by John R. Pletnicks, M.D.
Posted by: Ron Kennedy, M.D., Santa Rosa, CA
The venous system is a network of muscular tubes. It collects blood which has been pumped through the capillaries into the smallest of veins (which are called venules). The venous system of veins delivers blood back to heart. The design of this network is such that a blockage, even multiple blockages, cannot obstruct the flow of blood back to the heart. If there is a blockage, blood will find another route to its destination. There are so many other routes that single obstructions are simply no problem. This fact allows for the possibility of surgical repair of the venous system.
All veins come equipped with one way valves. These valves occur every one or two inches and are aimed in the direction of the heart. The purpose of these valves is to conserve the work done to pump blood toward the heart. In other words, they are there to prevent back flow. Blood is driven through these veins by two forces.
During rest the major force which drives blood to the heart is the pressure exerted by the heart itself through the arterial system and capillaries. During activity this force is augmented by muscular motion which squeezes veins which are adjacent to, and within, active muscles. Thanks to the valves this muscular pressure squeezes blood through the veins in only one direction: toward the heart.
Sclerotherapy is a medical specialty in which the doctor treats cosmetic and functional vein disorders. Many types of doctors deal with vein disorders, however not all doctors who deal with veins really understand how to do the job properly so that the problem is solved and does not return. The purpose of this article is to provide you with the kind of understanding about vein disorders which will allow you to discriminate between doctors who know their stuff and those who do not. It can also serve to educate doctors on this common problem.
Most people come to a sclerotherapist for one of two reasons: appearance and discomfort. Probably the majority are concerned about the cosmetic appearance of "spider" veins just under the skin. True spider veins are fed from the arterial system and when compressed they refill from the center giving the impression of a spider spreading its legs. However, by convention, tiny veins on the surface which are blue/black in color and have only venous origin are also called spider veins. True spider veins are rare, however ordinary spider veins are quite common. The term "spider veins," in this article, refers to the latter.
The technique of sclerotherapy is the injection of a sclerosing solution into these veins. When done correctly these spider veins disappear after passing through a phase of inflamation and bruising. However, unless the underlying condition (incompetent larger veins — see below) which gave rise to these spider veins is dealt with first, more spider veins will quickly appear.
An "incompetent" vein is one which has ballooned out to a diameter exceeding the size of its valves. This pulls the valves apart so that they cannot snap shut on backward pressure. This results in blood flow away from the heart and thus increased pressure throughout that local part of the venous system. The smaller veins cannot always withstand this pressure and some of them balloon out to become larger and visible. Because their walls are stretched so thin, blood can be seen through the walls giving a blue/black appearance. This appearance is what many people find objectionable. Spider veins can occur without incompetence of larger veins, however this is not the usual situation.
When the larger veins in an area cannot withstand this back pressure, they too balloon out. When this condition persists for months or years, the affected veins can become elongated and as a result of this elongation they become serpentine in shape. These enlarged serpentine veins are darker than normal veins — because blood stagnates there — and are known as varicose veins. Most people find these varicose veins objectionable as well, especially if they are painful, as they usually are when standing for any length of time.
Evaluation by a competent sclerotherapist begins with a history and physical exam focused on the problem for which you came. Then comes a Doppler examination of your veins. (If you call a doctor about your spider veins and that person does not know to examine the entire venous system in your legs, then you best not make an appointment.)
Doppler technology takes advantage of the sound which comes from an object, or objects (such as blood cells) moving past a stationary point. This adaptation of Doppler technology is a sound amplifier which renders audible the sound of blood rushing through blood vessels.
In the normal condition blood can be heard rushing in only one direction. The doctor will place the microphone on one of your veins and squeeze adjacent parts of your leg thus forcing blood through the vein being listened to. In the normal condition you and your doctor will hear a "Whoosh" followed by silence when the doctor releases the pressure on your leg. If the vein being examined is incompetent the sound will be "Whoosh, Whoosh," as blood can be heard rushing both toward the heart when pressure is applied and away from the heart when pressure is released. The doctor may then ask you to cough or bear down as if having a baby. This will reveal the presence or absence of competent valves between the point of the examination and the large veins in the pelvis.
In this manner all the major veins of the legs are examined. The doctor is discovering where the areas of incompetence are located — if in fact they exist. If areas of incompetence are located then those must be dealt with first. If they are not present, then injection of the smaller veins can begin immediately.
If the presence of incompetent veins is detected, the next test is with an ultrasound machine. An ultrasound machine allows the doctor to see a representation of your venous system on a screen and it also shows your doctor the direction of flow through the veins. With this machine the location and size of incompetent veins can be determined. If there are veins which are ballooned to 3 to 4 millimeters or more, those veins are better tied off in a surgical procedure which precedes injection of the "reticular" and the spider veins.
Reticular veins are larger than spider veins and they are the veins from which spider veins arise. They are incompetent veins but have not yet dilated and become serpentine (they are not yet varicose veins).
If incompetent veins are found but do not exceed 2 millimeters in diameter, the entire problem can be dealt with by injection alone. If defects larger than 3 to 4 millimeters are discovered, these must be surgically isolated and tied off. Usually these types of veins are "perforator" veins which connect the deep and superficial systems of veins. There are between 100 and 150 perforator veins. Occasionally, the deep veins are found to be incompetent and when this is the case, they must be dealt with first as the entire system is relying on the competence of these veins. Until these are working properly, the rest of the system is in jeopardy of further breakdown. However, deep veins are rarely incompetent because they live out their lives supported by the surrounding muscles.
If the incompetent veins are less than 2 millimeters in diameter they can be dealt with by injection. In the case of perforator veins, they are handled simply by injecting the reticular veins. This will close the perforator veins if they are 2 millimeters or less in diameter. When the deep veins work well and the incompetent reticulars and perforators are closed, then the spider veins can be injected. Ideally, this is done in two separate phases, but sometimes they can be done on the same day if necessary.
There will be a period of bruising which may last up to three months during which the cure may look worse than the illness. Also, if the reticular veins are injected,
there may be some blood trapped in pockets of those veins and this will require one year or more to resolve. Alternatively these veins can be punctured under local anaesthesia and the blood expressed out of the vein. This speeds resolution down to a few weeks.
In earlier times many doctors routinely stripped out the entire length of the great saphenous vein, the vein which runs from the inner ankle to the inguinal area. This should no longer be done routinely unless the entire vein is incompetent. Now we isolate the area of the vein which is incompetent and either excise it or inject it. It is often easier to remove that part of the vein than inject it because if injected it usually develops pockets of stagnated blood which require that year to resolve or must be drained two or three times to effect resolution. If excised, this can be done in a way that prevents scarring by making tiny stab wounds every 1-1.5 inches along the tract of the vein and pulling the vein out in sections through these tiny stab wounds.
When all is said and done the venous system of the legs should be both functionally and cosmetically repaired. To maintain your system in this condition you should take between 3,000 and 5,000 mg. of vitamin C (as the ascorbate form) daily for the rest of your life, and when possible wear support hose. Also, avoid lifting weights with your airway closed, and avoid straining at stool, also at childbirth — easier said than done. All of these actions (collectively known as the Valsalva maneuver) put extraordinary pressure on the venous system in the lower part of the body and tend to produce incompetent veins by stretching them out so that the valves can no longer snap shut and prevent the back flow of blood.
So, to recapitulate, there are four categories of veins which are of interest in an examination by a sclerotherapist: deep veins, superficial veins, perforator veins, and spider veins. The deep veins are buried beneath skin, muscle, and bone and cannot be seen except during surgery. The superficial veins are the ones you can see just under the skin. The perforator veins connect the two systems. Reticular veins are incompetent superficial veins. Varicose veins are superficial veins which are not only incompetent, but are swollen, elongated (and thus serpentine) as a result. The most fundamental problems must be fixed first and these are, in order: incompetent deep veins, incompetent perforator veins, incompetent superficial veins (reticular and varicose veins), and finally the spider veins. If your doctor does not understand these principles, you are unlikely to receive proper care.