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The Quest for Beautiful, Pain-Free Legs by Wenda Reed

Have you been keeping your legs covered to hide bulging, knotted varicose veins? Wish you could get rid of them in time for this year’s swimsuit season?

Better start now. The actual treatment may be quick, but if you want insurance to pay for removal of varicose veins, you must wear compression stockings for two weeks to several months before treatment to determine whether the treatment is “medically necessary.” And it will take some time after treatment before you are beach ready.

Catherine Horan, now 50, started feeling pain 10 years ago when she was carrying her second child. She was genetically disposed to varicose veins — the leading cause of the disease — and the baby exerted pressure on a vein in her right leg. She saw a doctor about vein-stripping surgery, in which an incision is made below the damaged vein, a flexible instrument is threaded up the vein, and it is grasped, removed and tied off. She was told there was no guarantee in her case that the vein would not come back, and insurance wouldn’t pay for it. She decided against the surgery.

The pain got worse. “I had cramping almost every night. It interfered with sleeping. I’d been wearing compression stockings because it hurt so bad,” Horan says. The stockings helped somewhat, but they were difficult to put on and they kept slipping down. The veins were also unsightly and ropey. “I went to visit my brother in Texas, where it was hot and I was wearing shorts,” she remembers. “He hadn’t seen me for a year; he looked at my legs and went, ‘Eewww!’”

When Horan went to Via Vascular, a vein treatment center near Northgate, three years ago, she discovered that her options had widened. In the past decade endovenous thermal ablation — destruction of the vein with heat from a laser or radiofrequency — entered the mainstream, and has now replaced vein stripping as the treatment of choice for eliminating most varicose veins. It does not require general anesthesia; it generally hurts less than vein stripping; the recovery time is shorter; the cost is lower; and there is no scarring. Early indications show that it is just as effective as vein stripping and may result in fewer recurrences of disease. Some doctors, however, still prescribe stripping, especially for very large varicose veins.

Horan was asked to check off a list of symptoms and given an ultrasound, which determined that the valves in her veins were not working properly. She was a candidate for medically necessary, minimally invasive endovenous laser treatment (EVLT, also known as endovenous laser ablation or ELA).

The in-office procedure did not hurt significantly, she says. As described and demonstrated by Dr. Frederic Joseph at Via Vascular and Jamie Young, his nurse manager, the procedure goes like this: The leg is numbed. A thin, long, white catheter with a small needle at the tip is inserted into the base of the damaged vein. Guided by ultrasound, the doctor can see the vein floating in a numbing solution. As he draws the catheter down the vein, laser energy is delivered to damage the vein walls, shrinking and closing the diseased vein.

The pain and bruising after the procedure were greater than Horan expected. Fortunately, the bruising was high on the thigh, and since she had the procedure done right after Thanksgiving, it wasn’t visible under winter clothing. “I’m really, really happy I had it done,” she says. “It changed my life. I wish I’d done it sooner.”

A SYSTEM GONE AWRY

Here’s a quick course on what causes varicose veins, described as knotty, swollen, enlarged and tortuous veins close to the skin.

Arteries carry red, oxygenated blood from your heart to all parts of your body. Veins carry the de-oxygenated blood, now bluish in color, back to your heart. In your legs, 90 percent of the blood goes back through deep veins. The other 10 percent goes through “superficial” veins that are outside the muscle layer and closer to the skin, although they’re still not visible. The biggest superficial vein begins at the ankle and ends at the groin and is called the great saphenous vein. The small saphenous vein runs up the back of the calf. Other superficial veins can also cause problems.

Small one-way valves in those veins open to allow the blood to be pushed out of the legs and back to the heart, working against gravity. They then close to prevent blood from flowing backwards.

For various reasons, the vein walls can lose elasticity and the valves can cease to function properly, so that blood flows backwards and pools in the legs (venous reflux). “It’s like a garden hose with a spigot that won’t shut off,” Joseph says. The saphenous veins are connected at various points to veins closer to the leg’s surface. Those surface veins fill with blood, stretch and bulge and are visible as varicose veins.

Heredity plays a large part in a vein’s tendency to become weakened and to bulge. Hormones, particularly progesterone, relax uterine muscles, and also relax the vein walls monthly and especially during pregnancy. Pregnancy can also put a strain directly on veins. The hormonal factors result in varicose veins affecting more women than men. “It’s a disease where you can blame both your parents and your children,” Joseph quips, referring to the effects of heredity and pregnancy. Aging and lots of standing also weaken the veins and valves.

“There’s often discomfort right where the vein is bulging,” says Dr. Jay Cook with Radia Vascular in Seattle and Mill Creek. “Legs can feel heavy, tired and swollen, more so as the day goes on. Almost all patients have a kind of restless leg syndrome, where they’re moving the legs in bed to try to get comfortable. There are conditions when people will actually bleed from the veins or have ulceration of the skin.”

Other symptoms may include aching or cramping, burning or tingling sensations, throbbing or tenderness. The veins may be red or warm to the touch.

“If you’re not having significant symptoms, insurance probably won’t cover it,” Cook says.
Joseph, Cook, Young and medical experts in the field all agree that vein disease will not reverse itself on its own and varicose veins will get worse with time.

“People live with them; they don’t realize that the symptoms they have in their legs are actually vein disease,” Joseph notes. “It’s one of the under-diagnosed diseases,” Young agrees.

TAKING THE PLUNGE

For many women, it’s a question of waiting until the symptoms become too uncomfortable to bear. This is true of Seattle resident Sue Ellingson, who had vein treatment a year ago when she was 44.

When she was pregnant with her second child, now 14, a bulgy vein popped out in the upper thigh of her left leg. It didn’t go away, but became worse with a third pregnancy. Then veins started to bulge in her calf. They didn’t become too uncomfortable until five years ago. “There was a lot of pain — more of a constant ache than cramping. It was really, really itchy. Heat bothered it because the veins would swell up. My left leg was actually bigger than the other one.”

She went to a vascular surgeon at Group Health, who diagnosed her with moderate vein reflux. He recommended vein stripping as the best, most permanent solution. “I was afraid of the vein stripping. I don’t like general anesthesia. I thought of it as the nuclear option,” she says. She decided to wait.

The pain increased. The breaking point was a summer vacation when the heat increased her symptoms to such an extent that it was painful to even go on a short hike. In photos taken from the back at some distance, she could clearly see the ugly veins on her legs.

She went back to Group Health and found out about radiofrequency ablation (RFA). This is almost the same as endovenous laser ablation, with a catheter being inserted into the great saphenous and/or small saphenous or other large superficial vein. It uses controlled heat from radio waves instead of lasers to damage, shrink and close the vein walls. The safety of both procedures is the same; some people find RFA a little less uncomfortable. It does not work for short or small varicose veins. Some treatment centers offer either laser or radiofrequency ablation; some offer both.

In order for insurance to cover her treatment, Ellingson had to wear compression stockings for three months prior to the procedure. “They’re awful!” she says. “They’re expensive, and they’re not covered by insurance. The leg felt really good right away when the stockings were on, but awful when they were off. It puffed right up. They weren’t doing anything about the underlying reflux.”

The in-patient RFA treatment, with a small incision, didn’t hurt at all, Ellingson says. The recovery period was another matter.

“I was in major pain for a full month,” she recalls. Ellingson also had to wear the compression stockings on both legs for 72 hours without bathing, and then continue with them on the affected leg for eight weeks. “You can’t wear jeans or tight pants,” she notes. “You have to elevate and ice the legs.” The bruising and discoloration were not major.

The day after the eight-week recovery period, Ellingson and her family went to Florida for a vacation. “I hit the Miami Airport and peeled those suckers off,” she says referring to the hated stockings. “It was amazing. It was a humid climate, but I had no symptoms. I could stand for long periods.”

The bulgy vein is all gone from her upper leg and the visible veins in her lower legs have been reduced by 95 percent, Ellingson says. “It’s great. I’m totally happy I did it. It made a huge difference.”

In November, she ran the 5K Turkey Trot and a few days later walked the Seattle Half Marathon.

Wenda Reed is a Seattle-area health writer and frequent contributor to Seattle Woman.

©Copyright 2011, Caliope Publishing Company