Vein Treatments

Podcast Transcript

Announcer:
Welcome to Love Your Heart. Brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute. These podcasts will help you learn more about your heart, thoracic and vascular systems, ways to stay healthy and information about diseases and treatment options. Enjoy.

Betsy Stovsky RN, MSN:
Good morning, everyone. I am here today with Dr. George Anton, who is a vascular surgeon. He has a specialty in varicose veins and spider veins and just all things vascular surgery, but definitely has a special interest in this area. So, we're very excited for him to be here today, to answer a lot of common questions that we get about this topic. So, good morning, Dr. Anton.

George Anton, MD:
Good morning.

Betsy Stovsky RN, MSN:
First thing, people have confusion, I think, about the difference between what spider veins are and varicose veins. So, could you talk a little bit about that?

George Anton, MD:
Yeah. Varicose veins are simply larger veins by definition, they're greater than three millimeters diameter. The spider veins are rather small and they develop in little clusters. They're associated with things called reticular veins, which are little larger blue veins under the skin. And basically all the deep veins, the superficial veins are somehow connected.

Betsy Stovsky RN, MSN:
So, what actually causes them?

George Anton, MD:
Well, the predisposition for spider veins, basically everything is genetic to some extent and it's also gender related. Women tend to get the spider angioma to a little more frequently than men because of pregnancy, basically, same thing with varicose veins. During pregnancy, the hormones will dilate the veins and then as the fetus grows it puts pressure on the pelvic veins that gets transmitted to the lower extremity veins and breaks little check valves within the veins.

George Anton, MD:
Also contributing to varicose veins and spider veins, they're somehow connected, is it can be job-related. Typically, people that stand in one spot for long periods of time, butchers, bakers, bartenders, machinists, tool and die makers, retail, hairdressing. And the pressure just builds up as they stand in one spot for long periods of time because their muscle pump isn’t working to lower the pressure. And then lastly, very heavy people tend to get more varicose veins because of the increased pressure.

Betsy Stovsky RN, MSN:
Mm-hmm (affirmative). So, when you talk about all those things that put people at risk, can you prevent them?

George Anton, MD:
Yeah. So, there are opportunities to lower the vein pressure because really, that's what causes all these vein problems. And there are three ways to lower your vein pressure, lie down, put your feet up above your heart. Not very practical if you have to go to work and have things to do, but during the day, periodically you can at least elevate them somewhat. The muscle pump exercise is good. Any form of pumping your feet up and down during long periods of standing or sitting is helpful. And then, external compression, usually just in the form of knee-high compression socks.

Betsy Stovsky RN, MSN:
So, when you talk about those socks and things like that, you do see things out in the store or various different types of compression stockings or socks. What should people look for when they're looking for that?

George Anton, MD:
Yeah. So, we've come a long way. The original compression hose, like you used to get in the hospital, the white ones, they're pretty ugly, they're hot, they're hard to get on and off. But we have so many new opportunities. You could go online and buy athletic compression socks. Okay. These are made for people who run long distances and so forth, and they're graded compression. The materials they're made of allow your feet to breathe. They don't sweat.

George Anton, MD:
And you measure your calf circumference and generally I tell people to buy something that fits you well, that is comfortable. There's all different brands out there, and they're are a lot cheaper than buying something in the drug store. You can get these for $20 a pair and they'll last you a long time. So, some of them, the copper type socks, a lot of them are antifungal, antibacterial, and they're extremely comfortable.

Betsy Stovsky RN, MSN:
And just because we get this question often, when people get those, how often should they wear it? Is it something you wear all day, all night? How should they wear those?

George Anton, MD:
Yeah. Well, you don't wear it at night because when you're at night, you're in bed, your feet are elevated, so there's no pressure. But I would say, we all wear them, every day here. So, if you're on your feet, you're working and it could be standing or sitting, it's no good either way, that pressure builds up. So, you wear these during the day. Interestingly, during the weekend, if you're running around and moving a lot, you probably don't even need them because of the muscle activity, and it just automatically lowers the vein pressure, but that stagnant sitting and standing for prolonged periods of time, these will be very helpful, extremely helpful.

Betsy Stovsky RN, MSN:
So now, let's say you have those, either the varicose veins or the spider veins, are they dangerous?

George Anton, MD:
To a degree. I mean, it depends on the size of the veins and how superficial. So, there are potential risks and complications. The main concern for most people is, "Do I have a blood clot?" Those are big concerns for people. And there's a deep venous system and then the superficial veins. So, the superficial phlebitis is painful because there are nerve endings surrounding these veins. Whereas, the deep veins aren't always painful, but they're more of a problem in terms of getting clots to your lung. They're a little more morbid. And then, the spider veins, the superficial veins, especially as we age, people over 65 generally, they can actually ulcerate and bleed. So, that's a pretty common occurrence also.

Betsy Stovsky RN, MSN:
And what about, it seems like some people who have the varicose veins, they have pain and some people don't, but does that mean that it's more serious if it's painful or just more irritating?

George Anton, MD:
Yeah. So interestingly, men seem to not have as much pain as women, and I think it's hormone-related and they tend to have, it's what I call a male pattern. It's a genetic thing where their veins are really large and complex. So, I think most of these people develop a pain and it's usually localized pain where the varicose veins are, because that's what triggers the little nerve endings. The swelling that they get, the heaviness, you can get itching, you can actually get eczema-type looking skin. And of course, the ultimate problem is venous ulcers, where you get holes in your skin, and that's a big problem.

Betsy Stovsky RN, MSN:
So, can you go through the different treatment options that you have for both spider veins and varicose veins?

George Anton, MD:
Yeah. Well, we'll separate them. The spider veins, the best treatment for spider veins is injection sclerotherapy with a solution that'll damage the lining of the vein and cause it to scar closed. That's the best option and it works well, provided the person doing it is obviously good at doing it, right? And it hinges on getting the needle in the vein. That's the rate limiting step, they're small veins. Obviously, we use small needles, but if you can't get the needle in the vein, two things happen. Number one, it won't work. And number two, you can damage the skin and actually get holes in your skin. So, you have to be careful.

George Anton, MD:
The other problem with sclerotherapy, for spider veins and reticular veins, they can stay in the skin. You can't believe the Photoshopped images, the before and the after, that they advertise. Veins are actual structures, so they're never going to completely 100% go away. Now, the sclerotherapy itself is effective 100% of the time, but there'll always be some residual veins left behind, somehow, some way. And then, so the spider veins are best treated with that. Of course, compression hose would help over the long haul. But the varicose veins, they're bigger, and there are various treatment options.

George Anton, MD:
Now, everybody should have some opportunity to wear the compression hose, elevate, pump, as we talked about, so-called conservative measures. And if that's enough, then that's fine. But beyond that, if you still have symptoms, pain, or a risk of developing clots in the superficial or deep system, the most important next step is to get a consultation, a physical exam, and then some ultrasound imaging, that's the key. And when we perform the ultrasound imaging, we look at the superficial system and the deep system, how they're connected and where the pathology occurs, where the broken valves are, where the so-called reflux is.

George Anton, MD:
So, the options for varicose veins at that point, again, there's different types of sclerotherapy. Sometimes there's ultrasound guided or regular, standard needle through the skin sclerotherapy. Historically, varicose veins were always a surgical treatment performed by surgeons. And there is opportunities to remove varicose veins, either under local, in an office setting, or more complex four-hour procedures as an outpatient in a hospital, for example. And then, there's forms of endovenous what we call ablation, typically of some saphenous vein or branch of it. And that can be, newer technologies have been around for 15 years or so, but you can use laser or radio frequency ablations. And most of those are performed as an office-based procedure with local type anesthesia.

George Anton, MD:
There's also mechanochemical devices, glue. So, there are what we call non-thermal, non-tumescent applications, which are less invasive, but nothing is risk-free. So, what I tell people is, you get all this information from a lengthy investigation with ultrasound imaging, and what I tell them is, "I just match the technology with your anatomy in an unbiased fashion. As a surgeon, I can do the sclerotherapy, I can do the office-based procedures, or I can operate four hours as an outpatient in the hospital. So, you have an opportunity to apply this, any technology, and you want to match it, because if you don't, you're going to get complications or it isn't going to work." So, the important thing is to do it in an unbiased fashion.

Betsy Stovsky RN, MSN:
And then, so I think that, that is a good, important point, because sometimes it seems like some clinics may advertise one specific thing that they do, but you're saying that really, patients are different and you need to really look to see what would best fit their needs.

George Anton, MD:
Right. The patients are different. What I tell people is, "Veins don't read the textbook of anatomy." So, all these studies that are performed in this office, I see it live. When the technologist is finished, I go in. And there's a lot of planning involved. You don't want to go into the procedure room or the operating room and say, "Well, we'll figure it out when we get in there." That's like jumping off a cliff and building the wings on the way down. You really need a good plan. And often, these people have multiple modalities to finish the job. It may include some surgical procedures, some laser or endovenous ablation, and sclerotherapy of some sort. So, to be able to apply all those, is going to give you the best long-term result.

Betsy Stovsky RN, MSN:
So, when you treat the vein itself, is there any change to the circulation afterward or are there issues that patients need to think about? Or, is that not really a concern?

George Anton, MD:
Yeah. Most people ask, "How are we going to reroute that blood?" So, as far as varicose veins are concerned, they're veins that are ... They don't belong there. Okay? They're there because they're under pressure, there's broken valves, they're pathological veins. And in fact, the blood is going in the wrong direction, right? It's called reflux. The blood in the veins are going away from the heart, from gravity. Okay? So, one of the advantages of any of these treatments is it does redirect some of your flow in the deep venous system. It does improve the circulation, the venous return, as it's intended to do.

Betsy Stovsky RN, MSN:
And what's the recovery like? As far as, let's start with spider veins, when you do the sclerotherapy, can they just go out and do their normal daily activities that day? Or what is-

George Anton, MD:
Now, everybody's a little different on this. I don't put people in compression socks and with the cotton balls and the tape. I'll inject these people and I wrap them with this Coban, that wrap, it's a rubberized ... And they'll leave it on for two or three hours, sometimes overnight, depending on the size of the vein. So, number one, getting into the vein and doing appropriate sclerotherapy is the key. And then, the compression early on is what's important. I don't keep them in compression or socks for three weeks. I just don't do that. Your best shot's your initial application for sclerotherapy and then compression. And I can put the exact amount of compression I want when I wrap the leg. Okay. But I tell them, "There's no real downtime from it. There's no limit in activity. You can do what you want that day. The next day, when you're unwrapped, you can exercise." I don't restrict anybody after sclerotherapy.

Betsy Stovsky RN, MSN:
Right. I remember, we have a video of you injecting with sclerotherapy. And it's like magic, the spider veins are just gone. And then, how long does that last?

George Anton, MD:
Well, you should see a difference immediately. If you don't, then you better go somewhere else and have it done, because you can see the difference right away. It's like a video game. And so, each area of spider veins, reticular veins, they don't clear up at one time, they're usually several sessions, but you should see a difference right away. And once I get them, they don't come back. If you're injecting veins that are small and under low or no pressure, they will not return. You may get new ones, but it's very efficient.

Betsy Stovsky RN, MSN:
So, let's move to the varicose veins then. What are the, as far as recovery time after each of those types of procedures that you mentioned?

George Anton, MD:
So, if you do some form of ablation technique, which is not cutting, close the vein. Again, I wrap these people. Some people put them in full-length compression hose. No matter how you do it, we promote walking and active motion, so you don't get clots. And generally, I don't have any real restrictions. You're not supposed to fly in an airplane for a week and I limit some of their activity. You're not going to do deep, heavy squats after an ablation. But you can get on a treadmill, you can get on an elliptical, ride a bike, the next day. Not too many restrictions at all.

George Anton, MD:
If you go the surgical side, it depends on the extent of the procedure. The local removal, we do in the office, these people virtually have no pain afterwards. So, these veins are removed, they can unwrap the next day and shower. Same thing with the outpatient surgical procedures, they may have 15 incisions in each leg, but they can unwrap the next day and shower. There's no real downtime. Or, what I tell people is, "You can do whatever you feel like doing the next day."

Betsy Stovsky RN, MSN:
Yeah. Well, you see patients every day, with these conditions. Is there anything that we didn't talk about that patients often ask you?

George Anton, MD:
Yeah. I'll tell you the most important part is meeting each other's expectations, because of the advertising that goes on now, everybody has an expectation that, "I'm going to have no veins at all in my legs at some point," and that simply isn't a realistic expectation. So nobody gets disappointed is to meet each other's expectations, and that requires some discussion and some dialogue. And every patient is different, and each leg in a patient may be different in terms of what treatment's available and what the residual is going to be. But they also worry about the recurrence, okay?

George Anton, MD:
So first of all, this venous insufficiency is common. At least one-third, 30 to 50% of any population is going to have venous insufficiency over a lifetime. So, once you get these treatments, and it could be a sequence of treatments, there are three things you need. You need to know the purpose, why we're doing it. Number two, you'd like to have it done without complications. And three, you'd like the extended warranty. So, those are the three things you can calculate with that essential ultrasound imaging. That's the key to understanding what you can do now and what their future may hold. What is the prognosis? What is the likelihood you're going to get more of these veins?

George Anton, MD:
If you have a lot of reflux in your deep venous system and you have this genetic predisposition, you're going to be coming back at some point. Okay. So, the recurrence rate, what? 15 to maybe 50%. There are surgeons that tell you, "You're just going to get new veins." And that's for the most part, true. Or, you fight age and gravity, that's what it's about.

Betsy Stovsky RN, MSN:
So, do you then see your patients again after a certain period of time, if they have that kind of history, just to see how things are going, or is it a one and done, or how do you see your patients?

George Anton, MD:
No. Right. So typically, there is an end point. It may take two months, three months, whatever it may take, but I don't bring people back on a regular basis, like you would check somebody after a carotid endarterectomy. There's no built-in surveillance, at least for what I do. And they'll know when to come back.

Betsy Stovsky RN, MSN:
Right. Well, I think this has been very helpful. I know you've answered a lot of questions that we get in our nurse line, that patients have about these procedures. So, I really appreciate you spending time with us today.

George Anton, MD:
Oh, yeah. You're welcome. I hope this is helpful.

Betsy Stovsky RN, MSN:
Thank you.

George Anton, MD:
Okay.

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