New treatment for varicose veins is less invasive, painful

By Marsha King
Seattle Times staff reporter

	COURTESY UW MEDICAL CENTER Legs with varicose veins before, left, and after endovenous ablation.
	E-mail this article Print this article Search archive Other links New treatment option for varicose veins [357K ] PDF

Debbie Cosbey first noticed the bulging varicose veins near the end of her pregnancy at age 40. The twisted mass ran like thick, dark purple ropes from her knees to the arches of her feet.

After the birth, the veins only grew more uncomfortable and unsightly.

It didn't help that her active job with Microsoft required standing up much of the day. By the time she got home at night, her legs throbbed. She quit aerobics class because the exercises hurt too much, and she avoided wearing clothing that might reveal even part of her legs.

"They just became very painful. ... And my legs would just ache. I would have to rub them."

But like many people with varicose veins, Cosbey resisted taking the time off work to undergo and recuperate from traditional "vein stripping" surgery.

"I was also kind of afraid of it," she said.

So she suffered for eight years until learning about a new high-tech treatment that promised no downtime and minimal discomfort

On a Friday in January, she had those nasty veins vaporized with a beam of laser energy at the University of Washington Medical Center in Seattle.

Cosbey was awake and comfortable during the procedure. Afterward, she got up off the table unaided and went out to dinner with her husband. The following Monday, she was back at work. She expects to return soon to aerobics class. And she can't wait to wear shorts and bathing suits this summer.

Varicose veins vs. spider veins • Varicose veins, thick, knotty, ropelike veins in the leg, are not only unsightly, they can be a medical problem. Varicose veins can cause severe pain, bleeding and may inhibit healing so that wounds persist for years. • Spider veins, threadlike blue or red discolorations that appear on the surface of the skin, often on the outer thigh, may be unsightly, but aren't serious. They are more of a cosmetic problem. Typically, they're successfully treated with a chemical injection or surface laser treatment.

"My legs are feeling great. I did it because of the pain. But the appearance was the frosting," she said.

Her procedure, called "endovenous ablation," is transforming the treatment of varicose veins.

It's not hard to see why.

The common condition affects tens of millions of people. Now it can often be cured in less than an hour in a doctor's office under local anesthetic with a high rate of success and less discomfort and downtime.

"I personally believe vein stripping will be a distant memory in five years," said Dr. Torrance Andrews, who performed laser ablation on Cosbey. Andrews is director of interventional radiology at the University of Washington Medical Center and Harborview Medical Center.

Not all doctors will go that far.

Some like the new technique, but believe there will always be a role for vein stripping.

"Not everybody's a candidate for vein ablation. It depends on their vein anatomy," says Dr. Kathleen Gibson, a vascular surgeon at Overlake Hospital Medical Center in Bellevue.

Gibson performs both traditional vein surgery and the new technique.

Others acknowledge endovenous ablation works but doubt it is truly superior to "vein stripping" in effectiveness, patient comfort level or cost.

"The data do not yet, in my estimation, show there is any advantage over the traditional technique," said Dr. Kaj Johansen, director of vascular services at Swedish Medical Center. Johansen has performed only traditional vein surgery.

Johansen says doctors at Swedish have designed a study to compare outcomes in patients treated with "vein stripping" against those treated with endovenous ablation.

Still, vein ablation is attracting an untapped baby-boomer market.

"You're offering a service to people who might not have considered surgery because they didn't want to take the time off," said Gibson.

"Now you're opening a door where more people can be treated."

A common, painful problem

Varicose veins — which can become prominent, ropelike and thickened — affect one out of two people age 50 and older, and 15 to 25 percent of all adults, according to the Society of Interventional Radiology.

More than an unsightly annoyance, varicose veins can cause severe pain that worsens over the day, and in extreme cases, bleeding and staining of the skin and wounds that persist for years.

The condition is a sign that the body's circulation system, which enables blood to flow against gravity from the legs back up to the heart, isn't working properly.

Normally, the leg muscles squeeze blood through one-way valves in the veins toward the heart. But when the valves weaken and fail, the blood flows backward and pools in the legs. The backwash causes the veins to swell.

The greater saphenous vein — a superficial vein that runs from the ankle to the groin — is the most common culprit in blood backup or reflux in the lower leg.

The only way to fix reflux is to permanently remove the vein or block the backward flow with vein ablation.

Risk factors for developing varicose veins include age, heredity, being female and having been pregnant, especially having been pregnant multiple times.

Conditions during pregnancy — increased blood volume, the growing uterus and greater production of the hormone progesterone — can all stress the vein system.

But varicose veins can also stem from inflammation, blood clots and injury.

Tom Abell, a serious runner his entire adult life, was surprised when in middle age a vein on the inside of his left knee kept getting "bigger and uglier" and more irritating.

He'd always thought of varicose veins as an unfortunate, "really ugly" problem that afflicted women.

Finally, after five years watching the vein dramatically bulge every time he jogged, Abell decided to see "if I could do something about it."

His condition was considered extensive enough to warrant removal or an endovenous laser ablation last month. The ease of the procedure impressed him, and Abell expects to start running again in a few weeks.

But why did he come down with the problem?

The 52-year-old aircraft dispatcher from Camano Island doesn't know. His doctor at Overlake Hospital conjectured maybe it's genetic or perhaps related to the years of jogging.

Procedures compared

The traditional treatment for saphenous vein reflux is surgical "stripping" — threading a flexible rod through an incision at the ankle or knee up through the thigh to another incision in the groin. The swollen vein is tied to the rod through the groin incision. Then the vein is pulled inside out back down through the lower incision. Recovery can be painful and take a couple weeks.

In contrast, the new vein ablation treatment inserts a tiny catheter inside the vein right below the knee to deliver heat energy to the vein walls either by radio frequency or laser.

The heat permanently scars the vein closed.

The constant pressure from a back flow of blood disappears immediately.

It's as effective as removing the vein from the patient's body. Over time, the cooked vein shrivels until it can't be found.

The puncture left behind is minute. The patient's only inconveniences are some bruising and possible leg cramping after surgery and having to wear compression stockings for about three weeks.

The procedure doesn't harm proper circulation in the leg. The leg essentially has two vein systems. The greater saphenous vein — when it's working normally — carries the smaller percentage of the blood back to the heart. The main transport of blood back to the heart is handled by other veins deep inside the muscles.

Shutting off a malfunctioning saphenous vein actually helps the deep-vein circulation system work better.

The FDA approved endovenous ablation using radio-frequency technology in 1999 and the laser method in 2002. Both types now are being used across the country. Medical centers where the treatment is offered in the Seattle area include Harborview and the University of Washington, Swedish, Overlake and Group Health Cooperative.

The cost of the surgery varies widely. Many insurance companies won't pay for endovenous ablation because it's more expensive than vein stripping, said Gibson at Overlake. Gibson and her partners charge $3,000 a leg to patients who pay out of pocket. Harborview charges about $3,800 per leg.

Ultrasound testing determines whether someone is suited for vein ablation, which is used only to treat the greater saphenous vein.

Sometimes, varicose veins don't stem from the greater saphenous vein. They can arise from the lesser saphenous system — a kind of communication breakdown in the body's deep-vein system. In such cases, patients often need surgery.

A significant percentage of patients who undergo vein ablation will need secondary treatment — such as chemical injection — to take care of varicose veins that branch off from the saphenous, said Gibson.

Untreated, problem worsens

If left untreated, varicose veins usually get worse. Discomfort turns into pain until a person may not be able to stand for long periods. The backed up pressure through capillaries causes fluid to constantly weep into the skin creating discoloration.

"Over time the skin becomes very fragile," says Andrews. "It doesn't heal well there's so much fluid in it. You can get ulcers which become big enough to expose bone. ... "

For years, Betty Grad had a deep coppery discoloration that looked like a sock around her right foot from blood pooling. But at 80, Grad could still play golf three times a week.

Her serious troubles started when a spider bite on the ankle turned into an ulcer that "got deeper and quite sore." It took two years to heal. Then another ulcer appeared, and then another.

In the past month, Grad contended with a fourth open sore about the size of a dime on the inside of her ankle. Her leg was bound in compression bandages up to the knee to encourage blood flow and keep fluid from accumulating.

To alleviate the pressure from the pooling blood, she slept with her legs elevated on pillows.

Every week she drove from her West Seattle home to receive a fresh bandage and special wound care at Swedish Hospital.

The source of her problems was a knotted swollen varicose vein that meandered up the inside of her upper thigh.

When a friend told her about the new laser ablation treatment at the University of Washington Medical Center, she jumped at the chance.

"I'm so looking forward to this surgery," said Grad, before the procedure. "I'm hobbling. I have a problem with stairs. Walking I can do, but it's not easy. ... "

"I want to get rid of the pain of these ulcers. I also want to be active again."

Immediately after the procedure, Grad noticed an improvement.

"I felt better walking out than walking in."

Since her procedure, Grad has been working out on a treadmill and cross-country ski machine at home as well as continuing with her weight training at the YMCA. In May, she may have vein ablation on her other leg. And when she feels stable enough, she hopes to take her big dog, Pearl, for a long romp on the beach.

Marsha King: 206-464-2232 or mking@seattletimes.com

Copyright © 2004 The Seattle Times Company