Treatments for Venous Disease

Deep Venous Disease - As noted on the venous disease page, treatment for deep venous thrombosis usually consists of intravenous administration of a potent blood thinner to stop the clotting quickly. Many times this involves a hospital stay although some patients may be candidates for outpatient blood thinners. Once the blood is thinned to a “therapeutic level” an oral blood thinner is prescribed for an additional 3-6 months. The blood thinner prevents more clot from forming but does not generally dissolve the clot. The body can dissolve or lyse the clot over time. The formation of a blood clot results in a scarring of the walls of the vein and damage to valves. If extensive, this can result in what is called post phlebitic syndrome leading to discoloration of the skin and ultimately venous ulceration. Therefore, it is important to minimize the extent of the clot by timely treatment.

There are a number of additional ways to treat deep venous disease.

Valve repair
In valve repair, the surgeon shortens the valves inside your vein to improve valve function. After making a small incision into your skin and the affected vein, the surgeon folds or tucks the valve flaps. They may place a fabric sleeve around the outside of your affected vein to help press the walls of the vein together to maintain valve function. This treatment is typically reserved for only very severe deep venous insufficency and is rarely performed.

Angioplasty and Stenting
In some cases of chronic deep vein obstruction, angioplasty or stenting may be recommended. An angioplasty is the use of a balloon to push open a narrowed or blocked portion of the vein. A stent is a metal-scaffold tube that helps to keep the narrowed areas open. The procedure is performed through small needle punctures in the veins, either behind the knee or in the groin. Typically angioplasty and stenting are safe procedures.

Fortunately, these treatments are rather uncommon and reserved for severe disease.  Most therapy typically centers around prophylactic measures to minimize the long term consequences. The best and perhaps the most important measure one can take is regular wearing of a quality graduated compression stocking. Please note, these are not the T.E.D. stockings given to you at the hospital after surgery designed to minimize blood pooling in the legs while in bed. These will be ineffective while ambulatory.

Superficial venous disease- By far, dysfunction of the superficial veins is more common. Because the superficial veins are poorly supported beneath the skin, when the valves begin to leak (venous insufficiency), an increased pressure is transmitted into the veins. Over time, the veins tend to enlarge and stretch. It has been estimated that ≈2.5 million people have CVI in the United States, and of those, ≈20% develop venous ulcers. The more serious consequences of CVI such as venous ulcers have an estimated prevalence of ≈0.3%, although active or healed ulcers are seen in ≈1% of the adult population. The overall prognosis of venous ulcers is poor, with delayed healing and recurrent ulceration being common. More than 50% of venous ulcers require prolonged therapy lasting >1 year. The socioeconomic impact of venous ulceration is dramatic, resulting in an impaired ability to engage in social and occupational activities, thus reducing the quality of life and imposing financial constraints. Disability related to venous ulcers leads to loss of productive work hours, estimated at 2 million workdays/year, and may cause early retirement, which is found in up to 12.5% of workers with venous ulcers. The financial burden of venous ulcer disease on the healthcare system is readily apparent: An estimated $1 billion is spent annually on the treatment of chronic wounds in the United States, or up to 2% of the total healthcare budget in all Western countries, and recent estimates place the cost of venous ulcer care at $3 billion annually. ^* Circulation. 2005; 111: 2398-2409,     Fortunately, progression of this disease tends to be slow.

If the dysfunction occurs in the tiny superficial veins, spider veins form and in most instances, are primarily a cosmetic concern. There are several treatment options for spider veins including compression stockings, injection, and/or laser. What’s right for you depends upon many factors and should be discussed with your doctor.

The larger superficial veins can be seen bulging and twisted beneath the skin. (varicose veins). In addition to being unsightly, they can result in symptoms ranging from aching, a feeling of heaviness, tenderness, swelling in the in the limb to skin erosion and ulceration. As with spider veins, treatment options are varied however today's techniques are far superior to the past. Many of us have known someone who has undergone a procedure called a vein stripping in the past which involves many incisions throughout the leg and the veins are literally pulled out. Much venous disease was left untreated because of the long recovery necessary from this procedure. Fortunately, this has largely been replaced by much improved modern methods that are minimally invasive and result in very little discomfort to the patient.  

Chemical ablation
Also known as sclerotherapy, your physician injects a chemical into your affected veins. The chemical or sclerosant scars your veins from the inside out so these abnormal veins can then no longer fill with blood. The size, location, and extent of the venous abbnormality dictates the type of sclerosant used. Blood that would normally return to the heart through these veins returns to the heart through  other veins. Your body will eventually absorb the veins that received the injection. While traditionally, sclerotherapy was reserved for spider and small varicosities, newer sclerosant and methods of injection are currently being tested for larger veins and expanded conditions.  

Thermal Ablation
Thermal ablation uses a thin, flexible tube called a catheter inserted into a varicose vein. The vein is then surrounded by local anesthetic which collapses the vein vein wall around the catheter and numbs the surrounding tissue so the patient experiences no discomfort from the heat. The tip of the catheter heats up by using either radio frequency energy or laser in turn, heating the walls of the vein, essentially sealing the vein closed. As with chemical sclerotherapy, your varicose vein is then no longer able to carry blood, and it is eventually absorbed by your body. 

At Quality Vascular Imaging, we get involved in this treatment because it is all performed under ultrasound guidance. The ultrasound image is used to ensure the fiber is in the correct vein and positioned properly. In the ultrasound video below, one can see the catheter in the vein (The bright linear reflector) as a needle is positioned just next to the vein and anesthetic is injected (which shows up as black)completely surrounding the vein with anesthetic. 

Once the anesthesia is in place around the vein, the laser fiber (catheter) inside the vein and as it is slowly withdrawn while the heating destroys the vein walls. These treatments have truley revolutionized treatment of venous disease. Performed in an out patient setting, only local anesthesia is used and the patient typically experiences very little discomfort and resume normal activities the next day.  

One additional note: if you decide to seek treatment, it is important to find a physician who specializes in the treatment of venous disease called a phlebologist. The ACP website can help direct you to qualified physicians in your area. www.phlebology.org While venous insufficiency can now be treated very effectively, unfortunately, there is no 100% cure. The veins treated by these modern methods will not likely return, but new veins can become insufficient. Regular use of a quality graduated compression stocking can greatly minimize your likliehood of experiencing significant reoccurrance.

www.compressionsocks.pro