Frequently Asked Questions (FAQs) Regarding Venous Insufficiency and Varicose Veins As Answered by Dr. Joseph Magnant, Vein Specialists at Royal Palm Square

Vein ProblemWhat are varicose veins?
Varicose veins are abnormally enlarged superficial veins usually seen in the thigh and leg. In many patients, they are a sign of a more serious underlying problem of the venous system. These veins often are branches of the superficial set of veins (long and short saphenous veins), which have leaking valves. As many as 30 million adults in the USA are affected by significant superficial venous insufficiency (saphenous vein and branches) and may have an easily treatable problem. Venous insufficiency is more of an ” umbrella” diagnosis, which refers to leakiness of the one-way valves within the veins that results in increased pressure in the veins. The increased pressure may cause bulging varicose veins, leg swelling, cramps or achiness of the calves, restless legs, spider veins, discoloration and thickening of the skin of the lower leg, and eventual bleeding or ulceration.

What will happen if I leave them alone?
Without treatment, varicose veins worsen with time. However, rather than focus on the varicose veins, it is probably more important to focus on the fate of the skin of the lower leg in this group of patients. Venous insufficiency may manifest itself in other ways as well, such as swollen, achy legs, discolored and thickened skin over the lower leg around the ankle area and purple, painful feet.

What are the risk factors for developing varicose veins?
Heredity is the most significant risk factor in developing significant venous insufficiency and varicose veins. The second most important risk factor is the history of full term pregnancy. The more full term pregnancies a woman experiences, the higher the risk of vein related problems. Other conditions that may contribute to the development of varicose veins and venous insufficiency include morbid obesity, prolonged standing or sitting, focal trauma to a vein (sports injury) and deep vein thrombosis.

Varicose veins are more common in females due to their childbearing status as well as the presence of estrogen. Despite this fact, males account for approximately 20-30% of patients who present for evaluation of varicose veins or other complications of venous insufficiency.

What are the symptoms of varicose veins and venous insufficiency?
Varicose veins and venous insufficiency may cause symptoms less obvious than the commonly noted spider veins, bulging lumps, bleeding veins or leg ulcers. Other symptoms may include swollen achy legs, a feeling of heaviness or fatigue of the legs, or itchy and discolored legs. Patients usually complain of increased swelling and aching toward the end of the day and often note improvement with elevation of the legs or after a night of sleep. Other patients may be under treatment for conditions thought to be related to the heart (congestive heart failure), kidneys (renal failure or diabetic kidney disease), excess salt intake, lymphedema (swelling after leg incisions) or for neurologic conditions such as neuropathy or restless leg syndrome (RLS). Restless leg syndrome has been strongly correlated with venous insufficiency, so patients who have been diagnosed with RLS are encouraged to seek further vein evaluation.

How can venous insufficiency be diagnosed?
Aside from the obvious signs of external varicose veins found at a physical examination, the most accurate method of diagnosing underlying venous insufficiency is duplex ultrasound. When performed by a qualified registered vascular technologist, one can precisely determine the location of the leaky veins and formulate a logical and effective treatment plan to cure the problem. The importance of the role of an experienced registered vascular technologist in performing the venous insufficiency study cannot be overstated. This is an outpatient examination, which takes approximately 30 minutes per leg, and is best performed at the direction of the Physician Vein Specialist who will be responsible for making the treatment decisions.

What are the modern treatment options for venous insufficiency?
Until the year 2000, the treatment options for varicose veins and venous insufficiency were limited to compression stocking therapy on the conservative end of the treatment spectrum or saphenous vein ligation and/or stripping on the surgical end of the spectrum. Since the Venefit™ Procedure was introduced (radiofrequency catheter based) in 1999 (originally called Closure or ClosureFAST, endovenous closure technique), an estimated 30-40 million adults in the USA with significant superficial venous insufficiency now have an effective, outpatient treatment for their swollen achy legs, varicose veins and venous leg ulcers. In the days of vein stripping, more advanced skin changes or ulcerations were required to justify the invasive procedure. With endovenous techniques of sealing the leaky veins from within with a small catheter, under local anesthesia, these patients can now be treated at a much earlier stage of their disease, more effectively preventing more advanced complications from occurring in the future.

How does the Venefit™ or Laser endovenous procedure work?
Under local anesthesia, a small catheter is inserted into the leaky vein through a needle stick in the mid calf. Either radiofrequency (The Venefit Procedure) or light (Laser) energy is delivered through a small catheter to the inside of the leaky vein, which heats and seals the abnormal vein closed. The catheter is inside the vein only long enough to seal the vein and is removed upon completion. The treated vein is gradually reabsorbed by the body and causes no harm. Over time, most varicose veins will resolve and limb swelling will improve within weeks.

How will the blood get back after you close this main vein?
The function of the leg veins is to return blood from the feet to the pelvis. This occurs through the pumping action of the muscles and properly functioning valves. Ninety percent of blood return from the feet to the pelvis normally occurs through the deep veins (inside the muscles). As long as the deep set of veins are working properly, the effect of closing a leaky superficial vein is actually beneficial. The leg circulation will be better off with the leaky vein closed rather than left open and leaking.

I’ve had varicose veins and discolored skin for 20 years, why fix it now?
The natural history of untreated severe venous insufficiency is that of progression to larger varicosities, clotted varicosities, bleeding varicosities, progressive leg edema and disability, and brownish discoloration and thickened skin, with potential for future ulceration. Prior to the introduction of endovenous closure techniques, it made sense to be conservative when considering “surgical” treatment of varicose veins and venous insufficiency. Although compression stockings offer some symptomatic relief from venous insufficiency, their use in no way constitutes a definitive treatment. The underlying problem persists after removal of the stocking and the process will progress in even the most compliant of patients. Just as an astute Internist would not wait for a complication of diabetes, high blood pressure or high cholesterol to occur before offering definitive medical therapy for these conditions, we should be equally proactive in objectively establishing the diagnosis of venous insufficiency and offering definitive therapy when appropriate. In this era of preventative medical care, it makes logical sense to investigate venous problems, institute a conservative trial of therapy, and when appropriate, offer definitive treatment prior to the occurrence of irreversible complications.

Is varicose vein or venous insufficiency surgery covered by insurance?
In instances where a patient is experiencing leg swelling, pain or inflammation related to bulging varicose veins, or skin changes predisposing ulcers or superficial clots, insurance companies may determine a medical condition in need of care. Generally, a three-to-six-month conservative trial of therapy, including elevation, anti-inflammatory medications and compression stocking therapy will be required to satisfy Medicare and most commercial insurance carriers’ inclusion criteria. Some carriers will also require certain training requirements of the type Vein Specialists satisfies, and most require a detailed letter of medical necessity predetermination. It is thus of paramount importance to keep detailed records of any treatment and history of vein issues.

Injection sclerotherapy is rarely covered by insurance unless there has been a history of recurrent hemorrhage or pain directly related to the varicosities in question or in cases of refractory venous ulcers despite previous closure procedures.

What is restless leg syndrome and how is it related to venous insufficiency?
Restless leg syndrome (RLS) is a constellation of symptoms of jumpy legs, and discomfort in the legs which is worse in bed and often relieved with ambulation. It is often worse in the third trimester of pregnancy and relieved after delivery. Many medical therapies have been employed, most of which make the patient drowsy thus allowing sleep to occur. Many of the symptoms are common to those seen in patients with venous insufficiency. In fact, in a patient with symptoms of RLS, one should consider the diagnosis of venous insufficiency as a contributing factor. Many patients with severe venous insufficiency and RLS symptoms experience partial or complete relief of their RLS symptoms after successful treatment of their venous problem.

Can my night time leg cramps and Charlie horses be caused by venous insufficiency?
Yes, many patients with venous insufficiency also have these symptoms after they go to bed. The cramps are thought to be secondary to fluid shifting out of the muscles as gravity is no longer playing a role when patients are lying flat. What liquid leaks out of the insufficient veins during the waking hours when patients are upright standing or sitting (due to increased pressure in the leg veins) returns from the muscles at night. This may also result in frequent trips to the bathroom to urinate (see next question).

I have heard fixing my leaking veins can relieve me from having to urinate 3-4 times each night? Is this true and please explain how so?
As in the previous question, one can understand that what leaks out of the veins during the day when upright has to return to the circulation at night, or the legs will continue to swell and burst. So when the legs are even with the level of the heart at night in bed, the liquid in the soft tissues can return to the circulation through the lymphatic system and the kidneys will turn this extra liquid into urine. The more swelling there is the more urine is made and the more trips will be made to the bathroom at night. Fix the leaky veins, stop the leaking of fluid from the veins and stop the nighttime leg cramps and urination.

Leaders in Vein Treatment The modern evaluation and treatment of venous insufficiency is the singular focus of Dr. Magnant and his professional and compassionate staff at Vein Specialists at Royal Palm Square in Fort Myers, FL. He can be contacted either by calling 239-694-8346 or through his website, www.weknowveins.com, where patients can submit their request for an appointment. He encourages readers to review his website which is specifically written for his patients and also take the time to view his photo gallery. Venous disease is not a laughing matter, but sometimes it is only through humor that some of us are motivated to act.

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