SPIDER VEIN TREATMENTS

This time of year I see many women who want to improve the appearance of their legs before summer and warmer weather arrive. Some have not worn shorts for years on account of self consciousness or outright embarrassment over the appearance of their legs. Some women with extensive and dense clusters of spider veins have aching or burning symptoms occurring when standing.

There is no reason patients should have to endure the symptoms or the appearance of unattractive spider veins. Appropriate treatment, which frequently involves sclerotheapy, can easily be performed in the office by an experienced vein specialists. If the spider veins are the result of more complicated vein problems, such a specialist will be able to diagnose this and recommend appropriate treatment.

Typically spider veins are injected with a chemical compound that damages the interior lining of the tiny veins, which sets in motion a chain of events within these veins ending with their disappearance. The treatment is performed using a tiny hypodermic needle. Patients usually report only minor discomfort. Other advantages of sclerotherapy include ease of in-office administration, short treatment duration, and immediate return to usual activities.

There are a number of chemical agents commonly used for sclerotherapy including the most commonly used ones - polidocanol, sotradectyl, and glycerine. Commercials tout the agent Asclera as new and miraculous. In fact Asclera is a brand name for polidocanol, which I have been using for years. Hypertonic saline was a popular agent in the past but now is rarely used on account of pain and a relative high rate of skin damage and ulceration. Vein specialist now generally use agents as effective as the hypertonic saline but without these drawbacks.

Patients considering sclerotherapy to rid their legs of unsightly spider veins would be wise to ask about the sclerosing agent to be used. The physician’s experience with the agents should also be dicussed.

HOW TO CHOOSE A VEIN DOCTOR

Now that the techniques for treating vein problems have evolved such that they are easily accomplished on an outpatient basis with good results, more physicians are becoming interested in providing these services to the many patients who have limiting symptoms and/or cosmetic concerns. But herein lies a dilemma for patients. Many patients do their own research, frequently using the internet, to find competent doctors to treat their vein problems. Should the patient see someone who exclusively treats vein problems or someone who treats vein problems in addition to other diseases specialties, say perhaps a cardiologist or an OB/GYN specialist, who have primary clinical interests in areas far afield from vein disease? Should the patient seek a surgeon with vascular experience or feel secure with a dermatologist or a radiologist who also treat vein disease?

While the “occasional” vein doctor, i.e. one who primarily practices in a specialty other than phlebology (the study and treatment of vein diseases), may be able to handle the more common vein issues, he or she will not have the vast experience to draw on and will not be as adept in recognizing or treating appropriately the more uncommon or subtle vein problems as the physician who treats exclusively vein diseases. Will such part time vein practitioners recognize the pitfalls and complications that may occur?

My advice to someone looking for a vein doctor is to seek out a doctor who specializes in and treats exclusively vein problems.

Next in consideration is the question of whether the vein doctor should have a surgical or nonsurgical background? Although I am sure many would disagree, I believe that the surgeon, especially one with a vascular surgery background, is best prepared to handle whatever may arise in treatment. Surgeons in general have greater manual prowess, and if a more invasive operation, such as tying off and dividing a vein well below the skin level, is required, the surgeon surely has in his training and experience a clear advantage over the radiologist, dermatologist, general medicine physician, and others lacking the vascular surgery training and experience. Such procedures done in the outpatient office setting would be no challenge for the vascular surgeon.

In summary, a patient suffering from vein problems would be well served to seek out a doctor who specializes in vein disease and treatment (phlebologist) to the exclusion of other specialty fields. Physicians, who dedicate their entire practice to the diagnosis and treatment of vein disease, are more likely to have extensive specialty training and education and to use state of the art equipment and be current with pertinent continuing education in the specialty. Within that group of vein specialists, a patient should look for a surgeon, especially one with vascular experience.

Spider Veins and Venacura

It is difficult these days to listen to the radio without hearing about a product called Venacura. Venacura is a catchy name for a commercial product that is touted as an almost miraculous cure for spider veins of the legs. Review of the official website claims 30 years of research, and that the “key ingredient” is Diosmin. Among the several benefits of the product proclaimed on the website are “to quickly diminish ugly bulging veins and faint spider veins”, reduce “the appearance and discomfort associated with spider veins”, to provide “relief from swelling and inflammation of the legs”, reverse “chronic venous insufficiency (vein disorders)”, and give “relief from leg ulcers” and “hemorrhoids”. All this for just under $50 (plus shipping cost, insurance extra) for a one month supply of pills and an assurance of complete patient satisfaction or your money back. And then there is the radio advertisement that tells of a woman who had called her doctor to cancel her appointment for her spider vein treatment after discovering the benefits of Venacura. 

Only one problem, the stuff does not work. If I were taken in by this hype and smart advertising (they must be making a fortune!), I would be out of my money and would still have my spider veins. Maybe another month would do it though? When some Venacura clients have complained of no results after one month of taking pills, the company representative has reassured then that most people do not see substantial benefit until the second month of pill consumption. 

I have attempted to find good clinical scientific studies that validate the claims made about Venacura. I am convinced there are no believable ones. There are a number of websites that attest to the efficacy of the product, but on close investigation most are owned by the Venacura company or are thinly veiled commercial sites that offer nothing to substantiate the claims. There are some reviews by users that claim their money went for no purpose since the product did nothing to help their spider or varicose veins.

Diosmin is a flavonoid, and some have claimed that flavonoids promote vein health. Results of clinical trials have been inconclusive. There is no evidence in my research that these compounds have the ability to remove existing spider or varicose veins. The company touts FDA approval for their Venacura, but FDA approval does not support any claims of efficacy, only that it is a safe dietary supplement.

At Dallas Vein Specialists I have treated thousands of spider vein and varicose vein patients over the years. I have seen the whole spectrum of varicose veins and spider veins. If there were a magical drug that removes spider veins, my vein specialist colleagues and I would have embraced it long ago. The standard for spider vein treatment remains sclerotherapy. This is the ONLY treatment that delivers consistent and safe removal of spider veins, and this treatment has stood the test of time. The modern minimally invasive treatments for varicose veins such as endovenous laser therapy (EVLT) and microphlebectomy have become the standard as well.

In summary, do not waste your money and time on something that does not work. Rely on the tried and true treatments for spider veins, varicose veins, and venous leg ulcerations - treatments that have been shown to be effective for thousands of patients in well done scientific studies.

SCLEROTHERAPY or VEIN LASER TREATMENT, WHICH IS BETTER FOR SPIDER VEINS ?

At Dallas Vein Specialists in the course of seeing numerous patients and treating their spider veins, I am frequently asked the question,  “What about LASER?” and “When do you use LASER?”. Little wonder that these questions come up so often and that patients are confused about the options for spider vein treatment, as there is so much talk about lasers. 

At Dallas Vein Specialists we use special lasers to ablate, or do away with, veins that are deep to the skin and usually course deep in the fat layers of the leg. These lasers work exceedingly well and result in the eventual disappearance of the treated veins, hence the term ‘laser ablation’. But we do not use lasers that are designed for skin surface veins such as spider veins.  This practice is for a very good reason, they do not work nearly so well as SCLEROTHERAPY, the treatment of veins by injection of chemical agents that result in the disappearance of the veins.

Spider veins may occur anywhere on the leg and are surface vessels, easily seen in the top layer of the skin. They are small, measuring less than 1mm in diameter, and are often numerous and frequently arranged in clusters. They may cause symptoms such as burning or aching when a person stands for a while, but the overwhelming reason most patients come in for treatment is the unsightly appearance of the spider veins.

In order to achieve the desired result of treatment, the disappearance of the spider veins, it is necessary to cause an irreversible injury to the spider vein blood vessel, after which the vessel will clot and no longer carry blood.  Then the body will remove the vein over time, a feat accomplished by the body’s own inflammatory process activated on account of the injury. The length of time this process requires varies with the size of the vessel and the location of the spider vein on the leg. Most spider veins begin to fade and look much better in 2 to 3 weeks, and most are gone in 4 to 6 weeks. For larger vessels, especially ones located about the feet and ankles, it may take 2 to 3 months before the last vestige of clot is entirely gone. Of course the treated areas will look much improved long before that.

Both laser devices designed to treat at the skin surface and sclerotherapy will produce damage to spider veins. In the case of the laser the results are much less predictable than with sclerotherapy. I have seen numerous patients at Dallas Vein Specialists who have had little or no response to repeated laser treatments and who have presented with frustratingly persistent spider veins, this after having expended time and money for the treatments, which are considerably more expensive that sclerotherapy. It is not uncommon to find that patients have also suffered laser-induced skin damage resulting in an ulcer or sore that was slow to heal. They have been left with scars from such skin injuries and still have their spider veins too! With sclerotherapy skin ulceration and sores, although they may occur, are rare indeed when the proper agents are used. The agents used at Dallas Vein Specialists are safe, not painful, and do not damage the skin.

As I mentioned the laser treatments cost time and money. The application of skin lasers to spider veins is a slow process, as the treatment is done one millimeter at a time. Consider the time it would take for the laser technician to treat one cluster of spider veins. Since the patient is paying for the use of the expensive laser and the treatment time, which usually requires several sessions to treat both legs, the expense can run into the thousands of dollars. And what of the patient’s time for multiple trips to the laser clinic? Whereas with sclerotherapy we are usually able to treat both legs and most if not all spider veins during the first 30 – 40 minute appointment. A further “touch up” treatment may be necessary depending on the number of spider veins and the success of the initial treatment, but such treatments are usually shorter and at less cost than the initial one. The treatments are much faster, because only one or two injections may fill an entire cluster of spider veins with the chemical agent.

Another consideration is patient discomfort. Patients frequently speak of the unremitting pain of the laser treatment citing the repeated jolt of pain each time the laser is ‘fired’. Consider how often this would be when so many ‘firings’ are necessary just to treat one spider vein cluster. With sclerotherapy the exceedingly small needle causes only minimal discomfort if at all. The chemical solutions are not painful, as we do not use hypertonic saline, which is an effective agent but one that causes pain on injection and is caustic to the skin and may result in skin ulceration. The sclerotherapy agents used at Dallas Vein Specialists are safe, not painful, and are highly effective for most patients.

In summary, the laser treatment of spider veins is more painful, expensive, and less predictive of good result than is sclerotherapy. Sclerotherapy in the hands of an experienced vein surgeon is highly effective and safe and requires less time and expense to achieve the treatment goal of resolution of the spider veins.

FACIAL SPIDER VEINS

At my vein practice in Dallas, Texas, I frequently get asked about the small spider veins of the face. “Why do I get them?” and “Can they be treated?” are common questions. Many patients do not realize that these small hair-like veins can be eliminated.

Spider veins of the face, like the spider veins of the legs, are called telangiectasias. They may occur in any person with or without other vein problems. They tend to occur as we age, usually first occurring in the 30’s and 40’s, and are quite common in people past 50. Rarely these veins may be seen in children, usually girls because of female hormones, or in any child with an injury to the face, such as may occur with a fall. While spider veins may be seen anywhere on the face, common locations include the junctions of the nose and the cheek and the upper lip near the nostrils, the cheeks themselves, and the chin. 

The Cause of Facial Spider Veins

The cause of facial spider veins is not known. Suffice it to say that they occur with aging and probably have a genetic link.  In some men facial spider veins tend to be worse with alcohol intake. In women estrogen has been thought to play a role. Chronic sun exposure may also be a factor. Some patients report the development of localized spider veins at the site of trauma such as over zealous extraction during a facial. Rosacea, a chronic inflammatory facial skin condition, causes redness and flushing and the appearance of small red spider veins. Any inflammatory skin condition affecting the face may predispose an individual to develop these facial veins. Chronic use of strong topical steroid agents may cause dilation of the skin vessels, and this has been suggested as a causative agent in some.

The Treatment of Facial Spider Veins

Treatment of facial spider veins is done for cosmetic reasons only. Treatments that have been advocated include sclerotherapy (injection of chemical into the spider veins), intense pulsed light (short burst of high intensity light exposure to the skin), skin laser, and pinpoint delivery of radiofrequency energy (VeinGogh). I will discuss each of these and my experience with patients who have received these treatments.

Sclerotherapy involves injection of a chemical compound that causes irreversible injury to the vein inner wall. The injections are done with a fine needle that enters the tiny vein. The discomfort is minimal, if at all. This is usually followed by clotting of the vein and its removal by the body’s own inflammatory process over ensuing weeks. While sclerotherapy is extremely effective and commonly used for spider veins of the legs, it is the most infrequently used treatment for facial spider veins. First of all it is not usually possible to introduce a needle into the veins, because these facial spider veins are much smaller than ones usually seen on the legs. These facial spider veins are so fragile that any pressure from an attempt to inject them would result in rupture of the tiny structure. In addition most vein specialists do not like to inject vein-damaging chemicals near the eyes. Therefore I do not employ sclerotherapy for facial spider veins at Dallas Vein Specialists.

Intense Pulsed Light (IPL) has been used for facial spider veins with limited success. Small and faint spider veins may sometime respond to IPL, but it works poorly on dense clusters and ones that are more prominent. Usually several treatments are necessary, and the cost can be substantial. Patients report some discomfort from the treatments.

Lasers have been used with success for facial spider veins. The potential for skin damage and the discomfort of treatments are drawbacks however. Scarring from skin damage and loss of normal skin pigmentation are concerning considerations.

VeinGogh treatment, a promising and effective new approach, is the delivery of a burst of radiofrequency energy to the spider vein via a hair-like metal probe that is placed directly on the spider vein. This causes thermocoagulation of the spider vein, which immediately disappears from the skin. The mild discomfort is usually easily tolerated. At Dallas Vein Specialist I have used the VeinGogh device with good success. There have been no significant problems such as scarring. Some patients have required more than one treatment to completely eliminate the spider veins.

Other treatments using creams or dietary supplements or vitamins have not been shown to be of any real benefit. Commercial claims of curing or removing spider veins of the face or legs should be viewed with great skepticism.

In summary spider veins of the face are cosmetic concerns and occur in many people as a consequence of aging. Various treatments have been proposed. Sclerotherapy or injection treatment is fraught with problems. IPL is of limited benefit, often providing improvement but not complete removal. Laser is effective but scarring, expense, and discomfort are limiting factors. VeinGogh using radiofrequency energy is effective, safe, and cost friendly.

TRAVELER’S THROMBOSIS

Since the 1990’s much has been written about the so-called “traveler’s thrombosis”, the development of clots in the veins of the legs in patients who have recently traveled and been relatively motionless for extended periods of time. It has been called “economy class syndrome” and “coach class syndrome”; however, other travelers who fly first class or spend hours in automobiles or trains are also at risk for this potentially dangerous condition.

When the clots involve the deep veins of the leg, so-called “deep vein thrombosis” or DVT, the condition is potentially life-threatening. If the clot extends, breaks off, and travels in the bloodstream to the heart and lung (acute pulmonary embolism), obstruction of blood flow occurs resulting in lung damage and even death. One may recall the case of 39 year-old NBC reporter David Bloom, who in 2003 died suddenly in Iraq after confining himself to long hours of travel in a military vehicle. In fact the association of prolonged inactivity in cramped conditions was first made in England during World War II when people slept in deck chairs in air raid shelters and suffered fatal acute pulmonary embolisms.

DVT and its complications can occur with any prolonged immobility such as being bedridden after surgery or a prolonged illness when the blood flow in the veins of the leg is slowed or restricted. Other conditions that are associated with DVT include obesity, pregnancy, cancer, and inherited clotting disorders.

Who is at greatest risk for Traveler’s Thrombosis?

Studies have shown than the risk of clots with air travel is related to the duration of the flight. The longer the flight the greater is the risk. For flights less than 4 hours the risk is slight, but for flights more than 8 hours the risk in one large study was development of leg deep vein clots in 1 of every 200 passengers. The rate of severe pulmonary embolism, a clot traveling to the lung, is rare for flights less than 8 hours but increases with longer duration flights.

Travel-related thrombosis is higher in persons with pre-existing risk factors for the development of deep vein thrombosis. These factors include recent surgery within 1 month, active cancer, prior unprovoked deep vein clotting, inherited predisposition to blood clots within veins, and prior travel-related clotting events. Pregnancy and obesity could be added to this list of risk factors as well.

Preventing Traveler’s Thrombosis

Since immobility and confinement to cramped quarters for long durations is the common denominator of traveler’s thrombosis, common sense would dictate that movement, especially walking about with some frequency, would lessen the risk. Interestingly, children are not at risk for traveler’s thrombosis, because they are so active. When walking is not easily accomplished, sessions of repeated leg calf tensing exercises serve to compress and empty the deep veins that course within the muscles. Avoidance of excessive alcohol intake and taking adequate water and fluids has been advocated. For some who have had bouts of traveler’ thrombosis and who are to experience a long flight, a single dose of heparin anticoagulant just prior to the trip may be advisable. In preventing clot formation in the veins there is little benefit in taking aspirin or Plavix (clopidogrel bisulfate).

Perhaps the easiest and best preventive measure one can take is wearing a good (prescription grade) pair of compression stockings. These are fitted to measure and  are “graduated”, meaning that the compression is highest at the foot and ankle and less as the stocking goes up the leg. Thus the pressure gradient promotes the normal flow and emptying of the blood within the veins of the leg. This below knee hosiery is relatively inexpensive and with good care and occasional use will last for years. For any flight or journey lasting for more than 3 hours compression hose should be a regular part of the traveler’s dress.

Knowledge and understanding of the condition called “traveler’s thrombosis” and measures to help prevent it will promote better health among the traveling public. Certainly any person who develops leg or calf swelling, tenderness, or pain or has shortness of breath or chest pain after a prolonged journey should seek immediate medical attention.

The Risks of the Latest Minimally Invasive Ablation Procedures for Varicose Veins

The modern era of varicose vein surgery has not only brought minimally invasive techniques that reduce patient suffering and increase the rapidity of patients return to usual activities including minimal work time loss but has also dramatically reduced the surgical risks of having varicose vein operations. Comparisons of risks and complication rates between the old vein stripping operation and the modern ablation procedure using radiofrequency or laser energy are striking and unquestionably come down on the side of the ablation procedure. 

The risks of endovenous laser ablation include infection, skin burns, nerve injury, and deep vein thrombosis. I will take each risk and discuss it, as I do with every varicose vein patient who comes to me at Dallas Vein Specialists.

INFECTION

Infection is rare in these procedures. Every attempt is made to prevent infection by providing antiseptic preparation of the surgical site, i. e. the leg, and by preventing contamination by maintaining a sterile operative field at all times during the operation.  To date I have not seen a leg infection from an ablation procedure.

SKIN BURN

This is a rare complication, and again I have not seen this complication in any of the many ablation procedures I have done. When it occurs, a burn of the skin is the result of the heat energy generated by the radiofrequency or laser that damages the overlying skin. Special consideration and care is necessary in patients with minimal fatty tissue over the vein to be treated. This complication, a skin burn, should not occur with careful planning of the procedure.

NERVE INJURY

Here I am talking about a sensory nerve injury and not a motor nerve. That is to say numbness of the skin and not muscular impairment or paralysis. There are areas where sensory nerves travel quite close to superficial veins. These areas are in the lower leg below the mid calf. Abnormal veins in these areas are usually not treated with the ablation technique, and thus a heat-induced injury can be avoided. Small areas of partial numbness may occur after endovenous laser or radiofrequency ablation treatments, but these almost always resolve within the first 3 months postoperatively.

DEEP VEIN THROMBOSIS

Deep vein thrombosis (DVT) is a serious complication and may lead to life threatening complications. Fortunately the risk of this complication is quite low  in patients undergoing an endovenous radiofrequency or laser ablation operation. 

Any thrombus or clot that develops within the inside of a vein that is located deep to the outer lining of the muscle should be closely followed. If the clot is in the large deep veins of the knee or thigh or involves the veins of the pelvis and abdomen, the patient should be treated emergently. Patients treated early with anticoagulation usually do well and the clot resolves uneventfully.

Patients may develop DVT with no symptoms or signs. For this reason I ask patients to come in for a quick look, using ultrasound, at the deep veins within a few days after the ablation procedure. This check is almost always clear with no DVT found. This is no surprise, as I take care during the procedure to avoid any contact or manipulation of any deep vein structure.

In summary the modern minimally invasive procedures for varicose veins are highly successful and allow a rapid recovery. The risks are quite low and acceptable such that no one should suffer the pain, discomfort, or unhealthy skin changes that accompany varicose veins.