The ClariVein self-contained disposable system for varicose vein treatment.
The closurefast catheter attached to the VNUS radiofrequency generator.
The endovenous laser fiber attached to Sciton's Joule platform.
Ultrasound imaging uses high frequency sound waves to produce pictures of the inside of the body. In 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, such as Venefit™ or EVLT procedures.
Nu Vela Esthetica is one of the most advanced vein centers in Southern California specialized in non-surgical treatment of bulging varicose veins. The phlebologist of the center, Dr. Raffi Dishakjian, M.D., a highly skilled physician in venous system treatments, takes pride that over the last eight years he has successfully treated hundreds of patients a year using cutting-edge, minimally invasive varicose vein treatment systems. At Nuvela, 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. Please don't hesitate to call our front desk to schedule an appointment to discuss your vein problems.
You may read about the details of the minimally invasive varicose vein treatments provided by Dr. R. Dishakjian by clicking the links given below, or continue reading this page for a brief description of vein disease and surgical and non-surgical options for the treatment of varicose veins.
An advanced and severe venous condition known variably as Superficial Venous InsufficiencyChronic Venous Insufficiency (CVI), Venous Disorder (CVD), or venous reflux, causes large, bulging, bluish veins; namely, varicose veins, to appear on the legs, causing pain, restless legs, leg heaviness and fatigue, swollen limbs and an unsightly appearance. This condition usually originates in the largest superficial veins in the leg; that is, the Great Saphenous Vein (GSV), the Small Saphenous Vein (also known as Lesser Saphenous Vein, abbreviated as SSV or LSV), accessory saphenous veins, and perforator veins. In healthy legs, valves open and close to assist the return of blood to the heart. Incompetence in these valves leads to the disruption in the unidirectional flow of blood toward the heart and allows its backflow from the deep veins into the superficial main veins of the lower leg, giving rise to venous hypertension. Subsequently, the pressure build up in these veins forces dilation and valvular failure in the more superficial branch veins, causing them to bulge and become visible on the skin surface as varicose veins.
THE PRINCIPLE SUPERFICIAL AND DEEP VEINS OF THE LEG
The visible dilation of superficial branch veins is what prompts most patients to seek medical attention. For some patients, symptoms of venous congestion are completely absent, and the cosmetic improvement of their legs is their primary motivator for seeking varicose vein treatment. Nevertheless, even these patients will benefit from the treatment of their varicose veins before progression of the condition into more advanced stages. In fact, untreated superficial venous reflux with varicosities always get worse over time (except after pregnancy), at variable rates, with worsening symptoms and appearance of more varicose veins and other potentially irreversible skin changes like permanent pigmentation, lipodermatosclerosis, and even venous ulcers.
What Does CVI and Varicose Vein Treatment Involve?
Currently, the elimination or removal of incompetent veins is the only effective and lasting treatment for chronic venous disorder (regardless of its stage) and associated symptoms, such as heavy and aching legs. This is achieved by either surgically removing the veins, or irreversibly damaging vein walls with heat, chemicals, or mechanical means. The damaged veins are eventually absorbed by the body and the blood in the deep venous system reestablishes its healthy flow pattern towards the heart. 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.
Which Veins Are Targeted?
Interestingly, the veins that are the root cause of the venous insufficiency, and therefore need treatment are often not the same bulging 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 or back of the knee where the largest superficial veins (the saphenous veins) communicate directly with the deep vein system. Accordingly, effective treatment of varicose veins usually requires the elimination of the saphenous veins before addressing the visible branch varicosities that are most obvious to the patient. Once the backflow of blood from the saphenous veins into the bulging varicose veins stops, the latter adjust back to normal pressure conditions and their appearance usually improves significantly, sometimes requiring no additional treatment. For best cosmetic outcome; however, any bulging and unsightly veins that are still present after a few weeks should also be treated. This is easily achieved with one of the many minimally invasive methods that could be performed in an office setting. Note that treating the enlarged, visible varicose veins alone, without first targeting venous reflux in the main superficial veins (like the GSV), is the most common reason for early treatment failure and recurrence of the varicose veins.
What are the Current Surgical and Non-Surgical Options?
Chronic venous insufficiency and the resulting varicose veins can be managed conservatively with stockings and compression; however, definitive CVD and varicose vein therapy require surgical or medical intervention. Duplex ultrasound is an essential diagnostic test in any treatment plan for varicose veins. 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 treatment.
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. This surgical vein removal modality requires hospitalization, general anesthesia, results in scarring, and significant post-surgery recovery. A more recent modification of this surgical method, called endoscopic vein surgery, uses a small camera to see inside the veins and remove sections of diseased veins through smaller incisions.
Fortunately, with the advent of technology during the last decade, incompetent saphenous and perforator veins are now mostly treated with endovenous ablation (shutting the vein from inside) and other minimally invasive techniques. The Venefit™ Targeted Therapy and Endovenous Laser Treatment (EVLT) are two such endovenous treatments that use controlled heat, delivered by means of a catheter, to achieve vein ablation, and as such, are known as endovenous thermal ablation procedures. Currently, the latter two endovenous ablation systems are the only ones that have received FDA approval for varicose vein treatment. Phlebectomy is another varicose vein removal procedure that is widely practiced; however, the technique is only applied for the removal of the very superficial veins; not the saphenous veins. Foam Sclerotherapy, another minimally invasive varicose vein treatment modality that relies on chemical ablation of the veins, is not approved by the FDA. Nevertheless, it is commonly used for the elimination of very superficial varicose veins, and sometimes for the ablation of saphenous veins. The ClariVein system on the other hand, which has received a broad FDA approval as an endovenous infusion device for the vascular system, is currently used off-label for ablative treatment of venous incompetence. Specific FDA approval for varicose vein treatment is pending at this time. Although the ClariVein system appears to promise a novel and alternative method, with some distinct advantages over heat based techniques, long term and large scale studies are not yet available on its safety and effectiveness.
BLOOD RESUMES ITS NORTMAL FLOW PATTERN AFTER ENDOVENOUS ABLATION
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.
BEFORE AND AFTER EVLT PROCEDURE
BEFORE AND AFTER VENEFIT PROCEDURE
More About Surgical Methods of Varicose Vein Removal
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 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.
Vein 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 surgery must have some kind of anesthesia, such as epidural or general anesthesia. Because the 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 week; a recovery period much longer than that needed after endovenous thermal ablation whereby patients return to almost-normal activities even on the next day.
More About Minimally Invasive Varicose Vein Treatments
Ambulatory Phlebectomy - Also known as microphlebectomy, is a common procedure for the treatment 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 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.
Transilluminated Powered Phlebectomy (TIPP) - The technique is a variant of ambulatory phlebectomy using the TriVex System. This varicose vein treatment 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 canula is used to cut and then remove the targeted vein by sucking it through a small hole at its tip. The 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 treatment technique, known as ClariVein, relies on mechanical agitation of an infused chemical (scleotherapy 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 treatment method 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 treating 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.
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 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 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 saphenous vein treatments with the current Venefit™ and Sciton's Joule EVLT systems runs at higher than 95 percent.
VENEFIT (VNUS CLOSURE)- PATIENT EDUCATION
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. Utrasound 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 method of venous insufficiency of the saphenous veins 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.
Are Venefit™ (VNUS Closure) and EVLT Procedures Covered by Insurance?
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.
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.
Review of varicose vein treatment with surgical and non-surgical procedures. The review was written by the vein surgeon of the center, Dr. Raffi Dishakjian, M.D., the medical director of Nu Vela Esthetica, Los Angeles vein center.
11200 Corbin Ave Porter Ranch California 91326 United States
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