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Vein Disease Questions


What are Varicose Veins?

Varicose veins are broken veins. Veins are designed to flow toward the heart through a series of one way valves. Due to influences that cause veins to dilate, valves begin to fail and backwards flow occurs within the vein. This allows blood to leak back with gravity and pool in the vein. This causes the veins to bulge and stretch and result in many unpleasant side effects such as aching and throbbing pain, heavy and tired legs and poor circulation.

Varicose veins may show up as spider veins (telangiectasias) or large bulbous veins (truncal varices).

Each is caused by the same process of vein dilation affecting different sizes of veins in a given limb.

What causes Varicose Veins?

One clear factor is heredity in over 80% of varicose vein cases. The second most common cause involves the hormonal influences that specifically affect women, e.g. pregnancy and circulating hormones. Obesity is becoming recognized as a scientifically proven independent risk factor for developing varicose veins and chronic venous insufficiency. Other contributing factors include occupations that involve prolonged standing, sitting and/or trauma to the leg.

What can I do to prevent varicose veins?

Walking or cycling, are wonderful ways to use your calf muscles and pump blood to your heart, lessening the venous pressure, and promoting normal venous health. Vocations that impair mobility, sitting and standing jobs, can adversely affect venous health. Compression stockings are not known to prevent varicose veins, yet they can help prevent blood pooling and increased venous pressure that lead to symptoms also helps improve circulation by preventing blood from pooling in the leg veins.

Do Varicose Veins affect women and men equally?

Women account for approximately 75% of varicose vein cases, mainly because of the unique additional risk factors for females, including circulating hormone levels and pregnancy. Men typically present with advanced stages of disease and often after complications of vein disease. One certainty is that women are far more commonly afflicted with symptomatic isolated surface disease due to hormonal influences and pregnancy.

Of 405 women with varicose veins:

13% had one pregnancy
30% had two pregnancies
57% had three pregnancies

Mullane DJ Am J OB Gyn 1952; 63:620

Treatment Related Questions


What treatment option is best for me?

Based on ultrasound findings and physical examination, we will advise you as to all suitable treatment options. No leg is the same. Your legs may have strikingly different treatment plans purely based upon the pattern of venous disease in the legs. We will tailor your plan to meet your specific needs.

I have obvious varicose veins. Do I need an ultrasound scan?

Veins at the surface can only successfully be treated if the source is identified and controlled. In the majority of cases, source of the visible problem is invisible to the naked eye. Ultrasound helps us identify the extent of disease in your leg deep to the surface. Only then is enduring outcome possible. Once the extent of disease is identified in your leg, a detailed treatment plan will be developed that will manage the entirety of YOUR specific venous problem.

Don’t I need these veins for my circulation?

No, once they become varicose (enlarged), they no longer return blood to your heart. They actually “steal” blood away from the primary pathway back to the heart. The greater saphenous vein is often used for bypass surgery, but only if it is a normal vein. If it is dilated and diseased it is no longer suitable for bypass. The good news is that there are several good alternative vessels to use for bypass grafting if necessary.

Will I have any down time or restrictions after treatment?

There is generally no down time after our procedures. Walking is strongly encouraged. The only limitation is generally vigorous exercise (abdominal crunches, heavy lifting and high intensity cardiovascular for about 1-2 weeks). We also ask you to avoid hot tubs/baths, as the exposure to heat causes veins to dilate and become larger.

I have had vein stripping, but now the veins are back. Why? How can you help me?

Vein stripping, though well intentioned, cannot comprehensively treat the source of your varicose veins. You may have a recurrence of varicose veins, or simply have a progression of your vein disease, either way, a whole leg duplex ultrasound study is necessary to identify the extent of disease and determine what treatment options are currently best for YOU. Generally speaking, you may have many treatment options depending upon the nature of your specific condition.

What is sclerotherapy?

Sclerotherapy means “scar treatment”. This involves injecting a sclerosing chemical into a diseased vein that destroys the lining of the vein wall triggering an inflammatory response allowing the vein to swell and seal. The chemicals most commonly used today are dilute detergents that have far a greater safety profile than what many hear about hypertonic ‘saline’ injections. Over time, the vein will shrink to become threadlike and disappear. Sclerotherapy may be used to treat small veins and large veins. Foam sclerotherapy involves mixing small amounts of air with detergent sclerosant to a consistency of foam. The volume, concentration, consistency and type of sclerosant depend on many features that an experienced Phlebologist can provide, often making a difference between success and failure.

Surface sclerotherapy for spider veins involves not only addressing the spider vein, but its root. We utilize additional visual aids that allow us to see far more than can be seen with the naked eye. What this means for you is more comprehensive treatment and far better results.

What is Endovenous Laser Treatment (ELT)?

ELT is a quick, minimally invasive laser treatment that requires no hospitalization, no general anesthesia, and no complicated surgery. The entire procedure generally takes less than one hour and causes minimal to no pain. Performed under ultrasound guidance, ELT involves applying laser energy to treat the underlying cause of varicose veins by closing off the vein to any future blood flow. The vein progressively shrinks, and becomes threadlike over the following months. Your body then naturally uses other healthy veins to return blood from the heart.

Not all lasers are the same. Endovenous lasers target either hemoglobin or water. Those targeting water have scientifically proven less post procedural pain and bruising. The reason for this is simple. Second generation lasers like the Sciton Pro-V used by our office delivers approximately 1000 degrees less heat than first generation systems. The energy doesn’t perforate the vein wall, as a result there is far less bruising. Having used both systems, the second generation systems offer a major improvement in patient safety and comfort by simply targeting water. Second generation lasers have increased the indications for endovenous laser as the second generation systems deliver less energy and are safer. The added benefit is that the success rates are absolutely phenomenal and the second generation lasers are able to treat vessels that primary systems are unsafe to treat.

What is Micro-Phlebectomy?

This minimally invasive procedure is indicated for large bulbous and ropey veins that persist after endovenous thermal ablation or after surgical stripping. Using small 2-3 mm incisions, the vein is teased out of the leg with small surgical hooks. Local anesthesia is applied, and there is a sensation of pulling or tugging at times.

The advantage of micro-phlebectomy is that it can debulk problematic veins that would otherwise require more treatments with sclerotherapy. The major drawback is that micro-phlebectomy is rarely an acceptable sole therapy for varicose veins and the fact that it cannot effectively treat disease located deep to the surface of the skin.

Despite the drawbacks, micro-phlebectomy is an effective tool when used adjunctively using endovenous laser and sclerotherapy.

What is Broadband Light (BBL) Therapy?

Using innovative filtered light therapy, the BBL gently heats up the target areas of the skin leading to changes that stimulate collagen growth, disrupt small vessels, or break up pigmented regions. For small red vessels, filters are tailored to a wavelength of energy specific to hemoglobin that absorbs the energy leading to small vessel clearing. There is typically little to no discomfort, and no anesthesia is required. BBL is considered supplemental therapy for patients with cosmetic leg veins that persist after sclerotherapy is complete.

Broadband Light is effective in helping other skin maladies including, sun spots, freckles, Rosacea, small facial veins, hyperpigmentation, Port wine stains, hemangiomas, fine wrinkles from sun damage, birth marks, Poikiloderma and unwanted hair of the face, etc.

When is the right time for treatment of my varicose veins?

We know that when veins are diseased, they worsen over time and often affect other veins, making what began as a simple problem, far more complex. Timing of treatment really depends on presence of venous complications and quality of life impairment. In the presence of leg ulcers, blood clots or advanced venous conditions with skin findings, there is urgency for treatment. Another indication is simply when your quality of life is impaired to the point it affects your routine daily activities.

Quality of life impairment may be cosmetic concerns or related to the symptoms of sustained varicose veins. The sooner you start getting your veins treated, the easier they are to treat and control.

Will I need to be hospitalized or take time off from work?

All treatment is performed on an outpatient basis in a location best suited for you and the procedure you will be receiving. You can typically resume normal activity following the procedures, but will require a driver after endovenous laser and ambulatory phlebectomy.

I plan on having more babies. Should I wait until I’m done having kids before treatment?

It truly depends. If you were miserable with your last pregnancy, the symptoms will be expected to be at minimum the same, and possibly worse. Pregnancy is a tremendous stress on the venous system from the first through the last trimester. The newer more durable techniques (endovenous thermal ablation) hold up very well to subsequent pregnancies.

Does vein treatment hurt?

It depends on which treatment. Traditional surgery has been compared to “de-boning a fish”, having extensive post treatment pain and bruising. In our practice, less than 10% take any pain medicine, the majority use anti-inflammatories as recommended and approximately 50% have no pain following their treatment session. No one has pain anything like that reported with traditional surgery.

What if I don’t have treatment?

That depends on your diagnosis and genetic predisposition. Complications of vein disease include leg heaviness, aching, fatigue, restlessness, itching, muscle cramps, leg swelling, rashes, thickening and hardening of the skin, enlargement of the calf, discoloration, leg ulcers, blood clots, hemorrhage and in extreme cases, even death. If you have symptoms, they will worsen over time and your disease state will become more complex.

Do I have to wear compression hose?

Compression stockings are a significant part of the standard of care with many large vein procedures. Smaller vein treatments do not require compression hose and have not been shown to benefit from compression. You will be advised to bring your compression stockings with you on any large vein therapy visit. Generally speaking you may be required to wear compression for as many as 7-10 days after endovenous laser or ambulatory phlebectomy. Compression hose have proven value when used for preventative care, during treatment and for long-term therapy after treatment. We carry the common sizes of stockings you may need. We will measure you and fit you with stockings if needed to make sure you have the compression necessary for YOUR specific venous condition.

Administrative Questions


Will insurance cover my treatments?

Insurers generally will reimburse a percentage of the diagnostic studies (ultrasound tests) and treatment cost when medical necessity is met. We have tremendous insurance experience and we will verify benefits and submit necessary documents when required by your insurance company. It is important to note that each insurance company reimburses different amounts for these treatments. We will work with you to ensure you receive the most reimbursement possible.

I love to exercise, I lift weights, I run and I play tennis. Do I have to limit my exercise?

Yes. Abdominal pressures can cause newly closed veins to reopen. For medium/small vein treatment, strenuous exertion is not allowed for 24 hours. Following the first treatment, either endovenous laser or ultrasound-guided sclerotherapy, we usually restrict strenuous exercise for about two weeks. Fitness can be maintained with walking during this time. Following the ultrasound mapping, and your treatment choice, the doctor will discuss your restrictions on an individual basis.

Follow-up treatments will require, at most, light activities for 24 hours. This is also true for medium and small vein treatments. /span>

How often will I need follow-up evaluations?

Follow-up visits are recommended because vein disease is progressive and subject to genetic and hormonal influences. Depending on the severity of your venous problem, a follow up program will be recommended to monitor your venous health, clinical improvement and assure enduring results.

What should I look for in a provider?

Experience does matter. Varicose vein disease can be very complex and every limb is unique. It is important to find a provider experienced in treating the entire spectrum of vein disease, and one who is dedicated to the exclusive management of vein disease. The complexity of vein disease does not enable a part-time provider to deliver the same symptom and cosmetic improvement that you should expect.

Dr. Schul has been practicing Phlebology since October 2002. His training involved a 4-month fellowship with the most experienced providers specializing in vein disease. He is an Active Member of the American College of Phlebology, and the first provider in Indiana recognized by the Indiana State Medical Association and the American Medical Association as a clinical Phlebologist.

Dr. Schul’s passion for venous research has led to numerous contributions to venous medicine and speaking opportunities on the National and World stages in 2005 and 2006. When it comes to experience, Dr. Schul has performed many thousands of cases that enable him to deliver exceptional results. The most valuable attribute that Dr. Schul shares is his passion in helping his patients achieve the symptomatic and cosmetic goals they so justly deserve. This attribute shows in both his bedside manner and administrative advocacy in helping patients acquire insurance benefits for their medically necessary condition.

What happens at a consultation?

This first step in your evaluation will also involve a diagnostic study to address YOUR venous concerns. You will become educated in your venous health and gain a greater understanding about the various procedures that may be necessary to manage your condition. You will meet our medical team and have ample time to ask questions. During your clinical evaluation, our administrative team will be calling to verify your benefits and be able to share expected costs and other important information. Plan on being in the office 60-90 minutes for your initial evaluation.