Get a Leg Up on Summer

A roadmap for treating legs that look like roadmaps

If your legs look like a roadmap, and especially if they hurt, you may have decided that this is the year you’ll do something about your unsightly veins. This is not your mother’s vein treatment—diagnosis and therapy have both improved.

Dr. Keith Nichols of The Circulatory Centers in Suffolk and Virginia Beach has been treating problem veins for 11 years. His oldest patient to date was 94; the youngest, 8.
You’d think diagnosis would be simple because varicose veins and their smaller cousins, reticular veins and spider veins, are easy to see. The big ropy blue, red or flesh-colored veins are definitely varicose veins. They’re caused when valves in the veins start leaking, causing the blood to flow backwards, Nichols says. Reticular veins are a lacy pattern of greenish blue veins and spider veins are both smaller and closer to the surface than varicose veins, Nichols says. Spider and reticular veins can be caused by hormone changes, exposure to the sun and injuries. But these smaller problem veins also can be caused by backflow from varicose veins—and that’s why proper diagnosis is key, Nicholas says. For effective treatment, the biggest leaks must be eliminated before focusing on smaller leaks, he says.

The source of the main leak can be deceiving on physical examination—the vein that appears to be the main culprit may not be the one causing the problem, he says.

“Fifteen years ago, we sometimes treated the wrong vein,” Nichols says. “We made that vein go away, but it was the wrong vein.”

Diagnostic ultrasound has made it easier to pinpoint the bigger vein with the bad valve causing the backflow, he says. “We find the biggest leak where the backwards flow is the worst—like having an open bathtub drain,” Nichols says.

Fifteen years ago, vein stripping was the standard treatment, Nichols says. That involves making an incision at the top of the leg and behind the knee and using a wire to pull the vein out, according to the Institute for Quality and Efficiency in Health Care.

Now there are nonsurgical options available. Nichols’ treatments of choice are Endovascular Laser Ablation (EVLA) and sclerotherapy.

For the larger varicose veins, Nichols uses EVLA to close the big leaks. A laser fiber is inserted into the vein via a needle stick, Nichols says. The laser heats the vein from the inside out and kills it. The body then reabsorbs the vein. EVLA can be done in the doctor’s office without general anesthesia, he says.

“EVLA is meant for larger, relatively straight veins to close high pressure large leaks,” Nichols says. “The success rate is 99 percent.”

You’ll be ready to return to work in one to two days, he says.


Once the large veins are closed via EVLA, Nichols often uses sclerotherapy to close the smaller spider and reticular veins. Sclerotherapy involves injecting a medication in the veins that causes the veins to close and later be absorbed by the body, he says. In the past, doctors used a saline solution “that hurts like liquid fire,” Nichols says. He uses polidocanol (trade name: Asclera) instead, which also has built-in Novocain-like properties and numbs as the procedure continues.

“I used saline one time when the patient insisted I use it,” he says. “The patient was happy with the results but for the next treatment, she wanted to go with the option that didn’t hurt.”

The success rate for sclerotherapy is not as high as for EVLA, but the technique is effective in veins where EVLA won’t work. “We can use sclerotherapy in veins where we can’t do EVLA,” Nichols says. “For EVLA, the vein has to be fairly straight to get the laser to go along the course of the vein. The vein can look like a cloverleaf on I-264 and sclerotherapy treatment can still be successful.”

Swelling usually subsides 20 minutes after sclerotherapy, but it can take a few days to eight weeks for the treated veins to completely disappear, Nichols says.

Not worried about how your legs look? Keep in mind that varicose veins also can cause pain and health problems. Varicose veins can lead to swelling, heaviness and aching in the legs as well as fatigue, he says. More serious problems include external bleeding and potentially threatening blood clots, Nichols says. The 94-year-old woman he treated had a varicose vein that caused her skin to break down like a bed sore, he says.

One more reason to seek treatment now as the weather improves: your recovery will include walking, Nichols says. Get treatment soon and you’ll be back on your feet and in shorts well before bathing suit season.

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