Long before my career as a vein doc performing varicose and spider vein treatments in the North suburbs of Chicago began, I worked a series of jobs and volunteered for many organizations around Chicagoland before and during my undergrad years: Lifeguard, delivering meals-on-wheels for the elderly, crisis hotline counselor, keyboardist in a band, operating room assistant. A pretty diverse set of experiences. Each informed and impacted upon my decision of which route to take in terms of a career choice.
Starting to post on this blog has forced me to reflect on a great many things. And, just like looking at a reflection in any mirror, we not only see the image as it is in front of us, but also as we would like it to appear. This dissonance is what compels us to grab a brush…start a diet…seize the day.
Looking through the retrospectoscope, I can’t say that I have always made the correct decisions…but I have always tried to operate on the premise that making the best decisions starts with having the best information at hand. In the medical world there is the concept of informed consent. This means that in order for patients to agree to procedures, they need to be informed of the risks and benefits involved. This is true for brain surgery as well as vein procedures. On the doctor side of the equation, I have to choose which treatment methods to add to my armamentarium by analyzing the evidence available from research as well as my experiences and those of my colleagues.
Having sifted through the data, there is a clear winner to treat superficial venous insufficiency: endovenous ablation. But it’s not enough for me to be certain of the benefits. I need to present the information to you as clearly as I can…including the alternatives…in order for you to make an informed decision that you feel comfortable with [see my previous Vein Rant #1 blog post]. My previous treatment post described conservative treatment options. As you recall, all of them are practical, but none are definitive as they can’t fix the underlying problem of venous valve insufficiency. In this post I will compare and contrast surgical vs minimally-invasive treatments.
Surgical Treatment
Previously this was the only option. Disadvantages to surgeries such as ligation of the saphenous veins and stripping them out of the leg include:
-The need for general anesthesia and the risks that go along with it
– Bleeding
-Infection
– Significant scarring
– Hospital costs. These were done in operating rooms and patients would frequently have to remain in the hospital after the procedure
-Prolonged recovery time
-Recurrence: 45% after “high ligation” alone. 18% after ligation and stripping
In time, innovative doctors found less invasive ways of removing varicose veins, especially the Ambulatory Phlebectomy. In this “microsurgical” approach, varicose segments are delicately extracted using specially designed instruments through teeny incisions. Advantages include:
-Can be done using local anesthesia
-No stitches are required
-Teeny scars
Ambulatory phlebotomies are now typically done in conjunction with endovenous ablation…our next topic of discussion.
Endovenous Ablation vs Surgery
In time, extremely clever physicians came up with an innovative,minimally-invasive,quick and dare-I-say elegant way of treating venous disease. You can pretty much look at all of the problems with traditional surgery and notice that Endovenous Ablation solves them all. Yes, I’m gushing about this, with good reason. This is what makes me get up to work each day with a smile on my face and a spring in my step. Endovenous ablation revolutionized varicose vein treatments and I say “Viva La Revolucion!”.
I have performed a great many of these procedures over the years and am firmly convinced that such treatments have significantly improved the lives of my patients.
In order for such treatments to work you need:
-Irreversible injury to the endothelial lining of veins
-Shrinkage of the vein wall collagen
– Scarring & closure of the vein…NOT CLOTTING!
You also have to strike a delicate balance: if you use too much thermal energy, you may burn the vessel and other surrounding structures.
The key points to remember are that these procedures are:
-Minimally invasive: think of it as putting in an IV under ultrasound guidance
-Relatively painless: you can do the procedure using only local anesthesia
-Allows for Quick Recovery:
-Back to your normal routine (with few exceptions, like no swimming) immediately
-Not only are you able to walk immediately after the procedure is done…you NEED to!
The two forms of endovenous ablation that are currently utilized employ either heat (thermal ablation) or chemicals (mechanical occlusion with chemical assist [MOCA]; sclerotherapy; venaseal® adhesive closure, to name a few)
Thermal ablation techniques have now been around for over a decade and have consistently proven to be effective and safe. The heat energy is derived from either radio frequency (Radio Frequency Ablation or RFA) or lasers of differing wavelengths (Endovenous Laser Ablation or EVLA…you may also see the acronym E.V.L.T®…this is a particularly trademarked name…think Kleenex® vs facial tissues). Both are performed with similar techniques.
At Rosen Vein Care, I use endovenous laser ablation as it has allowed me to safely treat varicose vein disease in a timely fashion with consistently outstanding results. In case you are wondering, I happen to use a 1470 nanometer laser, which has given me great results with far less bruising than I noted when I previously used a 980nm laser.
Here is a brief video produced by the makers of one of the lasers and one of the developers of the EVLT® procedure that nicely describes how endovenous laser ablation is done:
Another modality of delivering heat energy to treat varicose veins that is under development uses steam…yep, steam. It sounds fascinating but Im waiting to see how the evidence turns out from ongoing research before I would consider using it in practice.
Endovenous thermal ablation procedures are very well tolerated. It’s ironic, but the only discomfort that patients experience during the procedures relates to the times when local anesthetic is administered. Nobody likes to think of the dentist, but a good analogy is the fact that once the discomfort of getting local anesthetic to numb up your mouth is over, dental procedures are a snap. Note…if a vein doctor comes at your face to give local anesthetic: RUN!
Local anesthetic is absolutely required for 3 really good reasons:
1) To numb up your leg (duh)
2) The cool (both in temperature and in the “Fonzie” sense, I guess) fluid acts as a heat-absorber. The fluid absorbs some of the heat to protect the soft tissue, nerves, skin, etc around the area of vein that’s being treated. Otherwise the heat radiating out from the tip of the laser can cause mischief. We try to avoid mischief at Rosen Vein Care.
3) The fluid around the vein helps to compress the walls of the vein down against the laser fiber, thus ensuring that the heat gets to where we need it to work: on the vein wall.
The parts of the procedure before, and certainly after the local anesthetic has been given are…well…boring, at least to the patient, anyway. To me they are exciting and fun…which is why I love my job! After the local is in, patients shouldn’t feel a thing when the laser is turned on to heat-seal the vein shut.
This is a good point in time to insert my own two cents about sedating patients for these procedures. Not only do I think it is unnecessary to be sedated…meaning, given strong medicine to put you into a “twilight” ,kinda semi-sleepy state…I think it is unwise. Just before I turn the laser on, I tell my patients to let me know if at any point they feel even the slightest bit of warmth. If they do, their body is giving me the feedback I need to know that a bit more local anesthetic may be needed to protect the region around the vein from potential damaging effects of the laser. If patients are sedated, all feedback is essentially lost. Plus, honestly, the part of the procedure where I give local anesthetic is short and the effects are awesome: once it’s in, you feel nothing but…BOREDOM.
Once the laser is turned on, I slowly and steadily back it out of the vein I’m treating. Eventually I get to the point where I started the IV. I turn the laser off and remove it, along with the IV catheter out of the leg. [Boring…which is GOOD!]. After this, I bandage the spot where I started the IV (no stitches, only fancy steri-strip bandages, gauze & tape). Compression stockings are placed on the treated leg. I observe patients for a short while and then they are on their way! Typically patients wear the compression stockings for a week after the laser procedure and then I see them for a followup visit. In between, patients keep active and, when needed, only require naproxyn (similar to Alleve®) for any discomfort.
As with any medical procedure, there are clear risks you need to consider along with the obvious benefits that can be obtained from endovenous laser ablation. Understandably, most patients note some minimal discomfort at the sites where local anesthesia was injected and where the IV is started. Such pain is typically short-lived. Bruising is a given, but it’s a transient thing. It is usually gone after a week or two. Other rare risks exist and we can discuss these during your consultation.
I make it a point to call all my patients after their procedures to check on them, go over the aftercare instructions, address any concerns and answer any questions that have come up. Plus, all my patients get my cell phone number/email address to call/write if any concerns arise. That’s what I would want for me, that’s what I want to have in place for my patients. That’s another part of the Rosen Vein Care Difference.
Oh…and for most patients with commercial insurance and Medicare, if you are diagnosed with superficial venous insufficiency (the underlying issue that leads to symptomatic varicose and spider veins in many cases), endovenous thermal ablation is a covered procedure. Covererage depends on particular insurance policies. Out of pocket costs depends on a particular patient’s policy, copays, deductibles, etc. We help patients obtain the coverage they deserve and do our best to help you get a guestimate of what your out of pocket costs might be.
Other minimally-invasive, maximally comfortable procedures exist to treat superficial venous insufficiency. These newer procedures do not use heat. No heat, no opportunity for “collateral damage” of nearby nerves and other structures. That’s the theory anyway. I’m going to talk all about that in my next post.
Well…that just about wraps up this episode of Dr. Dave’s VeinBlog. As always, if I’ve raised more questions than I’ve answered and if you need specific information regarding your chronic leg issues, call 847-272-8346 or click HERE to leave your contact info and we will call you! Maria, my wonderful assistant, is standing by and waiting your call to schedule your initial consultation.
See you real soon!
