosant comprised of a gas and a liquid. Foam sclerotherapy can treat larger veins than standard liquid sclerotherapy. At Lumen, we utilize both liquid and carbon dioxide based foam sclerosants, because of their enhanced safety profile.
Typically, any superficial vein in the body can be sclerosed without harmful consequences due to the extensiveness of the superficial network in conjunction with the underlying deep venous system. This means that unsightly veins of the breast or other veins of the upper torso can be injected, or other veins of the upper torso. Hand veins are the most popular region for sclerotherapy outside of the legs, and they respond very well to sclerotherapy given adequate compression. Blue reticular facial veins around the eyes and temporal region respond well to transdermal laser therapy, obviating the need to chemically inject a sclerosant into the head and neck circulation.
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