you're not being vein: varicose veins

• 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