Tools of the Trade
The invention of Duplex Ultrasound revolutionized the diagnosis and treatment of vein disorders. Initially it was used to determine the presence of deep vein thrombosis, which until then required injecting contrast into the veins in an X-ray suite. It didn’t take long to discover that ultrasound could also determine the precise reason why a person developed varicose veins and what precisely would be necessary to eliminate them. I think of the ultrasound machine as the equivalent of a stethoscope in the hands of a cardiologist or an X-ray machine in the office of an orthopedic surgeon. All vein surgeons should do their own ultrasound tests to see firsthand what the patient’s problem really is so they can determine which treatment is best. My personal opinion is that it is no longer acceptable to send a patient to a vascular laboratory to learn from another individual what is really going on with the patient. The nuances of interpretation are simply too great to trust a third party.
Laser Closure of the Saphenous Vein
Lasers supply large amounts of heat energy. In humans, different tissues absorb different amounts of energy depending on the wavelength of the laser’s light. Early lasers targeted blood and the heat generated would then destroy the wall of the surrounding vein. These lasers effectively closed the saphenous vein, but post-procedure pain was common. These lasers are less commonly used today.
Newer lasers use a much higher frequency that targets water instead of blood, so much of the laser energy is directed to saphenous wall directly. As a result the saphenous vein closes with much less energy and, fortunately, much less pain. My current laser uses the highest frequency available today (1470 nM), and I have found that post-procedure pain is negligible. I use lasers when the saphenous vein is small and short. Lasers are only marginally more painful than radiofrequency, but I do not prescribe pain pills after either procedure.
Radiofrequency Closure of the Saphenous Vein
Radiofrequency (RF) is a variation of electrocautery, the same technology surgeons use to stop bleeding during operations. This technology for saphenous vein closure is a few years older than the laser. I was the first person in the United States to close a saphenous vein with RF (but after I reported my paper in 1994, I found out that a Russian doctor was using it even before me!). The original commercial RF device debuted in 2001 and revolutionized the treatment of varicose veins. The main objection with the original device was that it took a long time to heat the vein, and there were an unacceptable number of veins that re-opened months later. The VNUS Company, now owned by Covidien, then developed an improved RF catheter called the ClosureFAST, which is widely used today. The advantage of RF over laser is that there is almost no post-procedure pain and less bruising. I tend to use the ClosureFAST when patients have large saphenous veins that are close to the skin (typically thin individuals and men).
Injections remain the best treatment for spider and blue (reticular) veins. Lasers just don’t work very well on these common veins. Injections destroy the vein wall, and eventually your body absorbs the nonfunctioning vein and any clot trapped in it. The downside is that absorption can take weeks and even months. I use Sotradecol, one of the two FDA approved drugs for this purpose. The doctor’s experience and comfort level with the medication she uses is far more important than any advertised difference, since the solutions work the same way and the results have always been shown to be identical if experienced individuals use them. Injecting veins is an art, not a science. Experience is important, but even doctors who have been doing this for years get an occasional ulcer or staining, the two most undesirable cosmetic complications. Staining comes from incompletely absorbed blood, which contains iron. When that iron combines with oxygen the injected vein looks like rust and the body has a hard time transporting it away. Injected veins are firm (“sclero” means hard) and may look infected (which they never are). Time usually resolves both issues. Larger veins are treated with “foam” – the injection solution mixed with carbon dioxide (rather than air for safety purposes) so it looks like shaving cream. This sticks to the wall of the vein and doesn’t float away like the regular solution. Therefore a less concentrated solution can be very effective for in-between sized veins (usually the blue non-bulging reticular veins which form a net-like pattern under the skin).
There are only two ways to actually eliminate bulging varicose veins once the underlying saphenous vein problem has been shut down using a laser or radiofrequency catheter. I prefer to remove these veins with very small cosmetic incisions that heal beautiful without staining. Even extensive large veins can be removed under local anesthesia. Many non-surgeons inject them exclusively. This often results in a large bulging hard vein that takes months for the body to absorb. I often ended up stabbing the clotted vein anyway to release large amounts of trapped blood, and these large clotted veins stain the worst.
Tiny red veins respond well to the VeinGogh device, which consists of an extremely small wire that is fed by an electrical current. This is the same technology that was used for hair removal many years ago. The device works best on the tiny veins around the nose, but not larger blue veins under the eye. Although the device has been marketed for leg veins, the results aren’t as good as those on the face, so I don’t use this device on legs as often as I thought I would.
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