Do you have bulging or uncomfortable veins that have caused you either pain or embarrassment?
Varicose veins can occur in almost anyone, and affect up to 35 percent of people in the U.S., according to the Society for Vascular Surgery. While the veins themselves do not cause severe medical problems, the presence of these veins is an indicator of venous insufficiency, which is a condition that occurs when the veins have problems sending blood from the legs back to the heart.
Joseph M. Laureti, DO, FACC, board-certified cardiologist at Easton Hospital, specializes in the treatment of venous insufficiency and works with his patients to help them understand this common condition – and how treatment is not considered or performed with a cosmetic goal in mind. Rather, it is all about the patients’ symptoms and preventing advanced skin color changes.
Valves and Veins
We all have veins and all know what their job is: they are elastic blood vessels that carry the blood back to the heart after it’s carried to all other parts of the body, including through all of our extremities like the legs, feet, arms and hands. The veins are normally a low-pressure system with a series of valves that open and close, allowing the blood to travel one-way. The opening and closing of the valves is what allows the blood to basically travel ‘against gravity.’
When those valves aren’t working normally, the blood can begin to go backward, causing it to back up when the valves don’t close quickly enough. That backward flow is considered to be venous insufficiency. When the valves become weakened or damaged, blood begins to collect in those veins – causing the vein to become enlarged and, in some instances, even painful or leading to fatigue in the legs.
“The veins are a conduit, per say. They are a piping to get blood back to your heart. It’s a very low-pressure system. Blood is coming down from our heart via our arteries and it’s basically under pressure and goes around a capillary loop, and on the way up it’s coming up via the veins,” says Dr. Laureti. “The problem is, it’s relying on that being pushed up, and it’s fighting gravity. We were all born with two leaflet valves that direct the flow of blood back to our heart. In an ideal setting, the valves are supposed to close and prevent the backward flow of blood. Now, a combination of factors can lead to the dysfunction of superficial valves.”
These factors, according to Dr. Laureti, can include family history, obesity, multiple pregnancies, or a history of blood clots in the deep venous system.
Venous deficiency is found in what is known as the superficial veins – the vein that is above our muscle (the ‘deep’ veins are the ones found below the muscle). Both are directing blood back to the heart, but in the deep veins, an issue like a blood clot could eventually lead back to the heart. In the superficial veins, this rarely, if ever, occurs.
Dr. Laureti has a simple explanation for his patients – and one that any Lehigh Valley resident will be able to relate to: “When people leave my office, I want them to understand. So, I thought of a way to explain it that they can relate to,” Dr. Laureti explains. “I look at our two main highways in the Lehigh Valley – Routes 22 and 78 – and both can have their inherent problems. Rt. 78 is the better highway because it’s got three lanes in some parts, and moves a lot better. So, let’s label 78 as the ‘deep system.’ Now, on the way back to the heart, 85 to 90 percent of the blood flow goes back via the deep system. Let’s call Rt. 22 the ‘superficial system.’ About 10 to 15 percent of blood flow goes back via the superficial system. So, we’re trying to reroute from Rt. 22 to Rt. 78. Then, you have the roads that connect these highways – for example, let’s say Cedar Crest Boulevard. They’re called ‘perforators.’ The perforator veins connect the superficial veins with the deep veins. Now, when the superficial system develops insufficiency when the valve becomes dysfunctional, it can cause problems.”
Signs and Symptoms
Because they are so visible on our bodies, varicose veins are a well-known issue. However, the enlargement of veins is only one sign of venous insufficiency. Some people – particularly those who spend the day on their feet – develop tired legs, fatigue, swelling, heavy legs or cramping. If they elevate their legs or lay down for the evening, their symptoms tend to improve. However, the same symptoms happen all over again the next day – which is all due to venous congestion, when the veins become dilated and stretched.
If doctors are able to reroute the blood, the symptoms go away. If symptoms go untreated, this is when skin changes begin taking place and patients experience discoloration in their legs. While there is a clinical classification system in place that doctors adhere to, it’s important to know that skin discoloration and edema (swelling) happens in patients with advanced venous disease. Treatment can prevent venous insufficiency from becoming advanced.
“The reasons we go after venous disease are, number one, the symptoms, and number two, when we see these advanced skin color changes,” says Dr. Laureti. “The cost of treating a venous ulcer is astronomical, and just relieving this could make these changes go away and heal an ulcer, if not prevent it from happening. And basically what we’re doing is, we’re closing the superficial vein that has insufficiency. We reroute the blood to the deep system.”
While venous insufficiency is unlikely to present morbidity risk, there is still often reason to pursue treatment options. In the more severe aspects of venous disease, there could be time missed from work due to leg discomfort, or eventual worsening that could lead to skin discoloration or the formation of ulcers. Many people need a simple ultrasound to document the presence of venous insufficiency, and due to advanced technology, treatment options are minimally invasive.
Dr. Laureti prefers to treat patients in what he calls a “stepwise fashion,” with the first option being a thermal ablation. This is done if doctors identify venous insufficiency in the greater saphenous vein, which is the longest vein in the body, starting on the inside of the ankle but running above the muscle and under the skin along the length of the leg.
“With thermal ablation, you’re basically heating the vein and you’re injuring the innermost layer, called the endothelium. You’re basically closing it down. The two modalities that I have to close that down via thermal ablation are either with radiofrequency or with laser,” Dr. Laureti explains. “There is another modality that is fairly new, called VenaSeal, and it’s a glue that closes down the vein.”
Another procedure that can be done is called a phlebectomy, which involves several tiny cuts or incisions made in the skin. The skin is anesthetized and the doctor uses vein hooks to pull the vein up and out. Regardless of which procedure the patient is going through (thermal ablation, VenaSeal or phlebectomy), they can expect that these treatments are outpatient procedures that take between 40 minutes to an hour. It is important to note, however, that a phlebectomy would never be considered as a first option for treatment.
“You never do that first because these veins are usually coming off of the other veins. If you don’t take care of the first problem, the second problem will continue to occur,” cautions Dr. Laureti. “The problem is you have to remember, the treatment of venous disease is almost palliative. You’re helping symptoms as they occur, but you’re not curing the whole process. This continues to occur over time.”
While doctors can also offer sclerotherapy – a procedure in which a medicine is injected into the vein to make it shrink – to treat spider veins for cosmetic reasons, the first concern should be whether these veins are causing any medical symptoms that would ultimately be a more immediate concern.
Know Your Doctor
One thing that Dr. Laureti cautions prospective patients about is doing their homework and looking at the credentials of any physician that treats venous diseases.
“The diagnostic portion of it – being able to read an ultrasound – is very important,” says Laureti, who is a Registered Physician Vascular Interpreter (RPVI), a Registered Phlebology Sonographer (RPhS) and a diplomat of the American Board of Venous and Lymphatic Medicine (ABVLM). “A lot of people may have the treatment of venous insufficiency, or the treatment of varicose veins or spider veins on their website, and they’re looking at it more from a cosmetic angle. Our goal is not cosmetic. Our goal is treating your symptoms and your skin color changes, and that’s a medical goal.”
Conservative Ways to Treat Venous Insufficiency
Like any disease, venous insufficiency is most treatable in its earliest stages. Vascular specialists typically recommend some basic treatment strategies that patients can do to help themselves, which include:
- Compression stockings
- Frequent elevation of the legs
- Regular exercise
- Dorsiflexion exercises, which is the action of raising the foot upward toward the shin or moving your toes toward your head
- Avoiding wearing high heels frequently (high heels impair venous drainage)
- Avoiding long periods of standing or sitting (if you stand for long periods of time, take frequent breaks to sit down or elevate your feet)
- Practicing good skin hygiene