John W. Hovorka, MD

If infection is controlled, Complete Decongestive Therapy (CDT) is the least invasive treatment. CDT is the safe, effective use of manual techniques and bandaging to control swelling and edema. If you are highly motivated to learn about these techniques, look for a Certified Lymphatic Therapist (CLT). The National Lymphadema Network (NLN) and Lymphatic Association of North America are good places to start. These techniques have only been introduced to the United States recently. Although very few Physicians and Therapists have this type of experience, we have successfully treated back seromas following complex spine fusion surgery for Scoliosis and following Thoracotomy.

It is important to be appropriately classified so both the patient and the physician know what to expect.  I would suggest that you go back to your physician or vascular surgeon and review what is causing these small veins to appear.  The most common problem is the presence of "the feeder vein."  Small nose and face veins are what doctors call telangiectasias (the doctor word for small veins).  They are often "fed" by other veins that might not be under the surface.  Surgeons must always go for the feeder vein first.  There are three signs of a feeder vein.  The decompression test (rapid refill when one presses on it).  Another is visualization (seeing it).  This is aided (helped) with transillumination (a bright light and now the VeinViewer).  The last test to suggest a feeder vein is treatment failure which you are now experiencing. 

Cryo Laser and Cryo Sclerotherpy (CLaCS) is a specific method and technique designed and taught by Clinica Miyake to deal not only with leg veins but also veins elsewhere on th body including the face.  There is a specific classification scale (9 to 1) used to help clinicians and patients not only manage expectations but to guide treatment for lower extremity veins (veins on the legs).  For the face no such scale exists although the principle three tests mentioned above still apply. 

There are many accepted methods of dealing with facial telangiectasias and they range from using intense pulsed light (IPL) laser, radiofrequency and chemical ablation (sclerotherapy). 

It is important to realize that telangiectasias are classified as Clinical Class 1 of chronic venous disease.  Chronic Venous Disease is just that, a chronic condition.  If you do have some "feeder veins" that are causing the problem to recur even with CLaCS a series of staged treatments generally about two weeks apart are recommended.  In order to get rid of the veins in "one shot" more aggressive treatments are necessary which also increases the risk of adverse (bad) effects to the patient. 

You probably have problems that are deeper than just varicose veins.   There are different types of deep venous obstruction and deep venous obstruction is not treated by EVLT. 

LONG ANSWER:  EVLT works for veins that are bad in certain superficial Saphenous Veins.  An ultrasound ordered by a board certified vascular surgeon would be able to determine this.   As your vascular surgeon's ultrasound examination was "normal" your vascular surgeon knows that although the superficial veins are aching and painful, they won't just get better with EVLT or other simple procedures.  Your vascular surgeon also knows from this initial ultrasound that your deep veins are not completely blocked either. 

Venous Obstruction:  There are two types of venous obstruction.  Venous obstruction can either be completely blocked or not completely blocked.  The physician terminology is Occlusive or NON-occlusive venous obstruction.  As your ultrasound was "normal" you don't have occlusive venous disease.  Non-occlusive venous occlusion is generally painful. 

RECAP VENOUS OBSTRUCTION:

Deep venous occlusion:  A duplex ultrasound can generally tell if your deep veins are occluded (completely blocked).  Think of it like a helicopter sent up to see why traffic is being held up for miles.  If a bridge collapses it is obvious and the helicopter can report back to the newscaster (in this case your vascular surgeon) a certain bridge is out and this needs to be rebuilt or bypass road needs to be built.

Deep venous NON-occlusive obstruction:  Even if there is not a "bridge out" traffic can still get backed up for miles.  Only one single lane out due to a minor fender-bender can do this.  On the other hand it might be just increase in traffic around one or two corners in front of and behind a mountain at a certain times of day.  It can also be combination of both.  Endovenous stenting works because it is like adding the few lanes here and there to keep traffic from being backed up for miles. 

Q:  How does my vascular surgeon tell if I have the NON-occlusive type of venous obstruction and if so what to do about it? 

A:  Although NON-occlusive venous obstruction is common the testing is very extensive so the first test is to gauge your pain.  Your vascular surgeon needs to know your pain is chronic and won't just get better on its own (like clearing up a fender bender in the above example).   If pain your pain is bad enough to go back and sit in the waiting room all day again that is the first test to suspect significant non-occlusive venous obstruction. 

Treatment for NON-occlusive venous obstruction involves Conservative Management (which you are doing with the compression stockings and leg elevation) and surgical treatment such as endovenous angioplasty and stent placement for Quality of Life issues.  The evidence based medicine recommendation by the American Venous Forum Handbook of Venous Disorders 3rd edition is Class 1A . This is the highest recommendation given by this group.

Traffic Analogy:  Unless you had multiple helicopters in the air all the time it is difficult to tell where to expand the road, you won't look into it unless people are complaining.

Orthostatic Pain:  This means pain in your legs when you are standing up but not when you are lying down.

Visual Analogue Scale (VAS):  This scale ranges from 0 no pain, to 10 the worst possible pain.  For orthostatic pain we are interested in the last four weeks.   Rate your pain in the right leg and the left leg.  Usually endovenous stenting is considered when the pain is 5 or more, although some patients will qualify with less pain.

Quality of Life:  What we mean are certain patient surveys that have been validated (that means checked out and that they are valid).  Copies of these surveys are available for your physician at the end of the American Venous Forum Handbook of Venous Disorders 3rd edition (these are not available in the online edition).

Venous angioplasty and stenting of patients with orthostatic pain is reserved for those that want relief of their symptoms which are pain and swelling.  EVLT may be indicated at the same time as the angioplasty and stent placement due to the changes in the "traffic flow" brought out by the stent placement.  The veins bulging out of the skin can also be removed at the same time.

Unfortunately, the testing involved at this time to decide whom to treat is so involved that very few centers around the country are actually offering this type of very involved testing to treat NON-occlusive venous obstruction. 

Peter Neglen, MD, PhD has been charged with coming up with a dedicated venous stent.  He and Dr. Seshadri Raju, MD (president-elect of the American Venous Forum) are recognized world-wide as the foremost experts in this type of problem and their office is Flowood, Mississippi (a suburb of Jackson).  An evaluation there will require additional ultrasound testing as well as testing involving needles in your arms legs and feet and even a dye test of your veins.  If you qualify for a procedure you should plan to stay for at least a week.  An endovenous stent is a stainless steel device (much like a spring) that is permanently implanted and guided by IntraVascular UltraSound IVUS.  Generally more than one stent is required to be placed at the same time.  These stents have been followed for more than 10 years and this long-term data for relief of pain and swelling from Dr's Raju and Neglen is excellent. 

This particular problem although common is generally not mentioned precisely because no single good test exists for it.  All of the extensive testing and follow-up that is tough on both the patient and the vascular surgeon/ vascular lab to swallow. 

How would you feel if you had all kinds of tests and needles, then found out you actually were NOT a candidate for an endovenous stent?

Wearing stockings and waiting another few years to see if the testing for the endovenous angioplasty and stenting for non-occlusive iliac venous obstruction gets simpler is certainly a very prudent option.  Even office and outpatient clinics such as ours are beginning to develop the infrastructure to offer the testing required.  Until there is patient demand most vascular labs simply cannot justify the cost.

If your VAS score is 5 or more go BACK to your local vascular surgeons office and ask for your Quality of Life survey (be ready to tell the office staff where to find it in the book referenced above).  Then ask your local vascular surgeon when extensive testing based on Dr. Neglen's vascular lab may be available.  Remember that endovenous stent placement is based upon Quality of Life and is being pushed by the patient demand not by the medical device industry. 

However, if you just can't take it any more in 2010, and can afford to take off at least a week and travel to Flowood/Jackson, Mississippi an endovenous stent might just put that SPRING back in your step.

Spider veins are generally described in "doctor words" as telangiectasias. They can be "red" or "blue." In the United States as well as most other countries telangiectasias are considered NOT medically necessary or cosmetic and therefore treatment of these as well as the "reticular" or feeding veins are usually not covered. It is possible that you could have other signs or symptoms of a deeper more serious problem. For a more detailed answer about what IS medically necessary and therefore covered by insurance read on.

Telangiectasias or "spider veins" can be a sign to ask or investigate symptoms further. The most important thing is to be appropriately classified if you are having any symptoms or problems. Symptoms that are considered to be related and a "reimbursible" reason to visit a vascular surgeon or phlebologist that treats varicose veins are available on the Centers for Medicare Services (CMS or you local intermediaries website as Medicare contracts with other companies based on the area that services are provided in or where you live). In summary they are generally:

Swelling, Itching, Burning, Cramping, Restlessness. Other symtoms include ulceration, spontaneous hemorrhage or recurrent phlebitis.

If they are affecting your daily activities and/or quality of life you do need to see a qualified physician whom could be your family physician and/or a phlebologist or vascular surgeon.

There are many types of high quality compression stockings available and compliance with compression stockings is a requirement for most insurance to pay for a treatment (such as the injections that you had before). The testing as well as the non-operative medical management (office visits) will generally be covered by insurance. The stockings themselves with proper documentation may be paid for by insurance although this requires diligence and usually requres that you have a prescription be appropriately fitted and go through an accredited durable medical equipment company (DME).

Dear Shaza,

In phlebology (the study of veins) we typically follow a classification scheme to determine at what level your vein disease is. We do this by conducting a series of examinations including history and physical. We use our eyes, digital palpation, as well as duplex/ultrasound and other non-invasive maneuvers (sometimes even invasive testing) to determine what kind of veins they are and how serious your problem may be.

Symptoms of varicose veins include heaviness, aching, swelling, itching, burning and restlessness.

Some patients will receive some relief from high quality compression stockings. In the 21st century there are many brands, although it is most important that they be appropriately fitted. For a young woman usually 30-40 mmHg compression stockings would be necessary although some patients prefer 20-30 mmHg compression even if they need a waist or thigh high with a 20-30 mmHg knee high on top of it. Medication that helps with the symptoms primarily includes non-steroidal antiinflammatory drugs (NSAIDS) the most common of which is Motrin/Advil the generic name is Ibuprofen and it is an over the counter medication.

It is most important to be appropriately classified to know what treatment is best for you. Ultrasound can let us know if there is saphenous vein reflux. If present this may be taken care of by means of some type of surgery or minimally invasive corrective or ablative procedure such as laser or radiofrequency. Even if there is no significant reflux and your veins refill quickly they may have "feeder veins" that need to be addressed by a vascular surgeon or phlebologist.

Resources for finding a vein specialist are: American Board of Phlebology www.americanboardofphlebology.org The American College of Phlebology has links to physicians as well (www.phlebology.org).