The following are the most frequent questions I received so far through e-mail.
1. WHAT CAUSES VARICOSE VEINS?
Without going into details all three major components of the vein wall ( smooth muscle, collagen and elastin are damaged and in wrong proportions.
Varicose veins are the result of a weakness in the vein wall that is in most cases familial. (Hystochemical examination revealed more collagen and less elastin content in the vein wall.) This weakness causes distension of the vein and secondary incompetence of the unidirectional valve systems attached to the vein wall. There is at least one report showing that the number of venous valves in the superficial venous system is also reduced. We just don't know whether this is congenital or secondary i.e. caused by atrophy and thus detected later.
A reversed flow pattern (reflux), induced by gravitation, is established that will, with passage of time, just further distend the veins, and the situation will get worse. Pregnancies, especially multiple, excessive weight and inactivity ( being sedentary) will further aggravate the condition. Third world countries have the least incidence ( New Guinea less than 1%), while the so called civilized Europeans and North Americans have the highest (10-15%) incidence of varicose veins in their population.
The existence of the leaky valves can be detected way before the veins on the leg become obvious and twisted. A report from Germany has shown that in persons who will develop obvious veins later in their life the Doppler ultrasound examination revealed valvular incompetences (reversed flow) already at 12-14 years of age!
2. WHAT IS THE CONNECTION BETWEEN VEINS AND PREGNANCY?
During pregnancy there are several factors that can aggravate either the tendency or already existing varicose veins: the high level of the female hormone of pregnancy that relaxes the smooth muscles exisitng in the vein walls; the increased blood volume and increased abdominal pressure. These two are acting especially in the last trimester of pregnancy (7-9) months). One should also watch the weight gain that should not exceed 30 lbs. The following are to be done to ease possible discomfort and the aggravation of existing varicose veins:
1. Use of surgical elastic stockings during the day for the whole period of pregnancy: knee level first 2 trimesters, maternity panty in the last trimester. These are fitted items that should be prescribed by a physician. 2. Gravitational drainage by leg elevation 3-5 times a day for at least 5-10 minutes. The foot should be higher than the level of the heart.
3. Walking with elastic surgical stockings on and wearing laced up shoes.
4. Shower/bath should be taken in the evening rather than morning; hot water just further distends the veins in the morning causing early pain and discomfort.
5. Avoidance of salty foods will reduce the water retention tendency. Should the veins persist 2-3 months after delivery coonsult a surgeon for possible radical treatment.
As a general rule the best time to operate the varicosities in women in childbearing age would be after the patient is done with all the pregnancies as additional pregnancies promote undesired and early recurrences. However, if the patient had a miserable pregnancy due to the existing varicosities they should be operated after the termination of that pregnancy regardless whether the patient desires to have more children.
3. WHAT IS THE CONNECTION BETWEEN LONG DISTANCE TRAVEL AND VEIN THROMBOSIS?
People who have varicose veins or who have had deep vein thrombosis (DVT) should be extra careful during long distance travel by car or specially by plane. The motionless sitting position, and possible concomitant dehydration could facilitate blood clots as it stagnates in the leg veins by gravitation and by absence of calf pump activity. As measure of prevention gradient surgical stocking up to the knee should be worn during the flight. Get up every 45-60 minutes and walk in the aisle. In between, move your feet up and down. Fluids should be consumed in large amounts. In airplanes the air is dry favoring fluid loss through our breathing and perspiration making the blood more viscous. One should refrain from alcoholic beverages as these promote vasodilation and further fluid loss through the skin. Personally, I would also advise that the day of flight, or even a few days before, one tablet of baby Aspirin (81mg) should be consumed as well.
Fluids should be consumed in large amounts but not coffee or tea as they are diuretics and promote fluid loss and blood viscosity.
4. IS LASER TREATMENT INDICATED TO TREAT UNWANTED VEINS?
The public and the media are literally fascinated with LASERS. A LASER machine generates highly energized light waves that destroy biological tissues by generating excessive temperatures. In medical terms this is called thermolysis.
First, for varicose veins LASERS are not an option at all and possibly they will never be as the excessive energy needed to destroy big veins would inflict severe damage to the skin and other surrounding tissues resulting in unacceptable scarring.
Theoretically, therefore, only the spider veins could be treated. While there are several LASER machines approved by the FDA, the existing experience is too small and short to widely recommend it. Also, they may be beneficial for venules not more than 1mm in diameter and spider veins are often associated with feeder vein that are far bigger and which will need to be injected as well.
The much publicized PHOTODERM is based on a burst of high energy noncoherant flash bulb light and the SCLEROLASER, COHERENT and the LASERCOPE are far more refined tunable monochromatic energized light sources. All three are meant to "jump" over the skin and cause destruction of the targeted vein.
The treatment may be painful ( snapping a rubber band on the skin), and it may cause "coagulation necrosis". That means that the treatments may leave behind permanent dark pigmentation of the skin.
The cost of treatment will be higher than sclerotherapy: $350-450 dollars per session.
Responsible practitioners will tell you that these devices are supplemental modalities to the injection treatment. Personally, I believe that the second generation of spider veins especially telangiectatic matting that are resilient to further injection treatment should be possibly offered these alternatives. It also seems to me that the tunable monochromatic LASERSCOPE or SCLEROLASER will be far better than the flash bulb PHOTODERM which potentially could cause more severe tissue and skin damage.
One and a half years have passed since the above was written. Even today, almost 2 years later, the general assumption of moral practitioners is that the lasers have basically failed us in the treatment of spider veins of the leg. (For the facial spiders they are good and they should be used as the first line of treatment.) Personally, I think that the industry and several physicians who have had and may still have financial incentives in promoting these expensive machines have all but misled us, the public and physicians alike, all because of greed.
A well known practitioner who has clear financial interests in the PHOTODERM machine mentioned above, while demonstrating the greatness of this machine at a major venous meeting in 1996 has caused severe skin injuries on 2-3 provided volunteers.
Personally, when I will pay off my laser machine, the LASERSCOPE, I will have shelled out over 100.000 dollars and in ten life times I will not be able to recover my "investment". Now, after several years of industry’s praise of these "magnificent" forms of treatment, we hear that the wavelength of these machines should have been not in the range of 532-600 nm ( as most were) but double the range, namely 1064 nm. I am convinced that in several years we will hear departure from this new "standards" as well!
I was present at a recent meeting organized by the LASERSCOPE Company when this new wave length machine was introduced. When I criticized their statements regarding the "successes" of the previous laser machines in treating leg spider veins, one of the officials of the company , who shall remain nameless, almost attacked me physically after I had enough of the nonsense and decided to leave the conference.
The reader should also know of dirty tricks employed by another well-known practitioner in order to block the publishing of at least one medical report critical of the results of the Photoderm. Only after the firm stance of the author, who wrote to the chief editor of the medical journal, was his critical report printed on the pages of the journal, the Dermatologic Surgery.
Personally, I can testify that the results of the LASER are inconsistent, the treatment is long, requiring many sessions, is expensive, and is also painful. In many cases and after 1-3 sessions the disillusioned patients demand to revert back to the injection treatment. Sclerotherapy remains, therefore, even today the main form of treatment for spider veins of the leg. Lasers should be used sporadically on leg veins and only on cases of small areas of red spiders that do not respond to injection treatment. Also, if after 2 maximum 3 sessions no results are seen, the treatment should be stopped. Personally I take a photo of one small area and do a test dose possibly repeated one additional time. I do not charge for these test doses. Only if positive response is clearly visible while comparing the before and after photographs would I suggest targeting larger areas.
So, for the time being, the treatment of choice for varicose veins is surgical by AMBULATORY PHLEBECTOMY and the treatment for spider veins is by INJECTION SCLEROTHERAPY. The laser treatment would be complimentary to the traditional injection sclerotherapy.
5. TENDENCY TO CLOT or THROMBOPHILIA
Tendency to clot or hypercoagulable states ( Thrombophilia) are present in approximately 50% of patients presenting with venous thrombosis. It is imperative that the possible existence of these conditions should be considered in recurrent vein thrombosis especially the deep vein type ( also called DVT) of unknown origin and without obvious venous pathology. Also, DVT in young persons especially without precipitating factors ( surgeries, debilitating diseases with long bed rest, cancer, etc.etc.) or with previous family history of thrombosis should suggest an inherited disorder of the clotting mechanism.
This is rather a complicated subject and I advise the reader to print out these lines and show it to the physician.
There are two main groups of disorders:
1. Hereditary
Please note: Antithrombin III inhibits (inactivates) THROMBIN formation which is indispensable for the clot formation besides being a potent platelet aggregator as well. Similar activities has the Thrombomodulin. Thus both inactivate thrombin and prevent clotting. Lack of them will lead to excessive clotting.
Protein C and S inactivate ( digest) factor V and factor VIII and therefore prevent clotting. Their deficiencies will lead to excessive clotting.
2. Acquired
6. SUBFASCIAL ENDOSCOPIC PERFORATOR LIGATION in the presence of chronic venous insufficiency, including venous ulceration, is a new minimally invasive version of an old surgery known as the LINTON procedure, which has been abandoned as it had severe wound complications in up to 60% of the operations. The endoscopic procedure avoids that complication as it enters the leg via healthy skin in the upper calf. The method is good provided the indications are correct.
In persons with varicose veins and chronic venous problems, including ulceration, a good cleanup surgery of the superficial varicosities will completely heal in most cases an existing venous ulceration.
In persons with deep vein problems the procedure may have temporary good results as well. The chronic venous insufficiencies' skin problems is usually the result of a deep vein clot that , after several years, by damaging (occluding) the deep veins causes perforator vein outflow. The transmission of the elevated venous pressures from the deep veins to the skin can cause severe skin changes including venous ulceration. In these cases ligation of those perforator vein will be beneficial and will facilitate the healing of the skin changes.
The patient needs to be evaluated correctly by someone who understands venous diseases. A duplex ultrasound scanning, possibly phlebogram ( x-ray) (if the duplex ultrasound test was not conclusive enough) is mandatory. These two tests will document the presence and the localization of those offending perforator veins. A hemodynamic test called APG is indicated as well when superficial varicose veins are present . The test can show which of the two vein systems ( deep or superficial or both) cause the elevated venous pressure responsible for the severe skin changes, including ulceration.
7. THE CLOSURE METHOD IN TREATING VARICOSE VEINS.
Correctly called the endoluminal radiofrequency elimination of varicose veins (or simply "closure") the method uses radiofrequency current generated heat that can warm up tissues up to 180 degrees F.
The technology is not new at all. The radiofrequency current was used for decades in general surgery to cut tissues and coagulate (seal off) small blood vessels. In the last 10-15 years the technology is also used in cardiology to treat several forms of rhythm disturbances refractory to medical management.
It is known for a long time that connective tissue, when heated, shrinks. This is the direct result from heat’s impact on collagen, a fibrous protein that makes up 90% of the organic material of all tissues, veins included. Collagen is like a stretched out spring but when heated the bonds keeping the spring-like substance taut is released and the collagen spring shrinks into a jumbled coil shriveling the tissue. The probe (catheter) introduced into a vein under local anesthesia, is meant therefore to close the vein without the need to remove it surgically.
Another recent application of the method is in sleep apnea and snoring where the method can simply shrink the soft palate that vibrates in the back of the mouth and causes the person to snore. It competes with the laser in this application and appears to be possibly better as it has a shorter recovery time.
According to a recent print out by the industry ( which manufactures the catheters) the method was used in Europe on 186 varicose limbs. The follow up is very short, only 6 months to a year and only 41(?) patients (out of the total 186) were followed through this short period of time. There were 8 immediate treatment failures of the method. At the end of the short follow up period in additional 8 treated cases the veins were found totally or partially opened. Thus the projected 5 year failure rates would be in the range of at least 40-50% which is inadmissible for any surgical procedure. The rate of nerve injuries
( overheating adjacent nerves) was high and dependent on the length of vein treated. In the thigh area it was 8.9% but if the vein was treated in the ankle area the nerve injury rate reached 40.9%!!!. In an additional 7 cases thermal injuries (burns) to the skin happened as well! While the search for a method to treat varicose veins in the office is noble, the reader is advised to stay away from this method. The following reasons should be considered:
1. The method can treat only straight veins. The coiled and twisted varicose veins will need to be surgically removed in any case. (No injections, please as the veins will be opened again in a short time…!)
2. The above listed complication rates are very high and the number of treated cases are to small.
3. The follow up is very short. 5-10 years of follow up is required to properly evaluate a method. It is expected, as in the injection method, that with passage of time additional veins will open up resulting in high failure rates.
4. A method for office treatment of the condition does exist in the from of the minimally invasive surgery (ambulatory phlebectomy) doable under local anesthesia and without convalescence, stitches and scars. The method is well described on the pages of this web site.
5. The industry has created a "hammer" and the search for an appropriate "nail" is on now. My advice to the reader is not to allow yourself to become a "nail". Certainly consented participation in a research protocol conducted by a medical school is advocated. The results of minimum five years of follow up should guide us as to the validity of the method and not hit and run short studies which are meant to bring in money for the manufacturer of the machine.
6. There is a great similarity between promotion of this method to and the promotion of laser treatment for spider veins. Years after the introduction of laser machines the results of laser treatment for those small veins is still inconsistent and responsible practitioners will not offer it as the first form of treatment. Lasers have not replaced injection treatment for the condition in spite of the push from the industry ( which wants to make money by selling more and more machines of the kind) and from irresponsible practitioners.
7. In the same vein, the reader is reminded that some 10 years ago advertisement for LASER laparoscopic cholecystectomy (keyhole gallbladder removal) was wide spread. Not anymore, as experience has shown that the use of lasers was not just redundant but contraproductive! Whenever a new technology is introduced people should wait for several years before permitting routine use on their own body unless the patient agrees to participate in an experimental study.
8. Lastly, please do no fall for the fact that FDA has approved these machines. It is unfortunate, that important drugs, used for years if not decades in Europe, are held back by the FDA while questionable machineries are approved in just few months.
8. VARICOSE VEINS OF THE VULVA . THE PELVIC CONGESTION SYNDROME.
This condition is encountered exclusively in women during and after pregnancies. Normally, the blood from this part of body is drained back to the heart by veins that are branches of pelvic veins such as the internal iliac vein and the ovarian veins. The uterus is not far from these veins. During late stages of any pregnancy, due to the compression of these veins by the growing uterus, all veins in the area are exposed to increased venous pressures resulting in excessive blood congestion. Transmitted to the lower vein branches of the vulva and vagina the veins in the area may bulge, and cause discomfort and pain. Occasionally hemorrhoids will be present as well for the same reasons. Fortunately, however, in most cases after delivery, most of these painful bulging veins will disappear. It is, however, possible that after subsequent pregnancies these veins will be permanently present and will cause discomfort and pain while standing and mainly around the monthly periods. Many women may also complain of lower abdominal pain and some will complain of pain during sexual relations. While the syndrome is rare, it is unfortunate that is not easily recognized by the gynecologist and these women will go from physician to physician for help.
Once the condition is diagnosed or suspected the patient is be referred to an interventional radiologist. Most major community hospitals and certainly university hospitals have the needed equipment for such tests. The radiologist will correctly diagnose the problem by injecting a dye through a catheter inserted in the main vein of the leg in the groin. After positively diagnosing the offending and leaking vein the radioloigist will use, through the same catheter, either foam or special coils to close off the vein through which blood is flowing downhill filling up the veins of the vulva and vagina. Occasionally, concomitant injection of the visible vulval veins has to be done as well. This form of treatment is usually very successful and will avoid any surgical intervention.
The KT (Klippel-Trenaunay) syndrome is a congenital mesodermal abnormality consisting of a capillary nevus (port wine stain) that can be extensive; venous anomalies (lack of venous valves in the deep vein even total lack (agenesis ) or partial lack (hypoplesia) of deep veins, congenital varicose veins that can represent the only venous drainage of the limb, swelling and limb hypertrophy. The treatment is only symptomatic. Removal of the external varicosities should be done only after the deep veins have been fully studied and visualized. If they represent the only outflow tract, removal could have catastrophic consequences. The Parkes-Weber syndrome is similar but here one can find clinical and radiographic evidence of clear A-V malformations /fistulas. For additional info you have to do a literature search. Read: Ann Surg 1988; 207:213-218 and Br J Surg 1985;72:232-36.
10. WHAT ARE THE SIDE EFFECTS OF INJECTION SCLEROTHERAPY?
While there are several unpleasant side effects, we will mention the two most catastrophic ones.
SKIN ULCERATION is a common occurrence after injection of both type of veins, spider or varicose. It occurs when the sclerosing agent is injected in a high concentration and volume. In most cases the small ulceration will heal and will leave little or no scars . In cases of clear blunder (carelessness or incompetence) , permanent disfiguring scars could result.
This was the case of a patient from Iowa who went to treat her spider veins by a local plastic surgeon without much experience. After the third injection session severe skin injuries of both legs occurred (see photograph). As a consequence the patient, a teacher, has been disfigured for life.
At the trial, several years latter, Doctor Ferdinands shifted the blame to "skin allergy" (sensitivity) to paper tape, rather than high volume and concentration of the sclerosing agent. Unfortunately, our judicial system permits lawyers to come up with a lie defense and the jury acquitted the doctor.
INTRAARTERIAL injections of sclerosing agents does occur only when large varicose veins are targeted by injection sclerotherapy. (The reader should know that varicose vein sclerotherapy is by now obsolete in the hands of practitioners who critically evaluate the procedure's long term results.) Still, many surgically unskilled practitioners use the method, some even in conjunction with ultrasound imaging. Injecting, by mistake or incompetence, the strong concentrated solution into an adjacent artery ( rather than vein) can cause necrosis (death) to the tissues supplied by the respective artery. Tissue loss i.e. skin necrosis as well as gangrene of the toes or even parts of the foot (which needed amputation) have been described. A recent article in the Journal of Dermatologic Surgery and Oncology by Dr. Biegeleisen of New York has described several of these accidents which happened in his practice, in order to alert physicians to these dangers.
The Palm Beach Post of October 11, 1992 carried an article on Dr. Knight who inflicted severe injuries of the kind to several of his patients. In a subsequent issue of the journal , the same staff writer reported a $227,817 award to a patient (of the same practitioner) for expenses and pain.
As with anything else in medicine, the best treatment is prevention. Patients should refrain from going to vein mills. Patients should not fall for media advertisement. Ask your family or your Ob/Gyn doctor for a referral. Ask for patients' names who have previously had the procedure. If you have any doubts regarding the doctor's credentials please check with the Medical Boards for disciplinary actions. You may want to check the public records at the local court house regarding law suits. Never agree to be injected during general anesthesia and at the smallest sensation of pain during injections ask the physician to stop immediately.
11. VITAMINS & SUPPLEMENTS FOR VEIN DISORDERS.
The media is full of false, yes FALSE , advertisements of various supplements which are presented as miracle supplements in the treatment of especially unwanted spider veins. Derivates of horse chesnut and Vitamin K cream are among the two main advertised items, but probably there are other substances on the market for the same purpose.
Vitamin K is given to people who have a bleeding tendency especially due to liver problems or who have been on blood thinner medication. So, theoretically, if you would apply the Vitamin K cream on the skin, it could prevent excessive skin bruising in case of soft tissue trauma. It may or may not help. The fact that this statement of the manufacturer was never proven in a scientific study. One thing is sure, however, the spider veins or varicose veins will not go away. There is nothing magical in vitamin K to make an anatomical change such as the disappearance of the spider veins! The same applies to horse chesnut or any other supplements on the market. It may help leg swelling but the vein will remain the same.
The only reason I would suggest anyone to buy any of these products is that purchasing the drug is helping the economy of the country and this is a noble act.
12. WHAT ARE THE BEST CONSERVATIVE AND PREVENTIVE MEASURES FOR CHRONIC VEIN DISEASE?
People with chronic vein problems such as severe varicose veins and chronic venous insufficiency should follow the rules also known as the "RIVLIN'S RULES" set forth by Mr. Stanley Rivlin, Consultant Surgeon of London, UK.
It is my privilege to present the rules (accompanied by original illustrations that depict him in the Instructor 's role) to the readers of this site. Needless to say I have the personal permission of Mr. Rivlin to do so for which I am deeply indebted to him, for the second time. The first time was 5 years ago, in 1991, when he granted me the opportunity to visit and learn from him and also observe his superb surgical skills.
Rule 1. NEVER STAND STILL
Reason: In standing position the blood in your incompetent veins will pool , the pressure will increase and fluid (water) will accumulate in the soft tissues of the foot, ankle and lower calf.
Rule 2. WALK
Reason: Staying active will set in motion your calf muscle pump; blood will be pushed uphill toward the heart and the pressure in your veins should drop. Accumulated fluid is reabsorbed from the soft tissues. Distention and pain should improve.
Rule 3. ALWAYS WEAR LACE-UP SHOES
Reason: Wearing laced-up shoes (and for that matter support stockings) will minimize the fluid retention in the soft tissues of your foot and ankle that in turn will reduce the distension, discomfort and pain.This is a very important rule in long distance (over 5 hours) travel by car or plane. Don't remove shoes, as will be difficult to put on at the end destination!
Rule 4. DO NOT SLEEP IN CHAIR WHILE WATCHING T.V.
Reason: Calf muscle pump inactivity will induce swelling and discomfort. (See Rule 1)
Rule 5. WHEN SITTING, MOVE ANKLES UP AND DOWN
Reason: This will activate the muscle pump as well with the same beneficial effect mentioned in Rule 2.
Rule 6. DO NOT SIT CLOSE TO FIRE
Reason: Calf pump inactivity with local heat, which dilates veins, will further increase fluid retention and discomfort.
Rule 7. NEVER BATH IN THE MORNING, ONLY AT NIGHT
Reasons: At night, during sleep in the horizontal position, even bad veins can regain a more narrow shape (tonus). Heat in early hours of the morning will immediately distend these veins that will promote fluid retention quite early in the day with the accompanying discomfort and pain.
Rule 8. RAISE FOOT OF BED ON 9-INCH BLOCKS
Reason: Gravitational drainage will reduce elevated venous pressure and will ease the discomfort. Note: people with congestive heart failure, emphysema and obese people may have breathing problems and should possibly refrain from doing this. So should people with hiatal (diaphragmatic)hernia in whom this position may induce reflux of stomach contents into the lungs. Elevating the legs three to four times a day for 5-10 minutes above the level of the heart could be beneficial as well for the same reasons.
Mr. Stanley Rivlin , Consultant Surgeon, Vascular and Vein Unit, is located at 3 Upper Harley Street London NW1 4PN Tel: 0171-935 5843; Fax: 0171-224 0080.
I am sorry to inform the reader that Mr. Stanley Rivlin passed away but possibly his associate Mr. Baskerville is continuing his work. Mr. Rivlin was a great individual and I am indebted to him and he will remain in my memory for life.