2. e60 Circulation August 12, 2014
lifestyle changes, compression stock-
ings, nonsurgical office-based pro-
cedures, and surgery (Table 2). Most
patients will require a combination of
treatments to achieve the best results.
Regardless of whether a nonsurgical pro-
cedure or surgery is necessary for vari-
cose vein treatment, lifestyle changes
are crucial to ensure as complete and
durable a response to treatment as pos-
sible. Most insurance companies will
not cover the costs of nonsurgical pro-
cedures or surgery for cosmetic reasons.
Compression stockings are frequently
prescribed as the first step in varicose
vein treatment and are effective for treat-
ing discomfort and swelling. Consistent
compression stocking use decreases the
leakiness of venous valves and the pres-
sure in the veins. To be effective, com-
pression stockings should be placed on
in the morning with the legs elevated at
least to waist height and worn until bed-
time. A variety of strengths and lengths
are prescribed, depending on the severity
and extent of varicose veins. To ensure
comfort, compression stockings should
be sized according to the patient’s legs.
Devices are available to help patients
apply compression stockings.
Nonsurgical procedures for varicose
veinsincludelocalveintherapiesandvein
ablation. Local vein therapies, such as
injection (sclerotherapy) or laser therapy,
are used to treat spider veins and reticular
veins. Sclerotherapy involves injection of
a chemical that causes the small veins to
seal shut. Most patients will require mul-
tiple treatments for the best results.
Vein ablation (also called endovenous
ablation) uses either radiofrequency
energy or laser to close large veins with
leaky valves. Vein ablation is usually
performed in an office-based procedure
room with local anesthesia. Popularity
of vein ablation has increased because it
is less invasive than surgery, has a faster
recovery time, and can be performed by
a variety of physicians.
Surgery for varicose veins includes
vein removal through small incisions
(called microincision phlebectomy)
Figure. Types of varicose veins. Spider veins are reddish-bluish and thread-like (A).
Reticular veins are bluish and string-like (B). True varicose veins are large rope- or worm-
like veins that bulge out from the skin surface (C).
Table 1. Risk Factors for Varicose Veins
Category Risk Factor Effect
Hormonal Female sex High hormone levels
Lifestyle Prolonged standing/sitting High pressures in the veins
Smoking Injury to the veins
Acquired Obesity High pressures in the veins
Pregnancy High hormone levels
High pressures in the veins
Blood clots in the legs Obstruction of the veins
Leakiness of the venous valves
Age Leakiness of the venous valves
Inherited Family history of
varicose veins
Leakiness of the venous valves
Tall height High pressures in the veins
Syndromes with venous
abnormalities
Leakiness of the venous valves
High pressures in the veins
Obstruction of the veins
Table 2. Treatments for Varicose
Veins
Treatment
Type of
Varicose Vein
Relative
Cost*
Lifestyle changes
Weight loss
Exercise
Elevation
Avoid prolonged
standing/sitting
Smoking
cessation
All types $
Compression
stockings
All types $$
Non-surgical
procedures
Local vein
therapies
Vein ablation
Spider veins,
reticular veins
Large varicose veins
$$$
$$$$
Surgery
Small-incision
vein removal
Large vein
stripping
Small varicose veins
Large varicose veins
$$$
$$$$
*Insurance companies may require a 3- to
6-month trial of compression stockings before
paying for vein treatments and may not cover
treatments performed for cosmetic reasons.
Table 3. Tips for Preventing Varicose
Veins
• Lose weight if overweight or obese
• Exercise regularly
• Avoid prolonged standing and sitting
• Quit smoking
• Wear compression stockings consistently
if prescribed them
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3. Piazza Varicose Veins e61
and large varicose vein stripping.
Microincision phlebectomy is per-
formed under local anesthesia and is
most useful for small varicose veins.
Large varicose vein surgical stripping
has been largely replaced by less inva-
sive vein ablation procedures.
What Can I Do to Prevent
Varicose Veins?
Because varicose veins are associ-
ated with obesity, weight loss is an
important step in prevention and
treatment (Table 3). Regular physi-
cal activity such as walking may
help to improve calf muscle function.
Avoiding prolonged standing and sit-
ting encourages venous flow from the
legs. Smoking cessation is also an
important preventive measure.
Further Information
For additional information, please con-
sult the following resources:
• American Venous Forum
( w w w . v e i n f o r u m . o r g /
p a t i e n t s / v e i n - h a n d b o o k /
chapter-3-clotting-disorders)
• National Heart, Lung, and Blood
Institute (www.nhlbi.nih.gov/
health/health-topics/topics/ebc/)
• Rethink Varicose Veins (www.
rethinkvaricoseveins.com)
Disclosures
None.
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