Understanding Varicose Veins
       and Laser Ablation

G. Kimble Jett, M.D., P.A.


The Circulatory System

Arteries carry oxygenated blood to your legs and the veins carry de-oxygenated blood away from your legs. The blood
returns to the lungs to pick up more oxygen and returns to the heart to be pumped out again through the
arteries.

The venous system has two components. The first is the deep venous system. It lies below the muscles and transports
90% of the blood away from your legs. It is the system that can get blood clots, which may be life threatening if not
treated. It usually has nothing to do with your varicose
veins.

The second component is the superficial venous system. It transports approximately 10% of blood away from your
legs. You can get clots in this system that causes pain and discomfort (superficial phlebitis) but they are not life
threatening. The superficial system has everything to do with your varicose
veins.

Veins have one-way valves that open up
as the blood travels upward, and then close down tightly to prevent the blood from leaking back down. The deep and
superficial veins both have these valves.

When the deep system has faulty valves (the valves do not close tightly allowing the blood to leak back down) you will
develop profound and chronic swelling. When the superficial system has faulty valves you may develop varicose
veins.


Reflux


The condition that results from these leaky valves is known as reflux. When the blood is refluxing back down the legs
it puts excess pressure on the vein walls which causes them to expand. This expansion causes the valves to be even
more ineffective.

The Greater Saphenous Vein is the main tree of the superficial system. The varicose veins are like the branches of
the tree.

In order to treat the varicose veins effectively the entire greater saphenous vein must be treated. If we just removed
the branches the refluxing blood in the main tree would result in more varicose branches.

In rare cases you may have reflux in the greater saphenous vein that causes spider veins on the medial thigh, knee
and calf. But for the most part spider veins are unrelated to reflux in the saphenous vein, therefore insurance
companies consider their treatment cosmetic.




Can varicose veins cause significant medial problems?

When reflux is left untreated over many years, the constant pressure backup may cause a leaking of the blood into
the tissues. This leaking causes brown stains on the skin. This is known as stasis skin changes and can become
serious.

In cases where the stasis is severe a breakdown of the tissue may result in a chronic venous stasis ulcer. Venous
stasis ulcers are very difficult to treat and are chronic in nature with the ulcer reopening just when you thought it was
healed.

Because of this complication some insurance companies may consider it medically necessary to treat your varicose
veins.

Venous stasis ulcers do not occur in all patients with varicose veins. Unfortunately, we cannot definitively predict who
will go on to develop this complication. When skin changes begin to appear the likelihood of an ulcer increases.


Treatment Options for Varicose Veins

•        No treatment: Some patients opt not to treat their varicose veins. They may live their entire life with varicose
veins and never develop complications more serious than a chronic dull ache.

•        
Compression Hose: Compression hose aid in the treatment of varicose veins by helping to squeeze the blood
back out of the legs by means of an upward gradient compression. In many cases this will relieve discomfort.

•        
Ultrasound Guided Sclerotherapy: Under the guidance of ultrasound a needle is inserted into the greater
saphenous vein and a chemical is injected directly into the diseased vein. This chemical irritates the vein wall causing
it to collapse and scar down.

•      
 ** Endo Venous Ablation: A catheter is inserted into the greater saphenous vein at the level of the knee. This
is done using a large gauge needle, although sometimes a small incision may be needed to locate the vein.  A laser
fiber is then fed up the catheter into the proximal portion of the greater saphenous vein.  The laser fiber is slowly
withdrawn as it fires energy into the vein causing damage to the vein wall. This damage results in the greater
saphenous vein closing down.

•        Ambulatory Phlebectomy: After Endo Venous Laser Therapy has destroyed the proximal greater saphenous
vein the branches of the varicose veins are surgically removed. This is done through tiny incisions with an instrument
that resembles a crochet hook. The veins are hooked and pulled out of the leg. The incisions are closed with steri
strips.  No sutures are required. In most cases you can return to work the following day.

•        Ligation and stripping:  The traditional surgical method used to remove varicose veins. This procedure
involves numerous incisions requiring suturing and a prolonged recovery period.


What is the next step if I desire treatment?
As soon as you are ready to schedule your treatment, we will proceed. If you decide that you would like for our office
to submit a medical claim with your insurance before billing you, there are several steps which need to be followed.  
First, our office will contact your insurance company to confirm that your plan does not have any exclusions for
varicose vein coverage and to confirm that the treatment is a covered benefit. In addition, we will determine if
precertification, preauthorization, or medical predetermination is required.  Most plans do not require medical
predetermination; however, we encourage patients to allow us to submit for medical predetermination before
proceeding.  This process is to verify that your condition meets your insurance’s definition of “medically necessary”
which will allow for your insurance to cover the procedure as they would with any other in-office surgical procedure.  
Some plans will require the patient to pay an office visit co-pay while other plans may require a co-insurance amount.  
This can be determined by contacting your insurance company.






** Endo Venous Ablation Procedure


Prior to the laser procedure we will rescan your leg and take measurements of the vein.   We will outline the course of
the Greater Saphenous Vein with a marking pen.

Next we will clean your leg with an antibacterial solution and prepare a sterile field.  It is important to keep your hands
on your chest, under the drape. This will prevent you from contaminating the sterile field.


At this point we will insert the catheter at the level of the knee and feed it up to the groin.

We will inject more local anesthetic above the knee. This is done to eliminate pain when the laser is fired, as well as
compress the vein and thermally protect the surrounding nerves.

After the anesthesia has been given above the knee, we will insert the laser fiber into the catheter. This will be done
utilizing ultrasound to assure the proper positioning of the laser fiber prior to firing the laser.

A bright light will also be visible through the skin. This light is from the aiming beam, as the laser light is invisible.

To prevent any damage to the eye from the laser, we will put on safety goggles. The likelihood of damage to the eye
is almost non-existent. We would have to point the laser directly in your eye at close range to harm the eye.

We will then withdraw the laser slowly as it is being fired. You may experience an odd taste or smell during this part of
the procedure.

The greater saphenous vein will be injured by the laser energy resulting in closure.

After the laser is withdrawn we will cover the insertion site with a steri-strip and 4x4 gauze.  Over this, we will apply a
triple wrap. You are to wear the wrap for three days following the procedure.  After the wrap is removed, compression
hose will be worn for three weeks during the day.

Post operatively, you will have a significant amount of bruising, this is to be expected. We will prescribe an anti-
inflammatory medication to be taken for the first seven days.

To see a video concerning this procedure, click on the link below.

Laser Treatment Video




                                                    
Understanding Varicose Veins
and
Laser Ablation