The Course of Time: Varicose Veins Through the Ages

Evolution is a wonderful thing, but varicose veins are one associated aspect that humans could have happily lived without. Unfortunately, the ability to stand and walk on two legs came with unsightly and unhealthy consequences. But if you think vanity associated with the current “selfie age” triggered a deeper dislike of such visual flaws, think again. Humans have been self-conscious about their varicose veins for thousands of years. And as far as we know, treatments have been around — some more rudimentary than others — since 1550 BCE. We’re fortunate these days to have access to non-invasive medical techniques, but imagine for a moment, living centuries ago with varicose veins — what would you have done, and how would you have been treated? If you think you’re unlucky to have varicose veins, read on to understand the history of varicose veins and find out what people went through before the dawn of modern medical procedures. You might just see your plight in a different light.

 

Chances are, you stumbled upon this blog while researching your own venous situation. Of course, when you have a condition, it pays to know as much about it as you can, for your own peace of mind. So for a moment, let’s briefly revisit the basics: What are varicose veins? They are:

  • Abnormally large, tortuous veins that typically appear in the legs;
  • A cause of aching, swelling, itching, leg heaviness, and skin ulceration

 

So how far have humans come in the research and treatment of varicose veins? And what did people face when they needed treatment? The earliest record of varicose veins is in the papyrus of Ebers, written 1550 BCE, where the author described them as “tortuous and solid, with many knots, as if blown up by air”, and recommended people leave their veins in place.

Ebers Papyrus
Ebers Papyrus – 1500 BC

 

The first illustration of a varicose vein dated from 400 BCE, a votive tablet found at the base of the Acropolis — so that gives you an extra idea just how long varicose veins have been bothering people. It was around this time that Hippocrates, the “Father of Medicine”, suggested people do something about their varicose veins, because he noticed a correlation between veins and leg ulcers. This was the introduction of vein punctures, cautery (using a hot or caustic agent) and compression bandages as a treatment.

ancient depiction of varicose veins
Depiction of a varicose vein – 400 BC

 

Over the next few centuries, the developments in treatments were many and varied. For example, in 270 BCE, two Egyptian physicians made surgery possible through the invention of forceps to block veins and control bleeding. But a low point in surgical history was around 0 CE, when the removal of a varicose vein was too much for even a notorious Roman warlord. He had one leg done and opted out of having the other fixed, saying “I see the cure is not worth the pain.” Today easier, more advanced varicose vein treatments are available with no down time.

 

Mercifully, surgical developments in varicose vein treatment continued. A Greek surgeon realized around 600 CE that the great saphenous vein — the longest vein in the human body — could be ligated or removed. Then in 1485, a landmark development was when Leonardo da Vinci produced accurate drawings of lower-limb veins, helping medical world make sense of how the venous system worked.

da Vinci's anatomical drawing
Leonardo da Vinci – 1485 AD

 

Two centuries after da Vinci’s drawings were rendered, the first documented attempt at sclerotherapy took place — acid is injected to create thrombus — a blood clot. This set the scene for the 1800s, where a flurry of medical developments were made. Charles Gabriel Pravaz invented his injection syringe made of glass, rubber and leather, and Francis Rynd followed up with the hypodermic needle.

 

By the 1900s, critical tools of the trade had been invented, and surgical processes were now being refined and published. Options included saphenous vein ligation; vein perforation to treat ulcers; and application of a special agent to close varicose veins. The links between chronic pelvic pain and vein congestion in that region were discovered, known as Pelvic Venous Insuficiency, and Sven-Ivar Seldinger figured out a technique to access veins using guidewires.

 

Enter the modern age of venous treatment. Since the 1960s, treatment of vascular disease has included the use of guidewires, catheters, angioplasty and stents. If you had vascular issues these days, you were fortunate to have surgeons with many cutting-edge treatment options at their disposal. More recent and sophisticated treatments tended to have impressive scientific titles, such as duplex ultrasound scanning, radiofrequency ablation, foam sclerotherapy, and diode laser.

sclerotherapy
Sclerotherapy uses an injectable medication to close varicose veins.

 

Which brings us to now. Do you have a vascular disorder that concerns you? Rest assured, medical development has never stopped. Perhaps your treatment might include a ClariVein device, which can be used without tumescent anesthesia. Asclera is an option for closing small veins. And VenaSeal is a system that closes veins using an adhesive agent. Your specialists know just the right treatment for you and you have nothing to worry about. The days of the painful surgery that so terrified the Roman warlord are thankfully a thing of the very distant past.

 

history of varicose veins infographic

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What To Expect During Your Ultrasound

Some very common questions new patients have when they come in for their first appointment are “What are you looking for? How can you tell if I have varicose veins?” Ultrasound is excellent for diagnosing varicose veins and is used throughout the treatment plan. Patients can expect to have an ultrasound at all of their appointments.

When the exam is started, the sonographer adjusts the bed to what’s referred as the Reverse Trendelenburg position, which is with the foot of the bed much lower than the head of the bed. This simulates standing, which increases venous pressure on the legs, and the blood flow patterns can be evaluated more accurately than laying down flat on a bed, which creates 0% hydrostatic pressure and the flow patterns would be minimalized. The patient does stand for part of the ultrasound when the back of the legs are being evaluated.

The sonographer evaluates all the deep and superficial veins in the legs. The legs are checked for any superficial or deep blood clots. The starting and ending point of all the veins are evaluated, and the flow checked for reflux. Reflux in the veins is when blood is going in the wrong direction (towards the feet) when it should be flowing up towards the heart. The heart pumps the blood from the arteries to the

Reflux in a vein identified using color doppler.

extremities, and the veins take the blood back to the heart. The amount of blood returning to the heart varies at any moment, as this is achieved by breathing. When there is increased abdominal pressure, for instance, taking a deep breath, the diaphragm presses down on the lower venous system, decreasing flow, just for a moment, and when breath is exhaled, the pressure is released from the lower venous system, and the blood rushes back to the heart. This happens over and over.
There are valves throughout the veins, and when there is increased pressure on the veins, the valves will stop the blood from going back to the feet. When you have Chronic Venous Insufficiency Syndrome, the valves have stopped working and every time there is increased abdominal pressure, the valves won’t hold the blood where it is, and it all rushes towards the feet. This phenomenon can be visualized on ultrasound by using Doppler, which can tell what direction the blood is flowing. The sonographer has the patient reproduce this through the Valsalva movement (bearing down) multiple times throughout the procedure. This is how venous disease is diagnosed.

A week or so after the procedures another ultrasound is performed, this time to check for vein closure and to make sure there are no complications or blood clots. After several months the body has absorbed the vein and it is not visible on ultrasound anymore.

Ultrasound is a very useful modality in the diagnosis of varicose veins and has revolutionized the treatment and management of Venous Insufficiency Syndrome.

Varicose Vein Treatment: Understanding What Your Insurance Will Cover

Dealing with treatment of varicose veins can be tricky when it comes to prior authorization with an insurance company. There are many guidelines that need to be followed and they are specific to each insurance company. Examples including vein size, types of veins, pain level, compression stockings and Nsaid use are just a few that each insurance will look for at the time a prior authorization is submitted.

Pre-Authorizing Treatment

At IVC we are very aware of the importance of obtaining the correct measurements and making the patient aware of their responsibility before an authorization can be obtained. No one wants to go into a procedure without being sure that the insurance will pay their part. We want our patients to be relaxed on their procedure date, not stressed about whether they will have an issue with their insurance later on. Because patient care is so important to us, we pride ourselves in knowing what the insurance company needs, we have an open relationship with many insurance companies who appreciate our clinical notes and ultrasound reports and have open communication with us to explain any changes because we are not trying to sneak past their requirements.

Knowing Your Out-of-Pocket Expense

Not only can you have the confidence in our authorization department, we offer what many clinics do not, knowing what your out of pocket cost is before starting the varicose vein treatments. Knowing what your portion of the treatment will cost you will help you decide if the treatment is possible, and prepare with your HSA or Flex Spending accounts. You will hopefully better understand what your deductible, co-insurance and out of pocket max are and how they apply to the treatments you receive at IVC.

Getting started with your new patient appointment will not only educate you on insurance requirements and cost but will also get you started with those requirements and be ready if your deductible is met for the year.

Varicose Vein Procedures: Endovenous Thermal Ablation

Endovenous Thermal Ablation

The first procedure typically performed is the venous ablation. This is where the vein is burned with either laser or radio frequency catheters. During this procedure, the patient is sedated with valium, nitrous oxide, or both. The patient can choose the level of sedation they prefer.

During this procedure, the sonographer will map the vein to be ablated and mark a location that appears to be a good access point. What we look for is whether the vein is straight and has a large diameter, which makes accessing the vein easy. Veins will sometimes spasm or be a smaller diameter early in the morning when the patient hasn’t been standing or active all day, or when the leg is cold. In these cases, we use gravity, a Nitroglycerin patch, and a blanket to help warm up the leg and increase the diameter of the vein.

Once a location is marked, we prep the leg with a cleansing/sterilizing solution and set up the procedure using sterile technique. We ask that the patient not touch the sterile field, so to prevent infection. When the physician enters the room, he will also dress in a sterile gown and will don sterile gloves. We take every precaution to keep the patient safe and infection free.

At this point, the physician will access the vein and start the procedure. Once the vein is accessed, a “guide” wire is inserted and the sonographer will follow the wire up the vein to make sure we are in the vein and not in the surrounding tissue. After that, the catheter, with the heating element, is inserted and once again the sonographer follows the catheter with ultrasound to make sure it is in the vein to be treated.

Once the catheter is an acceptable distance from the deep venous system, we need to numb around the vein. This is two-fold: The first reason is to numb and protect the tissue surrounding the treated vein from being burned. The second is to compress the vein around the catheter so the walls of the vein will be treated.

Once this all complete, the catheter is slowly removed and the vein will be ablated. We close the access point with steri strips and the procedure is finished. The patient is then required to wear a compression stocking for one week.

Insurance Coverage of Varicose Vein Treatment

Getting treatment for varicose veins can be daunting and sometimes frustrating. We hear you and want to help.

Does this scenario sound familiar:
Physician: How long have you suffered symptoms?
Patient: Explains reason for visit.
Physician: Well, I know we can help you with that. What insurance do you have?
Patient: Gives insurance information
Physician: Oh, I’m sorry to tell you that not all these procedures are covered by your insurance.

If this has happened to you then you are not alone. Most insurance companies have complex policies that are difficult for even their own employees to understand let alone the layman. So, what is it that you need to know about insurance coverage for varicose vein treatment and whether or not your insurance will pay? Three things: symptoms, anatomy and conservative measures.

Varicose Vein Symptoms

Insurance companies are not in the habit of paying for cosmetic procedures; therefore, if you simply do not like the way your legs look then you will have to dig deep into those pockets to pay for those treatments on your own. However, many of our patients are not aware they are experiencing symptoms from their varicose veins because they did not know what to look for. Most patients experience aches and pains in their legs, along with heaviness and sometimes swelling. Another symptom commonly associated with varicose veins is itching. The insurance companies like to quantify these symptoms by determining how they affect your life on a daily basis (Activities of Daily Living). Read about Activities of Daily Living.

Vein Anatomy

We know you have no control over your vein anatomy but regardless the insurance companies have limitations on what they will and will not treat. When you come to an appointment at IVC, you will have a complete ultrasound that we call a “vein mapping”. This vein mapping allows us to determine which veins are healthy and which veins are not. It also allows us determine the diameter of the diseased veins and their shape so we know which modality we should use for treatment. You may hear us mention that a vein size is too small to be covered by your insurance. Most of the time, these smaller veins are not causing the symptoms you are experiencing; therefore, it is not detrimental to your health to not proceed with treating those veins.

Conservative Measures for Varicose Veins

Okay, now we have established that you are experiencing the symptoms the insurance wants for treatment and your vein anatomy meets their policy requirements. What are conservative measures and why do you need to do them? The majority of insurance companies are going to require a patient to have a trial period of wearing prescription strength compression stockings for at least three months prior to approving treatment. The styles really have come a long way from when our grandparents wore compression socks, but they still are tight and can be uncomfortable so the three months can sometimes feel like a lifetime. Insurances also like to see that you tried taking anti-inflammatories to alleviate symptoms. Some require these medications to be prescription strength and others require OTC. Either way, the insurance companies want to determine whether your symptoms can be managed by conservative treatment with medications and compression before they opt to pay for other forms of treatment.

Once you have completed your conservative measures trial period, then it is time to submit your clinical for prior authorization and move forward with treatment. Having insurance does not guarantee they will pay so it is very important to choose a clinic that will walk you through the process. Do not be afraid to ask questions to be informed as much as possible because ultimately the buck stops with you.

Utah Varicose Vein Center

If you suffer from varicose veins, you are not alone. Studies suggest that approximately 40 million people in the United States have variscosities. Half of this group are over the age of 50 and more than 60 percent are older women. Hormone changes throughout life tend to make women more susceptible to this condition. The problem may also develop due to genetics. Additionally, being overweight can also be a contributing factor. Anyone having an occupation that requires standing for extended periods or chronically lifts heavy weight may also be at higher risk.

Varicose Veins Causes and Prevention

While there is nothing that one can do about family history, and changing occupations may be difficult, other lifestyle changes may at least serve to delay varicose vein development. Maintaining a healthy weight and getting sufficient amounts of exercise weekly keep muscles toned and help leg veins perform more efficiently. Physicians at The National Institutes of Health also recommend that if needing to stand or sit for long lengths of time at a job, take breaks by changing positions. Avoid crossing your legs while sitting and elevate legs when sitting or just lounging around at home. Physicians at the Varicose Vein Center in Utah explain that the condition involves venous blood vessels that become engorged, swollen and sometimes twisted because valves within the veins falter. Veins return blood to the heart and lungs for oxygenation. The blood travels upward from the legs through the assistance of contracting leg muscles. Valves in the vessels keep the blood from flowing in reverse. When the valves weaken or completely fail, blood flow stalls and may pool or form dangerous clots. In many cases, the veins merely become visible beneath the skin and appear raised. In more severe instances, patients may experience swelling around the ankles, skin discoloration and sometimes develop open skin wounds called venous ulcers.

Varicose Vein Treatment

While some seek medical intervention to eliminate the appearance, many consult with Utah varicose veins physicians because the condition may cause physical pain or pose a health threat. Depending on the size and location of the problem vein or veins, specialists use different treatments that are designed to block blood flow to a particular vessel, which forces the blood to travel through other veins. A recent study performed by researchers in the United Kingdom determined that thermal ablation therapy, known professionally as endovenous thermal ablation, proved the most effective technique in alleviating the problem.

From the fall of 2008 to the fall of 2012, surgeons researched treatment methods on 800 volunteer subjects diagnosed as having varying degrees of varicose veins. Some underwent ablation treatments, another group received specially designed foam injections and the last group had veins surgically removed. After six months following the procedures, surgeons evaluated the patients for outcomes and possible complications. While all treatment techniques proved successful, the individuals receiving thermal ablation therapy experienced fewer adverse effects. However, when patients have veins with very wide diameters or veins that lie particularly close to the skin, specialists are more inclined to recommend surgical removal as a safer alternative. To determine the best individualized treatment method, you should consult with a vascular specialist at the IVC Interventional and Vein Center.

Get Ready For Summer With Compression Stockings

Now that winter is winding down, it’s easy to get lost in thoughts of a long-awaiting tropical vacation. Sandy beaches. Toasty temperatures. And maybe a pina colada.

Unfortunately, some of us get an unpleasant introduction to summer when we try on the swimsuit only to discover that a new varicose vein has decided to make an appearance. There it is, bulging for the world to see. There’s no easier way to ruin the mood than to think of everyone seeing those veins while you enjoy the sun in your swimsuit.

The good news is that varicose veins can be treated. And now is a good time to come in and have them looked at before summer. You can also keep them from getting worse with compression stockings. The concept is fairly simple: Strong elastic stockings apply pressure to your leg muscles, easing venous pooling. When your legs are in motion, that mild pumping action — aided by the pressure hosiery — enables blood to flow away from the legs, where clots may form.

Compression hosiery gently squeezes the muscles, even while a person is sitting, as well as when moving about. To reduce the pain, swelling, and discomfort of varicose veins, a doctor may recommend that the patient wear stockings that extend from foot to thigh.

Compression socks may work for some milder cases of varicose veins, but sometimes a more aggressive treatment may be required. The best idea is consult with a doctor. So if you have a vacation coming up during the months ahead, and are worried about unsightly varicose veins, give us a call and we’ll see what we can do.

Lisa’s Testimonial

“I can now stand and sit for extended periods and have been so pleased with the care and attention from IVC.”
I have suffered with painful veins for years. I had tried water aerobics, support hose, elevation and herbal treatments with little relief. I am now running and enjoying pain free legs on most days. This has been a great benefit to my life. I can now stand and sit for extended periods and have been so pleased with the care and attention from IVC.
Thanks to all the doctors and staff!!
Lisa G. – Treated 2011

Women, Pregnancy and Leg Pain

Many women come into IVC with leg pain that increases in intensity during their menstrual cycle. As an ultrasonographer, when a patient mentions that to me I start to thinking of pelvic congestion syndrome. Some of the symptoms include a heavy or full feeling in the pelvic area, lower back pain, and an increase in pain in the leg during their menstrual cycle.

Unfortunately women do not only deal with the hereditary factor of varicose veins but many women develop varicose veins that get worse with pregnancy. ” Britney Spears today is the equivalent of the average American woman- a single mother of two with dashed hopes, little faith in romance and varicose veins.” (The Varsity 2007) http://www.veindirectory.org/blog/2007/10/celebrity_varicose_veins_britn.html#ixzz1d2zvDKgA

We know that you are not Britney Spears and the quote seems humorous however, there is validity to the quote. Pregnancy can increase the size and the amount of varicose veins in the pelvic area as well as in the legs. There are treatment options out there for you! Please feel free to call us if you have any questions.

Follow A Patient: Introducing Vickie

My name is Vickie. I have been asked by IVC to document my experience so other reluctant individuals can know of my experiences, my treatment, my pain or non-pain, and recovery process. I am a retired educator from a suburban/rural school district where I taught or was in administration for over 40 years. I like to travel, take pictures, read, crafts, scrapbook, and most anything that does not include chores around the house. One of my new hobbies is baking cupcakes.

I have had issues with my legs for a long time. After standing in the classroom I would find myself experiencing leg aches and in the night, leg cramps. Sitting down just doesn’t work when students needed help understanding what I taught. I have several other physical conditions and was never sure what caused the tired legs and leg cramps, but when my very active family wanted to walk, run, play ball, or other exercise my response was always “this body wasn’t made for exercise.”

When I was traveling I sometimes was restricted in my activities because my legs hurt. I found ways to compensate but I still missed out on some of the fun. I only take pictures until I can’t stand any longer, not because the subjects have disappeared. It takes two days to bake cupcakes–one to bake and one to frost.

I attended the Mother’s Day screening IVC conducted at the Marriot. I didn’t know for sure if varicose veins were part of my problem but my family did have a history of having varicose veins. No one really did anything about them because striping them was too costly and painful. Sure enough, the apple doesn’t fall far from the tree and I have varicose veins in both legs.