Venous disease has many clinical presentations ranging from the subtle non specific complaints of tired, aching legs at the end of the day, to the obvious subcutaneous manifestations spider veins (telangectasias), varicosities, or non-healing ulcers. Patients who seek treatment often have little understanding of their medical condition and therefore rarely understand their therapeutic options. Without this knowledge patients and often referring physicians have unreasonable expectations of what their therapy may entail or what their clinical outcomes may be.

Advances in technology have rapidly changed, and continue to expand options available to patients. None the less, understanding the medical condition is paramount in choosing what therapeutic modality may be beneficial.

Under normal circumstances, veins return blood from the body to the heart where it is oxygenated in the lungs and pumped back out into the body via arteries; when veins become diseased and cannot adequately perform this function, this is “venous insufficiency”. The cause of venous insufficiency is often related to failure of the valves in the veins to close properly, allowing some blood to flow backward (retrograde) rather than forward (antegrade) toward the heart. When this occurs, particularly in the legs, gravity causes blood to pool in the veins thus increasing the pressure inside the vein. Veins are not designed to handle increased pressure so they respond by enlarging or bulging, forming varicosities in the larger veins, and telangectasias in the smaller veins. In the past, therapy centered on helping the veins overcome the pressure by using compression stockings, or by removing the diseased vein—vein stripping. Spider veins were treated by injecting them with saline solutions causing them to scar and close—sclerotherapy.

With the advent of ultrasound, a better understanding of venous insufficiency has been gained, and with advances in catheter technology minimally invasive techniques are now available for the treatment of venous disease. Moreover, patient selection has greatly improved so we can now more accurately tailor therapy according to the patient’s anatomy and physiology. All too often a patient reports that they have had sclerotherapy for their spider veins only to have them return months or years later. The patient is re-treated, and their spider veins return and despite the cost and disappointment, the cycle continues. If the patient is adequately examined, and a careful history taken, venous insufficiency might be identified and treated with a catheter vein ablation. This would result in more effective sclerotherapy as now the cause has been treated, not just the symptom. In fact cosmetic improvement following treatment may make further therapy unnecessary. This is not to say that cosmetic improvement is the goal of venous insufficiency therapy, quite the contrary.

The goal of treatment of venous insufficiency is two fold. The primary purpose of treatment should be directed to alleviating symptoms. Treating an asymptomatic patient with a procedure is not likely to improve quality of life; however, symptomatic patients often gain dramatic relief of pain, swelling, and leg fatigue if catheter treatment of a diseased vein is performed.

The second goal of therapy is to halt the progression of venous disease so that late manifestations such as blood clots (thrombophlebitis) and ulcerations can be avoided. The fact that almost ninety percent of patients do have significant cosmetic improvement following treatment, in my opinion, is a beneficial side effect not a therapeutic goal. While this may disappoint some patients, understanding the medical condition, and treatment modalities will keep clinical expectations reasonable. Put another way, I would rather have a disappointed patient without a procedure than a dissatisfied patient following one.

At Maryland Vein Professionals, we take pride in our ability to tailor therapy to a patient’s specific need as we believe that “one size does not fit all”.