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This is a very common condition affecting the veins of the lower extremities in
millions of people in the USA. Women are affected nearly twice as frequently as
men but it is not at all uncommon for men to be affected. The anatomy of the veins
of the leg is basically that of two parallel systems that extend from the foot to
the groin. The “deep veins” are located within the muscles of the legs. The “superficial
veins” are located just beneath the skin. The main superficial veins are called
the "greater saphenous vein" (on the inside of the thigh) and the "lesser saphenous
vein" (behind the knee and extending down the back of the calf). These veins are
not required for the normal functioning of the leg. In fact, these are the veins
that are removed from the leg when they are needed to create a "bypass" for blocked
arteries in the heart or some other portion of the body.
When these superficial veins become large, bulging, and tortuous, they are called
“varicose veins”. The condition results from a weakness of the valves within the
veins. This weakness can be hereditary, or acquired due to occupations associated
with prolonged standing, or due to an injury to the valves within the veins of the
leg (see Video #13).
Varicose veins can be relatively mild in appearance (although even the “mild” form
can be painful) such as what are called “telangiectasias” or “spider veins (see
photo 1), or they can be huge veins which are easily visible – sometimes
being so large that they can be seen bulging through a pair of pants (see
In addition to the cosmetic considerations associated with varicose veins, there
can be very significant leg symptoms associated with varicose veins. These symptoms
Over the course of years, varicose veins can lead to leg swelling ("edema"), brown
discoloration of the skin of the leg around the ankles (called "stasis pigmentation"),
or actual breakdown of the skin (called "stasis ulceration").
The swelling of the lower legs or “edema” is caused by leakage of fluid (essentially
water) out of the varicose veins because these bulging veins are under high pressure.
With prolonged pressure associated with untreated varicose veins, there is actual
leakage of blood cells into the tissues of the lower leg. The skin becomes brown
in color due to deposition of hemoglobin within the tissues. This “stasis pigmentation”
can be associated with itching and thickening of the skin (see photo 3).
With time, the skin can become so damaged and fragile that actual “stasis ulceration”
can occur (see photo 4). This condition can be extremely painful
and, although it rarely leads to limb loss, it is a cause of significant disability
Since the superficial veins in the legs are usually not necessary for normal functioning
of the lower extremities (this is the vein that is removed for bypass of blocked
arteries in the heart, for example), these veins can be removed without any consequence.
One situation where superficial varicose veins of the lower extremities cannot be
removed is when the deep veins of the leg are blocked due to previous episodes of
phlebitis. In this instance, the superficial veins should not be removed because
this may result in significant swelling of the lower extremity. Prior to removing
varicose veins of the legs, the patient's surgeon should evaluate the deep system
of veins (usually by ultrasound evaluation) to be certain that the deep system is
not blocked. Most varicose vein surgery can be performed in the outpatient setting.
The following outlines some of the most common treatment options for lower extremity
This is a non-surgical treatment used to eliminate small varicose veins and spider
veins. It involves injecting a sclerosant solution into the vein which causes the
vein to collapse and disappear. This procedure is performed in the office and generally
requires several visits since most people have multiple areas of spider veins on
their lower extremities.
Laser treatments can be used for removing spider veins of the lower extremities.
This involves no injections and is performed in an office setting.
Endovenous laser treatment is performed under local anesthesia in an office setting.
During this procedure, a laser catheter is inserted into a large varicose vein in
the thigh and laser energy is used to seal the vein closed. This is a variant on
surgical phlebectomy (in which a large saphenous vein of the thigh is actually removed
from the patient). The advantage of the laser treatment is that it can be performed
in the office under local anesthesia and recovery is faster than if the vein is
“stripped” using surgical techniques.
This is a surgical procedure in which small clusters of varicose veins are removed
through tiny (1/8 inch) incisions under local anesthesia in the office setting.
It is frequently used in conjunction with EVLT of the saphenous vein in the thigh.