applying compression stockings

Varicose Vein Sclerotherapy Treatment: What to Expect

Ultrasound-Guided Foam Sclerotherapy

Ultrasound-guided foam sclerotherapy allows your doctor to treat backwards flow (or “reflux”) in superficial veins that are not visible to the naked eye but are causing symptoms including pain, swelling, and varicose veins.  Ultrasound allows us to localize the unhealthy veins, inject the medication precisely, and guide the medication towards areas of varicose veins. This minimally invasive treatment will be done in our office and does not require any anesthesia. A fine needle is placed into the vein and a sclerosant foam medication (polidocanol) is injected.  The brand names are Asclera and Varithena. The medication irritates the vein wall, which causes it to stop flowing, then eventually close down completely. The blood continues to return to the heart through other healthy veins.

Preparing for your procedure:

  • Bring your prescribed thigh-high compression stockings to every appointment. Please try on your stockings prior to your first appointment to ensure proper fit.  We do not recommend shaving your legs beforehand because the compression stockings may cause ingrown hairs.
  • On the morning of the procedure, shower and use antibacterial soap to cleanse the leg.
  • We recommend you eat a light meal before you arrive.
  • Our procedure rooms are equipped with TVs and Netflix, but you are welcome to bring a book or iPad to use during the procedure if you prefer.
  • Please notify our office if you are scheduled to have any type of medical procedure or surgery 2 weeks prior to or after your treatment.
  • If you become pregnant or are breastfeeding, please notify your La Jolla Vein Care provider as your treatment will need to be postponed.

Medications

  • If you have asthma, please bring your inhaler to your appointment.
  • If your La Jolla Vein Care provider recommended a prophylactic blood thinner (e.g. Xarelto, Eliquis, or Lovenox) or an antihistamine (e.g. Zyrtec or Claritin), please take your first dose at least two hours prior to your procedure
  • If you were prescribed a blood thinner during treatment, continue to take it until your final ultrasound 3-7 days after the last treatment unless instructed otherwise.
  • If you already take aspirin or another blood thinner, you will continue it during treatment unless instructed otherwise.

The ultrasound-guided foam sclerotherapy procedure:

  • You will check in 10-15 minutes prior to your appointment, then change into disposable shorts supplied by our office.   .
  • We will clean your leg(s) with alcohol. We will then use ultrasound to “map” the veins to be treated.  Each vein will be accessed with a tiny needle through which the foam medication is injected.
  • You will flex the foot prior to each injection and then do calf exercises (pointing and flexing the foot) between injections.
  • After the treatment is complete, we will elevate your legs on a wedge pillow for 10-15 minutes while you continue 20 calf exercises per minute.
  • We will then help you into your thigh-high compression stocking, then you will walk around the medical campus for 30 minutes before getting in the car.

Medical Compression Stockings

  • Wearing compression stockings is a part of your vein treatment. Your veins will not only heal faster, but compression stockings reduce the risk of complications
  • You will wear compression stockings continuously for 72 hours (3 days).  You can remove them to take a quick cool shower the day after treatment or you can shower in the stockings.
  • After the 72 hours, you will wear the stocking for an additional week during the day (for a total of 10 days after each procedure). The 10 days will start over after each treatment session.
  • For comfort, you can fold down the silicone band at the top of the stocking at night.
  • If your stockings are slipping down, try wiping down the silicone beads with rubbing alcohol to make them tacky again. We also have glue available for purchase at our office to help them stay up.
  • If you experience numbness, tingling, or discomfort on the foot, you can remove the stocking at night, then put it back on first thing in the morning.  Sometimes the stocking has to be cut to relieve pressure. Be sure to NOT cut the toe band of your stocking as this will cause the toes of your stocking to roll. Instead, cut a 1/2 to 1 inch long slit on the side and in the middle of the foot area. First make a small cut; you can make it bigger if needed.

Activity

  • You can resume your usual activities on the day of treatment.  You can return to work the same day as long as you are able to walk and/or do calf exercises every hour.
  • Walk at least 30 minutes twice daily for 2 weeks after each treatment session.  There is no limit to how much walking you can do and inclines are okay.
  • Avoid pooling of blood in the legs by keeping the calf muscles active with heel-raises, pointing/flexing the feet, and walking.  Avoid high heels.
  • When you are sitting, the more you elevate your legs the better.
  • Avoid running, spinning, other strenuous exercise, and exercise in hot environments for 2 weeks after each treatment session
  • Avoid hot tubs and leg massages for 2-3 weeks after treatment.

Travel

  • Avoid long trips for the next 3 weeks.  For car rides over 1 hour, get out every 45 minutes and walk for 10 minutes.
  • On a long airplane trip, get up to walk around frequently, and flex your ankles every few minutes.
  • Wear your compression stockings during travel.

What to Expect Following Treatment

  • After treatment of dilated veins close to the skin (spider veins), it is normal for those veins to itch for a few hours.
  • Bruising at the injection sites is normal and will fade over about two weeks.  You may apply arnica or Recova cream to those areas.
  • Varicose veins may become firm and blue after treatment, then fade over a period of weeks. The skin overlying larger varicose veins may develop brown “hyperpigmentation” as the blood pigments within those veins are absorbed by the body.  This can take up to a year to fade.  Avoid exposing that skin to the sun until the pigmentation fades, so that it does not become permanent.
  • Aching and slight swelling is normal in the legs for several days after treatment, and generally improves with the following:
    • Walking 10-30 minutes is the most effective treatment.
    • Ice packs (or a bag of frozen peas or ice) over the sore veins, 15 minutes at a time, several times a day.  Protect your skin by placing a thin washcloth under the ice pack.
    • Anti-inflammatory medication such as ibuprofen (Motrin, Advil) or naproxen sodium (Aleve), taken as directed on the bottle.  If you cannot take those medications, acetaminophen (Tylenol) can be used.
    • For severe pain, or pain that worsens with walking, promptly call the office.
  • Treated veins will look worse before they look better.  Initially, large veins may feel tender, firm, and/or lumpy. Please point out any lumpy and/or tender areas to the doctor.  The whole healing process may take several weeks to months.

Adverse Effects

Although rare, sclerotherapy can be accompanied with unwanted effects including: trapped blood (a small amount of blood becomes trapped within the closed vein), hyperpigmentation of the skin (darkening of the skin), allergic reaction (rash, hives, or anaphylaxis) or infection.

  • Injection of the foam bubbles can be irritating to the body and cause symptoms including chest pain and headache.  We minimize this risk by giving you only a small amount of foam medication per day and by elevating your legs for 10-15 minutes after treatment.
  • Some patients develop “trapped blood” within larger varicose veins days to weeks after treatment.  This usually presents as a tender, possibly red, firm area.   It can generally be managed with ice packs and anti-inflammatory medication but we may offer needle drainage of the blood to alleviate pain and minimize the risk of hyperpigmentation.
  • Some patients develop new, tiny spider veins near areas of treated veins, which is also called “telangiectatic matting”.  This usually occurs 2-4 weeks after treatment and fades within 4-6 months but can take up to a year.  It is more common in women who take estrogen supplements.
  • There is a small risk of clot formation within the deep veins of the legs.  This risk is minimized by using ultrasound guidance throughout treatment to monitor the foam and to avoid injections near areas where the deep and superficial veins are connected through “perforating veins”.  We will ask you to do flex your foot during injections and to do calf exercises afterward to circulate the medication away from the deep veins.  Walking after treatment is also crucial to avoid pooling of blood in the deep veins, which can predispose to blood clots.

Follow-up Ultrasounds and Clinic Appointments

We will schedule an ultrasound 2-7 days after your final treatment to make sure veins are responding appropriately.  We will do the formal ultrasound of your superficial veins for backwards flow (or “reflux”) at one month.  At that point, we will re-evaluate your symptoms and anatomy and decide if additional treatment is indicated.  Be sure to come to all of your scheduled follow-up appointments to ensure that your veins are healing properly.

It is important to come to all follow-up appointments so your provider may follow your progress and address any adverse effects promptly.

 

foam

Foam Treatment for Varicose Veins Is Not New

 

Foam treatment of varicose veins is not as new as people think. It was originally described as early as 1944.  Foam sclerotherapy is a method for treating varicose veins. It involves injecting a foamed sclerosant medication into unhealthy varicose veins, causing them to eventually dissolve.

foam sclerosant

Medication used for foam treatment of varicose veins has a ‘frothy’ foam appearance.

In 1944, E.J. Orbach introduced the concept of a macro bubble air-block technique to enhance the properties of sclerosant in performing macrosclerotherapy.  Apparently, few vascular surgeons were interested in the subject and the technique languished.  The work of Juan Cabrera and colleagues in Spain attracted attention of some vein specialists and interest in the use of foam technology in treating venous insufficiency was reawakened. Administration of foamed sclerosant was reintroduced in the early 1990s by Cabrerra, who summarized a broad experience in 1997. By the 1990’s, broad use of diagnostic ultrasound imaging made it possible to monitor foam distribution with ultrasound scanning. Some 40 years earlier, and before the development of ultrasound scanning, foam had been used in Germany to treat varicose veins.  At that time, foam was made by special syringes and its distribution was assessed by touch, instead of ultrasound scanning. Tessari , prior to the year 2000 de

ultrasound appearance of foamed sclerosant

Foamed sclerosant inside a vein: Once foam is introduced into the vein, it is hyperechogenic on ultrasound. In this picture taken in 2009, Dr. Bunke points to the foamed medication inside the vein. Notice it appears ‘white.’

veloped an easy way of making liquid sclerosant into foam using two syringes and a three-way stop cock.   By 2000, Sica was able to report a three-year experience using foamed sclerosant in treating saphenous varices.  Since that time, foam has appeared increasingly in general use. Around 2000, Dr. John Bergan began describing the utility and success of foam treatment to physicians in the United States and can be attributed to bringing its awareness to North America. Over the past decade foam has gained world-wide popularity for the treatment of varicose vein tributaries  in place of surgery. In 2013, Varithena foam was FDA approved to treat the great saphenous vein and its accessories with foam sclerotherapy.  Dr. Bergan predicted that microfoam sclerotherapy will eventually replace all other methods.  Presently, it is most commonly used as an adjunct to endovenous ablation of the great and small saphenous veins or as a sole treatment for surface varicose veins. Since Dr. Bunke was trained by Dr. John Bergan, thousands of patients have been treated successfully with foam sclerotherapy at La Jolla Vein Care. Additionally, our office manager Anna, spent time in Spain with Cabrera’s team in observation of how varicose veins were treated with foam.

 

image of person putting on compression stockings

What to Expect After Saphenous Vein Ablation

After a vein ablation procedure, such as radiofrequency or laser ablation, it is normal for your leg to feel swollen. The swelling is the fluid that was placed around the vein called tumescent anesthetic. You will feel the swelling in the location where the vein was treated. If the vein in the thigh was treated, your thigh will feel swollen. If the vein on the back of your calf was treated,  the calfwill feel swollen. The tumescent will slowly be absorbed by the evening or next morning.

Sometimes, the tumescent will leak out from the tiny needle puncture sites. For this reason, we will apply gauze inside of your stocking. At night before going to bed, reach in and pull out the gauze and throw it away. It only takes one drop of blood to make the gauze look blood tinged. This is also normal and nothing to worry about.

Before going to bed, remove the ace bandage that overlies your stocking. You will wear the stockings overnight (for 72 hours to be exact). If your stocking causes foot pain or leg pain, or numbness in the toes, please remove your stocking during the night and sleep without it. It may be too tight. Call us in the morning so we can further advise.

The evening of the procedure, your leg may also feel sore and achy. When it starts to throb, get up and walk. This usually helps it to feel better. Ibuprofen or Tylenol are helpful to reduce discomfort. You can also apply ice, by placing ice in a zip lock bag and applying the cold to the sore areas on the leg. You do not need to sleep with your legs elevated, but may do so if this is more comfortable.

When you are sitting for longer periods, such as watching a move at night, elevate your legs.

To avoid blood clots, walk frequently throughout the day. A rule of thumb is to walk at least 30 minutes, twice a day. There is no limit to walking. After your procedure, you will be asked to walk 30 minutes around campus prior to getting into your car. This will help get the blood circulating and stimulate the tumescent to be absorbed.

varicose veins

Approach to Vein Treatment

Venous Reflux Disease is Treated By a Staged Approach

Step 1: The Underlying Problem

The 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 withinpage2image34774576

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 Step 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. Ask your provider for an estimate about how many treatment sessions/ vials are necessary to get the results you want.

photo of spider veins

close up photo of spider veins

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laser vein ablation

Laser Vein Ablation for Varicose Veins: What is it?

Laser Vein Ablation Uses Heat to Treat the Underlying Cause for Varicose Veins

Laser vein ablation, also known as endovenous laser therapy (EVLA), is a type of treatment for saphenous vein reflux, the underlying cause of most varicose veins. At La Jolla Vein Care, we offer ALL treatment modalities for varicose veins, not just one. Treatment is customized based on a person’s individual pattern of venous reflux (determined by ultrasound examination), personal preference, and personal health history.

The laser vein ablation procedure may be offered for backwards flow (or “reflux”) in your saphenous vein(s).  The great and small saphenous veins are the two main superficial veins that run along the inner thigh/ calf and the back of the legs, respectively. Some people have anatomic variations where the small saphenous vein in the back of the calf extends to the thigh. Many people also have reflux in their anterior or posterior saphenous veins.

This minimally invasive procedure can be performed in the office in less than 30 minutes and patients return to their usual level of activity the same day.

How does the treatment work?  The skin is numbed with lidocaine, then a tiny wire and catheter are inserted into the vein.  The catheter delivers laser energy to the vein wall, causing it to seal shut. The remaining healthy veins continue to bring blood back to the heart.

What should I expect on the day of treatment? The procedure is performed with local anesthesia but many patients elect to use a mild oral sedative (Valium), which is typically taken at check-in. Your leg will be prepped for the sterile procedure, then the doctor will perform an ultrasound to localize the vein.  Through a tiny puncture in the skin, the radiofrequency catheter is passed though vein under ultrasound guidance.  We then use a needle to administer a combination of cool saline and local anesthetic around the vein.   This solution numbs the vein and insulates it from the surrounding tissue.  Your doctor will then treat the vein painlessly with laser energy.  Once your vein has been treated, we will help you into your compression stocking, which you will wear for 72 hours continuously.  You will walk for 30 minutes prior to getting in your car.

What should I do after treatment?   You should walk 30 minutes twice daily after treatment.  This will alleviate discomfort and avoid pooling of blood in the legs.   It is normal to have aching in the treated veins.  This responds well to walking, ice packs, and anti-inflammatory medications such as ibuprofen (Advil®, Motrin®) and naproxen (Aleve®).

What should I avoid after treatment?  For at least two weeks after treatment, you should avoid air travel, strenuous exercise (anything more than a brisk walk), heavy lifting, saunas or hot tubs, and leg massages.  All of these dilate the superficial veins and interfere with their healing.

laser vein ablation

Endovenous laser vein ablation therapy (EVLT) uses a tiny catheter to seal incompetent veins shut.

What are the possible adverse effects?   Expect some bruising over the injection sites, which fades over about two weeks.  The skin overlying larger varicose veins may also develop some temporary inflammation and/or brown “hyperpigmentation” as the blood products within those veins are absorbed by the body.  Less common compilations (less than 2% of patients) include clots within the deep veins or a temporary area of skin numbness over a branch of a skin nerve that travels close to a vein.

before and after varicose veins

Varicose Veins in Men Common

There is a misconception that varicose veins only affect women. Although they affect women 3x more commonly than men, millions of men in America unnecessarily suffer with varicose veins.

Men, get back to enjoying an active lifestyle

Do your legs feel tired, achy, heavy or restless at night? Have you noticed that your legs swell or feel worse after sitting or standing for long periods of time? Has your tennis or golf game suffered lately? Perhaps you have slowed down significantly while performing your exercise or running routine? If you answered yes to any of the above, you may be suffering from consequences of venous insufficiency.

​There are a lot of myths and misconceptions about vein disease out there. You may hear that vein problems are only a cosmetic concern or that they only affect women. Truthfully, even some clinicians don’t seriously consider vein disease to significantly affect a patient’s quality of life. However, in addition to the appearance of your legs, vein problems can significantly affect your daily living.

​In the San Diego Population Study, a study of 2,400 men and women living in the San Diego area, UCSD researchers found that about 1 in 6 men (15%) had visible varicose veins and about 1 in 4 men (24%) had significant vein problems (reflux, obstruction) when they looked with an ultrasound machine.1 Furthermore, these researchers found that individuals with more advanced stages of vein problems had worse physical conditioning and quality of life.2 While the results from these studies are concerning and scary, the good news is we have made significant advances in minimally invasive vein treatment over the past twenty years. Most vein problems of the legs can be treated in office, under local anesthetic, and in less than an hour with a few sessions. Most patients can return to work on the same day of their treatments.

​If you think your veins may be causing you problems you weren’t previously aware of, please call (858-550-0330) and schedule a comprehensive evaluation at La Jolla Vein Care.

Sincerely,

Dr. Jonathan T. Unkart

Vascular Specialist

 

References

1.​Criqui MH, Jamosmos M, Fronek A, Denenberg JO, Langer RD, Bergan J and Golomb BA. Chronic venous disease in an ethnically diverse population: the San Diego Population Study. Am J Epidemiol. 2003;158:448-56.

2.​Kaplan RM, Criqui MH, Denenberg JO, Bergan J and Fronek A. Quality of life in patients with chronic venous disease: San Diego population study. J Vasc Surg. 2003;37:1047-53.

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Dr. Sarah Lucas in the News

If you missed Dr. Sarah Lucas, of La Jolla Vein Care on KUSI News, you can see her here on our media page.

Dr. Lucas discusses venous insufficiency in pregnancy, how many women it affects and how it affects them. 

thigh bruise_preview

How to reduce bruising after vein surgery?

How to reduce bruising after vein surgery?

Ice: Apply ice to tender areas. Ice can reduce swelling and bruising.

Compression: Compression stockings have been shown to reduce bruising after vein stripping surgery in studies.

Homeopathic agents like arnica can help reduce inflammation and bruising. Arnica pellets can be taken prior to treatment as well and Arnica cream or gel should be applied after (not before) treatment.

Dr. Bunke’s own creation, Recova Cream is an Arnica-based product, but unlike OTC Arnica preparations, combines other antioxidant, pro-healing compounds to enhance the skins ability to repair and recover. It include menthol, grapeseed extract and other flavonoids that have been shown to reduce vein-related leg symptoms like leg fatigue and swelling.

RecovaCream.com for more information. Recova Cream can be purchased in-office, on amazon or at SkinResourceMD.com.

A tinted version of Recova is available after facial procedures such as eye-lid surgery, laser treatments, botox and collagen fillers.

Anna Cardinell, La Jolla Vein Care Nurse Practitioner performing cryosclerotherapy treatment of spider veins.

Cryosclerotherapy Offers Painless Vein Treatment

La Jolla Vein Care is the first to offer Cryo-sclerotherapy in the San Diego area. Cryo-Sclerotherapy, also known as ‘painless sclerotherapy’ is the latest in luxury spider vein treatment. Cryo-Sclerotherapy is traditional sclerotherapy in combination with a Cryo device. The cryo device cools the surface of the skin before, during and after injections. This helps reduce the discomfort from the needle injections and most of the time the ‘pokes’ are not felt at all when using the cryo device. Cryo-Sclerotherapy is considered an upgrade from traditional sclerotherapy and can be scheduled upon request for an additional $100 per treatment.