Vascular Topics

Venous disorders include varicose veins, spider veins, venous ulcers, and other complications such as edema, ankle inflammatory disoders and thrombosis (vein clots). I specialize in state-of-the-art ultrasound evaluation of the deep and superficial veins. In conjunction with a full history and physical examination, I customize treatment for the individual patient. Treatment options include sclerotherapy for the treatment of spider veins and small and medium size varicosities. Larger varicosities are best treated by a combination of stab avulsion phlebectomy, invaginated saphenectomy and now radiofrequency (RF) ablation (Closure) and Laser ablation. These procedures are specialized microsurgical techniques that result in complete elimination of the varicosities with excellent cosmetic results and little or no scarring. All these procedures are be performed in the office under local anesthetics on a walk-in/walk-out basis. Advanced disease is often complicated by stasis dermatitis of the ankles, celluitis, ulcerations, and thrombosis (clots). These may require the use of all surgical techniques along with medical management. Medical management options include anti-coagulant, anti-inflamatory, and analgesic drugs as well as specialized compression bandages and stockings. The new endolumnal treatment options (Closure and Laser ablation) are highly effective and compare favorably to invaginated stripping. These procedures are used on the larger varicose veins, in particular the saphenous veins and tributaries. Insurance coverage is based on documentation of medical necessity recorded on the history and physical examination and ultrasound findings. Our staff will communicate with your insurance and provide them with all documentation necessary in order to facilitate determination of benefits and coverage.

The spider veins and small varicosities are treated using sclerotherapy. The treatment sessions vary in length depending on the size of the areas to be treated. it is not unusual to perform multiple sessions over several weeks. Sodium tetradecyl (Sotradecol) in varying concentrations or a 2:1 mixture of glycerine and lidocaine with epinephrine are used for optimum results and minimum side effects and complications. Although painful, almost all patients tolerate the procedure. We typically inject 0.1 to 0.2 ml of solution at a time using the smallest needles possible (32g). Pain is common during the procedure and can last for a few hours or up to a few days after treatment. However, most patients describe the pain as mild and does not require more than a few analgesic tablets for pain relief. Compression is required after the treatment and is provided by means of class 2 support stockings. Normal physical activities are not restricted and exercising can be resumed after a day. It is recommended that the patients wear the stockings daily throughout the scheduled sessions and for several weeks afterward. Besides pain, there can be bruising and dark pigmentation of the treated veins. These will gradually resolve over time. Clearing of the treated spider veins can continue for up to 12 months. However, new varicosities can develop in the interim, which is why we recommend periodic reevaluation and retreatment.

This procedure refers to the surgical extraction of the great saphenous vein (GSV) and/or short saphenous vein (SSV). We use ultrasound to assess the integrity of the valves, and/or presence of thrombus (clots). The short saphenous vein begins in the back of the ankle and foot and extends up the back of the leg and calf between the skin and calf muscles before connecting with the deep popliteal vein at the knee. When the valves within the segment become incompetent, patients develop progressively worsening systems and complications including large and bulging varicosities, edema, leg pain, leg fatigue, ankle discoloration, dermatitis, cellulitis, thrombosis, and ulcerations. The procedure is performed by ligating and dividing the juncture of the short saphenous vein with the deep popliteal vein through a small incision behind the knee. With a special instrument, the SSV is canalized and then the vein is inverted and pulled out through a small 3 mm incision at the ankle. Corresponding varicose branches are removed using the stab avulsion technique. Once removed, these varicosities do not recur. This procedure is always performed in the office under local anesthetic of lidocaine with epinephrine. Patients are fully ambulatory after the procedure and even allowed to drive. Procedure time is approximately 30 minutes to an hour, depending on the number of branch varicosities. Post-operative pain is described as mild or non-existent by patients. limited duration side-effects include bruising and ankle swelling. Routine activities are not restricted and exercise is allowed after seven to ten days. The great saphenous vein (GSV) originates over the medial surface of the ankle and runs upwards between the skin and muscles eventually terminating at the groin where it joins the deep common femoral vein (CFV). There are multiple short and long branches several of which also terminate at the juncture with the common femoral vein. In order to prevent recurrence and reduce the development of new varicosities, it is necessary to remove not only the diseased great saphenous vein but also the diseased long and short branches. This surgical technique is similar to that described above except that the great saphenous vein is divided and ligated at the groin through a small incision. It is turned inside out (invaginated) and pulled out through a 3 mm incision at or below the knee. All other varicose branches are removed using the stab avulsion technique. Relief of symptoms from incompetency of these veins is often described by patients as occurring immediately. Because the disease in this instance is usually more advanced, the procedure is typically performed as an outpatient procedure at a surgical center or hospital. However, in appropriate patients, we will perform the procedure in the office under a local anesthetic of lidocaine and epinephrine. In either case, normal activities are not restricted. Exercise is allowed after 7 days. Scarring is minimal to none. Side effects also include bruising and small hematomas and ankle edema which resolve within a short period of time. When performed in the office, there are no preprocedure requirements or restrictions, and patients are fully ambulatory after the procedure.

This procedure refers to the surgical extraction of the great saphenous vein (GSV) and/or short saphenous vein (SSV). We use ultrasound to assess the integrity of the valves, and/or presence of thrombus (clots). The short saphenous vein begins in the back of the ankle and foot and extends up the back of the leg and calf between the skin and calf muscles before connecting with the deep popliteal vein at the knee. When the valves within the segment become incompetent, patients develop progressively worsening systems and complications including large and bulging varicosities, edema, leg pain, leg fatigue, ankle discoloration, dermatitis, cellulitis, thrombosis, and ulcerations. The procedure is performed by ligating and dividing the juncture of the short saphenous vein with the deep popliteal vein through a small incision behind the knee. With a special instrument, the SSV is canalized and then the vein is inverted and pulled out through a small 3 mm incision at the ankle. Corresponding varicose branches are removed using the stab avulsion technique. Once removed, these varicosities do not recur. This procedure is always performed in the office under local anesthetic of lidocaine with epinephrine. Patients are fully ambulatory after the procedure and even allowed to drive. Procedure time is approximately 30 minutes to an hour, depending on the number of branch varicosities. Post-operative pain is described as mild or non-existent by patients. limited duration side-effects include bruising and ankle swelling. Routine activities are not restricted and exercise is allowed after seven to ten days. The great saphenous vein (GSV) originates over the medial surface of the ankle and runs upwards between the skin and muscles eventually terminating at the groin where it joins the deep common femoral vein (CFV). There are multiple short and long branches several of which also terminate at the juncture with the common femoral vein. In order to prevent recurrence and reduce the development of new varicosities, it is necessary to remove not only the diseased great saphenous vein but also the diseased long and short branches. This surgical technique is similar to that described above except that the great saphenous vein is divided and ligated at the groin through a small incision. It is turned inside out (invaginated) and pulled out through a 3 mm incision at or below the knee. All other varicose branches are removed using the stab avulsion technique. Relief of symptoms from incompetency of these veins is often described by patients as occurring immediately. Because the disease in this instance is usually more advanced, the procedure is typically performed as an outpatient procedure at a surgical center or hospital. However, in appropriate patients, we will perform the procedure in the office under a local anesthetic of lidocaine and epinephrine. In either case, normal activities are not restricted. Exercise is allowed after 7 days. Scarring is minimal to none. Side effects also include bruising and small hematomas and ankle edema which resolve within a short period of time. When performed in the office, there are no preprocedure requirements or restrictions, and patients are fully ambulatory after the procedure.

Changes in insurance policy allow us to offer these techniques for the treatment of an incompetent Saphenous Vein (Great Saphenous, Short Saphenous, Tributaries and perforators) associated with varicose veins. Currently, Medicare and almost all other insurance companies cover the procedure. The GSV is the largest and longest of the superficial veins and lies within a sheath in the fatty layer between the skin and the muscles of the thigh and leg. It originates from branches of the foot and medial aspect of the ankle and terminates at the common femoral vein in the groin (the saphenofemoral juncture-SFJ). Large tributary varicosities on the anterior and medial surface of the leg connect with the GSV. The dysfunctional valves within the GSV create dilatation and subsequent varicosities of the branches. The GSV will cause congestion of the veins and tissues resulting in symptoms that will prompt patients to seek medical advice. Ultrasound scans of the GSV are usually necessary to diagnose the incompetent GSV. Incompetence causes the blood within the GSV to flow backwards, stagnate and eventually to clot (thrombophlebitis). Early symptoms include swelling, leg fatigue, throbbing pain, restless legs and cramps at night. Advanced symptoms include bulging varicose veins, painful varicose veins, ankle pigmentation, dermatitis, cellulites, subcutaneous sclerosis, ulcers and thrombophlebitis. Incompetence of the short saphenous vein will cause almost similar symptoms.

The goal is to obliterate the saphenous vein or tributary at the highest point of valvular reflux which is usually at its respective juncture with the deep veins. The techniques ablate the veins by the heat generated at the tips of the radiofrequency (RF) catheters or Laser fibers.

The procedure is performed in an outpatient surgical suite in the office. Anesthesia is local lidocaine with light sedation. This allows the patient to be awake and able to ambulate after the procedure. A sterile field is established to include the extremity and surrounding area. A small spot on the lower leg or ankle is anesthesized with lidocaine in order to introduce the catheter into the saphenous vein. The catheter tip is advanced to the juncture, the groin for the long saphenous vein or behind the knee for the short saphenous vein. There is little sensation of pain as the catheter is advanced through the vein. Additional lidocaine is injected along the entire length of the saphenous vein to concentrate the heat on the inner walls of the vein and prevent pain and damage to adjacent tissues. The catheter is slowly withdrawn from the vein while heating the vein walls. The ultrasound is used throughout the procedure: it allows us to accurately place the tips of the catheter at the juncture and follows the catheter as it is withdrawn. Varicose branches are next removed using the stab avulsion method. Bandages are applied and the patient is allowed to ambulate.