More than 40 million Americans suffer from varicose veins. For some, varicose veins are a cosmetic nuisance, but for others, they can be quite painful, and could be an indication of other circulatory issues. But what are varicose veins, and how can we really deal with them? Here to shed some light on this vascular condition is Dr. Matthew Alef, a vascular surgeon at the University of Vermont Medical Center, and an assistant professor at the University of Vermont’s Larner College of Medicine.
Read the interview that follows or listed to the audio interview at the link below.
What are varicose veins, and how to we get them?
Dr. Alef: Varicose veins are peripheral veins, most commonly seen in the legs, which are no longer really performing their original function, which is to return blood to the heart.
So they’re kind of wasted veins under the skin?
Dr. Alef: They’re being lazy. They’re similar to spider veins. They’re actually on the same spectrum. Spider veins are smaller and right on the surface of the skin, similar to varicose veins in terms of there’s just blood sitting in those veins and not being returned to the heart.
Why do they become bulgy and unsightly under the skin?
Dr. Alef: This goes to the underlying cause of where varicose veins come from. Typically, healthy veins help return blood to the heart by your muscles acting as a pump and squeezing on those veins. Then one-way valves are contained within veins that help the blood not be pulled back down by gravity. So when we see varicose veins, those valves, for a variety of reasons, become diseased and no longer function. Now there are no valves to keep the blood from coming back down.
So it pools and becomes that unsightly, uncomfortable situation under the skin.
Dr. Alef: Correct. Fundamentally, all the symptoms related to varicose veins are from blood pooling in your legs and not being returned well.
What are some of those symptoms?
Dr. Alef: The most common ones we see are people that have aching or heavy legs, especially at the end of the day or once you’ve been on your feet for a long time. They can have associated burning or throbbing. Those veins can also itch, especially during the summer. Some patients have outright pain. Additionally, patients can get actual swelling of their legs and night cramps as well.
Can it lead to other health issues? Are they a nuisance or are they somehow related to bigger things?
Dr. Alef: For the vast majority of the patients, it’s mostly a quality of life disease. Therefore, how the patient feels about it and experiences symptoms, that’s what’s most significant. There is a subset of patients that can actually develop venous statis ulcers, which are actually where the skin is, over time, very thinned and then destroyed, causing ulceration. Additionally, some folks can get clots in those veins. That is not the dangerous kind of clot, but it is the annoying, symptomatic clot. It can be very painful. And finally, some patients, the skin becomes so worn away on top of that vein that they’ll bump their vein and actually bleed.
Do they typically occur in the legs? Can they occur in any extremity or in any part of the body?
Dr. Alef: It is very unusual to find varicose veins in the arms. There is a small subgroup of patients that can actually have pelvic veins that are no longer functioning. They can actually have varicosities up near their genitalia.
But typically it is found in most people around the legs.
Dr. Alef: The vast majority, yes.
And that’s because of the function of the blood moving through those extremities more often? The pressure that you’re maybe having in the legs?
Dr. Alef: If you look at those who are at risk for developing this disease, first of all, your genetics matter. When your parents or siblings have varicose veins, you’re more likely to get them as well. Advancing age is a major player here as well. Women get it more often than men, and especially moms who have had multiple pregnancies get it more often than non-moms. Additionally, obesity helps increase that pressure, which is what pregnancy does, it increases the pressure on the veins and the blood flow there.
I’ve also heard about people who are on their feet a lot, waitresses, waiters, people who work in retail. Does that play into getting a varicose vein?
Dr. Alef: There is some weak data that being on your feet often can increase your chances of having them. It’s a little bit more difficult to discuss with patients, because certainly I don’t want folks to be sitting or laying down all day. They need to live their lives, and in the healthcare profession, we’re on our feet all day as well.
What about crossing your legs?
Dr. Alef: It’s something that I talk to patients about, but honestly, again, I think that data is very weak. I think that if you’re more comfortable crossing your legs, I would continue doing so.
Once I discover that I have one of these varicose veins, how would I go about treating it?
Dr. Alef: The easiest steps that you can take are to make sure that you’re not obese. I would maintain an exercise regimen. The next thing, which is hit or miss depending on the patient, is to wear compression stockings. This is an easier sell in fall, winter, and spring. During the summer, they’re not as popular. Certainly, if you’re someone who works on their feet all day, I would give them a try, at least up to the knee. Oftentimes, you can have fresher legs at the end of the day with wearing compression stockings.
Do they help to reinforce that area of the vein that has weakened?
Dr. Alef: The way I describe it is this. The veins in your legs that do the vast majority of the work, getting blood back to your heart, we call the deep veins. They’re located very deep inside your legs, so you don’t see them. They’re underneath the fascial layer, which is very, very strong. When you wear compression stockings, it pushes on those superficial veins. It helps push the blood out of there to your deep veins. And the vast majority of patients with varicose veins, their deep veins are normal and healthy. So you’re getting rid of the blood in those lazy varicosities and getting them to the deep veins, which are doing the work.
What are the treatment options beyond the compression stockings?
Dr. Alef: I always start by telling my patients this is not a life-threatening or a limb-threatening problem. For the vast majority of patients, this is a quality of life problem. What that means in every day speech is how the patient feels about their veins means everything to me. I see plenty of patients that come in with questions. They have minimal symptoms or no symptoms; they just have unsightly veins. I tend to encourage them to go live their lives, and if it bothers them one day, I’m happy to treat them. Many patients come in and they are bothered, though. They have a variety of the symptoms that we mentioned previously.
There’s a few ways to go about treatment. We now do things in a minimally invasive fashion. Prior to my generation, we used to do something called a vein stripping, where we literally surgically remove these veins. Now we do this in a minimally invasive fashion, where we locate your superficial vein, which you don’t need. It’s the diseased vein that’s causing these problems. We locate it with an ultrasound. Then we puncture it with a needle and through that needle goes a wire. Through the wire goes a catheter, which is just a tube. And then there are actually two ways of treating the vein. We used to use only heat via a laser or radio frequency ablation. Now we have another technology, which is called VenaSeal, which acts as an epoxy glue. What we basically want to do is we want to close the vein. In many places, this procedure is called an ablation or a venous closure.
Since that vein is not doing its job, we want to get rid of the vein. Heat literally burns the vein, and the glue literally glues it shut. When we do this, all that blood is now more efficiently returned from the deep system that we mentioned. This can help solve, or at least help with many of the symptoms we previously mentioned, such as edema, aches, heaviness.
What happens to the vein in the body once it is either burned or glued shut, and it’s no longer functional or necessary?
Dr. Alef: Over time, it’s a piece of internal scar that goes away.
And with that closure, is the process painful?
Dr. Alef: With the new VenaSeal, which is the epoxy glue, there’s virtually no pain. Additionally, there’s virtually no recovery. You can actually run a marathon the very next day if you want to. With the older system, which is tried and true, which we still do quite a bit, patients complain of a little bit of pain. Most describe it as a pulled muscle on the inner aspect of their thigh. Occasionally, the skin over the top can be somewhat sensitive. I think the vast majority of patients have almost no symptoms by two to four weeks.
Do you need to wear compression socks after that treatment? Would it be better to have it done in the winter, perhaps, as opposed to in the heat of the summer?
Dr. Alef: Yes, we do require that you wear a compression sock afterwards. We don’t want any blood flowing into that vein that we just closed.
Additionally, there is a second part of this procedure, especially for folks that have very large, unsightly, bulging veins. We can do something called a microphlebectomy. So the venous closure procedure closes the diseased vein causing the varicose veins. For the actual varicose veins themselves, the procedure is I take a tiny knife, it doesn’t make any incisions, it’s a tiny poke through the skin. You take what looks like a crochet hook; you reach through the skin and grab the vein. These veins shrink down to almost nothing and are pulled through these tiny holes, and that way, we can actually get rid of all those bulging veins.
I’m guessing there’s anesthesia involved, or at least some kind of topical for the puncture?
Dr. Alef: This varies from patient to patient. Some patients like to be more anesthetized, some patients want to be wide awake, so it really varies on the patient and on the procedure we’re doing. If we do just a VenaSeal on someone’s leg, it can be done under local anesthesia only, a single needle puncture.
Would talking with the physician or the surgeon be important?
Dr. Alef: Yeah. I think that ultimately having a very frank and open discussion with your surgeon or physician is the most important thing here to understand the risks and the benefits. The risks of the procedure are minimal, but they’re not zero. No procedure is risk free.
The most concerning of which is what we call a deep vein thrombosis. It is possible to have a deep vein clot after doing a procedure like this. Nationwide, that’s about one in 200. In our own practice, I’ve only seen this occur once, but it is possible. We usually just thin your blood for several months afterward, but it is something we’re always on the lookout for. And that’s also why the patient’s own expression of their symptoms is so important to me.
Any final tips for those dealing with or wishing to avoid varicose veins?
Dr. Alef: The one thing I would say is this: Compression stockings are a very useful tool that we use. They’re not sexy, but when patients have symptoms and they’re alleviated by the compression stockings, that’s a good litmus test for if doing a procedure would help as well. Additionally, this is covered by insurance, but we must document that you’ve been wearing your stockings for at least three months.
I guess the final thing I would say is that this is elective. This is something that I would do when it works for you. I have patients ask me, “Gee whiz. I’m going to Europe next month, what should I do?” I say, “Please go to Europe. Give me a call when you get back and we’ll arrange it for then.” And I think it’s also something that’s more popular once the cold weather is back because you do need to wear your compression for two weeks after we do the procedure.