National Center of Excellence for Vein Disorders
Frequently Asked Questions
Why choose a physician with added certification in Phlebology? What is a Board Certified Phlebologist?
There is nothing wrong with having a general surgeon or radiologist to do your vein procedures. However, a dedicated surgeon who is also a phlebologist (vein specialist) brings a whole element of specialty care to the practice of vein disorders. At the Vein Treatment Center, the focus is not just one procedure for all patients, namely 'vein stripping', but rather a variety of procedures that are individualized and targeted to treat specific problems: varicose veins, truncal venous reflux disease, perforator venous reflux disease, vein related skin diseases, treatment of venous stasis ulcers, VNUS Closure, EVLT, topical lasers for spider and reticular veins, SEPS, etc. For a detailed evaluation, call the Vein Treatment Center for a consulation with Dr. Hratch Karamanoukian. Dr. Hratch Karamanoukian is triple board certified - in general surgery (American Board of Surgery), Cardiovascular Surgery (American Board of Thoracic Surgery) and Venous Surgery (American Board of Phlebology). We don't dabble in vein care, but treat it as a medical/surgical specialty. Ask your 'vein doctor' if he is Board Certified in Phlebology!
Dr. Raffy Karamanoukian is a diplomate of the American Board of Plastic Surgery (ABPS) and Diplomate of the American Board of Phlebology who collaborates with Dr. Hratch Karamanoukian at the Vein Treatment Center. Dr. Raffy Karamanoukian is Director of the Santa Monica Vein Center and is focused on the most advanced treatments for his patients with vein disorders. He also performs specialty muscle flaps and surgical wound treatments for patients with venous stasis ulcers. Dr. Raffy can be reached through his website www.SantaMonicaVeinCenter.com
Tell me about "getting medical information from the internet" ....
The Health on the Net (HON) foundation has been actively working to improve Internet access to quality health information. What are the highlights of the 8th HON Survey of Health and Medical Internet Users? Patients and physicians agree that accuracy of information is the most important issue facing users of the Internet as it relates to the retrieval of health care information. Nearly 52 percent of patients who discussed the results of their Internet searches with their physicians found that their physician became more productive. Half of the individuals surveyed used the internet for more information. The Internet will continue to be an important tool for patients seeking medical information. As always, credibility, content and disclosure are important issues for health related Internet information sites. www.VeinsVeinsVeins.com is a credible website about venous disorders, venous reflux, varicose veins, spider veins and all phlebology related issues.
Yes, especially if you don't mind wearing them. Light compression stocking use can reduce the feeling of heaviness in the legs, especially after standing for long periods of time. Airline stewardesses who wear light compression stockings (15 - 20 mm Hg) report markedly less leg edema (swelling) and less aching, tiredness and discomfort in the legs. Another benefit of wearing such support stockings during air travel is that it reduces the likelihood of forming blood clots (deep vein clots, DVT) in the legs. You cannot buy compression stockings off the rack from a pharmacy. For proper function, they must be fitted to accurately measures standards by professionals which are employed at medical durable supply stores. Find out from your phlebologist (vein specialist) a list of stores who specialize in venous compression garments.
Tell me about compression garments and stockings
The end result of vein problems in the legs is venous hypertension in the forom of high pressures in the veins during ambulation or walking. This condition is called ambulatory venous hypertension. The golas of compression therapy is several fold:
1. help prevent clot formation in hospitalized patients and individuals who are inactive
2. improve the return of blood from the legs
3. counter the effects of ambulatory venous hypertension
4. help control the progression of venous disease
5. reduce and control swelling in the legs (Edema)
Compression venous garments increase tissue pressure, reduce tissue swelling (edema), increase the velocity of blood flow in the veins and reduce venous reflux, i.e. tendency for venous blood to slush back into the legs.
To get evaluated for compression garments (compression stockings for vein problems), consult a vein specialist, also known as a phlebologist. The goals of compression garments is threefold:
1. they have to treat the condition
2. they have to be comfortable to wear and properly fitted
3. they have to be reasonably acceptable to wear from a cosmetic standpoint.
For more information or evaluation, contact Dr. Karamanoukian for a consultation at the Vein Treatment Center. Our offices are not in the business of selling compression garments - this is relegated to medical durable supply companies. But, a prescription is required from a Phlebologist for you to aquire these compression stockings that are considered 'of medical necessity'.
View animation of how varicose veins form:
I had VNUS Closure by a radiologist and still have all of my varicose veins. What should I do now?
It is very interesting that VNUS Closure is marketed for varicose veins, but in fact, is FDA approved for venous reflux disease. It is used to treat venous reflux disease involving the great saphenous vein, short (lesser) saphenous vein or perforator veins. However, it is being used for varicose veins by those who are not properly trained or who are using it for that reason. It can work to close varicose veins but can leave you with other vein problems that require additional expertise, often by doctors who are phlebologists (certified vein specialists).
Some doctors that perform VNUS or EVLT only know how to do this one procedure. Phlebology requires a whole armamentarium of treatment modalities and it behooves you to be aware of this and to seek someone who is not just a 'catheter jockey'. Anyone can do the VNUS CLosure procedure in my opinion. But only experienced phlebologists know how to take care of the rest of your vein issues - varicose veins, reticular veins, spider veins, perforator veins, skin changes, venous stasis ulcers...).
The doctor who treated you is probably not experienced in these procedures and in the attempt to sign you up for the procedure promised you the world. With proper evaluation, the physician should be able to tell you up front if the varicose veins associated with venous reflux disease of the great saphenous system will go away following VNUS Closure or EVLT. In fact, depending on how far they are from the thigh and in what distribution they occur in the leg, published studies show that less than 30 % of varicose veins go away and disappear after VNUS Clousre of the great saphenous vein.
If proper evaluation is performed, a phlebologist with large experience should be able to tell you at the time of consultation if additional treatments are needed such as microphlebectomy, sclerotherapy or laser procedures for spider veins, reticular veins or feeder veins.
In any case, nothing wrong was done. You had proper treatment for venous reflux disease and now you must see a phlebologist with experience to take care of the rest of these problems. There is no one procedure which treats all of these vein problems - and they all need different types of treatments and you should have sought someone who does all of them.
Most large cities have phlebologists who take a comprehensive approach to treat vein disease. Contact the American Board of Phlebology to find out which doctors in your city are Board Certified in Phlebology. Dr. Hratch Karamanoukian and Dr. Raffy Karamanoukian were one of the earliest in the U.S. to seek board certification in Phlebology and recieved that status in 2009. A Board Certified Phlebologist performs the whole gamet of vein care, from A to Z, and not just endovenous ablation procedures such as VNUS Closure and EVLT!
What is the latest about deep vein clots, air travel and air pollution?
Researchers at Harvard published a study in May 2008 in the Archives of Internal Medicine that investigated the association of particulate air pollution to deep vein thrombosis, i.e. deep vein clots (1). It is well accepted that air pollution is linked to heart disease and stroke but the association with deep vein clots was unknown until this study was published. Dr. Baccarelli and colleagues studied this phenomenon in subjects living in the Lombardy region in Italy. They examined the association of exposure to particulate matter of less than 10 microns. Using 870 patients and 1210 controls, they concluded that long-term exposure to particulate air pollution is associated with altered coagulation function and deep vein clot formation risk. Of note (and perhaps too detailed for this discussion), each increase of 10 microg/m3 in particular matter in air was associated with a 70% increase in deep vein clot (DVT) risk. So, avoid living in cities with a significant burden of air pollution ro reduce this risk. By the way, it will also reduce your chances of developing asthma, heart disease and stroke.
image taken from topnews.in on January 11, 2009
Deep vein thrombosis (DVT) and pulmonary embolism:
Deep venous thrombosis (DVT) is the formation of blood clots in the deep veins of the leg or arms (rarely). This potentially life threatening condition has an incidence of about 5 to 20 million cases per year in the United States.
The main clinical concern with DVT is the potential of a thrombus (blood clot) to break free, travel through the inferior vena cava, through the heart, and get lodged in the vessels of the lungs. This event, called pulmonary embolism, carries a mortality rate of roughly 20 to 30%.
The formation of DVT’s can be attributed to one or more of the following factors: venous stasis (sluggish blood flow), injury of the blood vessel wall, or hypercoaguability (increased tendency of blood to clot).
Risk factors for DVT formation include age >40, obesity, smoking, pregnancy, trauma, IV drug use, or prolonged immobilization - such as due to chronic illness or long trips in cars or airplanes.
People with cancer, congestive heart failure, lupus, or recent heart attack or stroke are also prone to DVT’s. Recent surgery, chemotherapy, and hormone replacement therapy are risk factors as well.
Patients with DVT’s of the lower extremities have pain and swelling of the affected leg about 75% of the time. Other symptoms may include increased warmth and redness of the leg and occasionally low grade fever. DVT’s usually occur in the mid to upper leg.
The most commonly used test to check for DVT is duplex ultrasonography, which has very good sensitivity and specificity in certain patients. It is most reliable when used on patients who are symptomatic, especially when the symptoms are localized above the knee and below the groin. The most accurate test for DVT is venography, in which dye is injected into the veins of the involved leg. A blood test can also be done, which checks for D-dimer fragments. This test is of limited usefulness, however, as it has a high rate of false positives.
DVT’s are treated by administering anticoagulants (blood thinners) such as heparin or warfarin. Patients are generally started on heparin for immediate anticoagulation, and then continued on warfarin for 6 weeks to 6 months. Patients who are anticoagulated for 3 to 6 months have roughly on half the DVT recurrence rate of those who are anticoagulated for only 4 to 6 weeks. Anticoagulants are contraindicated in patients with active bleeding or bleeding disorders. These patients may benefit from placement of a Greenfield filter in the inferior vena cava. By placing a filter in the vessel which returns blood from the legs, any thrombi are screened out before they can get lodged in the vessels of the lungs.
Unless one succumbs to the complication of DVT, such as a massive pulmonary embolism, the outcomes in patients are good.
Animation of a DVT (deep vein thrombosis)
Watch this video about clotting, DVT and pulmonary embolism
What is the difference between VNUS Closure and EVLT?
VNUS Closure uses radiofrequency energy to close the great saphenous or lesser (short) saphenous vein endouminally, that is, from within the vein. Instead of stripping the vein, access is gained into the great saphenous vein through a puncture wound and a catheter is passed into the vein and advanced towards the groin. As the catheter is pulled back and out of the body, radiofrequency energy is used and the vein is "Clsoed" or sealed from within.
EVLT or endovenous laser therapy is a trademarked procedure (formerly Diomed Holdings) which utilizes laser energy to do the same thing as the VNUS Closure catheter. The latest generation of EVLT devices, such as the one used at the Vein Treatment Center, called VenaCure EVLT Never Touch is associated with less bruising, pain and discomfort than VNUS FAST Closure. We have both technologies available at the Vein Treatment Center in Williamsville, NY as well as in our sister office in Santa Monica, CA which is directed by Dr Raffy Karamanoukian.
image of EVLT procedure
What is a telangiectasia? What is a spider vein?
A telangiectasia is a confluence of dilated intradermal venules of less than 1 mm in size. Telangiectasias are more commonly known as spider veins and thread veins. They can be pink, red and have different hues in the red to purple blue range. Spider veins occur in 15 % of men and 25 % of women in the general population.In the classification of veins, telangiectasias are classified as type I veins. We use the Palomar Laser system as well as traditional and foam sclerotherapy techniques to treat spider veins at the Vein Treatment Center.
What is a reticular vein?
A reticular vein is a dilated bluish intradermal vein, usually from 1 mm in diameter to less than 3 mm in diameter. They are usually tortuous. Reticular veins are also known as blue veins and intradermal varices. In the classification of veins, reticular veins are considered type III veins. Telangiectasias (type I veins) can result from refluxing reticular veins. When such reticular veins are associated with telangiectasias, they are called "feeder veins". If sclerotherapy is chosen as the treatment for a particuar patient, the reticular veins should be injected first and the telangiectasias last. Until the reticular veins are treatd first, telangiectasias should not be targeted so as to avoid early recurrence. We utilize dynamic foam sclerotherapy and ultrasound guided foa sclerotherapy to treat reticular veins at the Vein Treatment Center.
What is a varicose vein?
A varicose vein is a subcutaneous dilated vein larger than 3 mm in diameter in the upright posture. Varicose veins are also known as varix, varices and varicosities. Varicose veins can occur in ten quadrants: anterior thigh, medial thigh, lateral thigh, posterior thigh, anterior leg, medial leg, lateral leg and posterior leg. They can also occur in the medial and lateral ankles. Varicose veins are primarily from the great saphenous and short saphenous system of veins. The great saphenous vein courses from the ankle to the saphenous aperture, at the level of the groin where it joins the deep veins (femoral vein). The short saphenous vein, termed the lesser or small saphenous vein, runs behind the outer ankle to the back of the lack and joins the deep vein behind the knee, also known as the popliteal vein. Varicose veins originate in the great and short saphenous veins themselves or their branches.
Are spider veins purely cosmetic?
Varicose veins are enlarged veins that bulge through the skin and may appear as blue or purple knot-like cords. Varicose veins can occur anywhere in the body, but are more commonly found in the lower extremities. Spider veins, also known as telangiectasias are smaller than varicose veins and often look like a sunburst or "spider web." They are red or blue in color and are commonly found on the face and legs.
The most important consideration for a patient is to recognize whether spider veins are associated with venous reflux disease. If they are associated with venous reflux disease, then this has to be treated before cosmetic procedures such as sclerotherapy or topical lasers are used to obliterate these spider veins.
Venous reflux disease is currently treated in the office setting with the VNUS Closure procedure or endovenous laser procedures (EVLT, ELVeS, etc.). Alternatively, some surgeons still perform ligation and stripping procedures. Once these procedures are done, then it is ideal to follow this with topical transdermal laser treatment of the spider veins. It is more likely for spider veins to recur if underlying venous reflux disease is not addressed.
Another important point is that venous reflux disease is associated with symptoms in the legs, whereas pure spider veins are unlikely to be associated with symptoms in the leg - such as aching, pain, heaviness, tiredness, fatigue, itching, burning, cramping, throbbing, restlessness of the legs or swelling in the ankles or legs.
Venous reflux disease can be diagnosed with special maneuvers on physical examination. More specifically, it is confirmed and documented with Duplex venous ultrasonography.
In summary, be wary of just walking into any clinic to get laser treatments done for spider veins. Make sure that you are evaluated and venous reflux disease is excluded before you proceed with topical laser therapy for spider veins. This will save you the heartache of having repeat laser treatments which are costly and the dissatisfaction that goes with having repeated cosmetic procedures that are unnecessary.
Superficial thrombophlebitis of the legs is a condition where there is inflammation of superficial, as opposed to deep veinsof the lower extremities.
Superficial thrombophlebitis can occur in any superficial vein segment along the greater or lesser saphenous system. Patients experience pain and tenderness along the course of the vein - in the case of the great saphenous vein, it can be anywhere alng a line that connects the groin to the ankle. The skin overlying the varicose vein usually is warm to the touch, red and tender.
The significance of the phlebitis is that it can get quite symptomatic and painful - even trivial movement can trigger significant discomfort along these tender areas of the phlebitic vein and its branches.
Localized injury to the saphenous vein could be the inciting cause and/or some underlying thrombogenic disorder. Sometimes it occurs spontaneously without any discernable cause (idiopathic).
Treatment is with warm compresses or heating pads and taking antiinflammatory medications for 10-14 days.
Superficial thrombophlebitis of the great saphenous vein is only dangerous if the inflammation extends into the deep veins at the level of the groin, namely into the common femoral vein with thrombus (or clot) embolizing to the lungs (pulmonary emolism).
Often, serial Duplex venous ultrasound studies are necessary in order to ensure that thrombosis of the great saphenous or small (short) saphenous does not extend into the deep veins, comon femoral vein and popliteal vein respectively.
For a video clip of thrombosed superficial veins click on the clip below:
What can I do about a whole bunch of veins that are present on my foot?
A fan shaped pattern of small intradermal veins on the medial (inside) or lateral (outside) aspect of the ankle and foot is called corona phlebectatica, or corona phlebectasia.. Corona implies that they "crown" the ankle. Corona phlebectasia is thought to be an early sign af advanced venous reflux disease. This reflux typically originates at the saphenofemoral junction with venous blood refluxing into the great saphenous vein. Less commonly, saphenopopliteal reflux into the lesser (short) saphenous vein is the underlying cause of corona phlebectatsia. Other names for corona phlebectasia include "malleolar flare" and "ankle flare". Once the venous reflux is treated with VNUS Closure or EVLT, then the corona is treated with lasers, and rarely sclerotherapy.
How common are varicose veins?
It is estimated that in America, 72% of women and 42% of men will develop varicose veins by the age of 65. Prevalence is highly correlated to age and sex with women having an increased likelihood of having vein problems in each age group category.
This chapter is from the upcoming book "Doctor, Tell Me More About Vein Disorders" by Hratch L Karamanoukian, MD and Raffy L Karamanoukian, MD
What is lymphedema?
Lymphedema, unlike leg swelling (edema) due to venous reflux disease, is worse in the feet and toes. The foot and toes are involved and are described as "pillow feet and sausage toes". What descriminates lymphedema from leg sweling due to venous reflux disease is that leg elevation overnight DOES NOT relieve the edema. Also, patients rarely complain of symptoms other than the swelling. Patients with venous reflux disease complain of leg edema and heaviness and aching in the legs.
What medications cause leg swelling?
Medication related leg edema is almost always bilateral and equal. Medications that cause leg edema include - calcium channel blockers, hydralazine, estrogen and progesterone, NSAIDs (ibuprofen), COX2 inhibitors, clonidine, minoxidil, cilostazol, gabapentin and glucocorticoids, among others. Dr. Karamanoukian will go over your list of medications at the time of consultation to see if you are on any medications that cause leg swelling.
Do I have lymphedema or venous reflux disease?
Symptoms are usually lacking in patients with lymphedema. Patients with venous reflux disease typically have aching, pain, heaviness, tiredness, fatigue, cramping, throbbing and swelling. The foot and toes in lymphedema are described as "pillow feet and sausage toes" and the swelling is usually NOT relieved with overnight leg elevation. One of the benefits of being evaluated by a specialist who is Board Certified in Cardiac Surgery and Phlebology is that you will get evaluated by a clinician who can determine the etiology of lower extremity swelling and use his diverse background and expertise to help treat swelling in your legs.
How do vein valves work? What is venous reflux disease? What is venous insufficiency?
Vulvar varices are varicose veins in the external genitalia, i.e. vulva. They occur in 1 in 20 pregnancies, appearing in the second trimester usually. They usually present no symptoms but are considered 'unsightly' by most women and sometimes, their sexual partners. In some patients, they cause itching, burning or heaviness in the area.
It is important to exclude saphenofemoral venous reflux disease as a contributing factor - which is easily treated with VNUS Closure or EVLT.
this picture taken from phlebologia.com
What is congestive heart failure? How do you know if leg edema is from the heart or from venous reflux disease?
Congestive heart failure has been called the “new epidemic” of cardiovascular disease with 500,000 new cases diagnosed each year and a total of 3.5 million Americans affected by it at any time!
As the population ages and medical technology gets better and better, heart attack survivors will increase and the residual damage to the heart will leave more people with the diagnosis of congestive heart failure.
Unfortunately, the decrease in prevalence of congestive heart failure due to risk modification is not big enough to counteract the increasing population base of patients with congestive heart failure due to aging and a reduced mortality from heart related problems.
The annual health care cost of congestive heart failure in the United States exceeds $ 8 billion dollars and is projected to triple to $ 24 billion by the year 2010.
Dr. Karamanoukian is a heart surgeon and can tell you whether the swelling in your legs is from your heart, your kidneys, or from venous reflux disease.
Can restless legs result from venous reflux disease ? Venous insufficiency and restless legs syndrome (RLS)
The answer is YES. Venous reflux disease, also known as venous insufficiency can cause restless legs and in some patients restless legs syndrome (RLS).
In a recent study done in Texas, a cohort of patients who had restless legs syndrome were investigated by venous Doppler and determined to have venous reflux disease. They were randomized to receive 1) endovenous ablaion of the great saphenous vein with laser or 2) no treatment with endovenous laser.
Endovenous obliteration of the great saphenous can be performed with VNUS Closure or endovenous laser therapy (EVLT, ELVeS, EVL - all synonyms). VNUS Closure uses radiofrequency energy to ablate the vein.
In patients with RLS and venous reflux disease of the great saphenous vein, symptoms of RLS resolved following endovenous obliteration of the great saphenous vein. The authors concluded that patietns with RLS should be investigated with a venous Doppler to determine if they have venous reflux disease before they are initiated medical therapy.
Hayes CA et al. The effect of endovenous laser ablation on restless legs syndrome. Phlebology 2008; 23:112-117.
Dr. Karamanoukian has treated a lot of patients with RLS who have concurrent venous reflux disease. As well, he has developed an all natural formulation that helps treat restless legs and RLS. It is called Restless RLS.
Is leg elevation enough to heal a venous stasis ulcer?
Chronic venous reflux disease causing venous hypertension (i.e. high pressure in the venous system, not the arterial system) is believed to be the etiology of venous stasis ulcer formation in the legs. Compression garments and bandages as well as leg elevation has been considered a proven measure to help heal venous stasis ulcers. However, the most important component of care is treating the venous reflux disease using the newer ablative techniques such as VNUS Closure or endovenous laser therapy (EVLT). We have a very coprehensive program to treat patients with venous stasis ulcers (see section on Venous Stasis Ulcers).
Does horse chestnut extract help patients with venous reflux disease?
Absolutely yes. Horse chestnut extract, taken as 300 mg doses twice daily has been shown to be as effective as wearing compression venous stockings in eliminating symptoms associated with this condition. Conservative therapy of chronic venous insufficiency (CVI) consists largely of compression treatment with stocking garments. However, this often causes discomfort and has been associated with poor compliance. Therefore, oral drug treatment is an attractive option and researchers in the Cochrane Group have looked at the utility of using horse chestnut extract as an alternative. According to the Cochrane Group, "there appeared to be an improvement in chronic venous insufficiency, also known as venous reflux disease related signs and symptoms with the use of horse chestnut extract when compared with placebo". The evidence presented implies that horse chestnut extract is an efficacious and safe short-term treatment for chronic venous reflux disease. More definitive treatment includes endovenos oblitertion such as VNUS Closure or endovenous laser therapy (EVLT).
Can you do vein surgery on diabetics?
Absolutely yes. 20% of our patients have diabetes! However, meticulous surgical technique is necessary, as can be delivered by someone who has been trained as a heart surgeon.
What is Ambulatory Phlebectomy? What is Microphlebectomy?
Ambulatory phlebectomy is also known as microphlebectomy, tumescent ultracision microphlebectomy, stab phlebectomy, excisional phlebectomy, stab avulsion phlebectomy, hook phlebectomy and micro puncture phlebectomy.
The basic procedure in ambulatory phlebectomy is making a small puncture wound and removing varicose veins through them. They are typically done in the office using local anesthesia. Patients are discharged and can resume all activities immediately.
To see a short video clip of microphlebectomy by dr. Karamanoukian click on the link below:
In general, why do diabetics have impaired wound healing?
1. reduced tissue perfussion with oxygen and nutrients because of diseased small vessels
2. poor offloading of oxygen near the wounded tissue
3. poor deformability of red blood cells so that they are less likely to bring oxygenated hemoglobin to the wound
4. impaired immunity - poor chemotaxis - this is the body's ability to bring in white blood cells to the wounded tissue using chemoattractants
5. impaired immunity - poor phagocytosis - this is the ability of whie blood cells to engulf and eat (internalize) bacteria.
All of these factors contribute to the deficient wound healing in diabetics. As said above, meticulous surgical technique and experience with all facets of venous disease and surgery ensires success in over 99.7 % of cases.
What are the side effects of sclerotherapy?
You asked about side effects and most importantly one should remember that any of the sclerosant solutions can cause hyperpigmentation which in rare cases, can last as long as a year or more. To prevent hyperpigmentation, meticulous technique should be used as well as avoiding excessive pressure during the injection process to avoid extravasation of blood. As well, treating venous reflux disease will also reduce the likelihood of hyperpigmentation. Another important problem can be clot formation in injected reticular veins which should be evacuated with a micro puncture blade to minimize dermal pigmentation - i.e. hyperpigmentation. In patients at risk for hyperpigmentation, lasers are chosen instead.
Video clip of sclerotherapy by Dr. Karamanoukian (click on the link below):
What lasers are used to treat venous reflux disease? ELVes, EVLT and Cool Touch CTEV
The EVLT procedure uses a 810 nm Diode laser to ablate the great or lesser saphenous veins and to treat venous reflux disease.
The ElVeS system used a 1470 nm radial laser device and accomplishes the same goal in obliterating the saphenous veins.
Cool Touch uses the CTEV™ 1320 nm Nd:YAG Endovenous Laser to obliterate the great or lesser saphenous veins.
What is EVLT (endovenous laser therapy)?
Endovenous laser therapy is a minimally invasive alternative to traditional vein stripping. It utlizes a single skin puncture using local anesthesia in order to pass a laser fiber into the greater or lesser saphenous veins. It is typically performed in a doctor's office. Instead of painful ligation and vein stripping which puts patients out of commision for days or weeks, patients return to work the next day. This is significant benefit to patients and health care providers. Endovenous obliteration of the saphenous veins, also known as endovenous ablation procedures, have allowed patients to leave the office after 45 minutes and resume their exercise routines. Patients are encouraged to walk as much as possible afterwards and elevate their legs when they are sitting down. EVLT treats venous reflux disease where blood shuttles back into the legs because vein valves are not functoning properly. By ablating (closing) the vein below the valve, blood does not reflux back into the legs. Patients report less pain, heaviness, tiredness, fatigue, itching, burning, cramping or throbbing in the legs as well as relief from sweliing in the legs.
What causes varicose veins?
Varicose veins could occur in isolation or can result from associated venous reflux disease. Venous reflux disease occurs in 10% of patients with varicose veins. However, it is important when treating varicose veins to determine if the patient has venous reflux disease. If venous reflux disease is found, it is treated now with VNUS Closure or EVLT (endovenous laser therapy). Once VNUS Closure is performed, the varicose veins that are still there are treated with microphlebectomy, and rarely with treaditional sclerotherapy. Other factors that contribute to the formation of varicose veins include obesity, hormonal changes (women), family history of varicose veins and venous stasis ulcers and male parent with varicose veins and venous reflux disease, among others.
What does smoking do to wound healing? Should I stop smoking before surgery?
The association between cigarette smoking and delayed wound healing is well known to cosmetic surgeons, plastic and reconstructive surgeons, thoracic surgeons and general surgeons. The documented effects of the toxic constituents of cigarette smoke arise from nicotine, carbon monoxide and hydrogen cyanide. All of these have been shown to have deleterious effects on wound healing and wound repair:
- Nicotine is a vasoconstrictor that reduces nutritional blood flow to the skin, resulting in tissue ischemia and impaired healing of injured tissue
- Carbon monoxide diminishes oxygen transport and metabolism in ijjured and healthy tissue
- Hydrogen cyanide inhibits the enzyme systems necessary for oxidative metabolism and oxygen transport at the cellular level
- Smokers have a higher incidence of unsatisfactory healing after face-lift, rhinoplasty, blepharoplasty and breast augmentation
- Smokers should be advised to stop smoking 3 weeks prior to elective cosmetic surgery or any traumatic injury requiring reconstructive surgery
What are inherited conditions that predispose one to deep vein thrombosis (DVT)?
Inherited conditions can lead to a genetic predisposition to develop venous thrombotic events (deep vein clots):
- Factor V Leiden mutation (most common)
- Activated protein C mutations
- Antithrombin mutations
- Protein C mutations
- Protein S mutations
- Elevated factor VIII levels
- Prothrombin gene mutations
These conditions are frequently the cause of clot formation in young individuals (< 45 years) and may contribute to deep vein clots at any age. To learn more about these conditions, or if you have developed a deep vein clot at an early age - or have had recurrent deep vein clots (more than 1), consult your doctor to get evaluated for these inherited conditions using a simple blood test.
What are acquired conditons that predispose one to deep vein thrombosis (DVT)?I
n addition to inherited risk factors for deep vein clots, there are also acquired conditions that lead to DVT's (deep vein thrombosis).
This is a list of the 7 most common acquired causes for deep vein clot formaion:
- antiphospholipid syndrome
- anticardiolipin antibodies
- lupus antibodies
- activated protein C resistance
- malignancy (tumors)
- autoimmune disorders
Sometimes, the first clinical presentation of a deep vein clot is a malignancy that has hereto yet to be diagnosed. Patients are investigated and found to have a malignant tumor, such as breast cancer, lung cancer or colon cancer !
How do vitamins affect wound healing?
Vitamin A deficiency has been associated with slowed epithelization, decreased collagen synthesis and increased susceptibility to infection. Vitamin C is an essential cofactor for collagen synthesis. In conditions such as scurvy, which is rare in today's world, the collagen synthesized is not hydroxylated - it is relatively unstable and subject to degradation. Vitamin K* deficiency results in a deficiency in the production of vitamin K dependent clotting factors - factors II, VII, IX and X. This results in bleeding, hematoma formation and retarded wound healing. Vitamin K deficiency is rare in healthy individuals. *we do not recommend taking vitamin K as it increases clotting and may predispose patients to deep vein clot formation.
What is a venous Duplex scan?
If you are suspected to have problems with your veins, a Duplex ultrasound may be done to determine the extent of venous disease. Ultrasound imaging, also called ultrasound scanning involves exposing the lower extremities to high-frequency sound waves to produce 2 or 3 dimensional pictures. Because ultrasound images are captured in real-time, they can show the structure and movement of the body's internal organs, as well as blood flowing through blood vessels. A Doppler ultrasound study os routinely used as part of a venous ultrasound examination to evaluate blood flow in the superficial and deep veins of the lower extremities. Ultrasound and Doppler combned is called a Duplex scan.
What is the most common reason for performing a venous Duplex scan?
The most common reason for a venous ultrasound and Doppler (Duplex) scan is to exclude deep vein clots (DVT). A Duplex scan is also performed to determine if there is venous insufficiency, aslo called venous reflux disease.
What is venous refluc disease? What is venous insufficiency?
Venous reflux disease can occur throughout the venous system, in the deep or superficial veins.
Superficial venous reflux disease can cause reflux of blood from the deep veins into the superficial veins in the legs - namely into the great and lesser saphenous veins. The greaer saphenous system is on the inside of the thigh and leg and starts at the ankles and drains into the deep femoral veins (common femoral vein) in the groin. he lesser (or short) saphenous system is in the backs of the legs (leg meaning below the knee).
Until now, venous reflux was treated primarily by tying off these veins (ligation) and removing the offending superficial veins (stripping). Known as ligation and stripping, millions of men and women received these operations and were bedridden for days and were unable to return to their normal activities for weeks.
The VNUS Closure procedure and its laser equivalents (EVLT, ELVes) have taken another approach to this problem. Instead of stripping the veins, a catheter is introduced into the vein and energy is delivered endovenously (i.e. in the vein) to shut the vein from the inside and as a result, channel blood into the healthier deep veins of the lower extremities.
The VNUS Closure procedure (FAST Closure) and EVLT (endovenous laser therapy) can be performed in the office by skilled surgeons using a puncture wound in the thigh and patients can walk off the table 35 minutes later and most are able to resume almost all of their activities within 24 hours.
Arnica after vein surgery?
Is there scientific data to support the use of Arnica after cosmetic surgery or vein surgery?
Going back to 1998, the Cochrane Study group analyzed the efficacy of homeopathic Arnica Montana in published studies. Eight trials fulfilled all inclusion criteria. Most related to conditions associated with tissue trauma. On balance, the authors of this landmark study showed that there is no evidence to support that "homeopathic arnica is efficacious beyond a placebo effect ".
Since then, there has been a resurgence of studies done in a scientific manner. The vast majority show efficacy in using Arnica to reduce bruising after cosmetic surgery, orthopedic surgery and head and neck surgery:
A recent study showed that arnica may be effective in reducing edema during the early postoperative period following rhinoplasty. Arnica does not appear to provide any benefit with regard to extent and intensity of bruising (ecchymosis).
In patients who had a face lift, Arnica was shown in a computer model that graded the degree of bruising to be efficacious and helpful in reducing the amount of bruising.
Until more randomized controlled studies are published, the preponderance of current data suggests that Arnica Montana reduces bruising and tissue swelling (edema) after cosmetic surgery.
I had vein surgery 10 years ago and have developed a lot of veins in my thigh and groin ..... what can I do about neovascularization?
This process is called neovascularisation, or 'new growth'. It is a phenomenon that is gaining increasing recognition in the vein literature and among phlebologists. It has been shown that following the ligation and stripping procedure, many tiny vein branches can grow and develop through scar tissue in a matter of months, providing a new connection between deep and superficial veins even after an entirely adequate operation. Recognition of this fact has led to a number of modifications of surgical technique aimed at reducing the incidence of the problem. So, yes, you are still a candidate for newer techniques and modalities of care to take care of this problem.
What techniques are used to prevent neovascularization?
Vein stripping has a limited role today with the advent and popularity of VNUS Closure and EVLT. However, when it is necessary and done, it is recommended that cautery be used to destroy the ends of veins so as for them not to 'reconnect'; another technique is to cover the stumps of the large veins such as the divided great saphenous vein with PTFE so as to minimize likelihood of connection with the deep system of veins; finally, a standard of care should be to routinely strip the great saphenous in the thigh so as to prevent 'connection' to the saphenous below the knee.
Do I have to wear compression stockings once my venous ulcer heals?
Once venous stasis ulcers have healed, graded compression stockings have to worn regularly in order to reduce the likelihood of recurrence. Studies show that grade II compression stocking (20 - 30 mm Hg) are needed and they should be at least to the level of the knee. Compliance in wearing compression stockings is noted to be poor, with only 1 in 2 patients following through with these recommendations. The compliance does improve if there is monitoring by home health care nurses or when there is physician supervision. In a recently published study, recurrence of venous stasis ulcer is 32% at 5 years when compression stockings are worn and 70% at 5 years when compression stockings are not worn.
image from makemeheal.com accessed on January 11, 2009
image from dukehealth.org accessed on January 11, 2009
Why do you do the Doppler tests in your office? can I get them elsewhere?
Of course you can get them elsewhere. At the Vein Treatment Center we have developed a one-stop-shop where you come in for your consultation, are seen by the doctor who may recommend a venous doppler scan. The alternative would be to send you to another place where a diagnostic study is done by a technician and or ultrasonographer who does not practice phlebology. You are then brought back to discuss the findings of that test at a later date. Innumerable variations and subtleties of varicose vein disease often get lost if the doctor provides treatment based solely on an outside report, without the benefit of a hands-on look at the actual anatomy and physiology of the venous system. Once Dr. Karamanoukian examines your legs, he or his technician will perform the venous Doppler study and will immediately put the results in perspective and give you a treament plan. The treatment plan will be followed and you can schedule the proposed procedures before you leave the office and only after all of your questions are answered !
Why not choose a general surgeon?
There is nothing wrong with having a general surgeon do the procedures. However, a dedicated surgeon who is also a phlebologist (vein specialist) brings a whole element of specialty care to the practice of vein disorders. At the Vein Treatment Center, the focus is not just one procedure for all patients, namely 'vein stripping', but rather a variety of procedures that are individualized and targeted to treat specific problems: varicose veins, truncal venous reflux disease, perforator venous reflux disease, vein related skin diseases, treatment of venous stasis ulcers, VNUS Closure, EVLT, topical lasers for spider and reticular veins, SEPS, etc. For a detailed evaluation, call the Vein Treatment Center for a consulation with Dr. Hratch Karamanoukian. Dr. Raffy Karamanoukian is a diplomate of the American Board of Plastic Surgery (ABPS) who collaborates with Dr. Hratch Karamanoukian at the Vein Treatment Center. Dr. Raffy Karamanoukian is Director of the Santa Monica Vein Center and is focused on the most advanced treatments for his patients with vein disorders. He also performs specialty muscle flaps and surgical wound treatments for patients with venous stasis ulcers. Dr. Raffy can be reached through his website www.SantaMonicaVeinCenter.com
What is saphenopopliteal venous reflux disease?