Podiatric Vein Care
Finishing Touches and Long Term Management for a Vein Free Leg

After all medical venous insufficiencies are addressed through endovenous techniques one can focus on the surface of the skin. Keep in mind if the surface of the skin is addressed prior to treating the underlying vein insufficiency failure will exist. Finishing cosmetic questions are usually addressed through an ambulatory phlebectomy for the bulging surface varicosity, ultrasound-guided sclerotherapy or transcutaneous laser treatments.

An ambulatory phlebectomy is a procedure where the varicose vein is removed. The patient stands while the vein site is marked with a surgical marker. Local anesthetic is used to numb the area. A stab incision is made and a vein hook similar to a crochet hook is used to lift the vessel out of the leg and the vein is manipulated until a long stand is removed. Pressure is used to provide hemostasis or in the case of very large varicosities, a simple stitch is used. Phlebectomy sites are typically closed with a steri strip.

Ultrasound-guided sclerotherapy injections use a chemical to treat tributaries or distal branches. Sclerotherapy uses chemicals such as glycerin, saline, polidocanol (Asclera®) or sodium tetradecyl sulfate otherwise known as Sotradecol®. Three to five treatments are recommended on a monthly basis. Patients must understand the veins will look worse after injections due to the bruising as well as thickening, hardening, and coagulant that exist inside the vessel. Once a vein is hardened the body will then break it down causing lightening of the vessels to occur. Patients must understand these will not disappear as noted on television ads and commercials. It can take up to six months for a full effect of sclerotherapy to be noted. Transcutaneous laser uses a YAG laser or any Class IV strong laser to target hemoglobin in the vessel.

This heat steam cavitation effect will burn the vessel itself causing damage to the vessel wall and the body can break it down. Fading of the appearance of the veins will follow. Vessels treated with laser also require approximately three to five treatments scheduled on a monthly basis. Small spot hemangiomas are also treated very well with the use of the laser.

For the long term benefit of chronic venous insufficiency it is important that patients understand the need for compression therapy. Although the adherence to the recommendation is low it is our job to educate the patient on the importance and benefits of compression therapy. If a patient will not wear a full length stocking 20-30mmHg, try to have them at least wear a knee high compression sock with 15-20mmHg of pressure. Compression therapy is the single most important treatment a patient can do to slow the build-up of the hydrostatic pressure that is the main factor in reflux. 

If you are interested in learning more about phlebology and incorporating it into your practice you can do so by checking your state scope of practice and then getting educated. The American Vein and Lymphatic Society along with the American Venous Forum and Cardiovascular Credentialing International for ultrasound education are a great place to start. Conferences such as the International Vein Congress are helpful and have break out workshops.