Varicose Vein Sclerotherapy: Everything you Ever Wanted to Know

After ablation of the trunk veins, frequently their branches, the varicose veins, close up on their own. But sometimes, they don’t. In that case, we treat them with a procedure called sclerotherapy.

Sclerotherapy involves directly inserting a needle into these varicose veins and injecting something that cases the inside wall of the vein to become irritated. The vein then closes off.

Generally the agent injected is sotradecol. It comes as a liquid. Most doctors turn it into a foam solution by stirring it up with air. This foam coats the inside of the vein and helps break down the wall of the vein.

Details of the procedure

Sclerotherapy is much less involved than ablation.

  • The patient lies down on the procedure table.
  • The doctor places a very small needle inside the varicose vein, sometimes with the help of the ultrasound machine, sometimes with the help of a “vein light”.
  • The doctor injects the foam.
  • Sometimes the patient has to lay inclined on the table for a few minutes to prevent the foam from traveling beyond the varicose veins.

What happens after the procedure?

Generally, you need to wear the compression stockings for a fixed length of time. Here at VIP, we have our patients wear the stockings around the clock for 24 hours, and then anywhere from 3 to 7 days for 12 hours a day.

Varicose Vein Ablation: Everything you Ever Wanted to Know

The lynchpin treatment for varicose veins is endovenous ablation. Let’s define the term: “endo” means inside; “venous” means related to the vein; “ablation” means to remove or destroy. So “endovenous ablation” basically translates into “destroy the vein from the inside”.

Remember that the anatomy of superficial veins of the leg is like an upside-down tree. The trunk of this tree is the Greater Saphenous Vein, or GSV, a long, straight vein that runs along the inside of the thigh.

The branches of the tree are the small veins under the skin. When valves in the GSV are damaged, blood flows the wrong way–down the leg instead of up toward the heart–and the small branches, which are usually not visible, grow and bulge under the skin as varicose veins.

A similar structure exists below the knee. The major trunk is the Lesser Saphenous Vein, or LSV, which runs along the calf.

Unless the reflux in the major trunks (GSV, LSV) is treated, the small branches won’t go away. So the first step in treating varicose veins generally consists of endovenous ablation: destroying the vein from the inside. Endovenous ablation involves placing a small probe inside the vein at the level of the knee, sliding it up to where the trunk begins, and sliding it back down as the tip of the probe burns the inside of the vein.

Simple, right?

Well…it’s slightly more involved than that, but not by much. Here is the more detailed version of the procedure:

  • The skin of the leg is cleaned and a sterile workspace is created.
  • The doctor gives a numbing shot near the knee where the probe will enter the vein.
  • While watching under ultrasound, the doctor puts a needle into the vein. The doctor exchanges the needle for the probe which looks like a long plastic tube. Using the ultrasound to guide the path of the probe, the doctor slides the probe up the vein close to its origin at the top of the thigh.
  • In order to both numb and insulate the area around the vein, a solution of saline mixed with a local anesthetic is injected all around the vein along its entire length. This part usually involves a few more numbing shots to the skin itself which sting for a few seconds.
  • The doctor turns on whatever technology is being used to do the ablation–laser or radiofrequency–and slides the probe back along the length of the vein. This part only takes a minute or two.
  • The probe is removed and bandages are placed on the leg at various places. A compression stocking is then placed on the leg.

What happens after the procedure?

Generally, you need to wear the compression stockings for a fixed length of time. Here at VIP, we have our patients wear the stockings around the clock for 3 days, and then 12 hours a day for another 11 days.

What Causes Deep Vein Thrombosis (DVT)?

Generally speaking, DVT causes can be both genetic and behavioral.

Having a family history of parents or siblings suffering from blood clots can increase your own DVT risk. An undiagnosed clotting disorder can put you at risk of DVT, as well. Behavior-related causes of DVT include smoking and obesity.

Other contributing DVT causes include:

  • Surgery or traumatic injury
  • Cancers and their treatments, both of which may adversely affect the blood’s ability to clot
  • Other serious illness, such as congestive heart failure, heart attack, stroke or sepsis
  • Varicose veins
  • Pregnancy
  • Contraceptives/estrogen therapy; this risk especially increases in smokers

In terms of events that may “trigger” the condition, specific DVT causes revolve around extended sedentary behavior. When we’re healthy, our muscles help our blood keep moving. But when we’re not moving around, blood tends to pool and clot at the lowest part of the body.

Prolonged bed rest due to illness—and recovery from surgery or trauma—are common causes of DVT. Likewise, sitting on an airplane for six or more hours without moving around is one of the leading causes of deep vein thrombosis. For this reason, DVT is sometimes referred to as “economy class syndrome.”

People who have had injury to their veins—due to trauma, athletic accidents or surgery—also face higher DVT risk.

What makes deep vein thrombosis especially dangerous?

There are two main concerns.

If untreated, a piece of a deep-vein blood clot can break loose and travel to the lungs, causing pulmonary embolism—a potentially life-threatening event that affects approximately 60,000 Americans annually. The primary treatment to prevent this is anticoagulation: the administration of blood-thinning medication such as lovenox, a shot, and coumadin, a pill. Anticoagulation generally prevents the clot from moving to the lungs.

However, there is a second reason to be wary of DVT. Even with anticoagulation, there can be long term consequences, namely something called post-thrombotic syndrome, which results in pain and swelling for the rest of a patient’s life.

Our goal here at VIP in treating DVT actively and aggressively is to prevent post-thrombotic syndrome.

Deep Vein Thrombosis (DVT) Treatment with Thrombolysis: Catheter-based Clot Removal

At Vascular and Interventional Physicians, our specialty-trained interventional radiologists perform a minimally invasive, non-surgical procedure that removes blood clots, as known as deep vein thrombosis (DVT), from patients’ legs. The procedure, called DVT thrombolysis, can be done on an outpatient basis. In the days following the procedure, the pain and swelling related to the deep-vein blood clots generally resolves. Once the clot is removed from the veins of the leg, patients are able to resume their normal activities within a week.

What is Deep Vein Thrombosis (DVT)?

Thrombosis means the formation of clot. So deep vein thrombosis means formation of clot in the deep veins. There are two systems of veins in the legs: the superficial veins, which are close under the skin, and the deep veins, which are not visible. The deep veins are very important because they carry the majority of the blood back to the heart.

Traditional Treatment for DVT

For many decades, the traditional treatment for DVT has been “anticoagulation”: drugs that thin the blood. Some examples are lovenox, which is a shot in the skin, and coumadin, which is a pill. Another name for coumadin is warfarin.

Anticoagulation does not directly treat the clot; it prevents new clot from forming in the hope that the body will dissolve the clot that’s already there. Anticoagulation tries to the tip the balance in favor of the body dissolving the clot.

The biggest problem with treatment with anticoagulation alone is that, depending on which studies you look at, despite taking blood thinners, 33-50% of people develop something called “post-thrombotic syndrome” which is lifelong pain and swelling of the legs.

Why does post-thrombotic syndrome develop?

Blood in the arteries is propelled forward by the heart. After this blood makes its way through the tiny capillaries of the organs and limbs, it no longer has the strong impetus to move forward on its own. So within the deep veins of the arms and legs, there are one-way valves which prevent blood from going the wrong way. As you move your limbs, contract your muscles, and walk, blood is propelled back to the heart, and the one-way valves prevent blood from going the wrong way.

When clot forms in the deep veins, it heals by scarring and thinning over many months. This process can damage these very important one-way valves. Once damaged, blood can flow the wrong way—away from the heart, down toward the feet—and pool within the leg veins. You can imagine the result: swelling and pain.

Post-thrombotic syndrome literally translates into “after clot syndrome”.

Thrombolysis: A Safer Alternative to Traditional Treatment for DVT

In DVT thrombolysis, we place a catheter into the vein to actively remove the clot. It’s a complementary treatment to anticoagulation, so the patient still needs to take the blood thinner medication after the procedure. But the goal is to get rid of the clot as soon as possible in order to minimize damage to those important one-way valves, thereby preventing post-thrombotic syndrome.

How Our Treatment Works

The procedure is minimally invasive, is done with the patient sedated, and takes about 2 hours. A small needle is placed into the vein at the back of the knee and a flexible wire is extended into the vein through the clot. A specialized catheter is run along this wire to the site of the clot to dissolve, break apart, and remove the clot.

The physicians at VIP use cutting edge catheters for DVT removal, including the Angiojet, which uses highly pressurized jets of saline to fragment and remove clot, the Trellis, which uses a clot-dissolving medicine called tPA to break up the clot and suction it out.

Inferior Vena Cava (IVC) Filter

The various branches of veins in the each leg come together into the common iliac vein, one on each side. The right and left common iliac veins join together to form the inferior vena cava, which is the main channel through which blood drains into the heart. When we perform the DVT thrombolysis procedure, there’s a chance some of the clot can break off and travel toward the heart and lungs.

Therefore, sometimes the physician performing the procedure places a little basket into the IVC called an IVC filter to trap any clot that breaks away. This filter is temporary and is usually removed within 2-3 months.

Iliac Vein Stent

Occasionally, the root problem is a narrowing of the iliac vein. In this situation, a mechanical stent is placed to open up the vein and prevent future clot development at the site.

Conclusion

As a minimally invasive treatment, DVT thrombolysis improves quality of life compared to those patients who are on blood thinners alone. Compared with traditional treatment for DVT, hospital stays can be shortened or eliminated. Patients return to their normal activities in a shorter time. The risk of having lifelong leg pain or swelling, known as post-thrombotic syndrome, is thought to be lessened. No incisions or invasive surgeries are required.

Varicose Vein Treatment Options

If you want to cut down a tree, you don’t start trimming the branches; you cut the trunk. Similarly, if you want to treat varicose veins, you start with the ultimate problem: reflux in the major trunks of the leg veins—the greater saphenous vein, which runs along the inside of the thigh, and the lesser saphenous vein, which runs along the back of the calf. If this reflux isn’t taken care of, other treatments will have little effect. Usually these refluxing trunk veins are not visible on the skin.

To figure out which veins are refluxing, we need an ultrasound of the leg.

Ablation * Sclerotherapy * Phlebectomy

After the ultrasound, the refluxing trunk veins are closed with a procedure called an ablation. Some practices use a laser to close the trunk, in which case the procedure is called “endovenous laser ablation”. Others use a different kind of energy called radiofrequency and the procedure is called “RF ablation”. Both involve putting a small catheter (tube) into the vein and essentially burning it on the inside.

Sometimes, the ablation procedure is enough to make the varicose veins disappear. Usually, though, they need a little bit of help. That’s where two other procedures, sclerotherapy and phlebectomy, come in.

In sclerotherapy, a soapy foam solution is injected directly into varicose veins, which leads to a breakdown of the cells lining the inside of the veins, and this leads to those veins closing down. The remnants of those veins are eventually absorbed by the body.

Phlebectomy is usually reserved for those larger cord-like veins. It involves making multiple tiny small incisions in the skin and scooping out parts of the vein. Again, the remnants of those veins are eventually absorbed by the body.

Different medical practices use different approaches to which combination of procedures are used. Some perform sclerotherapy at the same time as the ablation; others do the ablation first and see the varicose veins go away just from that. Some never use phlebectomy; others use a combination of sclerotherapy and phlebectomy after the trunk is ablated.

But Wait… Don’t I Need my Veins?

Good question. Yes, you need some way of taking blood from your legs back to your heart. Luckily, there are two systems of veins designed for this: the deep veins which carry 80% of the blood and the superficial veins which carry 20% of the blood. Everything we’ve talked about so far involves the superficial veins, the ones close to the skin. When we close them off, whether by ablation or by sclerotherapy or phlebectomy, the deep veins take over that extra burden.

But what if the deep veins are damaged or show reflux? Another good question. That’s why in the initial ultrasound we look at both the superficial veins and the deep veins. We look at the superficial veins to look for the reflux and we look at the deep veins to make sure they’re healthy enough to take that added responsibility in the future.

Treating Veins is Sometimes like Playing Whack-a-mole

Unfortunately, superficial venous reflux disease is chronic problem and will usually require long-term care. We can make the diseased veins go away, but inevitably, down the road, new ones appear.

Why do people get varicose veins?

In a word: reflux. The blood is going the wrong way.

Arteries carry blood from the heart to the organs and the arms and legs. Veins carry blood back to the heart. In between are tiny capillaries.

Blood in the arteries is driven by the pumping of the heart. After blood travels through the capillaries, there is no “push” to carry blood further. So the human body has come up with an ingenious way to keep blood moving in the right direction: veins have one-way valves. Every time you contract the muscles of your leg, blood is pushed up to the heart through as the valves open. And when you’re not moving, the valves close to keep blood from moving back down. Over time, this system is good enough for blood to work its way back to the heart.

When these valves get damaged for whatever reason, blood pools in the veins, and the veins and their branches expand giving the appearance of bulging veins under the skin.

And that, my friends, is why people get varicose veins.

Dr. Wittenberg Speaks at Colon Cancer Survivors Forum

Dr. Wittenberg recently had the opportunity to speak at the Colorectal Cancer Patient and Survivorship Symposium.   It took place on March 22, 2014 and was attended by over 150 patients with colon cancer and survivors.  The seminar was an opportunity for leaders in different medical specialties to share cutting-edge treatments and coping strategies to those most affected by colorectal cancer.

Some of the topics that Dr. Wittenberg spoke about include:

  • Y-90 Radioembolization – a procedure in which a catheter is placed into the artery supplying blood to tumors spread to the liver, and radioactive particles are injected that specifically target the cancer tissue.
  • Microwave Ablation – a procedure in which a small probe is inserted through the skin into a liver tumor, and then heat is used to kill the tumor cells with microwave energy.
  • Radiofrequency Ablation – a similar procedure that uses a probe through the skin to generate radiofrequency energy and kill the tumor cells.

Those in attendance surely left the conference armed with new strategies with which to fight their cancer, greater hope for the future, and renewed vigor.

 

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