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.