Superficial Venous Disease & Varicose Veins

Varicose veins are extremely common, affecting 80% of men and 85% of women. Varicose vein disease is unfortunately severely under diagnosed, which may be due to the belief that varicose veins represent an isolated cosmetic problem. The very real truth is that varicose veins may result in pain and discomfort, disability and decreased quality of life.

The good news! If you think you may have varicose veins or are experiencing symptoms typical of varicose veins, then diagnosis and evaluation is easy and pain free. Please see below for symptoms and their treatments:

Early stage symptoms:

  • Aching
  • Throbbing
  • Burning
  • Itching
  • Dry and irritated Skin

More advanced symptoms:

  • Swelling or edema of the leg
  • Cramping
  • Skin discoloration such as browning or bronzing of the skin typically the lower leg and ankle regions
  • Leg heaviness and fatigue
  • End stage manifestation:
  • Skin ulceration
  • Venous ulcers are an end stage manifestation

Function of veins and cause of varicose veins:

While the heart pumps the blood to our bodies via conduits called arteries, the blood flows back to the heart via veins. When the blood reaches our feet it must be pumped back centrally to the heart. Since we do not have an “auxiliary” pump in our feet, we instead rely on a series of valves in our veins to transport the blood back to the heart. With the aid of our leg muscles, the blood is pumped step-wise back to the heart like an elevator stopping on each floor of a high-rise building.

When the valves in our veins are competent and close completely, blood can be easily transported back to the heart and the system is effective. However, when the valves become impaired or dysfunctional, blood is coaxed centrally but then leaks back down into our feet with gravity. This results in both exacerbating the problem over time (i.e. worsening of varicose veins) and the typical symptoms of varicose veins such as leg swelling, heaviness, fatigue and skin discolorations due to pooling of the blood in our legs.

Superficial versus Deep Veins:

We have two pathways for blood to arrive back in our pelvis and reach the heart. One is called the superficial system or veins under the skin and the other is called the deep venous system.

The superficial system functions as an aid to the deep system. Therefore, if the superficial system is damaged or impaired, rerouting the blood into the competent, working, deep veins may result in varicose vein treatment.

Work up for varicose veins begins with a thorough consultation with Dr. Friedman or Dr. Kase, both Board Certified and specialty trained in Interventional Radiology and Vein Procedures.

After a discussion of your history and a physical exam, patients will undergo an ultrasound – much like evaluating a baby – but we look at your leg veins instead. Our goal is to see if the valves in your veins are damaged or malfunctioning. We also look at your deep veins to make sure that there is no clot which may be both life threatening and contributing to varicose veins. All of this is pain free and does not involve any radiation.

After a comprehensive evaluation, we will discuss treatment options which are tailored to each patient and their unique physiology and venous underlying issues. We do not just treat the visible veins, we treat the underlying root cause to try and obtain the most durable results. We tailor the combination of therapies discussed below to each patient, their needs and desired outcomes to achieve the ideal treatment plan.

The usual first step when patients experience symptoms of varicose veins is graduated compression stockings. Compression stockings are specialized socks which are manufactured to compress the leg in a graduated fashion, meaning that socks will be tightest at the ankle and less tight at the knee or thigh, depending on length. They serve in compressing the diseased veins to aid in decreasing the stagnation of blood in the leg. While graduated compression stockings are often advised in most circumstances, they may be ineffective or incompletely effective on their own in decreasing or alleviating symptoms of varicose veins.

Other simple steps in aiding venous disease include the following:

  • Leg elevation above heart level when not standing.
  • Avoid standing or sitting for prolonged time
  • Increasing exercise, especially walking.
  • Weight loss and maintenance of healthy weight and healthy diet

Conservative measures have their niche such as in patients who are not eligible for medical therapies due to comorbidities or advanced age or pregnancy.

EVLT uses a thin laser fiber which is inserted into the incompetent vein via a small entry point, about half to a quarter size the width of your pinky. After confirming that the laser is in the appropriate position local anesthetic is injected around the vein and the laser fiber is pulled back through the vein under very stringent control. The laser seals the vein shut therefore rerouting the blood from the damaged veins to the competent, healthy veins.

EVLT is a highly effective, minimally invasive treatment for the treatment of varicose veins. If eligible, EVLT offers the advantage of both minimizing or completely eliminating the appearance of varicose veins and treating the underlying problem. EVLT is akin to cutting down the tree trunk which feeds the venous branches, thus eliminating the root cause of the varicose veins.

The procedure requires no general anesthesia or sedation and as previously stated, is minimally invasive.

Patients are encouraged to walk immediately after the procedure which usually takes a total of about one hour. The majority of the procedure time is utilized for discussion, vein mapping with ultrasound and patient positioning. The actual treatment takes less than 15 minutes!

VenaSeal is a highly effective, minimally invasive procedure for the treatment of varicose vein disease.  In contradistinction to EVLT where the laser emits heat to injure the inside of the vein resulting in venous closure, VenaSeal uses a surgical adhesive or “glue” that is placed within the vein to physically cinch the vein shut.  VenaSeal and EVLT are both non-invasive procedures that result in great outcomes with long-term evidence; however, VenaSeal does offer several advantages to our patients, maximizing patient comfort and recovery.


  • VenaSeal is Non-thermal, therefore there is no risk of thermal injuries to the surrounding soft tissues which is a theoretic possibility with EVLT procedure.
  • Less pain and bruising.
  • No need for post-procedural compression stockings.
  • Rapid recovery with same-day return to daily activities.


  • Considered an “implantable” by the FDA
  • Rare localized allergic reactions from the glue

Sclerotherapy is the practice of injecting either foam or liquid agent into an open vein, causing the vein to collapse and scar down. There are various sclerotherapy agents which are used depending on the type and size of vein being treated. Here at Advanced Vein and Aesthetics, we primarily use Asclera® or Sodium Tetradecyl Sulfate to treat the gamut of venous diseases.

Sclerotherapy may be used for small veins such as spider veins, reticular veins which are small bluish or greenish veins under the skin or larger varicose veins, usually with the aid of ultrasound.

Sclerotherapy is performed in the office either via direct visualization of the target vein with the naked eye or the use of a bright light or under ultrasound guidance. Using these methods, any vein which is diseased or which appears unsightly may be treated.

Sclerotherapy is relatively painless with small needles used, similar to PPD needles which are about the size of a human hair. Most patients report little to no discomfort.

Ambulatory Phlebectomy also called microphlebectomy is the physical removal of large or medium sized varicose veins using a minimally invasive technique. The veins are first visualized and marked with the patient standing. After lying down, cleaning the leg and administering a small amount of local anesthetic, a small nick or needle puncture allows for the physical removal of the targeted vein.

The procedure is not painful and is immediately effective. Microphlebectomy is an outpatient procedure which is easily performed in the office in less than one hour. There are no stitches associated with the procedure and patients are provided simple after-care instructions.

Raju S, Neglén P. Clinical practice. Chronic venous insufficiency and varicose veins. N Engl J Med. 2009;360:2319–2327.

The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum