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Understanding Sclerotherapy Vein Treatment

By Dr Ken Seifert – Follow me on +

My name is Ken Seifert, M.D. I work at Optima Vein Care and I will be publishing in this blog weekly to help inform the public about the work we do and the help we can provide you with your spider veins and varicose veins.

Continue reading “Understanding Sclerotherapy Vein Treatment” »

Polidocanol for Vein Sclerotherapy

By Dr Ken Seifert – Follow me on +

My name is Ken Seifert, M.D. I work at Optima Vein Care and I will be publishing in this blog weekly to help inform the public about the work we do and the help we can provide you with your varicose and spider veins.

Last week I started to talk about what is perhaps the most important method of treatment of varicose veins: sclerotherapy. I talked about the substances used for sclerotherapy. The substance we use now is called polidocanol. It works by injuring the layer of cells that line the inside of veins. Your immune system will then attack the vein and over the course of time, sometimes several months, the vein will dissolve and get reabsorbed. There are several subjects that I want to write about having to do with sclerotherapy.

The first subject is concentration of the polidocanol. We use three different concentrations, depending on the size and the depth of the vein. For tiny veins just under the skin we use a very dilute concentration. For slightly larger veins that are a little deeper, we use a medium concentration and for the main veins of the superficial system we use the strongest concentration. The advantages of a strong concentration is that it is more effective. The disadvantages of a strong concentration is that the vein will dissolve faster and the iron in the blood will get under the skin and stain the skin brown. This brown staining often goes away, but not always and even when it goes away, it is very concerning until it does go away. The fading of the staining can take up to two years to go away. There are some measures we can take to speed up the fading of the staining, but we try to prevent it. The best way to prevent it is to use a lower concentration of polidocanol, but then there is a potential for failure. Personally, I prefer to have to re-sclerose a vein rather than try to wait for staining to go away, but the issue can lead to frustration for both the patient and the Doctor.

Staining is usually not a problem for the major parts of the superficial vein system, as these veins are usually deep enough that the skin will not stain. But for some of the smaller branches and for the small surface veins staining occurs and can take months go fade. It is very concerning. Some people just want the pain to go away but many hope for improved appearance. And even brown stains can be better looking than the bulges that were there before, but all patients must be aware that brown stains, even permanent brown stains, can sometimes replace the ugly bulges. But by carefully choosing the concentration of polidocanol, I can minimize that risk. This careful choice, though, can also prolong the treatment as I work my way up in concentration of solution in a methodical progression from weaker to stronger solutions to find the right concentration that results in ablation of the vein with minimal staining.

Next week I will write about another technique used in sclerotherapy: Foaming.

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Sclerotherapy vs Microphlebectomy

By Dr Ken Seifert – Follow me on +

My name is Ken Seifert, M.D. I work at Optima Vein Care and I will be publishing in this blog weekly to help inform the public about the work we do and the help we can provide you with your varicose and spider veins.

In the last blog I wrote about a procedure called “microphlebectomy” in which I remove large veins that are large branches of the vein system that you see bulging under your skin.

In many people, the bulges are not as large and I do not recommend microphlebectomy. The other way the visible veins can be treated is by a procedure called “sclerotherapy”. The word means “scaring therapy. We use a substance that causes the inside lining of the vein to become inflamed and the vein then closes and scars shut and is reabsorbed by your body.

The inflammation is mild and painless. There sometimes is some itching involved, but it is not severe. The process may take several months to complete, and it is not unusual for a vein to have to injected several times before it is completely treated. However, the needles we use for this are small, even tiny, so that the entire procedure is painless and no anesthesia is used, or is necessary.

There are three substances that have been used in the United States. Long ago, the most commonly used substance was hyper-tonic saline. That is, a salt water solution with a high concentration of salt. The high concentration of salt caused the cells that line the inside of the vein to burst and that led to the inflammation that would destroy the vein and allow it to be reabsorbed. Hyper-tonic saline had one advantage: No one is allergic to salt water. But it had two disadvantages. First of all, it hurt when it was injected. It stung. Secondly, if some of the hyper-tonic saline got under the skin, outside of the vein, it could cause the skin to become inflamed and the skin could die, leaving a scar. For those reasons, hyper-tonic saline has fallen out of favor and I have not used it for the last 15 years.

The next substance to gain popularity was sodium tetradecyl sulfate. It was introduced and approved by the United States Food and Drug Administration and was widely used until about three years ago and is still used. It acts by dissolving the protective layer of the vein lining. The immune system then attacks the vein and the vein begins to shrivel up and gets re-absorbed by your body. This process may take weeks or even months, especially for the larger veins. It is this that makes me favor microphlebectomy, which I described in the last blog, for large veins. By “large” I mean about the size of your little finger. But for smaller veins than that, or even when there are only a few, say two or three large veins, sclerotherapy is often the best approach.

More recently, a new substance has gained favor and I now use it almost exclusively. That is polidocanol. It was used in Europe for decades and was approved for sclerotherapy by the United States Food and Drug Administration in 2010. It works like sodium tetradecyl sulfate, but is more forgiving in that it will not cause the skin to scar if some of it gets out under the skin during an injection.

Sclerotherapy is a very important part of vein treatment and I will write some more about it next week. Follow Optima Vein Care on Google+.

Microphlebectomy Vein Procedures

My name is Ken Seifert, M.D. I work at Optima Vein Care and I will be publishing in this blog weekly to help inform the public about the work we do and the help we can provide you with your varicose and spider veins.

You can think about the superficial vein system of the legs like an upside down tree, with trunks and branches and twigs. The main trunks of the superficial vein system are the great saphenous vein that starts in the groin and goes down the inside of the thigh and leg and ends at the inside of the ankle and the small saphenous vein that starts behind the knee and goes down the back of the calf and then goes over to the outside of the ankle. There are other trunks, especially originating near the great saphenous vein. If these trunk veins are incompetent, that is, if they have valves that are allowing blood to leak backwards, then they need to be closed. The best way to close them is by using an optical fiber and a laser to heat them from the inside. If the trunk is not straight enough to do this, then I can sometimes inject an irritating substance into the vein and use that to close the vein, and sometimes I have to resort to making an incision and cutting down on the vein, under local anesthesia and tying the vein closed directly.

That will take care of the trunks. What about the branches? They usually will get smaller after the procedures on the trunks, but they rarely go away and often still are almost as visible as before.

There are two ways I can make the branches go away. The first is a procedure called ambulatory microphlebectomy, or just microphlebectomy. In this vein procedure, I will have you stand and then I will use a Sharpie marker to mark the veins on your legs. Using the same tumescent local anesthesia I used for the EVLT procedure, I make tiny incisions at each mark. By tiny, I mean 2 mm long. I have a special scalpel blade that only allows a 2 mm incision. Then, I use a special hook to grab each vein and pull it up to the skin where I can pull it out.

The vein breaks off, and any branches break off. You might wonder what happens to the blood in the vein and in the branches. As I pull the vein out, the blood is squeezed back into your circulatory system, but inevitably, some of the broken veins leak blood out of the wound. The tumescent anesthesia has a substance in it that causes the vein to go into a spasm and not leak as much. Being in a recumbent position lowers the pressure in the vein so less blood leaks out, and then we apply pressure with a dressing and compression stocking and that keeps the bleeding minimal. There is some bruising under the skin following the operation due to blood from the broken vein. It goes away in a few weeks.

The incisions I make to do this are usually easily closed with a steri-strip, a sterile piece of tape. Occasionally I will have to use a suture, and this will have to be removed in a week. But usually, a steri-strip will do. These incisions often heal with no scar at all and are completely invisible. Other times they end up looking like a freckle. The way they look depends on the the patient’s skin and the location. But I have never had anyone who was upset about the scars from microphlebectomy.

There is another way to treat the branch veins. I’ll talk about that next week.