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Q What is venous insufficiency?
Venous insufficiency is a very common condition resulting from decreased blood flow from the leg veins up to the heart, with pooling of blood in the veins. Normally, one-way valves in the veins keep blood flowing toward the heart, against the force of gravity. When the valves become weak and don’t close properly, they allow blood to flow backward, a condition called “reflux”.
Q What are varicose veins?
Veins that have lost their valve effectiveness and have become elongated, rope-like, bulged, and thickened. These enlarged, swollen vessels are known as “varicose veins” and are a direct result of increased pressure from reflux. A common cause of varicose veins in the legs is reflux in the thigh vein called the “greater saphenous”, which leads to pooling in the visible varicose veins below.
Q What are the symptoms of varicose veins or venous insufficiency?
Symptoms caused by venous insufficiency and varicose veins include aching pain, easily tired legs and leg heaviness, all of which worsen as the day goes on. Many people find that they need to sit down in the afternoon and elevate their legs to relieve these symptoms. In more severe cases, venous insufficiency and reflux can cause darkening of the skin and wounds that may be very difficult to treat. One percent of adults over age 60 have chronic wounds known as “ulcers”.
People who have venous insufficiency can have symptoms even without visible varicose veins. The symptoms are caused by pressure on nerves by dilated veins.
Q How common is venous disease and varicose veins?
Chronic venous disease of the legs is one of the most common conditions affecting people. Approximately half of the U.S. population has venous disease, of which 50 to 55% are women and 40 to 45% are men. Of these, 20 to 25% of the women and 10 to 15% of the men will have visible varicose veins. Varicose veins affect one out of two people aged 50 and older, and 15 to 25% of all adults.
People without visible varicose veins can still have symptoms. The symptoms can arise from spider veins, as well as from varicose veins because, in both cases, the symptoms are caused by pressure on nerves by dilated veins.
Q Who is at risk of varicose veins?
Risk factors include age, family history, female gender, and pregnancy. In women, pregnancy, especially multiple pregnancies, is one of the most common factors accelerating the worsening of the varicose veins.
Q How is venous insufficiency diagnosed?
Your interventional radiologist, a doctor specially trained in performing minimally invasive treatments using imaging for guidance, will use duplex ultrasound to assess the venous anatomy, vein valve function, and venous blood flow changes, which can assist in diagnosing venous insufficiency. The doctor will map the greater saphenous vein and examine the deep and superficial venous systems to determine if the veins are open and to pinpoint any reflux. This will help your interventional radiologist to determine if you are a candidate for minimally invasive treatment, known as “vein ablation”.
Q What is the vein ablation treatment?
This minimally invasive treatment is an outpatient procedure performed using imaging guidance. After applying local anesthetic to the vein, the interventional radiologist inserts a thin catheter, about the size of a strand of spaghetti, into the vein and guides it up to the great saphenous vein in the thigh. Then laser or radiofrequency energy is applied to the inside vein. This heats the vein and seals the vein closed.
Reflux within the great saphenous vein leads to pooling in the visible varicose veins below. By closing the great saphenous vein, the twisted and varicosed branch veins, which are close to the skin, shrink and improve in appearance. Once the diseased vein is closed, other healthy veins take over to carry blood from the leg, re-establishing normal flow.
Q What are the benefits to vein ablation?
The treatment takes less than an hour and provides immediate relief of symptoms. You can return to normal activity immediately with little or no pain. There may be minor soreness or bruising, which can be treated with over-the-counter pain relievers. There is no scar because the procedure does not require a surgical incision, just a nick in the skin, about the size of a pencil tip.
Traditionally, surgical ligation or vein stripping was the treatment for varicose veins, but these procedures can be quite painful and often have a long recovery time. In addition, there are high rates of recurrence with the surgical procedures, on average 10 to 25%.
Q How successful is the vein ablation?
The two-year data show 93 to 95% success rate. This is a much higher efficacy rate than surgical ligation or stripping.
Q Are there other treatments for varicose veins?
Ambulatory phlebectomy and injection sclerotherapy are also used. Ambulatory phlebectomy is a minimally invasive surgical technique used to treat varicose veins that are not caused by saphenous vein reflux. The abnormal vein is removed through a tiny incision or incisions using a special set of tools. The procedure is done under local anesthesia and typically takes under an hour. Recovery is rapid and most patients do not need to interrupt regular activity after ambulatory phlebectomy.
Injection sclerotherapy can be used to treat some varicose and spider veins. An extremely fine needle is used to inject the vein with a solution which shrinks the vein. This is often done after vein ablation to improve the appearance of any remaining spider veins.
Q What is an interventional radiologist?
Interventional radiologists are doctors who specialize in minimally invasive, targeted treatments performed using imaging for guidance. They use their expertise in reading X-rays, ultrasound, MRI, and other diagnostic imaging to guide tiny instruments, such as catheters, through blood vessels or through the skin to treat diseases without surgery. Interventional radiologists are board certified and fellowship trained in minimally invasive interventions using imaging guidance. Their specialized training is certified by the American Board of Medical Specialties. Your interventional radiologist will work closely with your primary care or other physician to be sure you receive the best possible care.
Q Is treatment always required?
No. The majority of varicose and spider veins are treated for cosmetic purposes. If you are uncertain about your particular case, a consultation should answer the question.
Q How long does a consultation take?
A comprehensive consultation, including a duplex ultrasound, will take between 15 and 20 minutes.
Q Does sclerotherapy hurt?
Most people feel little if any discomfort. Occasionally, you may experience a mild burning sensation at the injection site. This is only temporary and subsides in a few minutes.
Q How many sclerotherapy treatments will I need?
This depends on the severity and number of veins that need attention. Although most people will notice improvement after the first or second treatment, most areas will need to be treated approximately three times for optimal results.
Q What are the side effects of sclerotherapy?
Following treatment you may develop bruising at the injection site. This is normal and usually resolves in approximately 14days. Slight staining of the skin or telangiectatic matting (tiny new veins) can occur but is usually temporary. An allergic reaction to the sclerosant is rare. Sclerotherapy is a safe and effective treatment for varicose and spider veins.
Q How long will the results last?
Since spider veins are a chronic condition, new veins may appear over time. Returning for touch-up visits every couple of years will help most people to remain “vein free”.
Q What is deep Vein Thrombosis (DVT)?
Deep vein thrombosis is the formation of a blood clot in a deep leg vein. It is a very serious condition that can cause death or permanent damage to the leg. In the United States alone, 600,000 people with DVT are admitted to hospitals each year. One in every 100 DVT patients dies.
Q How does a DVT form?
The deep leg veins are surrounded by powerful muscles that contract to force blood upward against gravity, back to the lungs and heart. One-way valves inside the veins prevent downward backflow when the body’s clotting system functions abnormally, and when the circulation of blood slows down due to illness, injury or inactivity.
Q What are the risk factors for DVT?
Factors that increase your risk for DVT include:
  • Previous DVT or family history of DVT
  • Recent surgery
  • Prolonged immobility, which can be due to stroke, paralysis, prolonged bed rest or sitting, or prolonged air travel (known as “economy-class syndrome”)
  • Hormone therapy or oral contraceptives
  • Current and recent pregnancy
  • Previous or current cancer
  • Trauma and/or orthopedic procedures
  • Varicose veins
  • Congestive heart failure
  • Use of central venous catheters
  • Inflammatory bowel disease
  • Inherited blood clotting (coagulation) abnormalities
  • Obesity
  • Age above 40 years
Q What are the typical symptoms of DVT?
Common symptoms include:
  • Swelling of the leg
  • Calf or leg pain or tenderness
  • Leg fatigue
  • Discoloration of the legs
  • Surface veins become more visible
Q How is DVT diagnosed?
If you suspect that you may have DVT, you should immediately go to an emergency room to be evaluated by a physician; it’s a life-threatening disease. If your physician agrees that DVT is a possibility, then he/she will probably order an ultrasound examination of your leg veins. In some cases, DVT is diagnosed by an interventional radiologist using a venogram, which is an X-ray image of your veins. This test allows the physician to see inside your veins and locate a clot that is blocking blood flow.
Q What problems does DVT cause?
DVT is life threatening and can cause permanent damage to your leg:
Pulmonary Embolism
When DVT is left untreated, a piece of clot can break off and travel through circulation to the lungs; this is known as “pulmonary embolism”. The clot can interfere with the lung’s ability to provide oxygen to the body and, in severe cases, can cause heart failure and/or death. With early treatment using blood thinners, people with DVT can reduce their chances of developing a life-threatening pulmonary embolism to less than 1%.
Post-Thrombotic Syndrome
Post-thrombotic syndrome is an under-recognized but common long-term consequence of DVT. When DVT is treated with blood thinners alone, the blood clot is not actively dissolved. Rather, the blood thinners prevent new clots from forming, but the already present clot remains in the leg. The body may eventually fully or partially dissolve the clot, but the vein valves often become damaged in the meantime. The continued vein blockage and valve damage cause abnormal pooling of blood in the leg, which can cause the post-thrombotic syndrome. Patients with the post-thrombotic syndrome often experience chronic leg pain or heaviness, swelling, difficulty walking, changes in the skin color and texture, and, in severe cases, skin ulcers (sores). These symptoms may develop within several months or years. Unfortunately, these problems occur to some degree in as many as 60 to 70% of people with DVT.
Q How is DVT treated?
DVT is treated with blood thinners to prevent pulmonary embolism and to prevent further clot formation. In patients with extensive DVT, an additional treatment option is catheter-directed thrombolysis. In patients who cannot receive blood thinners or in whom blood thinners have failed to prevent further clot formation, an additional treatment option is the placement of an inferior vena cava filter.
Catheter-Directed Thrombolysis
Catheter-directed thrombolysis is performed under imaging guidance by an interventional radiologists. This procedure is designed to rapidly break up the clot, restore blood flow within the vein, and potentially preserve valve function to minimize the risk and severity of post-thrombotic syndrome. Using imaging guidance, the interventional radiologist inserts a catheter into a leg vein behind the knee and threads it into the vein containing the clot. A clot-dissolving drug is infused through the catheter directly into the clot and repeated over one to two days. The fresher the clot, the faster it dissolves. A venogram is repeated to demonstrate that the clot has dissolved, and to detect any narrowing in the vein that might lead to future clot formation. If vein narrowing is present, the interventional radiologist can treat it using balloon angioplasty or by placing a stent.
Vena Cava Filter
In patients in whom catheter-directed thrombolysis and blood thinners are not medically appropriate, an interventional radiologist can insert a small filtering device into the large vein that drains the legs (the inferior vena cava) under imaging guidance. This vena cava “filter” functions like a catcher’s mitt to capture blood clots that break off.
If you would like to have a consultation please contact the Vein Institute, Toronto’s premier clinic for leading edge, state of the art treatments for leg varicose, spider and facial veins.
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