So “You Need Surgery”…
“You need surgery.” The very word ‘surgery’ strikes fear in the hearts of patients who seek treatment for varicose veins. The word ‘surgery’ conjures up visions of aseptic smelling hospitals, all-too-revealing patient gowns, getting put to sleep, being cut open, not to mention disfiguring scars and prolonged, painful days of recovery and missed work. During my 10 years as an Internist, I used to tell my patients to avoid getting their varicose veins operated on unless they were symptomatic to the point that the patients could not deal with them anymore. And for good reason…at that time vein stripping was still considered treatment of choice for most patients with varicose veins. It was a major procedure done under general anesthesia (the most dangerous part of surgery) and the results were certainly less than dramatic and oftentimes the scars were just as bad as the veins had been. I have personally seen multiple 6 inch scars on young female patients’ legs that had the old fashioned surgery done. They were basically mutilated. This was ‘accepted’ by patients as the inevitable outcome of surgery for vein disease.
Out with the old and in with the new. The current techniques of vein surgery differ dramatically from the old. Gone is the need for general anesthesia. Vein specialists have multiple options for sedation for vein surgery, which is now usually done in the physician’s office and not in the hospital. Intravenous medications can be given to relax the patient similar to those given for a colonoscopy. This is called conscious sedation…the patient is not asleep but is merely sleepy and will usually have no memory for the surgical procedure and will feel no discomfort. Alternatively, a few select specialists have begun using nitrous oxide (laughing gas) for sedation and pain control during vein surgery. The advantages of nitrous oxide are rapid onset of sedation, rapid ‘wearing off’ after the end of the procedure, and no chances of allergic reactions or over-sedation that are possible with IV medications.
The current technique for removing bulging varicose veins is called ambulatory phlebectomy. This is done by numbing up the bulging veins with local anesthesia, making tiny incisions next to the veins, and actually pulling out the diseased veins and removing them. Many people confuse this with ‘vein stripping’ which it is not. Vein stripping refers to the old technique (invented in 1905 and still done basically the same way) where a large internal vein underneath the skin is removed using special instruments. Vein stripping is done under general anesthesia and requires that several large incisions be made at the ankle, knee, and groin. These incisions must be closed with either staples or sutures and will usually leave scars. In contrast, phlebectomy removes visible bulging veins through tiny (1-2 mm) incisions that are usually closed with Band-Aids or sterile tapes and leave no scars behind.
The technique that has replaced vein stripping is Endovenous Thermal Ablation. In this technique a specialized catheter is placed into the vein through a tiny 2 mm incision made with local anesthesia. Once the catheter is in place, the vein to be treated is also numbed with local anesthesia and the catheter heats up inside the vein. The heat kills the vein and causes it to spasm and close. The body will completely reabsorb the vein over the next few weeks to months. Long term studies of this new technique demonstrate 80-98% success after 5 years, depending on which type of catheter is used, vs. only a 50% success rate after vein stripping.
The most important piece of equipment you need before vein surgery is a competent vein specialist! Do your homework! There are lots of doctors out there claiming to be vein specialists, but very few are actually board certified in vein disease (Phlebology). Just because a doctor has bought a vein laser machine or has general or vascular surgery training does not mean they are experienced in these new techniques, which have only been around for a few years. Contact the American Board of Phlebology to search for a board certified vein doctor in your area.
James W. Altizer, MD, FACPh, RVT, RPVI
Vein Center of Charlotte
