For Medical Providers | The Vein Institute of Rochester

For Providers

Should I send my patients to the Vein Institute?

Venous insufficiency often goes undiagnosed. Many patients have underlying venous insufficiency without visible signs. If your patient suffers from any of the following symptoms, a consultation at The Vein Institute can help.

  • Dull aching or throbbing in the legs
  • Leg heaviness and fatigue
  • Restlessness
  • Swelling
  • Cramping and Charley horses

The following signs indicate more advanced stages of venous insufficiency. A consultation at The Vein Institute is the first step in developing a treatment plan for your patient.

Bulging Varicose Veins

bulging-varicose

* Results vary. The images displayed here do not constitute a promise or representation of any particular outcome.

Corona Phlebectatica

corona-phlebectatica

* Results vary. The images displayed here do not constitute a promise or representation of any particular outcome.

Atrophie Blanche

atrophie-blanche

* Results vary. The images displayed here do not constitute a promise or representation of any particular outcome.

Stasis Dermatitis

stasis-dermatitis

* Results vary. The images displayed here do not constitute a promise or representation of any particular outcome.

Lipodermatosclerosis

lipodermatosclerosis

* Results vary. The images displayed here do not constitute a promise or representation of any particular outcome.

Ulcers

ulcers

 * Results vary. The images displayed here do not constitute a promise or representation of any particular outcome.

Why The Vein Institute?

Vein stripping of the past has been replaced by office based procedures that require no sedation. Thanks to our minimally invasive techniques, your patient will be back to most normal activities the same day. Our Interventional Radiologists’ expertise in ultrasound guided procedures will ensure your patient gets the most accurate and thorough diagnosis and treatment.

We’ll handle every aspect of your patient’s vein care internally, from their first consultation through their final follow up. Most insurance plans do not require a formal physician referral. We obtain all necessary procedure authorizations. You’ll receive detailed reports after each appointment to stay informed of your patient’s progress.

venous-ulcer-treatment-progression-full

* Results vary. The images displayed here do not constitute a promise or representation of any particular outcome.

What is EVLT treatment?

Throughout the centuries, major open surgical treatments have given way to the latest, state-of-the-art minimally invasive approaches. Previously, the only treatment option available for venous insufficiency was a major surgery called vein stripping, an invasive procedure with a long recovery that tended to fail after a few years. A new treatment has been developed by interventional radiologists, doctors who are experts in ultrasound imaging and specialize in minimally invasive treatments.

EndoVenous Laser Ablation Therapy (EVLT) is an outpatient procedure performed using ultrasound imaging guidance. Instead of pulling the vein out as was done in vein stripping, the problematic vein is heat sealed shut from the inside using a laser tip, all through an opening in the skin not much larger than needed for a typical IV. After administering local anesthetic to the area and getting venous access, the interventional radiologist inserts a catheter into the vein and uses ultrasound to expertly guide it up the vein in the leg to a precise location.

After numbing the area around the vein, laser energy is applied to the inside of the vein, heating the vein and sealing it closed. Once the diseased veins are closed, the blood is rerouted to normal, healthy deep veins and the pain and symptoms start to disappear.

EVLT takes roughly 45 minutes and is performed as an outpatient procedure using local anesthesia. It involves minimal pain, no scarring, quick recovery and immediate return to normal activity.

Benefits of Vein Ablation Treatment

  • Minimally invasive– no surgical incision, no visible scars
  • High success rate and low recurrence compared to surgery- success rate for vein ablation ranges from 93-99%
  • Extremely safe with very low complication rate
  • Minimal recovery time– patients are encouraged to walk and resume most normal activities the same day
  • Covered by nearly all insurance plans
  • Takes less than an hour
  • Performed in a comfortable outpatient office setting
  • No general anesthesia or sedation required for most patients

What are the possible complications of EVLT?

Complications are rare, but can occur even when the procedure is technically successful. Such complications include severe bruising, prolonged redness and/or tenderness around the puncture sites or over the treated vein, infection of the puncture site (thrombophlebitis), clots extending into the important deep veins (deep vein thrombosis), numbness and paresthesias, and burning of the skin.

What is Ultrasound Guided Foam Sclerotherapy treatment?

Ultrasound-guided sclerotherapy is a technique for closing troublesome incompetent refluxing veins and varicosities.

With this treatment, a chemical irritant called a sclerosant is injected into the vein to be treated, rather than heating it closed. It causes the inner lining of the targeted vein to become irritated, closing the vein.

This is needed in situations where the veins are too close to the skin to be heat sealed (risk of burn), too tortuous (many turns and bends), or too numerous for a single laser treatment to be successful.

ultrasound-guided-sclerotherapy

ultrasound-guided-sclerotherapy-2

What is the difference between deep veins and superficial veins?

There are two sets of veins in the legs. The important veins located within the leg muscles called deep veins carry nearly all the venous return to the heart.

The main deep veins in the leg include the common femoral vein, the femoral vein, the profunda femoris vein, the popliteal vein, and the calf veins. For the blood to travel up to the heart against gravity, the blood is squeezed forward with muscle contractions, while one-way valves help prevent retrograde flow.

As these deep veins return nearly all the blood from the lower extremities, a clot in the deep venous system called a deep vein thrombosis (DVT) usually causes pain and swelling in the leg, especially if the thrombus is at or above the knee. This is also worrisome as it can propagate secondary to stasis, break off and travel to the lungs causing a pulmonary embolus (PE), or cause chronic leg issues like post-thrombotic syndrome. In severe cases, circulation of the legs can be compromised.

In contrast, the second set of veins are called superficial veins, so named because they are closer to the skin in the subcutaneous tissue. Because of their superficial location outside of the musculature, there is minimal assistance from muscle contraction in moving blood upwards against gravity. Rather, the superficial veins rely mainly on their one-way valves to return the blood.

The two main superficial veins in the leg are the great saphenous vein (GSV) coursing medially up the calf and thigh to the groin, where it confluences with the common femoral vein of the deep system, as well as the small saphenous vein (SSV) located in the posterior calf, where it typically dumps blood into the popliteal vein of the deep system.

There are other veins in the leg called perforator veins, which connect the deep and superficial venous systems. Also, intersaphenous veins connect the GSV and the SSV and can play an important role in hemodynamic flow.

What is chronic superficial venous insufficiency and why does it cause varicose veins?

Chronic superficial venous insufficiency is the disease process which causes varicose veins. Blood returning via the superficial veins have an uphill battle, literally. As they rely almost entirely on these one-way valves to help return blood to the heart against gravity, one could imagine what the consequences of valve failure might be.

When that blood refluxes down the superficial vein in the wrong direction, it pools in the lowest, most dependent veins and engorges and dilates them. For many people, these enlarged, swollen veins bulge out of the skin and are known as varicose veins and are a direct result of increased pressure from reflux. For others, the dilated veins are in the subcutaneous tissue (not visible on the skin surface) or manifest in other ways, like skin discoloration from poor skin circulation (stasis dermatitis) or purplish discoloration of the ankle with numerous tiny veins (corona phlebectatica).

Regardless of whether or not there is an outward manifestation of these dilated, engorged veins in the leg, symptoms nearly always accompany these incompetent veins. The symptoms are generally the body’s reaction to blood stasis in these veins, and includes classic dull/aching pain, tired and heavy legs at the end of the day, restlessness and cramping/charley horses at night, and ankle swelling.

Normal vs Incompetent Vein Valves with Reflux

Normal vein valves on the left versus incompetent valves with reflux on the right.

Normal vs Malfunctioning Valves

What is the difference between varicose veins and spider veins?

Varicose veins are the outward manifestation of blood pooling in the legs secondary to reflux and valve incompetence. They are described as abnormal veins on the skin surface >3 mm in diameter.

As their presence is a harbinger of underlying disease, their treatment is considered medically necessary if they cause symptoms, and therefore it is generally covered by insurance.

Conversely, spider veins are tiny veins on the skin surface measuring <1 mm in diameter. Spider veins are not necessarily a sign of underlying superficial vein disease and therefore they are considered cosmetic in terms of treatment.

Difference between Spider and varicose veins

* Results vary. The images displayed here do not constitute a promise or representation of any particular outcome.

Difference between spider veins and varicose veins.

What are the risk factors for chronic superficial venous insufficiency/varicose veins?

The biggest risk factors include family history and pregnancy. Genetics is a primary cause, and it has been suggested that if both parents have CVI, their children have a 90% chance of having CVI at some point. If one parent has CVI, then women have ~60% chance and men a 25% chance of having it. If neither parent has it, then both men and women have a 20% chance.

Pregnancy is a key factor contributing to the formation of varicose and spider veins. The most important factor is circulating hormones that weaken vein walls.

There is also a significant increase in the blood volume during pregnancy, which tends to distend veins. This causes valve dysfunction which leads to blood pooling in the veins. Varicose veins that form during pregnancy may spontaneously improve or even disappear a few months after delivery.

Other risk factors include standing or sitting for long periods of time during the day (especially fields such as nursing, teaching, hairdressing, or factory jobs), advancing age, prior injury or surgery in the legs, and obesity.

Risk Factors for Varicose Veins

  • Family history/genetics
  • Pregnancy, especially multiple pregnancies
  • Older age
  • Female gender
  • Prior surgery or trauma

What are the signs and symptoms of chronic superficial venous insufficiency/varicose veins?

The main symptoms of venous insufficiency are generally vague and overlap with symptoms of other diseases, making diagnosis very challenging without the telltale sign of bulging varicose veins.

Compounding this is the fact that much understanding of superficial veins has come from recent advances in ultrasound, so many physicians out in practice do not have much exposure to this new information.

Classic symptoms include a dull/aching pain that is generally annoying but “in the background”, and typically worsens during the day as gravity takes its toll. Leg heaviness and fatigue also top the list of symptoms that patients complain about. Ankle swelling, usually symmetric and bilateral in patients with no prior heart disease, is a common sign. Patients will also complain of itching and heat with a “prickly” feeling.

Finally, many patients will experience cramping or Charley horses, especially at night, as well as restlessness that manifests as patients constantly moving their legs around in bed and propping pillows between their legs.

The last symptom, restlessness, is an interesting topic as many questions arise distinguishing this from restless leg syndrome. While still controversial, our experience at The Vein Institute and some recent literature suggest that while restless leg syndrome definitely has a neurological component for many, varicose veins can definitely cause a restless feeling as well.

We know this because nearly all of our patients who describe restlessness as a symptom describe complete relief following treatment. Therefore, it is unclear as to whether restlessness is a separate symptom that is seen in restless leg syndrome and chronic superficial venous insufficiency, or if restless leg syndrome actually has two separate etiologies.

Either way, our experience is that patients who have restless legs and chronic venous insufficiency who undergo treatment typically have a resolution of their symptoms.

Varicose Vein Symptoms and Signs

Symptoms of varicose veins are very vague and nonspecific, which makes diagnosing patients who do not have bulging veins so hard. Many patients have varicose vein symptoms but it’s difficult to determine exactly how many since they remain undiagnosed. Varicose veins are almost always genetic (mom, dad, and/or grandma had it whether they knew it or not). For most women, varicose veins are triggered by pregnancy. For men, prior trauma or surgery could be instigating factors. For many, the time and cause of onset are not known.

The patients who are most difficult to diagnose have one or more varicose vein symptoms, often severe, but have no visible bulging varicose veins. Patients do not need to have bulging varicose veins to have the underlying disease (chronic venous insufficiency) or experience the symptoms. We can readily see those abnormal veins underneath the skin with a quick and easy ultrasound exam.

Here are the classic symptoms (what patients subjectively feel or see) and signs (what doctors see objectively and observe during an examination).

Dull, throbbing, aching, or pain in the legs

Especially felt at the end of the day – who doesn’t this describe as you get older? People classically describe this as a background annoying pain, pressure, or cramping/tingling-type feeling that is tolerable during the day/at work when you’re busy as you don’t think about it but is really felt at the end of the day when you get home and relax. It can become quite debilitating.

Leg heaviness

Again progressive throughout the day, but really pronounced if you are stationary, such as a movie or a long flight; patients with a strong condition say it feels like they have “lead” in their shoes or socks.

Tired legs/leg fatigue

Always feeling like your legs are tired and lethargic, which again describes many people.

Swelling

Progressive swelling as the day goes on, usually at the foot and ankle level, telling as it usually leaves a “sock line.” Swelling can happen for many other reasons, but younger patients and/or patients who have no history of heart disease or other causative factors should get an appointment to see if chronic venous insufficiency can be ruled out.

Itching

The superficial veins which cause chronic venous insufficiency help drain the skin of the leg. When this circulation is poor due to incompetent veins, the skins can become very dry and scaly, especially in the shin, calf, and ankle regions. Many patients claim to use up to one bottle of lotion per day to constantly keep their legs from being so dry. Obviously, many dermatologic issues can present in the same way.

Burning sensation over legs/prickly feeling

People have trouble describing this, but relate a heat or burning feeling or feeling of “creepy crawlers” underneath the skin of the leg, oftentimes near a bulging varicose vein.

Restless legs

Traditionally, this has been thought of as a neurological issue; however, many patients with chronic venous insufficiency/varicose veins relate symptoms of restless legs as well – this manifests as a constant need to move or shake your legs, especially at night. People also describe that they “just can’t get their legs comfortable” in any position, so they constantly shift their legs, put a pillow between their legs, or elevate their legs on a pillow.

Charley horses or leg cramping

Similar to restless legs at night, many people with varicose veins relate waking up in the middle of the nights with severe cramps or Charlie horses, for which they usually jump out of bed and have a ritual to stop the pain and cramping.

Easy bruising

Constantly get bruises over the legs, usually from minimal injuries or bumps, which tend to last a lot longer than other bumps or bruises on the body.

Skin darkening and/or hardening

Usually over the shin and calf region, this starts as darker spots and progresses to a reddish brown skin discoloration, oftentimes accompanied by a hardening of the skin in the same region.

Bleeding varicose vein

Classically, women will relate shaving the leg over a small bulging vein and then see severe bleeding; men will also describe excessive bleeding after a small bump and scrape over a bulging vein; although still only veins, varicose veins that bleed are under pressure and can take significant time and pressure to ultimately stop.

Skin breakdown/ulcer

This is one of the worst complications, usually occurring after decades of poor venous skin circulation from venous insufficiency and usually after many of the previous signs and symptoms. This refers to an open wound or sore in the leg; the varicose vein causing this is almost always underneath the skin and the ulcer. These can be difficult to treat given that wound care and covering it only treats the problem superficially – patients need to have the underlying vein problem treated to actually have this symptom cured.

Signs of chronic superficial venous insufficiency include the obvious hallmark of bulging varicose veins. In addition, ankle swelling which is not secondary to heart or kidney disease is common. Corona phlebectatica is a chronic manifestation that includes purplish discoloration of the ankle with numerous tiny bulging or spider veins. Skin discoloration/darkening in the dependent gaiter region is called stasis dermatitis and is a sign of longstanding disease. When severe, lipodermatosclerosis can occur, which is a hardening of the skin secondary to inflammation of the fat under the epidermis. These patients have a tapering of their legs above the ankles, forming a constricting band resembling an inverted champagne bottle. Finally, venous stasis ulcers are the dreaded consequence, and they may be confused with ulcers from other etiologies.

Various photos of multiple presentations of varicose veins

* Results vary. The images displayed here do not constitute a promise or representation of any particular outcome.

Various photos of multiple presentations of varicose veins.


Stasis dermatitis

* Results vary. The images displayed here do not constitute a promise or representation of any particular outcome.

Stasis dermatitis showing skin darkening secondary to poor skin vein circulation. (above & below)

More Stasis dermatitis

* Results vary. The images displayed here do not constitute a promise or representation of any particular outcome.

Severe stasis dermatitis

* Results vary. The images displayed here do not constitute a promise or representation of any particular outcome.

Severe stasis dermatitis with inflammation, maceration, and early ulceration.


Venous stasis ulcers

* Results vary. The images displayed here do not constitute a promise or representation of any particular outcome.

Venous stasis ulcers classic of severe chronic superficial venous insufficiency.

Do varicose veins need to be present to have symptoms?

No. The best analogy is to think of it like the tip of an iceberg showing above the water, but hiding a substantial presence below the surface that is not visible.

Varicose veins are only a small part of chronic superficial venous insufficiency that can be seen on the surface. In order for that to occur, blood must engorge veins just below the surface.

For some people, the dilated veins bulge at the skin surface. For others, the veins are simply under the skin and cannot be seen.

In our experience at The Vein Institute, patients who have varicose veins have one advantage in that they have a clear sign of the disease process, as opposed to those without bulging veins who sometimes wait years and see multiple doctors without a diagnosis for these relatively vague symptoms.

What are spider veins?

Spider veins are abnormally dilated veins that can be seen on the skin surface. Spider veins (also known as telangiectasia, thread veins, or broken veins) are the smallest or mildest form of abnormal veins and are classically blue, purple, or red in color.

By definition, they are up to 1 millimeter in diameter. Their fine branching pattern can look like lines, tree branches, or spider webs (hence their name).

They are almost always found on the legs or the face and can cover either a very small or very large area of skin. They can be asymptomatic and simply a cosmetic issue, but sometimes present with venous insufficiency symptoms such as pain, heaviness, swelling, and restlessness in the legs. Flow abnormalities in veins 1-3 mm in diameter, called reticular veins, can lead to the development of spider veins and are a critical consideration in spider vein treatment.

Conversely, varicose veins are simply the larger version of these abnormally dilated veins, measuring >3mm. They often look like cords and appear twisted and bulging. They can be swollen and raised above the surface of the skin.

Varicose veins are often found on the thighs, backs of the calves, or the inside of the leg. Varicose veins are generally a sign of more serious underlying venous disease and associated with symptoms.

spider vein vs reticular

* Results vary. The images displayed here do not constitute a promise or representation of any particular outcome.