GSV with reflux

Ultrasound Findings of Normal vs. Diseased Great Saphenous Vein

The Great Saphenous Vein (GSV) is the most commonly affected superficial vein to become diseased (valves no longer function and become leaky).  While venous reflux can involve the deep system and perforators, the superficial venous system is most commonly involved.  The superficial venous system consists of the great saphenous vein (GSV), accessory saphenous veins (AASV), small saphenous vein (SSV), several tributary veins and junctions where they connect to the deep system which include the sapheno-femoral junction (SFJ) and the sapheno-popliteal (SPJ).  Additionally, common anatomical variations of the SSV can occur, such as the presence of the vein of Giacomini (VOG) and a thigh extension (TE).

 

Normal GSV This is the GSV imaged on ultrasound in a longitudinal view. It is healthy without reflux.

GSV with reflux

GSV with reflux

Venous-valvular dysfunction within any of these veins may result in the appearance of varicose veins and can produce a range of symptoms.  Symptoms of venous insufficiency may include leg swelling, aching, heaviness, fatigue that is worse at the end of the day. Common nocturnal symptoms include restless legs and leg cramping. The GSV is most commonly affected, and is most frequently the source of varicose veins. Venous reflux can be determined by ultrasound.

 

 

Veins are not always visible to the eye

What are the adverse effects of vein treatment?

Adverse effects of vein treatment are uncommon.

Patients generally do very well with vein treatments, all of which have a low risk of complications. Most patients feel the benefits within a couple of weeks of treatment, for others it may take longer. With all treatments, the benefits need to be discussed along with the potential side effects or adverse events. The following are potential adverse effects from thermal vein ablations we tell our patients.

  • Aching over the treated veins is normal. This responds well to walking, ice packs, and anti-inflammatory medications such as ibuprofen (Advil, Motrin) or naproxen (Aleve).
  • Bruising over injection sites is also normal after vein treatment and resolves in about two weeks.
  • Hyperpigmentation over a vein can occur from blood pigments that are released as the vein is healing. It is more common in patients with large bulging veins and certain complexions. Hyperpigmentation tends to fade over many weeks if you stay out of direct sunlight.
  • Intravascular hematoma refers to a large varicose vein that becomes firm and tender days to weeks after treatment. This also responds well to ice packs and anti-inflammatory medications. We may also recommend a confirmatory ultrasound and/or offer needle drainage of the trapped blood to alleviate discomfort and minimize skin pigmentation.
  • Deep vein clots are very uncommon, and usually are limited to patients with poor mobility, advanced age, hormone treatment, and/or genetic tendency for clotting. We monitor all patients with ultrasound throughout treatment so we can detect clots at a very early stage before they cause a symptom. We may recommend surveillance ultrasounds, extra walking, and/or a short course of blood thinners.
  • Numb spot over a treated vein is another uncommon event after radiofrequency or laser vein ablation. This occurs when a branch of a skin nerve gets stunned during the heat treatment. It tends to improve over several weeks. The nerves that control the movement of the leg and foot are located far from the superficial veins.
vv ankles

Oh My! My Vein is Bleeding, What Now?

Sponatenous bleeding or Hemorrhage caused by rupture of a varicose vein is a hidden danger of varicose veins.  It usually occurs in the small blue veins around the ankle and shin (blue blebs), and the amount of bleeding and blood loss can be significant.

Untreated varicose veins are at a higher than usual risk of bleeding or spontaneous rupture.   Over time, varicose veins become larger, and the vein wall becomes weak and stretched out. These veins, which are already weak are also under high pressure (because of venous reflux, or the ‘backflow’ and pooling of blood in these veins). As a result, the high pressure can cause the veins to spontaneous burst and bleed heavily. Because they are under high pressure, they bleed like an arterial bleed and patients describe the bleeding as ‘blood shooting across the room.’  The varicose veins that are susceptible are veins closest to the surface of the skin

I have studied over 100 patients who have had an episode of spontaneous vein hemorrhage. Most patients describe that it occurs during or after a warm shower (warm water causes veins to relax and dilate, allowing more blood to pool within the veins) or during sleep. It is painless and patients report that they notice it because they feel something wet in bed or if awake, they describe it as bleeding that ‘shoots across the room.’  Patients who are on blood thinners can lose large amounts of blood, especially if it occurs while they are sleeping. Some people have required blood transfusions. The small blue spider veins around the ankle are equally at risk of rupture as are the larger bulging veins.

vv hemorrahge

This is a patient who experienced spontaneous hemorrhage of their varicose veins. Notice the appearance of the blue, bulging veins that we describe as, ‘blue blebs.’ These veins are dilated, weak, and are close to the surface of the skin. The pooling blood within these veins causes high pressure, ultimately resulting in a spontaneous rupture or hemorrhage. The bleeding is rapid since varicose veins are under high pressure.  This is a common condition that we see at La Jolla Vein Care. If spontaneous vein hemorrhage occurs when you are home, immediately place pressure with towels and elevate your leg on several pillows. Standing will make it bleed more. If the bleeding does not stop with these measures, immediately seek medical attention.

If someone you know has experienced bleeding from their varicose veins, they should be seen by a doctor. Treatment will prevent the veins from bursting again.

venous stasis

3-Stage Approach to Vein Treatment

When visible signs of venous disease such as spider veins, varicose veins, or skin changes are present, this is usually the tip of the iceberg, and an underlying vein problem is present. An underlying vein condition (venous reflux disease) can be detected with ultrasound. A treatment plan is focused on treating the underlying vein problems first, then working outwards.

How Is Venous Reflux Disease Treated?

Step 1: The Underlying ProblemThe first step is to treat the underlying problem, the venous reflux. The specific pattern of venous reflux was detected by ultrasound. Venous reflux usually starts in the saphenous veins. The saphenous veins are most effectively treated with vein ablation procedures. This involves placing a small catheter within the vein and using heat or a solution to produce injury and eventual closure of the vein. The most commonly used treatments for the saphenous veins are radiofrequency ablation (RFA), laser ablation, mechanico-chemical ablation (MOCA or Clarivein), and in some cases Varithena Foam. The treatment recommendation is customized, based on where reflux is present and other clinical factors.

Step 2: Varicose Veins

After the underlying saphenous vein reflux is corrected, the bulging veins (varicose veins) can be treated by injecting a foamed medication that will cause them to scar and eventually dissolve (foam sclerotherapy), or to remove them using tiny incisions. The most common method is foam sclerotherapy.  This is also known as ultrasound-guided foam sclerotherapy (UGFS).

Step 3: Spider Veins

Spider vein treatment is always considered a cosmetic procedure. If improved cosmesis is a goal of treatment, make sure to discuss this with your doctor and plan on having cosmetic treatment as the last step. Spider vein treatment is accomplished by sclerotherapy, which is an injection of a liquid medication into the spider veins. Most patients use 3 vials, and have an average of 3 treatment sessions.  Ask your provider for an estimate about how many treatment sessions/ vials are necessary to get the results you want.

 

doctor explaining to patient

Understanding What Your Doctor Is Saying About Your Veins

If you’re not a vascular specialist, it may be difficult to understand the words used to describe your vein condition. Vein terms are not used in everyday life.  Especially, when it comes to the anatomy of the veins. Below is a glossary of the terms, we as vein specialists, use on a daily basis but may be foreign to the patient.  This is provided from the American Vein and Lymphatic Society (AVLS) healthyveins.org.

Anatomical Vein Terms

Anterior: The front of a body part.

Posterior: Back of a body part.

Deep Leg Vein: The veins that are deep in the thigh and leg that carry blood back to the heart.

Connective Tissue: This strong tissue is the white tissue that covers muscle.

Great Saphenous Vein: (sometimes called GSV or long saphenous vein) A long vein that can be seen just in front of the anklebone. This vein travels along the inside of the leg and thigh (about one-half inch beneath the skin in the thigh) until it empties into the deep vein called the common femoral vein in the groin.

Perforating Vein: A vein that passes directly from a superficial vein to a deep vein.

Popliteal Vein: The deep vein located behind the knee. The small saphenous vein originates from the popliteal vein.

Small Saphenous Vein: (sometimes called SSV, Lesser Saphenous Vein, or LSV) A superficial vein that starts at the outside of the foot and travels up the back of the calf where it empties into the deep vein (popliteal vein) in the crease of the knee.

Spider Vein: A tiny varicose vein that may be blue or red color that does not protrude above the skin surface and frequently looks like a spider. Common medical terms you may hear for spider veins are telangiectasias and telangiectatic veins. Slightly larger varicose veins that do not protrude above the skin are called reticular veins.

Superficial Vein: Any vein in the lower extremity above the deep fascia that covers the muscles of the thigh and leg.

Varicose Vein: A bulging vein that protrudes past the skin surface and usually measures greater than one-fourth of an inch (6.4 mm) in diameter.

Vein Function Terms

Competent Vein: Blood flow occurs in the proper direction back to the heart. Also referred to as Having No Reflux Or Normal Flow Direction.

Incompetent Vein: Blood flows in the wrong direction. Also referred to as a vein that has reflux.

Reflux: Blood that flows backward in the veins.

 

Anatomical Images and Explanations

Normal Blood Flow: After the blood has been replenished with oxygen in the lungs, it is pumped to the body by the heart. Blood that is pumped to the lower extremities is pumped back to the heart partially by the action of the calf muscle pump. The blood returning from the lower extremities in the deep and superficial veins goes past a series of one-way valves. These valves stop the blood from flowing backwards in the veins.

Reflux: The valves in the veins close just as blood begins to flow backwards. If the valves do not close properly, the blood falls backwards through the poorly closing or leaking valves. The veins downstream that are now unprotected by valves further upstream are exposed to the weight of an increasingly high column of blood. These downstream veins cannot endure the pressure of the column of blood and expand becoming snake-like in appearance. This causes the veins to bulge through the skin surface and become varicose veins.

image of person putting on compression stockings

How To Wear Compression Stockings

How to put them on, tips and troubleshooting common issues with compression stockings

Compression stockings are an important part of conservative management and after treatment care of venous reflux disease. It is important to wear compression stockings correctly, and obtain a proper fit to make sure they are as comfortable as possible.

Applying stockings with ease:

  1. Turn your stocking completely inside out
  2. Locate the smaller foot hole of the stocking and tuck the foot in until you reach the heel
  3. Place your thumbs on either side of the tucked in foot hole, with the heel located on the bottom
  4. Put your foot in the stocking until the heel of the stocking has met your heel
  5. Grab the larger hole or top of the stocking (it should be hanging off your foot) and pull the stocking up onto your leg
  6. Inch and pull the stocking until it has reached either below the crease of your knee for knee highs, or the highest portion of your thigh for thigh highs.

Cant keep your stockings up? Try these tips!

  1. When someone’s stocking is falling down, their first instinct is to tug at the top band to pull them back up. This is mistake #1! By tugging and pulling at the top band, it is stretching out the top of the stocking which will make it fall down faster and more often. Instead of tugging at the top, simply inch and pull the stocking up by the fabric that is at the ankle. This will allow for the stockings extra fabric to be moved the the thigh or calf and will keep the stocking up better.
  2. Wash and DRY the stocking! Stockings are very durable and can handle a washing machine and dryer. Putting a wet stocking in the dryer will bring it back to its original compression which will make the stocking stay in its rightful spot for longer. Just don’t use fabric softener when cleaning the stocking.
  3. Is your skin dry? The silicone top band on most thigh high stockings wont stick to dry skin which will make the stocking slip down. Moisten skin with lotion, skin cream or even water to allow the stocking to stick to your skin.
  4. Be in the correct size! Stocking that are too small on the thigh will roll at the top making it nearly impossible to keep them up. Be sure to be sized properly to ensure proper fitting. There are even stockings that are made with larger calf and thigh ranges which may help those who have a “rolling” issue. Alternatively, to too small of stockings, stockings that are too big will fall right down! Don’t borrow stockings from friends to prevent being in the wrong size. Be sure to be fitted correctly to ensure the stocking is the correct size.
  5. If none of the tips above help, be creative! You can use Spanx, suspenders to even safety pins to keep stockings from falling down.

Is the foot too tight? Some stocking brands run narrow. Signs the foot is too tight is toe numbness or foot pain. Talk to your doctor if you feel the foot is too tight.

 

Microsoft Word - Laser.docx

What Vein Treatment is Best for Me?

Vein Treatments, what are my options?

In recent years, the expansion of different vein treatments has been readily available for patients. Depending on each patient’s vein condition, different treatment options may be recommended. Unlike in the past where vein stripping surgery was the only option, there are now multiple minimally invasive vein procedures that are not only fast but minimally invasive and very effective. For patients who have underlying saphenous vein insufficiency, treatment options include: Radio-Frequency Ablation (RF or RFA), Endovenous Laser Therapy (EVLT), Clarivein® (Endovenous Mechanical Ablation), Varithena Microfoam and also the most recent treatment to obtain FDA approval for the indication of venous reflux disease, called Venaseal (vein glue). For patients who also have bulging varicose veins, treatment options may include, Microphlebectomy (Ambulatory Phlebectomy) or foam sclerotherapy. But, how does one know which treatment is right for them? With an ultrasound and consultation with a board certified vein specialist, a specific treatment or treatment plan may be recommended based on what would be best for the patient and their needs.  To learn more about our approach to treatment, and the treatment options, click here.

varicose veins

Understanding Insurance Coverage for Varicose Veins

Does Insurance Pay for Varicose Vein Treatment? Here’s the criteria that determine if insurance pays for varicose vein treatment

Most insurance types (including Medicare and Molina) will cover varicose vein treatments that are considered “medically necessary care” but not for “cosmetic care”.  Varicose veins (bulging leg veins) have to cause symptoms such as leg pain to be covered by insurance. Spider veins (tiny cluster of blood vessels at the skins surface) are considered as a cosmetic treatment and are not covered by any type of insurance.

4 Main Criteria for medically necessary vein treatment

  1. Varicose veins must cause leg pain or other symptoms.

Medically necessary vein treatment means that the varicose veins must cause symptoms such as: leg  pain,  heaviness, persistent swelling, night-time cramping or burning. Complications of varicose veins that may indicate treatment include leg ulcer (open wound) from the vein problem, recurrent blood clots or phlebitis, ruptured bleeding vein, or skin discoloration around the ankle.

  1. Symptoms affect daily life.

The symptoms must be severe enough to affect a person’s ability to do their daily routines or work. For example, a teacher may have varicose veins that prevent them from standing and doing their job, because they have to take frequent breaks to elevate their legs. A server at a restaurant may no longer be able to work long shifts, due to leg pain after a few hours. Symptoms can interfere with lifestyle by limiting the amount of exercise one hopes to achieve, or inability to cook or do house chores due to leg pain.

  1. Conservative treatment must be tried for 6-12 weeks.

In most cases, insurance require that conservative measures have been tried for several weeks. Conservative measures include compression stockings, leg elevation, exercise, weight loss, anti-inflammatory medication such as ibuprofen or venoactive agents such as horse chestnut or Vasculara, and hot/cold packs.  Many insurance types REQUIRE 6 to 12 weeks of wearing medical grade compression stockings prior to being approved for treatment.  You should have your consultation as soon as possible and begin implementing conservative management into your lifestyle. You should begin keeping a daily log documenting that you are using conservative treatments. If your primary care physician has already prescribed compression stockings, it is helpful if you have a note, you’re your doctor or the prescription, as this counts toward your conservative management time period.

  1. Venous reflux must be demonstrated on ultrasound.

Underlying venous insufficiency must be documented by ultrasound examination. The ultrasound study to determine the treatment and the physician visits are covered benefits with most insurance types.

Treatments that are not covered by insurance because they are considered to be ‘cosmetic services’ include:

  • Varicose veins that do not cause any symptoms
  • Spider veins

Does Your Vein Condition Qualify for Medical Necessity?

If you have answered ‘yes’ to each of the 4 categories, then you are likely to meet medical necessity criteria for vein treatment. Disclaimer: this is a simplified questionnaire for patient convenience and understanding.

  1. Do your varicose veins cause at least one of the following symptoms?
  • Leg pain
  • Heaviness
  • Persistent swelling
  • Aching, heaviness, or throbbing

And/ Or have you suffered from one  of the following complications of varicose veins?

  • Leg ulceration
  • Ruptured bleeding vein
  • recurrent blood clots or phlebitis

 

  1. Do your symptoms (leg pain, etc.) affect your daily life?
  • Yes, it affects my job
  • Yes, it affects my home
  • Yes, it affects my daily routine or leisure

 

  1. Have you already tried conservative management, and the conservative management has not completely resolved your vein condition?
  • Yes, I have tried compression socks/stockings/ AND two or more of the following:
  • Leg elevation
  • Exercise
  • Weight loss
  • Ibuprofen or other NSAID
  • Ice or heat packs
  • Venoactive medication such as Vasculara or OTC supplements like horse chestnut or grapeseed extract

 

  1. Did you have an ultrasound examination that demonstrated underlying venous reflux disease?
    • Yes, my ultrasound demonstrated and documented backward flow in my veins (venous reflux)
    • No, the ultrasound examination concluded my veins have normal function.

However, some individual insurance policies exclude varicose vein treatment- this is usually a result of the employer exclusion. Sometimes in this case, one may ask the employer to include varicose vein treatments on the policy. You may call the number on the back of your insurance card to ask specifically if they cover vein treatments. When you start a vein treatment process with us, we will help you to understand what your insurance will cover. Our prior authorization specialist will obtain preauthorization (approval) for your treatment and can answer questions.

For a list of insurance types we accept at La Jolla Vein Care, click here.

varicose vein before after

How Long Does it Take for Varicose Veins to Go Away?

While the veins are shut down immediately, it can take several weeks (sometimes months for more severe cases) for the veins to completely break down within the body.  Some patients will require multiple visits, depending on the severity of the condition. The body’s healing process will vary from person to person.  No two people’s vein condition are the same.

In general, your legs will feel better before they look better. In general, legs typically start to feel better a couple of weeks after treatment. For very symptomatic patients, legs may feel better almost immediately. For less symptomatic patients, the benefits of less leg fatigue, aching and other symptoms may be noticed several weeks later. For the noticeable varicose veins at the surface,  it takes several weeks to months for these to break down and fade away. The cosmetic benefits follow the health benefits of vein treatment.

Your doctor can better assess your timeline at your consultation. Symptom relief comes earlier than cosmetic results. Discuss your goals of treatment (symptom relief vs. cosmetic results or both) to better understand the timeline.  It is important to have reasonable expectations as it is not possible to have ‘immediate’  cosmetic results.  Whatever your goals are, we will work with you to obtain the results you want. Our mission is to help patients achieve long lasting relief from varicose veins.

 

varicose veins and spiders

What Causes Varicose Veins?

WHY ME?

Who gets varicose veins and why.

Both women and men can develop vein disorders at any age.  It can affect the healthiest of individuals, but there are some conditions that increase your risk of developing varicose veins.  They are mostly inherited; if both of your parents had varicose veins, you have a 90% chance of also having them.  Other factors that increase your chance of developing vein disorders include being female, hormonal changes, pregnancy, getting older, having a job that requires many hours standing or sitting, being overweight, and a history of leg injuries.

  • Increasing age. As you get older, the valves in your veins may weaken and not work as well.
  • Heredity. Being born with weak vein valves increases your risk. Having family members with vein problems also increases your risk. About half of all people who have varicose veins have a family member who has them too.
  • Hormonal changes. These occur during puberty, pregnancy, and menopause. Taking birth control pills and other medicines containing estrogen and progesterone also may contribute to the forming of varicose or spider veins.
  • Pregnancy. The hormones during pregnancy greatly influence the leg veins. Varicose veins can even be a symptom of pregnancy and can show up during the first trimester. As pregnancy progresses, there is a huge increase in the amount of blood in the body. This can cause veins to enlarge. The growing uterus  also puts pressure on the veins. Varicose veins usually improve within 3 months after delivery. More varicose veins and spider veins usually appear with each additional pregnancy.
  • Obesity. Being overweight or obese can put extra pressure on your veins. This can lead to varicose veins.
  • Lack of movement. Sitting or standing for a long time may force your veins to work harder to pump blood to your heart. This may be a bigger problem if you sit with your legs bent or crossed.
  • Leg Injuries