ANATOMY OF LARGE VEINS
The large veins include:
- Great Saphenous Vein
- Anterior Accessory Saphenous vein
- Small Saphenous Vein
Normally, each of these three veins has one-way valves so that blood flows from the ankle to the groin. Varicose veins are large, dilated veins in which the one-way valves no longer work and when one sits or stands upright the blood flow falls back down toward the ankle. The great saphenous vein runs from the groin down the anteromedial thigh, medial to the knee and down the medial calf to the ankle. The anterior accessory saphenous vein runs from the groin down the anterior thigh and toward the anterolateral thigh. The small saphenous vein runs from behind the knee from the bend of the leg and goes down the posterior calf and posterolateral and toward the lateral side of the ankle. When one sits or stands and the valves do not work, then blood, like water, runs downhill. It is desirable and normal that blood only runs uphill when the valves normally catch the blood at intervals and keep it from falling downhill.
The anatomy of the great saphenous vein does have one special consideration below the knee and that is beginning a short distance below the knee the saphenous nerve comes close to the great saphenous vein or is even tightly adhered to the wall of it. The exact area that this occurs is variable but many times it can be determined by high-quality duplex Doppler ultrasound and a good-quality observer (vascular technologist). Injury to the nerve can cause numbness to the medial side of the foot or even a burning neuropathy due to injury to the nerve from midcalf to the medial side of the foot. This problem is also true for the small saphenous vein. Beginning a few centimeters below the popliteal crease (a crease from bend in the knee) and usually a third of the way down to half the way down, the sural nerve joins the small saphenous vein and the sural nerve supplies sensation to the lateral side of the ankle and foot.
WHAT ARE TREATMENT OPTIONS?
Historically, these large veins were treated by ligation and stripping under general or spinal anesthesia although it could be done with the use of tumescent anesthesia (a dilute anesthesia with bicarbonate and epinephrine) injected around the vein. With this there was often pain when there was a large side branch which pulled from a wider area than was anesthetized.
Later was developed a technique of visualizing the vein with duplex ultrasound and injecting sclerotherapy into the vein under duplex guidance to destroy the lining of the vein and cause it to thrombose and scar down. If the vein was very large and it refilled, then it became very painful and required one to two months to resolve. This technique also nearly always required usually more than two and really more than four treatment sessions.
Next came the placement of a long catheter into this vein and while observing it under duplex Doppler ultrasound inject chemical into the vein as the catheter was withdrawn and this was more effective than placing a needle directly into it.
Ligating or dividing the vein in the groin or below the knee was tried which did give temporary relief of symptoms, but there was a high rate of recurrence when this procedure was used. At first it appeared promising but later became obvious that this was not very good.
Next came endovenous laser where the vein was cannulated and a laser fiber was placed a short distance distal to where the great saphenous vein emptied into the common femoral vein in the groin and in the small saphenous vein was placed distal into near where the small saphenous vein emptied to the popliteal vein. The laser was activated and the laser fiber was slowly removed causing destruction of the lining of the vein and part of the wall of the vein.
Recently a new device has been released, which is a device placed into the vein that rotates at a high rate of speed that destroys the intimal lining and causes spasm in the vein wall causing it to shrink. As it is withdrawn, sclerotherapy is injected to cause this vein to scar down and this is called a ClariVein device. This procedure does not require anesthesia or tumescent anesthesia and is less painful and sometimes not at all painful. The rate of recurrence of problems following its use ranges anywhere from 13 percent to 2 percent and its use has further modified this recurrence rate of shrinking. By abrading the lining of the vein, it allows some of the sclerotherapy to get deeper into the wall of the vein. Some of the microscopic slides of this were presented at the American College of Phlebology in November of 2014 and they appear very similar to the destruction of the vein wall with laser. It appears that this will not have injury to the nerve adjacent to the wall of the vein in the lower leg that is associated with surgery and endovenous laser. The instance of injury to these nerves with surgery was 14 to 16 percent and with laser slightly less but around 4 percent had a painful neuropathy from burning the nerve in the vein wall below the knee. This procedure may solve that problem.
Another thing new that has not been released is the placement of glue in these veins. It is anticipated that this may be released in 2015 but no date is set.
Different lasers have different eye-catching names, but they differ primarily in the nanometer of wavelength of the laser energy that is delivered. The laser is a single wavelength that is generally between 810 nanometers in length and 1450 nanometers in length. The laser energy from these wavelengths is absorbed by different tissues and thus different tissues are heated. With the shorter wavelengths being absorbed by hemoglobin and the red blood cells, this is heated to cause heat to the vessel wall. The long wavelengths are absorbed by targets in the vessel wall and super heat these structures causing direct heat to that area to scar the vein shut. Our preference is the longer wavelength lasers.
Whatever laser technique is best is many times associated with the physician’s experience using that wavelength and knowing how to run that specific laser. Because the laser does cause heat and thus is painful, tumescent anesthesia is placed around the vein under duplex guidance and usually this causes numbness from 2:00 p.m. to midnight or until 3:00 to 4:00 in the morning and occasionally all night. By then there is only mild and really moderate discomfort. This tumescent anesthesia is usually mixed as 1000 cc (approximately one quart) and contains dilute lidocaine or another local anesthetic, some epinephrine and some bicarbonate. With this the treatment of the vein is usually painless. If you ever experience any pain, always tell your physician because the tumescent anesthesia that is left over is going to be thrown away and we do not want to throw it away if you need it. Do not suffer in silence.
The techniques mentioned to this point require one thing and that is a road through a straight vein and, as many of you know, the tributary veins are branches of the three refluxing veins previously mentioned, that come out of the large veins have a swirling appearance and are usually very tortuous and a guidewire catheter cannot be passed through these.
When the tributary veins that are very tortuous cannot be negotiated, then these will be marked every 2 cm to 5 cm and a short 5 mm incision can be made every 2 cm to 5 cm to remove these tortuous veins. These will take one to at most two stitches to close and some can even be closed with Steri-Strips.
Your physician should explain all of these to you if they apply and you should not hesitate to ask any questions as to how your anatomy effects what techniques can be used.
WHAT TESTS OR STUDIES WILL I NEED BEFORE PROCEEDING?
Before any of these procedures are undertaken, the patient will undergo a supine and upright (in our office standing) venous duplex Doppler to be absolutely certain that the deep venous system, which carries all the blood to your heart, is open and that the superficial veins are not the only drainage from your leg. If the deep venous system is blocked, you will create higher venous pressures in your lower leg than the average person. With an upright exam, and we nearly always use a standing exam, you will be able to observe which veins are not working when color flow is being used. You should not hesitate to ask to be shown the difference of what vein works and what vein does not. We will apply pressure over your lower leg to force blood up the leg and then release the pressure and all blood flow should stay 100 percent stopped when the pressure is released. There should be no blood that falls down your leg when the pressure is released. If blood does fall down your leg, we can demonstrate that to you. If this study is not done with the patient upright, there can be a 3.5 percent false positive and a 3.5 percent false negative result.
These procedures are usually durable over a lifetime although occasionally after a period of 3 to 10 years other veins may open and a vein such as an anterior accessory saphenous vein or a perforating vein that was not refluxing may begin to reflux and you may begin to notice veins again. You will need a repeat standing and supine venous duplex Doppler and see if it is necessary to treat these. This is true even if you underwent a great saphenous vein stripping and the vein was completely removed because other veins may begin refluxing such as an anterior accessory saphenous vein, a small saphenous vein that was normal before, or a perforating vein. Perforating veins are veins that go under the skin and straight into the deep veins in your leg. Normally, there is one-way flow going straight into your leg but occasionally the one-way valves fail in these and blood flow squirts back out under the skin.
WHAT CAN I EXPECT DURING AND AFTER MY PROCEDURE?
You will have medications prescribed to you that you are to take prior to your procedure. These are usually an antibiotic and some medication for anxiety and mild discomfort.
You will be awake during the procedure and we hope you will talk with us because we have talked to each other all we want to and we would like to talk to someone new. If you go to sleep, we will awaken you and tell you what we are going to do next. Every patient will be monitored with cardiac, respiratory, blood pressure and pulse oximetry monitoring. Everyone is connected to these and the fact that you are connected to these is no indication that you have any unusual problem. This is just standard monitoring for everyone. If any of the side branches of the three main veins are not very large, then over three to nine months many of these side branches will no longer have a head of pressure to them and will become small and disappear or require no more than limited sclerotherapy injected through the skin into them. The larger tributary veins will take a long time to resolve even if they are going to resolve. There are very few people who desire to wait this long, but there are some insurance companies that will only pay for treating one of the three main veins first. If your insurance company is not going to pay for the large veins to be done, over a period of time they will become smaller and it will be much more economical to treat them because it will require fewer injections of foam sclerotherapy to finish the work.
You will need to wear support stockings for a period of time afterwards while any swelling of the leg is resolving and any residual veins are resolving.
After your procedure, you will usually be asked to walk and be active. Beginning after the procedure you will get up and walk at least five minutes each hour and then elevate your leg. The following day you can walk all you want to and return to work. We do not want you to do any high-impact workout and hard running because the resting blood flow that is usually 300 cc to 400 cc per minute into the leg can increase to 900 cc to 1200 cc per minute and with a high-impact workout many times higher than this. What goes into the leg must come out of the leg. We do not desire to have high flows that can cause any veins to reopen. We just desire normal to slightly increased flows.
Again, if you ever experience pain during the procedure, be sure and tell your physician and do not suffer in silence. Do not let your physician throw away any extra tumescent anesthesia that is left over when you need it. That is what it is mixed for—to keep you comfortable.
WHAT ARE POSSIBLE COMPLICATIONS?
Complications are rare but can happen. These include clotting in your deep veins or clots that can propagate and break loose and go to your heart and lungs. Therefore, one to seven days following your procedure you will undergo a followup venous duplex Doppler to be sure that you are not forming clots that should not be where they are so we can decrease the chance of anything happening by starting you on a temporary blood thinner.
WHAT IF I NEED MY VEINS LATER?
The great saphenous vein and occasionally a long anterior accessory saphenous vein and small saphenous vein may be used for coronary artery bypass. It is desirable to save all good, usable vein for use at a later date if needed. We will always try to save all veins possible.
Fortunately, as most of you know, the removal of the vein for a heart bypass rarely causes any problem except for some transient swelling for a few weeks and rarely for months and this usually resolves. These veins are not needed because all the blood flow will go up the deep venous system and not the superficial system under the skin that we obliterate.
WILL INSURANCE COVER MY PROCEDURE?
Each insurance company has different requirements of compression stockings, length of time you must wear them and documentation of how much your problems interfere with your activities of daily living and your work. Most insurance companies require that we see you one to three times during this period of time to document your compliance with your support stockings as required by your insurance company and the symptoms you continue to have.
Medicare is a separate situation and below is a list of the current guidelines. There are proposed new guidelines, but at this writing they have not been accepted; however, they are more reasonable than those currently in effect. Any changes in guidelines will be updated on this site as soon as we are notified.
Medicare is worse than other insurance companies as far as what they approve and what they do not. Usually with private insurance companies you go through pre-certification or pre-approval by sending them a copy of your supine and standing venous duplex and your history. Medicare does not pre-certify or pre-approve anything and do not want anything sent to them requesting pre-certification or pre-approval or special situation. Medicare has published that they will pay if you have recurrent thrombophlebitis in these superficial veins, two small spontaneous bleeds or one large bleed requiring hospitalization and a transfusion, an ulcer on your ankle that does not heal or recurs, or pain that is so severe that it shall mean the following:
1. You cannot do your shopping
2. You cannot shower
3. You cannot play with children
And it does list one other and that is
4. If you are currently employed and it is interfering with your ability to keep working.
Until October of 2014 Medicare can go back three years on a post-payment audit of a physician’s records and require that every penny be sent back, which leaves the physician with loss of money on the supplies, time, wear and tear on equipment which is a significant loss. Beginning in October of 2014, it is my understanding that this will be five years. You may be asked to sign a waiver that if they do this you will pay for the procedure out of your own pocket. It is my understanding that the people who do the post-payment audits get a certain percentage of whatever they can collect that was considered inappropriate use of medical dollars and that the money that they paid must be returned.
Medicare does not want a copy of your supine and standing venous duplex sent in and a request to approve this. They just say do the procedure and then if there is a post-payment audit they will decide if you met criteria.