Varicose veins—enlarged, colored and twisted veins just beneath the skin—affect up to 25% of adults, and as many as half of all adults over age 50.

For many, varicose veins are merely unsightly. For some, aching legs may be a symptom, although these are not really a health risk. The main health risk is that, over the long term, skin ulcers may develop around the site of varicose veins.

The good news: The newest varicose vein treatments are quick, safe and highly effective. Most can be done quickly in your doctor's office.

Finding A Specialist

Veins are responsible for returning blood to the heart to be reoxygenated. They contain a series of one-way valves that let blood move forward but not backward. But aging, obesity, pregnancy and other factors can make certain valves—especially those in the legs—malfunction, causing blood to pool in these veins, making them enlarged, twisted and purplish.

Varicose veins are unsightly but usually not medically dangerous. However, they may also be the sign of a valve dysfunction either in the deep or superficial veins.

Common mistake: Failing to seek evaluation from a board-certified vascular surgeon, interventional radiologist or other doctor who specializes in treating varicose veins. To find one, go to the Web site for the Society for Vascular Surgery ( or the Society of Interventional Radiology (www.sirweb. org). These specialists will give you a careful exam to determine if the veins are linked to a more serious problem.

Another benefit: If underlying medical problems are detected, your health insurance is likely to cover the treatment cost. Varicose vein treatments for purely cosmetic reasons are typically not covered by insurance.

Getting Examined

When the doctor examines you, he/she will start with a visual exam and take a full history, including symptoms such as swelling (a possible sign of a more serious problem), itching or painful, aching legs at the end of the day and any history of blood clots.

The most important exam element is a venous duplex ultrasound scan of the veins in both legs, from hip to ankle. The scan takes about 30 minutes. The doctor may have the equipment in his office or refer you to an accredited vascular lab. The scan will detect any blood clots or other blockages in the deep veins of your legs. If there is a blockage in the deep veins, your superficial veins could be providing a pathway for blood going to your heart-and treatment for superficial varicosities without tending to the deep-vein issues could cause serious leg swelling and other complications.

The scan also maps out the network of varicose veins and determines if they're linked to a dysfunction in the major valves of the great saphenous vein--the large superficial vein running the length of each leg. If these valves principally located in the groin and top of the thigh-are dysfunctional, this vein must be closed from groin to knee before treating any tributary veins. Otherwise, lower varicose veins will persist and new ones develop.

Saphenous Vein Treatment

Treatment for great saphenous veins used to involve inserting a plastic tube through an incision and pulling out the vein ("stripping"). Technology developed during the past five years has now replaced the old method with two new treatments: Radiofrequency endovenous obliteration and endovenous laser therapy.

In both procedures, a catheter is inserted into the vein—usually from the knee to the groin—heated and gradually withdrawn, causing the vein to collapse. (Following the procedure, the blood previously flowing through the vein becomes naturally redirected into other leg veins.) Results are immediate. The process uses local anesthesia and may be done in the doctor's office, though many physicians prefer a hospital or surgical center. The patient is up and walking after the procedure and wears compression bandages for 24 to 48 hours afterward. The procedure is only minimally painful and patients are able to resume normal activity after 48 hours.

I prefer to treat smaller varicose veins at the same time as well.

Smaller Varicose Veins

Once the great saphenous veins have been treated—or if ultrasound reveals that the saphenous valves are fine—the doctor can then treat any smaller varicose veins requiring attention.

Sclerotherapy is the "gold standard" for treating small-to medium-sized varicose veins. A small needle is used to inject a solution that irritates the vein's internal lining, causing it to collapse. The vein is still there, but it visually disappears since it no longer contains any blood.

The doctor typically makes a series of injections along the vein. The procedure is relatively painless, though the injections may sting slightly. The patient is up and walking afterward and then wears compression bandages for several weeks. Depending on the number of varicose veins, more than one session may be needed. Although both legs can be injected during one session (if there are multiple veins to be treated), for patient comfort and to limit session duration to less than one hour, you may need several sessions. I like to schedule sessions four to six weeks apart.

Sclerotherapy, delivered by an experienced doctor, has an excellent success rate and is quite safe. Still, it's not completely without side effects. Some patients may experience temporary bruising, sores, redness or brown pigmentation around the injection site. In rare cases. the patient may have an allergic reaction (itching, swelling to the sclerosing liquid--this is seldom serious. Doctors sometimes test a small area before the procedure if the patient has a history of allergies. Or some liquid may escape from the vein, causing temporary irritation.

Sodium tetradecyl sulfate (Sotradecol) and concentrated saline solutions are the only FDA-approved sclerosing agents in the US. Polidocanol (Aethoxysklerol) is used extensively in Europe and by some US doctors but is not approved by the FDA-So I do not use it for that reason. Several more agents are expected to become available soon—including Varisolve, a foam version of polidocanol used widely in Europe and currently in clinical trials in the US. The foam delivers the sclerosant more efficiently because it is less likely than a liquid to be diluted and deactivated when it mixes with the blood. This makes it more effective than other agents, especially in larger veins.

Ambulatory ("stab") phlebectomy is used for varicose veins too large to be treated with sclerotherapy. Instead, the veins are removed. The doctor makes a series of tiny incisions along the vein, then uses a tiny hooked instrument to pull vein segments out through the incisions. The procedure is typically done in the doctor's office using local anesthesia. The incisions are so small that often no stitches are required. The patient can walk immediately following the procedure and wears compression bandages or compression hosiery for at least two weeks afterward.

Treating Spider Veins

A common variation of varicose veins are spider veins (networks of tiny purple or red blood vessels just under the skin surface), a purely cosmetic problem. Treating them is generally not covered by insurance. Two treatments are sclerotherapy-an approach made possible by the recent introduction of extra-small sclerotherapy needles—or laser therapy, in which a laser is beamed through the skin to collapse the blood vessels. Both treatments have a success rate of more than 90%.

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