By Julia Sommerfeld
MSNBC

Aug. 21 —  For many of the 30 million Americans with varicose veins, the only thing worse than the condition itself is the idea of having a swollen blood vessel ripped out through their groin — the standard procedure for large, distended veins. But new high-tech treatment options are giving patients a leg up on varicose veins.

THOSE TWISTED blue bulges are more than just an issue of vanity— they cause some degree of pain or discomfort in the majority of cases. And while women are more likely to develop the condition, millions of men are also affected.
       “Everyone thinks varicose veins are just cosmetic, but they cause symptoms,” said Dr. John Bergan, a professor of vascular surgery at the University of California at San Diego. “They bother people with achy pain and heaviness; therefore, treatment is important.”
       Varicose veins can occur anywhere in the body but they most often affect the legs. The most common symptoms are tired, aching and heavy-feeling legs, and patients often experience cramping at night.
       Varicose veins can occasionally cause serious complications. “If you took 100 patients with varicose veins and did nothing for them for two years, about half of the limbs would have leg swelling; 25 percent would have phlebitis [inflammation and clotting], which can be disabling and painful; and 5 percent would get an ulcer, a non-healing sore,” estimates Bergan.
       Blood clots that occur in varicose veins can, on rare occasion, dislodge and travel to the lungs, so sudden pain, redness, swelling or warmth of the leg should be reported to a doctor immediately.
       According to the American Society for Dermatologic Surgery, approximately 6 million workdays are lost each year due to complications from varicose veins and nearly 100,000 Americans are seriously disabled by the condition.
       
BATTLING GRAVITY
 In healthy leg veins, blood travels upward toward the heart with the aid of resilient vein walls and one-way valves that combat gravity’s downward pull. But in some cases, defective valves or a weakness in the vein’s walls allow blood to flow backward and pool in the vessel, causing it to bulge under the skin.
       No one really knows what causes varicose veins but weak vein walls and flawed valves appear to be hereditary and related to female hormones — which is why women are more than three times as likely to suffer from the problem than men, and pregnancy and birth control pills can further increase the risk.
       “We believe it is a defect in the way the collagen is laid down in the vein wall, almost like a radial tire with a defect in the radial construction causing a blowout. Once the blowout occurs, the valve leaflets no longer meet,” according to Dr. Robert Weiss, an assistant professor of dermatology at Johns Hopkins University School of Medicine.
       Additionally, advancing age and added pressure due to obesity or standing still for long periods of time can make veins more vulnerable.

Varicose veins are distinguished from spider veins by their rope-like appearance. Spider veins don’t bulge under the skin but rather appear as red or purple squiggles, often in a web-like pattern. Since spider veins are caused by the same factors, their presence indicates an increased likelihood of developing varicose veins.
       “Spider veins and varicose veins are different forms of the same thing. All are caused by pressure building up and gravity, but varicose veins are the bigger pipes and spider veins are the smaller pipes,” Weiss said.
       Like varicose veins, spider veins can form anywhere on the body, but are most common on the legs, where they can cause a dull, aching pain.
       
GETTING ‘CLOSURE’
       There is no way to repair dysfunctional valves or weakened vein walls, so treatments aim to re-route blood flow by eliminating the diseased vein — either by pulling it out or sealing it off. Neighboring healthy veins then take over the function of the missing one.
       Vein stripping — which involves tying off the ends of the vein and ripping it out through an incision in the groin — has been the standard treatment for large varicose veins for decades. But now, “Closure,” a novel technique that employs radiowaves to shrivel varicose veins, offers a less-invasive remedy for vessels up to half an inch in diameter.
       In Closure, a doctor inserts a catheter into a small incision behind the knee and, with ultrasound guidance, through the greater saphenous vein, which runs along the inner leg and is usually the source of varicosities. The catheter contains an electrode that emits radiofrequency energy inside the vein, causing it to heat, collapse and seal shut.
       Vnus Medical Technologies, the maker of the Closure device, says the procedure has been performed on around 1,000 patients in about 60 centers in the United States so far. The Sunnyvale, Calif.-based company says Closure, which was approved by the FDA in March 1999, will likely jump in popularity since studies presented at several recent scientific meetings and follow-up data published in the May/June edition of the journal Vascular Surgery found the technique 90 percent to 95 percent effective, comparable to standard treatment.

       “Closure appears to be just as good as old-fashioned vein stripping, but with less pain, swelling and black-and-blue discoloration,” said Bergan, who co-authored the study.
       Unlike vein stripping, which is usually performed in an operating room under general anesthesia, Closure is performed in a doctor’s office under local anesthesia. Most Closure patients can resume normal activity immediately after treatment, whereas recovery usually takes about a week after vein stripping. Another advantage to Closure is that it leaves just a small nick behind the knee whereas stripping leaves larger scars.
       “I expect Closure to replace stripping in about 90 percent of patients in about 5 years,” said Weiss, who helped to test the technique.
       Closure’s possible side effects — including numbness, swelling, bruising, and in rare cases, blood clots — are similar to those of standard treatments. An additional risk of Closure is burning of the skin, which occurred in about 4 percent of cases in clinical trials. But doctors say that injecting local anesthetic under the skin can prevent that side effect.
       A downside to Closure is that it doesn’t work well in patients with very tortuous veins because the catheter is inflexible and has trouble weaving through winding curves, Weiss said.
       For people with snake-like veins, adds Weiss, there’s another alternative to vein stripping — a relatively new procedure called ambulatory phlebectomy. Though it’s more invasive than Closure, it’s much less traumatic than stripping.
       In ambulatory phlebectomy, a hook is used to pull out the affected vein through sequential small punctures made along its length. The procedure can be done in a doctor’s office under local anesthesia and leaves very tiny scars.

ZAPPING VEINS
       For small varicose veins and spider veins, sclerotherapy, a doctor’s office procedure that involves injecting an irritating chemical into the vessel that causes it to close up, is the dominant treatment method. But zapping such faulty veins with heat from high-intensity laser beams is growing in popularity.

       Until recently, lasers were used primarily for spider veins on the face. Veins in the legs have been difficult to treat as they are deeper and the skin is thicker.
       But, “new lasers with longer wavelengths penetrate deeper veins and longer pulse duration allows for larger veins,” said Dr. Melanie Grossman, an associate professor of dermatology at Columbia Presbyterian Medical Center in New York.
       Weiss, however, still prefers sclerotherapy since it is less expensive and his patients report lasers are actually more painful.
       But, he says, lasers are very useful for patients who are needle-phobic or have veins smaller than the sclerotherapy needle, as well as for those with vessels around the ankle, where sclerotherapy poses a higher risk of ulcers.
       The newest treatment on the horizon for small varicose veins and spider veins is an intravascular laser in the experimental stage that Weiss is investigating. The new laser slides into the vein through a tiny fiber optic probe and zaps the vein walls from the inside. It’s showing promise as a supplementary treatment after Closure, sclerotherapy or ambulatory phlebectomy are used to eliminate larger vessels.
       Treatment costs vary widely across the country and depend on the individual characteristics of patients’ veins. Health insurance will usually pick up approved treatments for veins that cause pain or other symptoms; however, those being eliminated for strictly cosmetic reasons are usually not covered.