28, 6, 2020

3-Stage Approach to Vein Treatment

2020-09-17T17:58:02-07:00

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.

image of an Iceberg as a metaphor for the hidden dangers of vein disease

Iceberg, a metaphor for the hidden dangers of vein disease

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.

 

3-Stage Approach to Vein Treatment2020-09-17T17:58:02-07:00

Varicose Vein Sclerotherapy Treatment: What to Expect

2021-11-13T13:29:56-08:00

Ultrasound-Guided Foam Sclerotherapy

Ultrasound-guided foam sclerotherapy allows your doctor to treat backward flow (or “Venous 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:

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 in to your thigh-high compression stocking, then you will walk around the medical campus for 30 minutes before getting in the car.

Medical Compression Stockings

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 exercises, 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

Travel Compression Stockings

  • 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 improve 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 by 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 the pooling of blood in the deep veins, which can predispose to blood clots.

Follow-up Ultrasounds and Clinic Appointments

Follow-up Varicose Vein 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 backward 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.

Varicose Vein Sclerotherapy Treatment: What to Expect2021-11-13T13:29:56-08:00

Foam Treatment for Varicose Veins Is Not New

2020-09-18T01:53:21-07:00

 

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.

image of foam sclerosant

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 developed an easy way of making liquid sclerosant into foam using two syringes and a three-way stop cock.

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

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

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.

 

Foam Treatment for Varicose Veins Is Not New2020-09-18T01:53:21-07:00

9, 9, 2015

11, 2, 2015

Dr. Bunke Explains Non-surgical Varicose Vein Treatments on San Diego News

2015-02-11T20:06:34-08:00

Vein Stripping is a thing of the past! Watch La Jolla Vein Care’s Dr. Bunke on San Diego Living explain alternative non-surgical vein treatments to the outdated vein stripping surgery!  The episode was aired yesterday, February 10th, on CW’s Channel 6. As Dr. Bunke explains, a common misperception about varicose vein treatment is that vein stripping surgery is still used as the main method used to treat varicose veins. The truth is, vein stripping surgery is nearly obsolete, with endovenous ablation being considered as the standard of care for treatment of the great saphenous and small saphenous veins. There are other treatment methods such as ultrasound guided foam sclerotherapy for the branching, bulging veins at the surface of the skin.

This news segment provides animations about how these vein treatments work.

For the endovenous ablation, specifically radiofrequency ablation of varicose veins, also known as the Venefit procedure (previously called VNUS Closure) is described. Dr. Bunke explains that a thin, flexible tubing called a catheter is placed inside the diseased vein. Radiofrequency energy is delivered to heat the vein and seal it shut. The body will gradually dissolve the treated vein. The blood is directed through other healthy veins.

A foam sclerotherapy animation is also shown. Foam sclerotherapy involves injecting a foamed medicine into the vein that will cause it to collapse, shrink and eventually dissolve.

These varicose vein procedures are minimally invasive and can be performed in the office without general anesthesia and almost immediate return to normal activities.

 

 

Dr. Bunke Explains Non-surgical Varicose Vein Treatments on San Diego News2015-02-11T20:06:34-08:00

18, 6, 2014

History of Foam Sclerotherapy Treatment of Varicose Veins

2021-11-05T10:56:45-07:00
foam

Foamed sclerosant inside a vein: Once foam is introduced into the vein, it is hyperechogenic on ultrasound. In this picture, a La Jolla Vein Care doctor points to the foamed medication inside the vein. Notice it appears ‘white.’

foam03*

Foamed sclerosant used for sclerotherapy has a ‘foam’ or frothy-like appearance.

In 1994 and 1950, 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 developed 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. Varithena foam was recently FDA approved to treat the great saphenous vein 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.

History of Foam Sclerotherapy Treatment of Varicose Veins2021-11-05T10:56:45-07:00

26, 3, 2014

Am I Too Old? Varicose Vein Treatment at Any Age

2021-11-04T19:02:17-07:00

We’re often asked, ‘Am I too old to treat my varicose veins?’  The answer is no. Since modern varicose vein treatments are largely non-surgical, there are appropriate treatment options for those of any age. While varicose veins are more common with each decade of life, they can appear on young teenagers or at any time in older adults.    For active older adults, addressing varicose vein conditions is even more important to maintain healthy legs.    Otherwise, symptoms of leg heaviness, fatigue, swelling and pain can slow you down.  There are other complications of untreated varicose veins such as superficial thrombophlebitis, varicose vein rupture and leg ulceration, in severe cases.  There are a variety of minimally invasive treatment options for varicose veins, and depending on the individual preference, severity of the condition and the veins affected will help you and your doctor determine the best treatment course.

This is a 90-year-old female who wanted her varicose veins treated because they were bothersome to her when she played tennis and she didn’t like the way they look. These varicose veins were treated with painless injections, given at two treatment sessions. This is called foam sclerotherapy treatment of varicose veins.
The after picture is at one month following the varicose vein injections (foam sclerotherapy). She tolerated the treatment well and she was able to return to normal activities right away, with the main restriction being wearing compression stockings for several weeks.

 

Am I Too Old? Varicose Vein Treatment at Any Age2021-11-04T19:02:17-07:00

4, 2, 2014

New Foam Treatment of Varicose Veins

2021-11-04T19:24:26-07:00

In November of 2013, the US Food and Drug Administration (FDA)  approved Varithena,™   a new type of foam treatment for the treatment of patients with incompetent veins and visible varicosities of the great saphenous vein (GSV) system. Varithena is a pharmaceutical-grade, low-nitrogen, polidocanol foam dispensed from a canister device. In two pivotal, placebo-controlled Phase III trials, VANISH-1 and VANISH-2, Varithena achieved a clinically meaningful improvement in the symptoms of superficial venous incompetence and the appearance of visible varicosities and addressed the underlying venous incompetence in the majority of patients treated. Varithena (polidocanol injectable foam) is a sclerosing agent indicated for the treatment of incompetent great saphenous veins, accessory saphenous veins, and visible varicosities of the great saphenous vein system above and below the knee.  Varithena improves the symptoms of superficial venous incompetence and the appearance of visible varicosities.  Treatment is a minimally invasive, non-surgical procedure that requires neither tumescent anesthesia nor sedation.  Foam sclerotherapy has been used for years by medical doctors. What is new with Varithena, is that the foam is pre-made with low-nitrogen as opposed to room air, and is dispensed in a proprietary canister.   It is not yet available in doctor’s offices. Making Foam

New Foam Treatment of Varicose Veins2021-11-04T19:24:26-07:00

2, 6, 2011

Dr. Oz Show Highlights Foam Sclerotherapy Treatment for Varicose Veins

2021-12-27T14:27:47-08:00

The June 1st episode of The Dr. Oz Show brought attention to foam sclerotherapy. He describes it as the latest, most advanced technology to eradicate painful, varicose veins. Dr. Oz’s guest demonstrated how the procedure is performed: He used a vein light to visualize the veins, followed by a painless injection of a foamed solution. He also mentions that the old Varicose Vein Treatments hurt because of the saline solution that used to be used, but newer solutions such as polidocanol, are nearly painless.

We’re pleased that Dr. Oz brought much need attention to foam sclerotherapy, as we have been using it as an alternative to surgery for years. What most people don’t realize is that foam sclerotherapy is not new, but rather newly recognized. Foam sclerotherapy offers patients a non-surgical alternative for the treatment of varicose veins. There is essentially no down-time and return to normal activities is immediate.

Dr. Oz Show Highlights Foam Sclerotherapy Treatment for Varicose Veins2021-12-27T14:27:47-08:00
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