• It might be about you
Why are we here?
25% women 15% men
When did vein trouble start?
• Varicose veins were first described:– The Egyptians
• Ebers papyrus over 3500 years ago
When did vein trouble start?
Mural paintings:Tassili caves (Sahara)
• 5000–2500 BC.
When did vein trouble start?
• Hippocrates – 4th century BC– Remove veins with incisions
When did vein trouble start?
• 625 A.D.• The Greek, Paulus Aegineta
– Favored ligation of the saphenous vein• 'Varices of the leg may be operated …
…upon those in the inner parts of the thigh where they gradually arise…
…below this they are divided into many branches.’
Who gets Varicose Veins?
• What did your parents legs look like?
– Risk of developing varicose veins:• 89% if both parents had varicose veins• 47% if one parent had varicose veins• 20% of neither parent had varicose veins
Cornu-Thenard, A, J Dermatol Surg Oncol 1994 May; 20(5):318-26.
Who gets Varicose Veins?
• Moms, How many children do you have?
– Of women with varicose veins• 13% had 1 pregnancy• 30% had 2 pregnancies• 57% had 3 pregnancies
Mullane DJ Am J OB Gyn 1952; 63:620
What Varicose Vein problems?– Aching– Tiredness, heaviness in legs– Pain:
• Throbbing• Burning• Stabbing
– Cramping– Swelling (peripheral edema)– Itching– Restless legs– Numbness
How do Varicose Veins Happen?
Nerves close to Veins
Nerves close to Veins
Normal Vein Blood Flow
Normal Vein Blood Flow
Valves in the Veins
Valves in the Veins
Abnormal Valves in the Veins
Abnormal Valves in the Veins
The End Result
The Bottom Line
• Before any Treatment:– Complete evaluation of the venous system
• Superficial and Deep• Look for ‘Leaky Valves’
– Ultrasound evaluation is the standard way to define the venous anatomy
The Bottom Line
• Before any Treatment:– Complete evaluation of the venous system
• Superficial and Deep• Look for ‘Leaky Valves’
• Treatment of Varicose Veins– Tailored to each individual’s findings
Leaky Veins
Leaky Veins
Leaky Veins
Knowing the Anatomy
Knowing the Anatomy
Tip of the Iceberg
Tip of the Iceberg
Tip of the Iceberg
What are treatment options?
What are treatment options?
Compression HosesCompression Hoses
What are treatment options?
Help for Putting Them On
What are treatment options?
What are treatment options?
Shut down Leaky Shut down Leaky VeinVein
Sclerotherapy
Sclerotherapy
Sclerotherapy
Removal of Local Veins
What are treatment options?
Shutting down Leaky Shutting down Leaky VeinVein
• Vein StrippingVein Stripping• Laser ablationLaser ablation
Vein Stripping
30yrs after Vein Stripping
• Recurrences: – up 70% after 10yrs– Neo-vascularization
What are treatment options?
Shutting down Leaky Shutting down Leaky VeinVein
• Vein Stripping• Laser ablationLaser ablation
EVLT
• EndoVenous Laser Treatment– FDA approved 2002
EVLT
EVLT
EVLT
EVLT vs Vein Stripping
• EVLT– As effective for shutting off ‘leaky vein’– Less Post-procedure pain– Return to work/activities quicker– Less bruising and hematomas– Less numbness – Requires only local anesthetic– No incisions– Patients are happier with results
Results
Results
Results
What Causes Varicose Veins?
• Dilatation of veins due to genetic defect in elastin or collagen
• Venous Hypertension caused by• Gravity• Obstruction/Compression of venous outflow
………leading to abnormal valve function
Normal Vein Blood Flow
Valves in Veins
Abnormal Valves in the Veins
Result of Abnormal Valve Function
Varicose Veins are not just a Cosmetic Problem
• Aching• Heaviness• Throbbing, burning pain• Swelling• Itching • Numbness
Varicose Vein Treatment
• Specific to each patient’s anatomy• Evaluate venous system with ultrasound• Evaluate deep and superficial venous
system• Goal - find the veins with “leaky valves”
Big and Small Varicose Veins
Large varicose veins Reticular veins Spider veins
Treatment
• Conservative treatment• Compression stocking• Leg elevation – above the level of your heart
Compression Stockings
“Butler” Device
When to go beyond “Conservative Therapy”
• Recurrent superficial blood clots (SVT)• Bleeding• Symptoms persist• Venous ulcerations• Cosmetic improvement
Superficial Thrombophlebitis
• Blood clot in superficial vein
Superficial thrombophlebitis
• Complication related to varicose veins
Treatment of superficial thrombophlebitis
• Warm moist heat• Ibuprofen • Leg elevation and compression• Observe for red streaks tracking to deep
system (rare)• Possible invasive procedure
Invasive Procedures for Varicose Veins
• Vein stripping • Laser ablation
Vein Stripping
Why Not Stripping?
• Up to 70% reoccur after 10 yrs
• Recovery is longer• More bruising/pain• Increased hematomas• Larger incisions
Laser Ablation--EVLT• EndoVascular Laser Treatment
• FDA approved 2002• Standard of care for treatment of varicose veins
EVLT• Thermal ablation using laser fiber inserted
in vein which destroys endothelium• Uses ultrasound- guided technique to
position laser fiber • Anesthetic injected using ultrasound to
surround vein• Thermal heat applied as laser fiber slowly
withdrawn from vein to destroy inner lining of vein (endothelium)
EVLT
Post – operative care EVLT
• Limit strenuous activity• Ibuprofen• Weight lifting restriction for 7-10 days• 24-hour use of compression stockings for
7 days
Results
Results
Vein Excisions
• Often used in conjunction with EVLT• Removal of short segments of veins• Microincisions to “tease” out veins• No sutures
Vein Excision
Sclerotherapy
• Used on small veins less than 3mm• Reticular and spider veins
Sclerotherapy
• Small needle injection under skin• Sclerosing agents—pilidocanol (Asclera)
• Destroys endothelium of small vein• Mild to no discomfort• Compression for 5 days after procedure• In office
• Saline injections• Foam sclerotherapy
Chronic Venous Insufficiency
Chronic Venous Insufficiency (CVI)
• Affects 27% of population• Often associated with prior DVT or incompetent valves—causing
severe edema—leading to complications
Conservative Treatment of CVI
• Goal — control edema to prevent complications
Conservative Therapy for CVI
• Compression stockings• Leg elevation• Skin care
Complications of CVI
• Cellulitis• Treatment--antibiotics, leg elevation
Complications of CVI • Venous ulceration• Health care costs > 1$ billion/year Before treatment
Management of Venous Ulcer• Leg elevation• Compression After treatment
• Wound care• Possible antibiotics • Evaluate arterial circulation• Possible invasive tx
Invasive TreatmentGoal—”shut down the problem vein”
• EVLT • Vein excisions• Ligation of saphenous vein