Ultrasound imaging uses high frequency sound waves to produce pictures of the inside of the body. In varicose vein treatment, it is used to map out the veins and to detect venous incompetence or blockages to blood flow due to blood clots. The machine is also used as an aid in the placement of a needle, a catheter, or a laser fiber during foam Sclerotherapy or endovenous ablation of varicose veins, such as Venefit™ or EVLT procedures.
The closurefast catheter attached to the Venefit™ radiofrequency generator.
The endovenous laser fiber attached to Sciton's Joule platform.
The ClariVein self-contained disposable system for varicose vein treatment.
The SEPS Procedure.
Varicose Vein Treatment at Our Vein Center
The appearance of bulging leg varicose veins is what prompts most patients to seek varicose vein treatment. For some patients, symptoms of chronic venous insufficiency, CVI are completely absent, and the cosmetic improvement of their legs is their primary motivator for seeking varicose vein treatment. Interestingly, the veins that are the root cause of bulging leg varicose veins, and therefore need treatment, are often not the very superficial varicose veins for which patients may have originally sought medical attention. Patients are often surprised to learn that a huge bulging varicose vein network on a calf may have its origin at the groin level (saphenofemoral junction) or back of the knee (saphenopopliteal junction) where the largest superficial veins, the saphenous veins, communicate directly with the deep vein system.
CVI and the resulting varicose veins can be managed conservatively with compression stockings; however, definitive CVI and varicose vein therapy requires the elimination of the saphenous veins before addressing the visible branch varicosities that are most obvious to the patient. Duplex ultrasound is an essential diagnostic test in any varicose vein treatment plan. The test is necessary prior to any treatment, because it pinpoints where the damaged valves are in the veins and therefore can dramatically increase your chances of successful varicose vein treatment.
Currently, the removal or elimination of incompetent veins is the only effective and lasting treatment for CVI (regardless of its stage) and associated symptoms, such as bulging superficial leg varicose veins and heavy and aching legs. This is achieved either by surgically removing the veins, or by one of the newer non surgical, minimally invasive varicose vein treatment procedures. It is important to understand that in most patients, the superficial venous network, including the saphenous veins, is a secondary, redundant system that is not essential for normal circulation of the venous blood in the legs. For this reason, patients undergoing Coronary Bypass Surgery with harvested veins (most commonly the GSV) suffer no adverse circulatory effects in the legs, unless the deep veins are non-functional.
Varicose Vein Treatments by the Vein Specialist at Nu Vela
Nu Vela is one of the most advanced vein centers in the Los Angeles area specialized in non-surgical varicose vein treatment. The phlebologist of the center, Dr. Raffi Dishakjian, M.D., a highly skilled physician in venous system treatments, takes pride that over the last nine years he has successfully treated hundreds of patients a year using cutting-edge, minimally invasive varicose vein treatment systems. At Nu Vela, Dr. R. Dishakjian makes sure that you always receive outstanding clinical care by personally performing all the required tests, including Ultrasound Diagnosis, and other ancillary vein treatment techniques like sclerotherapy for the treatment of spider veins. The varicose vein treatments provided by Dr. Dishakjian include:
It should be noted that regardless of the treatment method, the treatment of varicose veins is followed by the application of graduated compression stockings. These are usually worn for 1 to 2 weeks after a procedure to improve the circulation of blood and speed up the healing process.
EVLT PROCEDURE FOR VARICOSE VEIN TREATMENT
VENEFIT PROCEDURE FOR VARICOSES VEIN REMOVAL
Description of the Minimally Invasive Treatments Available at Nu Vela
The following sections are about a brief description of the varicose vein treatments provided by Dr. Dishakjian, the vein specialist of the vein center. Details of each of the procedures could be accessed by going to the relevant pages in our website.
Endovenous Thermal Ablation
Nowadays, endovenous thermal ablation techniques have almost put an end to painful surgeries. These varicose vein treatments are geared towards correcting the superficial venous hypertension by thermally ablating the enlarged and diseased saphenous or perforator veins. Endovenous ablation refers to the minimally invasive Ultrasound guided varicose vein treatment procedures, whereby varicose veins, usually the saphenous and perforator veins, are entered into and shut down from inside the veins by means of controlled heat generated by a radiofrequency (RF) catheter or laser fiber.
Currently, the Venefit™ Targeted Endovenous Therapy, (formerly known as VNUS Closure) and Endovenous Laser Treatment (EVLT) are the only two endovenous systems that are approved by the FDA for the treatment of varicose veins at the source of reflux in the saphenous and perforator veins. The Venefit™ system uses a radiofrequency generating electrode, whereas the EVLT uses a laser fiber to thermally ablate a vein.
During a treatment session, a vein doctor uses Ultrasound imaging to introduce a RF catheter or laser fiber into a diseased vein and precisely positions the catheter or laser fiber at the source of reflux from the deep system. Tumescent anesthesia is then injected along the whole section of the vein to be treated before application of heat. The introduction of large volume of dilute anesthetic solution around the vein is essential to protect the surrounding structures, like other veins, arteries, nerves, muscles and skin from burns and injury. Both varicose vein treatment procedures have very high, long term success rates at producing irreversible occlusion, fibrosis, and ultimately disappearance of the vein. It should be noted that endovenous procedures commonly require about an hour of operative time, are performed mostly under local anesthesia with mild discomfort, recovery downtime is minimal, and do not result in scarring. In fact, most patients are fully ambulatory and may go back to work the next day. In our experience, the success rate of varicose vein treatment with the current Venefit™ and Sciton's Joule EVLT systems runs at higher than 95 percent.
VENEFIT (VNUS CLOSURE)- PATIENT EDUCATION
Microphlebectomy also known as ambulatory phlebectomy, is a common procedure for the removal of superficial varicose veins. It involves the use of a surgical instrument resembling a sharp crochet hook to remove superficial veins through small 1-3 mm incisions in the skin overlying the veins. The vein removal procedure is usually performed in an office setting by injecting local anesthesia directly over and under the vein. The incisions are closed with Steri-strip tapes or occasionally, with a single small suture. Patients are discharged immediately after the treatment and can resume normal activities. However, the final cosmetic appearance, like for any surgical procedure, may take several months or more. It should be noted that saphenofemoral (groin area) and saphenopopliteal (back of the knee) junctions cannot be treated with simple phlebectomy. These junctions are the communicating points with the deep venous system, and simple pulling of a vein can cause damage to and uncontrolled bleeding from the deep veins. Junctional reflux is usually addressed by endovenous ablation methods. Veins that may be removed by ambulatory phlebectomy include major tributaries such as the anterolateral vein, pudendal vein, as well as varicose and reticular branches of the Saphenous vein around and below the knee.
Foam sclerotherapy is another technique for varicose vein therapy which is a modification of traditional liquid Sclerotherapy. In foam Sclerotherapy, a detergent class sclerosant (like STS or Polidocanol) is agitated with a gas (air, oxygen or carbon dioxide) to form foam. This foamed version of the sclerosant is then injected into the targeted vein under direct ultrasound imaging. Ultrasound guided foam Sclerotherapy has distinct advantages over traditional Sclerotherapy since it increases the potency of the sclerosant by providing a larger surface area of contact with the vein wall for a short period of time, while allowing the visualization of the spread of the foam by Ultrasound Imaging. For these reasons, foam Sclerotherapy can successfully treat larger veins beyond what liquid Sclerotherapy can achieve.
In the United States, ultrasound guided foam Sclerotherapy is most commonly used to treat branch varicosities of the saphenous veins, as well as superficial or very tortuous varicosities unsuitable for endovenous catheter based thermal ablation techniques (like EVLT or Venefit™). Outside of the United States, however, foam Sclerotherapy is used more commonly as a primary treatment varicose vein treatment instead of thermal ablation. The long term success rate of the endovenous thermal ablation techniques for the GSV, however, is significantly higher (>95%) than foam Sclerotherapy (~70-80%), necessitating repeat procedures for optimal outcome. In addition, heat based techniques result in better permanent sealing of the vein, with less subsequent accumulation of denatured blood in the treated vein, with less inflammation, pain and brown discoloration.
Insurance Coverage of Venefit™ (VNUS Closure) and EVLT
Among minimally invasive varicose veins treatments, the Venefit™ (VNUS Closure) and EVLT procedures have the broadest and most favorable insurance coverage by most of the major health insurance plans and Medicare. Eligibility of reimbursement is based, of course, on established medical necessity as determined by your physician and health plan, based on your medical history, as well as sign and symptoms of vein disease. Please don't hesitate to call our front desk to schedule an appointment to discuss your vein problems and insurance coverage eligibility.
Other Surgical and Non-Surgical Varicose Vein Treatment Options
Until the early 2000's, the only treatment for varicose veins of the legs was painful surgery that involved the removal of the dilated and incompetent saphenous vein segments, and simultaneously tying and cutting its connecting points with the deep venous system. Since then, many modifications of the older treatments and new treatments have evolved. Here we present a brief description of the surgical varicose vein treatment procedures, not available at our vein center, and a few non-surgical varicose vein treatments that have not yet received FDA approval.
Vein Ligation/Stripping - Although varicose vein surgery has evolved over the years and has become less invasive than it has been previously, vascular surgeons are performing fewer vein surgeries because there are newer, non-surgical ways to treat varicose veins. Vascular surgeons usually perform surgery instead of one of the newer, less invasive techniques, whenever there are blood clots or swelling (inflammation) in the target veins (phlebitis), veins are very large in size, and very superficial in location, (like in a very thin patient with very large saphenous veins close to the skin), and the lack of physician training in endovenous techniques. Non medical reasons for choosing surgical stripping over endovenous techniques may be economic in nature, like, lacking of investment in high tech minimally invasive systems (Venefit™ or EVLT) by the physician and/or the local hospital system, or denial of coverage except for surgical treatment by some managed care health plans.
The commonest varicose vein removal surgery is called high ligation and stripping (HL/S). In this procedure, the vascular surgeon makes an incision in the groin over the top of the Great Saphenous Vein. A second cut is made over the same vein around the inside of the knee area. The vein is then tied shut and severed from both ends. A special wire called the stripper is then introduced into the vein from the knee side and advanced to the groin, where it is tied to the cut-end of the vein. The vein is then pulled out of the leg tissue attachments forcibly, as the wire is pulled out from the knee-end, a procedure called vein stripping. The cuts are then closed with stitches (sutures) and bandages and compression stockings applied. The varicose vein removal operation takes about 1 to 1 1/2 hours.
Varicose vein surgery is commonly performed under a general, spinal or epidural anesthesia in a hospital setting. In one variation of this surgical technique, an Ultrasound guided tumescent anesthetic is injected at the time of surgery around and along the targeted vein, as an alternative to general anesthesia.
Varicose vein removal by ligation/stripping procedure requires hospital stay of one or two days, recovery time of one to four weeks, and typically results in extensive bruising of the surgical site. The risks of the procedure include sensory nerve injury resulting in pain and numbness, bleeding, deep-vein blood clots, infection, scarring and the anesthetic risk.
Endoscopic Vein Surgery - This entirely new surgical technique for the treatment of varicose veins is derived from cardiovascular surgery. During the surgery, a special endoscope (tiny video camera) is introduced under the skin through an incision just above the knee. The varicose veins are then removed through small cuts. A further small incision must be performed in the groin area. People who have this varicose vein removal surgery must have some kind of anesthesia, such as epidural or general anesthesia. Because this treatment puts high demands on technical equipment of the clinic and requires surgical/endoscopic experience, the procedure is performed in a hospital and usually applied during cardiovascular surgery, or when varicose veins are causing skin ulcers. Patients can resume their normal activities within a few weeks; a recovery period much longer than that needed after endovenous thermal ablation, whereby patients return to almost-normal activities even on the next day.
Transilluminated Powered Phlebectomy (TIPP) - The technique is a variant of ambulatory phlebectomy using the TriVex System. This varicose vein removal modality is carried out in a darkened operating room, where a vascular doctor uses an external transillumination light source device, much like a flashlight, to accurately pinpoint the targeted veins for removal. During the procedure, veins are loosened and released from the surrounding tissue with a tumescent anesthetic solution, similar to a liposuction procedure, whereby a special cannula is used to cut and then remove the targeted vein by sucking it through a small hole at its tip. This varicose vein removal technique is only applied to the very superficial veins, the incisions usually do not require stitches, and patients can return to normal activities in 2 to 3 days.
ClariVien - Another emerging minimally invasive endovenous varicose vein treatment technique, known as ClariVein, relies on mechanical agitation of an infused chemical (sclerotherapy solution) to destroy a diseased vein. The ClariVein device is a hand-held single use device equipped with a catheter that contains a rotating wire driven by a motor situated inside the device. The procedure starts by introducing the catheter, under Ultrasound guidance, into the targeted vein. After positioning the tip of the wire precisely, the device is turned on causing the wire to rotate and scrape the inner walls of the vein and simultaneously disperse the infused sclerosant. This combined mechano-chemical technique aims at efficiently sealing the vein with the smallest possible amount of infused chemical. The main advantage of this varicose vein treatment over heat based endovenous techniques is the elimination of the need for the sometimes uncomfortable step of local anesthetic injection, as well as lack of the residual leg numbness after the procedure. Currently, there are no long term studies documenting the effectiveness and safety of this system. In time, ClariVein may become a viable mainstream varicose vein treatment modality. This system is currently FDA-approved as a non-specific vascular infusion device, but not specifically as an ablative varicose vein treatment.
The SEPS Procedure - (subfascial Endoscopic Perforator Surgery) is an endoscopic procedure for removing incompetent perforator veins in the legs that result in venous ulcers due to chronic venous congestion. During this procedure, your vascular doctor makes several small skin cuts through which he/she inserts a special canula equipped with balloon tip (similar to a laparoscopic procedure). The balloon helps identify the veins by separating them from the surrounding tissues. Surgical clips are then used to occlude these defective perforator veins under direct endoscopic view. The SEPS procedure typically requires about 2 to 3 hours of operative time and 2-3 weeks for full postoperative recovery.
Although this procedure is sometimes described as minimally invasive in nature, it is more traumatic than the alternative endovenous thermal ablation modalities ( EVLT and Venefit), results in some scarring, often requires general anesthesia, and as such, is not an office based procedure.
Questions About Cost of Varicose Vein Treatment or the Treatment?
Consultations with the vein doctor are free with the purchase of any service. We charge a nominal refundable consultation fee for the first office visit only. This fee is fully credited towards a subsequently purchased service. Note that Consultation does not include the charge for venous Duplex Ultrasound test, when indicated. However, the cost of the test is mostly reimbursed to you with a follow-up endovenous treatment procedure.
Call 818-832-4500 for any enquiries regarding treatment cost, procedure details, or scheduling a consultation session with Dr. Dishakjian, M.D., cosmetic surgeon and phlebologist. Consultations with the doctor are free with the purchase of any service. We charge a nominal refundable consultation fee for the first office visit only. This fee is fully credited towards a subsequently purchased service.
Our vein clinic is located in the northwest San Fernando Valley, SFV, with easy connection from most local Los Angeles freeways. Click the "Contact Us" button at the top for directions.