FAQ About Varicose Veins, Spider Veins And Vein Treatment In Houston, TX
If I want to have my leg veins evaluated for possible treatment, what type of medical specialist should I see?
Treatment of veins is a highly specialized field. If you go to a vein practice and the person evaluating you is not a physician, leave immediately. Treatment begins with evaluation. If the evaluation is flawed, the treatment plan will be flawed as well. The specialists who treat veins are called vascular surgeons. A board certified vascular surgeon understands vein anatomy and physiology, and how it relates to your circulation. Vascular surgery is the only specialty recognized by the American Board of Specialties that includes treatment of venous insufficiency as a part of the training curriculum.
In recent years, the number of vein clinics directed by non-vascular surgeons has increased. In many of these clinics, nurse practitioners or physician assistants evaluate patients and determine the treatment plan. The patient doesn’t even meet the physician performing the procedure until the day of their procedure, and rarely sees him or her again. This often results in the wrong treatment.
Dr. Bardwil is a board certified vascular surgeon based in Houston and is credentialed to perform, as well as interpret, venous ultrasound. At your initial meeting, Dr. Bardwil will meet with you to perform a comprehensive venous evaluation and will advise you on the best treatment option for your vein problems. He will also evaluate you at each of your subsequent follow-up appointments. Dr. Bardwil understands circulation, vein anatomy and physiology, and will individualize your treatment to better meet your goals and expectations.
How does the doctor evaluate the veins?
A true clinician knows that evaluation begins with a thorough medical history and a physical exam. Vascular ultrasound was developed by a vascular surgeon (see our tribute to Dr. Eugene Strandness) and is an extension of the physical examination. The surgeon who will be treating your veins should perform the ultrasound study, and he should be both a board certified vascular surgeon and a registered vascular technician (RVT).
I have both varicose veins and spider veins on my legs … what’s the difference? Are spider veins and varicose veins the same thing, or are they two separate problems with different causes?
That’s a very good question. Varicose veins are dilated and have a “ropy” appearance, with blue vessels that look like lumps under the skin. Spider veins are small blue or red vessels visible within the skin, usually on the leg, foot, face, neck or chest.
There is a six stage venous severity scoring system, which is used to classify veins by severity. Spider veins are considered least severe of the veins and are a considered “class one.”
Varicose veins are the result of increased vein pressure in the veins. Spider veins may be the result of varicose veins, but varicose veins are not the result of spider veins. In that sense, they are related, but through different processes.
Both spider and varicose veins are caused by heredity. Hormones can affect both, thus they are seen in women more often than men. As we age, the incidence of each increases.
There is an underlying problem with vein function, which usually needs to be addressed in order to effectively treat varicose veins. Thus, the sequence in treating veins is as follows: (1) address underlying problems first, (2) treat residual varicose veins next, and (3) spider veins are treated last. If there are spider veins, but no varicose veins, then the spider veins can be treated.
What can be done to correct varicose veins?
The treatment of varicose veins involves eliminating the abnormal veins. The varicose veins are superficial veins, so they are considered expendable, just like the appendix and gallbladder are expendable.
The best option for treating varicose veins used to be vein stripping. This procedure involved removing the saphenous vein in the operating room, and was the standard of care until a little over 10 years ago.
Today, with technology approved by the FDA in 1999, vein treatment can be performed in the surgeon’s office rather than the operating room. The standard of care now is to close the saphenous vein with a laser in the surgeon’s office, utilizing local anesthesia rather than general anesthesia. Being able to perform vein treatment procedures under local anesthesia reduces risk for patients, as the need for general anesthesia is no longer required.
Once you heal from the laser procedure, you will follow up with Dr. Bardwil in our office. Any residual bulging veins can be dealt with by either performing a microphlebectomy, which involves removing the veins in small segments through 2mm-sized incisions or by injecting the veins with solutions to further shrink them.
What factors contribute to varicose veins?
- Heredity (the most significant cause)
- Pregnancy
- Hormone Replacement Therapy
- Birth Control Pills
- Prolonged Standing or Sitting
- Inactivity
- Advancing Age
- Obesity
I’ve seen articles talking about venous reflux, and sometimes the articles talk about venous insufficiency. What’s the difference between venous reflux and venous insufficiency?
It’s best to talk about these two topics together. Arteries bring blood down the legs; veins bring the blood back up the leg for full circulation. One-way valves in the veins are what make this possible; however, when the one-way valves are not working, the blood can begin to flow in both directions.
“Reflux” is the term that describes this abnormal two-way blood flow. Blood tends to stagnate in the leg veins when reflux is present. The presence of reflux can be determined by performing a venous ultrasound and, when present, confirms the diagnosis of venous insufficiency.
“Venous insufficiency” exists when the vein’s valves are not functioning properly. When this occurs, the blood is not efficiently drained from the legs. This creates increased pressure in the veins of the legs. Venous insufficiency can give rise to varicose veins, swelling, heaviness, fatigue and aching in the legs. It is estimated that 25 million people suffer from venous insufficiency. In its most severe form, this can cause profound swelling, skin breakdown, or ulceration.
I saw an ad on TV and made an appointment to see a vein specialist. When I came in for my appointment, a physician’s assistant evaluated me. Is it normal not to see the actual physician?
No. Treatment of veins is highly specialized. If the person you are seeing is not a physician, leave immediately. Being evaluated by anyone that is not a physician is below the standard of care.
What is the best treatment for varicose veins?
Treatment begins with a thorough evaluation, including a physical exam and venous duplex ultrasound, particularly when dealing with varicose veins. If there is an underlying problem, this should be addressed prior to removing varicose veins.
The most frequently identified problem contributing to varicose veins is that the valves of the greater saphenous vein are not functioning properly, thus allowing blood to flow in two directions instead to one. The blood in this vein backs up into tributary veins, causing the bulging varicose veins. If the greater saphenous vein is abnormal, treatment involves closing the vein with a laser. After the saphenous vein is closed, the varicose veins will shrink or sometimes even disappear. Residual bulging veins are then removed by making 2mm-sized incisions and removing them in segments. This is called a microphlebectomy. All procedures are performed in an office setting, utilizing local anesthesia so that patients remain comfortable and free of pain during the procedure.
Can microphlebectomy be used on all skin types?
Yes. Microphlebectomy (also known as ambulatory phlebectomy) can be used on all skin types. If you have dark skin, that does not prohibit you from having the procedure. In general, darker skin types are less forgiving than lighter skin types. In a person with a lighter skin type, the incisions where veins have been removed leave almost no marks; whereas people with darker skin may have residual marks where the veins were removed. The lasting effect should be a cosmetic improvement over bulging veins. With time, you may notice that the tiny incision scars will fade.
What is ultrasound-guided endovenous laser treatment?
Endovenous laser treatment is performed by using ultrasound guidance to access a vein (usually the Greater Saphenous Vein or GSV), with a needle and placement of a laser fiber into the vein the surgeon intends to treat. This procedure was developed as a less invasive alternative to “vein stripping.” It has the advantage of being less invasive than vein stripping and is designed to be performed using local anesthesia in an office setting instead of under general anesthesia in a hospital or surgery center. Performing procedures under local anesthesia reduces risk for patients, and patients are able to return to work the next day (depending on the type of work they perform).
The procedure received FDA approval in January 2001. Since that time, thousands of endovenous laser treatments have been performed. Although other devices are available (such as radio-frequency), the laser is more versatile in treating both larger and smaller diameter veins, as well as shorter vein segments. It should be noted that there are reputable vein specialists who use radio-frequency energy instead of the laser for treatment.
I’m scheduled for endovenous laser treatment for a large varicose vein. My primary care doctor is against it. What should I do? The surgeon is an interventional radiologist who is specializing in vascular vein removal.
First, interventional radiologists are not surgeons. In fact, interventional radiologists cannot even admit patients to the hospital, and they certainly do not have the qualifications acquired by a vascular surgeon. When it comes to the treatment of veins, primary care physicians know that veins are Dr. Bardwil’s area of expertise, and will defer to his opinion.
Serious complications from endovenous laser treatment are rare, but like with any surgery, complications can occur. When they occur, it is usually a result of inadequate risk assessment, or misdiagnosis. There is a reason why it takes 6-7 years to become a vascular surgeon. Interventional radiology training does not involve diagnosis or treatment of disease processes. Interventional radiologists are often apt to miss the big picture. For example, they recommend treatment of leg veins, when a patient’s legs are swollen secondary to heart failure.
If your primary care physician has a different opinion than the radiologist, listen to your primary care physician and see a vascular surgeon for a second opinion. This practice offers second opinions for patients in your situation.
What is the EndoVenous Laser Ablation Procedure (EVLA)?
This procedure involves using an ultrasound to guide placement of a laser into the saphenous vein and using heat to close it.
The procedure involves ultrasound-guided puncture of the vein designated for treatment. A laser fiber is advanced up the leg, stopping a safe distance below where it empties into the deep vein. Once the laser fiber is in position, local anesthesia is injected along the vein to be closed. Once the anesthesia has been injected, the laser is activated and slowly withdrawn. The laser fiber produces a beam of energy, which uses heat to seal the vein. Once the abnormal vein is closed, the pressure it was causing is resolved. The blood automatically diverts itself to the normal veins. Since the root of the problem is eliminated, swelling and symptoms improve. Most varicose veins will subsequently become smaller or disappear altogether.
What is the difference between EVLA, ELAS, and EVLT?
The EVLA, ELAS, and EVLT are all names for the same procedure, which involves using laser energy to close the saphenous vein. These procedures fall under a class of procedures referred to as endovenous thermal ablations. As the name implies, the procedure involves going inside of a vein with a laser fiber and using heat to close the vein. The different names are the result of different laser manufacturers not wanting to infringe on trademark names held by a competitor. To avoid confusion, we will refer to these procedures as EVLA (EndoVenous Laser Ablation).
How does EVLA work to treat venous insufficiency?
ELVA is used to treat venous insufficiency, which occurs when the valves in your leg veins are incompetent and unable to allow the flow of blood in only one direction. Since blood can now flow in two directions, gravity works against what the veins are trying to accomplish. Over time, this results in an array of uncomfortable symptoms. The only proper way to solve this problem is to eliminate the abnormal vein. EndoVenous Laser Ablation (EVLA) is a great solution to treat venous insufficiency because it is a less invasive approach than traditional therapy, and very specific in targeting the abnormal veins. Sealing off abnormal veins then allows other healthy veins to take over the redirected blood flow, thus reducing or eliminating any unwanted symptoms.
How is the EVLA procedure different from vein stripping?
ELVA is preferred over traditional vein stripping because it is more precise in targeting the abnormal vein. It is also less invasive and can be performed in the surgeon’s office instead of a hospital or surgery center, and because it can be performed utilizing local anesthesia instead of general anesthesia, is less risky than going under general anesthesia.
Can vein surgery be performed safely outside of a hospital setting?
15 years ago, all vein procedures were performed in the operating room of a hospital or surgery center, and were performed using a general or spinal anesthetic. The procedures are now performed in an office setting using local anesthesia. This provides for less risk, as a general anesthetic is no longer needed. The patient is awake during the procedure, but if the patient is anxious, oral Valium is offered.
Even though the patient is awake, the Texas Medical Board requires monitoring during these procedures. It takes a skillful and responsible surgeon and surgical team to provide the level of care which is equal to or better than what was previously provided in the operating room. A vascular surgeon has the knowledge and experience to perform vascular surgical procedures safely in an office setting and employs clinical staff members familiar with vein treatment procedures.
Are there any potential risks or complications?
As with any medical procedure, potential risks and complications can occur. Dr. Bardwil will review potential complications of the EVLA procedure at the consultation and discuss these with you. Risks for serious complications are considered rare for this procedure when performed by an experienced, board certified vascular surgeon. It is important that your procedure be performed by a surgeon, because in the rare event that a complication does occur, because of your surgeon’s education and training, they are better prepared to avoid problems and to quickly recognize and manage any problems. Radiologists who claim to be “vein specialists” do not have this level of knowledge, training, education, or skill set. Remember, vascular surgeons are the ones called when problems do arise.
Will getting my varicose veins removed cause cardiovascular problems?
Vein problems and cardiovascular disease are unrelated, other than that the leg veins can be used for bypass surgery. Since treatment of leg veins involves elimination, normal veins should not be eliminated. Abnormal veins would not be suitable for bypass, and since more stents and less bypass surgery is used to treat cardiovascular disease today, there is little lost in treating abnormal veins. Treating abnormal veins by elimination will not worsen your circulation or lead to cardiovascular disease.
Is endovenous laser treatment painful?
The endovenous laser treatment is performed in an office setting utilizing local anesthesia. The most uncomfortable part of the procedure are injections used to numb the area. Once the leg is numb, there should be no pain. Patients can expect to feel sore after the procedure, but soreness should resolve within a week or two.
How long does the EVLA procedure take?
The procedure takes about 30-45 minutes.
How soon may I resume normal activity?
With our 1470 wavelength laser, you should resume normal activity immediately. This is a true advantage over the earlier wavelength laser used to close veins. This newer technology became available about four years ago, and we were one of the first vein practice to use it. We encourage walking as often as you would like. You should be able to return to most activities the day after your procedure.
Is there any scarring, bruising, or swelling after the treatment?
Patients report minimal to no scarring following the EVLA procedure. Bruising will usually clear up in one to two weeks. There may be slight tenderness during the first few weeks after treatment.
What is ultrasound-guided sclerotherapy?
Ultrasound-guided sclerotherapy is a very effective method for treating varicose veins beneath the surface. Visualization of the intended vein on the ultrasound monitor allows precise needle placement into the diseased vein. A sclerosing solution is injected into the veins, resulting in closure of the vein. When foam sclerosing solution is used, it can be visualized flowing into the target veins. The number of treatments varies depending on the severity of your condition. Dr. Bardwil will determine if this procedure will be appropriate, effective, and safe for you.
How soon will my symptoms improve?
It depends on the severity of symptoms prior to the procedure. Many patients report a noticeable improvement in the pressure they feel in their legs almost immediately after the procedure.
How effective is the ELAS procedure in closing the vein?
When the vein is closed with the laser, this procedure is effective in closing the vein in almost 100% of cases. The vein will remain closed permanently more than 95-98% of the time.
What happens to the treated vein left behind in the leg?
Over time, the body usually reabsorbs the closed vein. The vein is usually indistinguishable from other body tissue by ultrasound a year after the procedure was performed.
Does the doctor’s office staff understand insurance rules regarding coverage of varicose vein treatments?
Treatment of veins can considered medically necessary, cosmetic, or both. As there is a medical component, Medicare and private insurance will cover treatments deemed medically necessary. Since veins are the only things that Dr. Bardwil has treated for the past 10 years, he and his office staff are well versed in the various Medicare and insurance policies regarding treatment of veins.
Rules and requirements vary by plan. Although some policies are universal, each carrier has specific rules which must be applied; these rules are continuously changing. Dr. Bardwil’s office staff is well versed in the insurance requirements and monitors them for changes in policy. Your procedure is scheduled several weeks out, allowing time for us to obtain insurance approval. To avoid unnecessary surprises, you will be given an estimate of your out-of-pocket expense, co-pays, or monies required to go toward your deductible. Approval is obtained prior to the procedure and you will be notified when approval is obtained. Procedures are not performed without insurance approval.
Is the ELVA treatment covered by my insurance?
Yes, but criteria for coverage has become more restrictive and all criteria must be met in order for insurance to approve your procedure. Each insurance plan has its own guidelines for coverage. In general, coverage is based on medical necessity. Dr. Bardwil’s staff will discuss the specifics of your insurance coverage further at the time of your consultation.
What happens if I don’t have insurance or I have a high deductible?
Dr. Bardwil has payment plans available. Please inquire at the time of your consultation if you know you have a high deductible or your procedure is not covered by insurance.
Is the EVLA procedure suitable for me?
Dr. Bardwil can tell you if this procedure is an option for your vein problem. Unlike practices that are only able to identify ultrasound findings, Dr. Bardwil’s vascular surgery background allows him to identify what effect closing a vein will have on your symptoms and the appearance of your veins.
How does VNUS Closure work?
The VNUS Closure works by using radio-frequency energy to close the saphenous vein. It was the first in a class of procedures referred to as endovenous thermal ablations to be approved for use in the United States by the FDA in 1999. This class of procedures eventually replaced vein stripping as the new standard of care.
The procedure involves using ultrasound guidance for placement and positioning of a radio-frequency catheter into the abnormal vein, and using heat to seal the vein as the catheter is slowly withdrawn. This procedure is an improvement over vein stripping, but has certain limitations. These limitations include limits on the maximal diameter of vein that can be closed, risk of nerve injury, risks of the vein reopening, and blood clots.
The FDA approved laser technology for these procedures in 2001. Laser technology is more sophisticated, with no limits on vein size, lower rates of reopening, lower incidence of blood clots and nerve injury. Ask Dr. Bardwil if you are a good candidate for this procedure.
How is the VNUS Closure procedure different than laser?
The VNUS Closure was the first of this class of procedures used to replace vein stripping. This was a major advance. Laser technology is newer and is an advancement over VNUS Closure. The surgical technique is similar in the performance of these surgical procedures. Ultrasound is used to guide placement of each device. Both laser and VNUS Closure involve closing the vein instead of removing it.
Laser technology came after the VNUS Closure came into play, and improved shortcomings in treating veins, and thus is superior. Laser is also more versatile. Laser allows treatment of both larger and smaller veins than is allowed for with VNUS Closure. It also is better in accommodating treatment of multiple veins, and multiple types of veins at the time of the procedure, thus reducing the number of procedures that a patient has to withstand.
There is no vein that can be treated with the VNUS Closure that can’t be closed with the laser, but there are often veins that can be closed by laser, but not by the VNUS closure device. Although Dr. Bardwil still owns a VNUS Closure device, he rarely uses it. Laser is the preferred method of treatment.
Does the surgeon use laser or radio-frequency energy to close the veins?
Radio-frequency was the first device approved by the FDA for closing veins, and was an improvement over vein stripping. And now, laser technology is an improvement over radio-frequency.
Dr. Bardwil has extensive experience with radio-frequency and laser. Although proponents of radio-frequency claim that patients undergoing the radio-frequency procedure experience less pain post-procedure, Dr. Bardwil finds that with the newer wavelength lasers, there is not an appreciable difference. On the other hand, the reported results of veins remaining closed is better with laser than with radio-frequency. The reported complications are less with laser than with radiofrequency. The laser is a more versatile device. It can be used to treat larger diameter veins and shorter segments of veins as well. It also allows for treatment of multiple veins in a single setting. Laser procedures can also be performed more cost effectively, as the cost of disposable supplies is less. This translates into lower out-of-pocket costs for patients choosing to have their veins treated. Because of these reasons, LASER IS PREFERRED OVER RADIO-FREQUENCY.
Is your vein surgeon certified to perform and interpret venous ultrasound through the American Registry for Diagnostic Medical Sonography (ARDMS)?
ARDMS is the globally recognized standard of excellence in sonography and has certified more than 80,000 individuals. ARDMS is composed of three key groups.
Credentials awarded by ARDMS document personal achievement of recognized professional standards and are widely accepted in the medical community by sonography and vascular professional organizations.
As a board certified vascular surgeon, Dr. Bardwil is held to the highest standard in diagnosis and treatment of venous disease. He also holds additional certifications. He is certified as a Registered Vascular Technologist (RVT) to perform ultrasound studies, and holds a Registered Physician Vascular Interpretation (RPVI) certification as well, allowing him to also interpret the ultrasound results. These later two certifications are demonstration of proficiencies required to perform venous ultrasound. They are not obtained by completing specialty training, and are separate from the board certification process. Without exception, any physician performing and interpreting venous ultrasound studies and venous procedures should be certified as an RVT and also have the RPVI certification. This includes vascular surgeons as well as radiologists.
I went to the Emergency Room 10 days ago. There’s a sizable bump in my vein. It’s not swelling. The area above the vein is extremely tender and hard. Google says it is a blood clot and states that I shouldn’t be worried. Aren’t blood clots dangerous? Could this develop into a varicose vein or something more severe?
If you can feel the hard vein in your leg, and the doctor in the emergency room told you that you have a blood clot, then what you have is superficial thrombophlebitis. This is a blood clot in a superficial vein. It does not have the same significance as a clot in your deep veins.
There are two systems of veins in your legs. The deep veins are beneath the muscles and are more important to the circulation. The superficial veins are above the muscle. They may be visible at the surface or beneath the surface and not visible. As long as they are above the muscle, then they are considered superficial. Superficial thrombophlebitis presents as clots in the superficial veins. These clots are initially red, tender, and hard. They usually respond well to heat and anti-inflammatory medication. The process is usually self-limited, and rarely do these clots involve the deep vein. When they occur in the arms, it is often related to a previous IV. They may also occur in varicose veins. Although in and of itself, phlebitis is usually not dangerous, it may on occasion be an indicator of an undiagnosed illness or clotting disorder. Self-diagnosis is not recommended – a knowledgeable physician should evaluate you.
How does Dr. Bardwil treat spider veins?
The gold standard for treatment of spider veins is sclerotherapy. Dr. Bardwil began performing sclerotherapy in 1990. Twenty-five years later, the solutions used in sclerotherapy have improved, and Dr. Bardwil’s technique has become more sophisticated. He is well-versed in all of the solutions so that he can individualize your treatment. Dr. Bardwil also has a 1064 wavelength laser, as well as the VeinGogh device. These are sometimes used in specific situations. No one currently practicing in Houston has more experience with treating spider veins than Dr. Bardwil.
Which treatments work best for facial spider veins?
Facial spider veins can be treated by sclerotherapy, laser, and by VeinGogh an Ohmic Thermolysis System. For discrete spider veins I prefer the VeinGogh. For large green veins around the eyes, I use sclerotherapy. For diffuse red veins covering the face, rosacea, I will use the broadband light by Sciton to perform photo facials. The photofacial stimulates collagen, so this may have a beneficial effect on fine wrinkles.
What are venous stasis ulcers?
When venous insufficiency is left untreated over many years the constant pressure may cause a leaking of inflammatory cells into the tissues. This process causes inflammation, thickening and brown stains in the skin, which are an indication that the process has become more 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.
Venous stasis ulcers do not occur in all patients with varicose veins. When skin changes begin to appear, the likelihood of an ulcer increases. Prevention is the by treating the abnormal veins before an ulcer forms is the best therapy. Once the ulcer has formed, treating the veins will facilitate healing and diminish the rate of recurrence.
Wound care is essential in managing venous stasis ulcers. This is one more reason why surgeons are better equipped than other specialists such as radiologists, in managing venous disease.
Is there a long-term follow up plan?
It is important to have a long-term treatment plan because veins are chronic, and while we treat vein problems, we don’t cure vein problems and even under the best circumstances they can recur. It is important for us to track our results so that we can continuously improve the level of care we provide and ensure that you get your best possible result.