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Varicose veins

The job of the veins is to take blood back to the heart. There are two systems of veins: a deep system, contained within the muscle and not visible from the outside, and a superficial system, which is just under the skin surface. Most of the time, your legs are below the level of your heart, so how does your body get the blood in the veins to move against gravity? The answer is, the muscle of your leg acts like a pump. When you are walking or cycling or moving your leg in other activities, your leg muscle is moving.  The muscle then contracts against the deep vein contained within the muscle, and forces blood out of the leg and upwards. Because the deep and superficial vein systems are connected, the superficial vein system will empty too. The direction of blood in the veins should be going from the superficial veins into the deep veins, and from the deep veins up to your heart. There are a series of valves in the veins to keep the blood moving in this direction. Valves are like one-way doors: they open to let blood flow past them, then close and don't let the blood flow backward in the reverse direction. 

Most people with varicose veins will have a problem with the valves. If the valves in the deep system are not functioning, you get leg swelling (edema). If the superficial vein valves are the problem, then you get bulging, engorged superficial veins (varicosities). 

Varicose veins are common. About 30% of women and 15% of men in their 40's have varicosities, and the incidence increases with age. Risk factors for varicose veins include increasing age, female sex, family history, leg trauma or leg surgery, history of deep venous thrombosis (DVT), obesity, and sedentary lifestyle or profession that involves prolonged standing.

In some cases, varicose veins may be a purely cosmetic issue. Often however, varicosities produce leg discomfort: aching ,throbbing, fullness or an engorged feeling in the legs. Other times, varicosities can lead to superficial vein blood clots (thrombophlebitis), bleeding episodes, and progressive skin damage (chronic venous stasis disease), which is a predisposing factor for skin infection and ulcers.

Treatment for varicose veins is considered medically indicated when there are symptoms of discomfort or if there are complications. 

Vein ablation (closure procedure)


Vein ablation is used to treat varicose veins associated with superficial venous incompetence. Usually we use it to treat valve dysfunction in the greater or lesser saphenous vein. It is a minimally invasive technique that has replaced vein stripping. Instead of ripping the entire vein out of the inner part of the leg (stripping), we shut the vein from the inside using heat. Under ultrasound guidance, a thin catheter is inserted into the vein through a needle stick. The catheter is advanced through the vein. A solution is inserted around the vein to insulate it and to collapse the vein walls around the catheter. The catheter is then used to  "cauterize" the vein closed using heat energy, as the catheter is pulled out of the vein. Sometimes laser is used for vein ablation, but more typically, the heat source is radiofrequency energy. Once the vein is closed, the  blood is diverted into the healthier veins in the leg, and more normal blood flow is achieved because there is less pooling of blood in the superficial veins. The treated vein scars closed, and over time becomes obliterated.

Vein ablation can be performed as an in-office procedure under a local anesthetic. Sometimes this procedure is combined with a minor surgical procedure that involves removing clusters of larger varicosities through small (1/2cm) incisions or tying off (ligating) other feeding veins called perforators. In this case, the surgery is typically performed in an outpatient surgery center under a light general anesthetic or "twilight anesthetic." Most often, we treat one leg at a time. Surgery takes 20-90 min, depending on the number of large varicosities being treated. You will need a ride home. 

After surgery, you will have an Ace wrap (stretchy bandage) on the leg, extending from the foot to the groin. It needs to stay on and dry for 2 days. If it feels too tight or too loose, you can re-wrap it. There is no bedrest after surgery, and no crutches or cane. You are encouraged to get back to your regular activities as soon as possible. Driving is permitted after 24 hrs, as long as you are not taking pain medication. Most people will take pain medication only for a day or two after surgery; for many, acetominophen or ibuprofen is adequate. People who work typically return to work in 2-3 days. A feeling of fullness, bruising or soreness over the treated area is typical; sharp pain is uncommon. Cool compresses and walking exercise can help. The second or third week following the procedure, it is common to feel a tightness or "rubber band sensation" in the inner thigh as scar issue forms around the treated vein. This is a normal part of the healing process and may last a few weeks to months. Gentle massage and stretching are encouraged. May patients also feel that rubbing arnica cream into the area also helps.

A few days after surgery, we perform a repeat ultrasound to ensure that the treated vein is successfully closed. A week or so after that we see you back to check the wounds and to discuss sclerotherapy, if you want to pursue this.

The risks of surgery are low (less than 1-2%). Occasionally we see wound healing problems, minor infection, or a small clot under the skin surface.  The risk of DVT is less than 1% (similar to the risk of DVT if you had a cast on your leg). 

A personal story

John Hendee had a vein ablation procedure. He shares his experience.

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