The Treatment of Varicose Veins and Spider Veins

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1 The Treatment of Varicose Veins and Spider Veins St. Joseph Vein Center Surgical Specialists of St. Joseph, P.C. Glen H. Hastings, M.D., F.A.C.S. 820 Lester Ave., Suite 105 St. Joseph, MI (269)

2 Table of Contents Introduction 3 Understanding Varicose Veins and Spider Veins Circulatory System 4 Vein Anatomy 6 Treatment Options 8 Endovenous Closure Overview 9 Informed Consent 10 Patient Instructions 12 Ambulatory Phlebectomy Overview 13 Informed Consent 14 Patient Instructions 16 Ultrasound Guided Sclerotherapy Overview 17 Informed Consent 18 Patient Instructions 20 Sclerotherapy Overview 21 Informed Consent 22 Patient Instructions 23 Compression Stockings 25 Insurance Coverage 25 Contact Information 26 Introduction to Dr. Hastings 27 2

3 Introduction to the Vein Center Welcome to the St. Joseph Vein Center at Surgical Specialists of St Joseph. Our goal is to provide a comprehensive treatment of vein diseases. The most common vein problems or diseases we see are varicose veins and spider veins. One of the most problematic complications of varicose veins is venous stasis with ulceration. We offer minimally invasive and non-surgical treatment options including Laser Endovenous Closure of Varicose Veins, Ambulatory Phlebectomy, and Sclerotherapy. On your first visit we will be doing a comprehensive consultation to determine the extent of your venous problems. The consultation will include a limited venous ultrasound exam done at the time of the physical exam. After this consultation I will be able to give you an analysis of your venous problems and develop a treatment plan to correct these problems. To evaluate the venous problems we use venous duplex exams extensively, and through the course of your treatment you may have multiple exams done to assess the progress. The Vein Center provides treatment for all venous problems including large painful varicose veins, spider veins, and venous ulcerations. We participate with Medicare and with most commercial insurance companies. If your varicose veins are causing symptoms such as pain, swelling, bleeding, ulcerations, or phlebitis, then the treatment of varicose veins will usually be covered by your health insurance. If your varicose veins are not symptomatic or you are just being treated for spider veins, these are usually considered cosmetic treatments and may not be covered by your health insurance. Enclosed in this booklet is a general overview of venous disease to help you understand the proper function of the venous system, and how varicose veins and spider veins develop. This overview explains the cause and pathology of varicose veins and spider veins. Also included is a description of each type of treatment we use for treating vein disease at the Vein Center. These include a description of the treatment, the risks and benefits of the treatment, and patient instructions for patients undergoing the treatment. Please keep this booklet nearby and refer to it as we proceed with the treatment of your venous problems. If you have any questions or concerns at anytime during your treatment, please bring them to my attention. My goal is to treat your venous problems to eliminate your symptoms and improve the overall appearance of your legs. We do this using minimally invasive procedures to minimize the pain associated with the treatment and minimize your recovery time. Thank you for using the St. Joseph Vein Center at Surgical Specialists of St Joseph, P.C. Sincerely, Glen H. Hastings, MD, FACS 3

4 Understanding Varicose Veins and Spider Veins To understand varicose veins and spider veins you need to understand the circulatory system of the legs. The Circulatory System In the circulatory system, arteries carry oxygenated blood from the heart to your legs and the veins carry the deoxygenated blood away from the legs back to the heart. The blood returns to the lungs to pick up more oxygen and then is pumped out from the heart back through the arteries. The venous system has two components. The first is the deep venous system. It lies below the muscles and transports 90% of the blood out of the legs. It is the system that can form blood clots which may be life threatening if not treated. The deep venous system usually is not associated with varicose veins. The second component of the venous system is the superficial venous system. It transports approximately 10% of the blood out of your legs. You can form clots in this system that cause pain and discomfort. This is referred to as superficial phlebitis. These blood clots are not life threatening. The superficial system is the origin of most varicose veins. The veins have one-way valves that allow the blood to travel upwards out of the legs and prevent blood flow from reversing back into the legs. These valves are found both in the deep and superficial veins. When the deep system has faulty valves that leak we see reflux of blood in the deep system and this can lead to swelling of the leg. When the superficial system has faulty valves that leak we see development of varicose veins. Venous Reflux The condition that results from leaky valves within the veins is called venous reflux. When the blood is refluxing down the legs it puts excess pressure on the vein walls, which causes them to expand and enlarge. This expansion causes the valves to become even more ineffective and the disease progresses. Over months and years we see progression of the varicose veins extending down the leg with larger veins and more numerous varicose veins developing. In the superficial venous system the greater saphenous vein is considered the main trunk of the superficial system. It runs from the inside of the ankle along the inside of the leg all the way up to the groin. Most varicose veins are branches of this main trunk. It is damage of the valves with venous reflux in the greater saphenous vein that leads to most varicosities. In order to treat the varicose veins effectively we need to remove all segments of the veins that are refluxing. Often this involves treating or removing the greater saphenous vein. We also need to close or remove the varicose branches within the leg. There is a secondary superficial venous trunk on the back of the calf called the lesser saphenous vein that runs up from the outside of the ankle up to behind the knee. Sometimes we see venous 4

5 reflux within this vein. This leads to varicose veins developing on the back of the calf. When that occurs we need to treat the lesser saphenous vein, as well. Spider veins are caused by reflux in tiny veins of the skin causing the veins to enlarge and have higher pressure. Usually the spider veins are not associated with larger varicose veins or saphenous vein reflux. But in some cases the spider veins will be associated with saphenous vein reflux. Also with spider veins we see reticular veins, which are prominent blue veins that seem to connect areas of spider veins. Reflux within these reticular veins contributes to the formation of spider veins. Treating the reticular veins is an important part of treating spider veins. Varicose Veins and Ulcerations When venous reflux is left untreated for many years, the constant pressure backing up in the veins causes leakage of blood into the tissues. The greatest pressure is near the inside of the ankle, so most of this leakage occurs near the ankles. This leakage causes brown staining of the skin and thickening of the skin. This is known as stasis skin changes. This can progress to ulcerations. This is referred to as a chronic venous stasis ulcer. Venous stasis ulcers are very difficult to treat. They are usually chronic in nature and often reoccur as soon as they heal. Because of this potential complication in patients with large varicose veins and a large amount of reflux, there is a medical need to treat these varicosities. The venous stasis ulcers do not occur in all patients with varicose veins. Unfortunately, it is hard to predict who will progress to this complication over the course of years. Therefore, it is best to treat large varicosities before the venous stasis changes occur. Treatment The goal in treating varicose veins is to close or remove all segments of the superficial veins that are refluxing. This will often require closure of the greater saphenous vein and sometimes the lesser saphenous vein. Venous duplex imaging is used to examine the legs to assess both the deep and superficial veins for venous valvular reflux. Also, the duplex will evaluate the deep venous system for a possible blood clot. In treating the spider veins we usually just need to close the spider veins and any associated reticular veins. However, if there is suggestion that there may be venous reflux in the greater or lesser saphenous veins, a venous duplex would be done to rule out disease within the greater or lesser saphenous veins that may be contributing to the spider veins. If there is reflux in the saphenous veins, then treatment of these veins may be necessary, as well. 5

6 Anatomy of a Vein Veins have cuplike flaps called valves spaced along their inside walls. Valves open upward, so blood can move up the vein. When valves close, they keep blood from falling back down the vein. Important Veins in the Leg Veins have cuplike flaps called valves spaced along their inside walls. Valves open upward, so blood can move up the vein. When valves close, they keep blood from falling back down the vein. When a muscle contracts, the valve opens. Blood is squeezed up the vein. When a muscle relaxes, the valve closes, holding the blood in place. Femoral Vein Popliteal Vein Lesser Saphenous Vein Greater Saphenous Vein Three Types of Veins Superficial Veins collect the blood just beneath the skin. Perforating Veins carry blood from the superficial veins to the deep veins. Deep Veins run through the muscles and carry 95% of the blood back to the heart. 6

7 Impaired Venous Circulation If a vein is damaged, blood flow back to the heart is reduced. Although the muscles still squeeze blood up the vein, weak or injured valves cannot support the weight of the blood when the muscles relax. Some blood leaks through the valve, putting extra pressure on the valves below. This is called venous reflux. Over time, these lower valves weaken and the damage progresses down the leg damaging more valves. As a result, you may develop ropy varicose veins, pooling or clotting blood, or a combination of these problems. A Damaged Vein Heredity, Injury, Pregnancy, or a blood clot may weaken the vein. When this occurs, the wall near the valve begins to sag. The valve may no longer close fully, allowing blood to move in both directions when the muscles relax. Most vein problems begin with damaged valves. A Ropy Vein Once a vein is damaged, blood pressing against the sagging wall may cause the vein to bulge or twist like a rope. Eventually, the valve can t close. Blood may begin to pool or clot in the vein. Blood moves in both directions. Blood presses on the vein causing it to twist Pooling Blood A valve that doesn t close cannot hold blood when the muscles relax. Instead, the blood drops down to the first healthy valve. If valves in a deep vein are damaged, blood may back up into the perforating and superficial veins. Clotting Blood When blood moves slowly, it may collect in one or both valve cups. The blood may become sticky and gathers at the vein wall. Over time, the blood forms a clot, which may grow big enough to close of the vein. Blood drops to the first healthy valve Blood clots in the valve cups. 7

8 Treatment Options for Varicose Veins No Treatment: Some patients opt not to treat their varicose veins. They may live their entire life with varicose veins and never develop complications more serious than a chronic dull ache. Compression Stockings: Compression stockings aid in treatment of varicose veins by helping to squeeze the blood out of the legs by means of gradient compression. This is accomplished with elastic stockings, which fit the legs very tightly. In many cases this will relieve the discomfort caused by the veins. Ultrasound Guided Sclerotherapy: Under the guidance of ultrasound a needle is inserted into the varicose vein and a chemical is injected directly into the diseased vein. This chemical irritates the diseased vein and wall and causes it to collapse and scar shut. Laser Endovenous Closure: A catheter is inserted into the greater saphenous vein at the level of the knee. This is done using a needle under ultrasound guidance. A catheter is then fed up the vein to the upper greater saphenous vein near the groin. The laser fiber is placed into the catheter and the laser is fired while the catheter is withdrawn causing damage to the vein wall along the length of the vein. The damage results in occlusion or closure of the greater saphenous vein. Ambulatory Phlebectomy: After Endovenous Closure has closed the greater saphenous vein on the thigh, the varicose branches of the greater saphenous trunk are surgically removed. This is a minimally invasive procedure done through tiny stab incisions that are 2-3mm in size. A small vein hook is used to hook each vein and pull it out through the incision. There are no sutures required and in most cases you can return to work the following day. Sclerotherapy: Used only to treat small varicose veins. A needle is inserted into the varicose vein and sclerosing agent is injected into the vein. This chemical inflames the walls of the vein and causes it to collapse and scar shut. Ligation and Stripping: This is a traditional surgical method used to remove the greater saphenous vein on the thigh and varicose branches on the leg. This usually involves larger incisions with a longer recovery period than endovenous closure or ambulatory phlebectomy. Treatment Options for Spider Veins Sclerotherapy: A needle is inserted into the spider veins and sclerosing agent is injected into the spider vein. This chemical inflames the walls of the vein and causes them to collapse and scar shut. Laser Therapy: A Laser is used to heat the veins through the skin causing damage to the vein walls. This causes the walls of the veins to collapse and scar shut. 8

9 Laser Endovenous Closure for Treatment of Varicose Veins This is a minimally invasive treatment to close the greater saphenous vein of the thigh or the lesser saphenous vein behind the knee. A laser fiber is placed into the vein through an endovenous catheter under ultrasound guidance. The Laser is used to damage the wall of the vein, causing it to collapse and seal shut. This procedure replaces the surgical vein stripping used in the past to treat large varicose veins. The procedure is done in the office under local anesthesia. Most patients return to work and near normal daily activities the very next day. Description of Procedure Prior to the procedure we will repeat the ultrasound of the leg marking and identifying the greater saphenous vein from the groin down to the knee level. The leg will be cleaned and draped sterilely. Using a small needle and guide wire we will access the greater saphenous vein just above the knee using ultrasound guidance. You will receive an injection of local anesthesia along the length of the saphenous vein being treated. With ultrasound guidance a catheter is inserted over the guide wire and into the greater saphenous vein and advanced all the way to the groin level. At this point we place a laser fiber through the catheter into the vein under ultrasound guidance. The catheter is withdrawn while the Laser is fired to close the vein to the knee level. Once this is completed we wrap the leg with a compression bandage to give good compression of the treated vein. Following the procedure you go home with the compression bandage on the leg. This will stay on the leg continuously for twenty four hours. When you remove the compression dressing, you will start wearing a thigh-high compression stocking. We recommend that you wear the stockings daily for two weeks. You may take the stocking off at night and to shower. The procedure should have very little discomfort. During the closure of the vein you may feel a little stinging or tingling of the vein. This will only last a short time. Walking after the procedure helps relieve this discomfort. Following the procedure we recommend that you have someone drive you home. We will let you resume nearly all activities the next morning. You will be able to drive and return to work the next morning. You can expect some tenderness and mild swelling along the treated vein for several weeks. Following the procedure we will see you in the office after one week for follow up. You will have a venous duplex exam at that time to verify that the vein has been successfully closed. Any areas that have not been successfully closed can be treated with ultrasound-guided sclerotherapy. 9

10 Informed Consent for Laser Endovenous Closure Endovenous Closure is a minimally invasive option for treating greater saphenous vein incompetence (leaky valves). The first stage of your surgery will involve inserting a catheter at the level of the knee and feeding it up the greater saphenous vein (the root of your problem) under ultrasound guidance. During the second stage of the treatment, the catheter is slowly removed while the Laser is fired causing the vein to collapse and seal shut. This will relieve the backflow pressure (reflux), which is causing your varicose veins. Following the procedure we will put you in a compression Bandage which you will wear day and night for two days. After the two days you will then wear your compression stockings during the day for the next two weeks. One week after surgery we will evaluate your results using ultrasound. If we find any branches remaining we will destroy them with a procedure called ultrasound guided foam sclerotherapy. Utilizing ultrasound the varicose vein is visualized on a screen and the Physician uses this technology to guide the placement of a needle directly into the diseased vein. A foam sclerosing agent is injected directly into the veins. This causes an irritation to the inner lining of the vein resulting in closure of the vein. Varicose Veins and Spider Veins are chronic and recurrent conditions. The variety of treatments available will not offer a cure, but rather a control of the condition. Surgically removed veins cannot come back, veins that are closed with the laser or sclerosed will not return. However, your tendency towards developing new veins will not be relieved by this or any other form of treatment. You may develop new varicose veins or spider veins and need additional treatment in the future. Potential Risks and Side Effects All surgical interventions carry an inherent risk of infection, allergic reaction, bleeding and anesthetic complications including cardiopulmonary complications. Below are possible risks and side effects that are specific to Endovenous Closure. Allergic reaction: Very rarely, a patient may have an allergic reaction to the anesthetic agent. The risk of this is greater in patients who have a history of allergies. Pain: Patients may experience moderate pain following the procedure. The leg may be tender to the touch after treatment, and an uncomfortable sensation may run along the vein route. This discomfort is usually temporary. Swelling: This may occur after treating veins in the leg. It usually resolves in a few days but may last a few weeks, especially after treatment of large varicose veins. Wearing the prescribed compression hose lessens ankle swelling. Deep Vein Thrombosis: is a very rare complication, the dangers of phlebitis include the possibility of pulmonary embolus (a blood clot carried to the lungs) and post phlebitic syndrome, resulting in a permanent swelling of the leg. Eye injury: laser therapy carries a small risk for eye injury to the unprotected eye. You will be asked to wear Laser safety glasses during the Laser treatment. Transient hyperpigmentation: Patients who have Endovenous Sclero Ablation may notice some discoloration after treatment. This discoloration is almost always transient and will resolve in about three months. In rare cases this darkening of the skin may persist up to a year. Nodularity: Nodularity at the site of vein closure may persist for up to a year. This occurs when there are pieces of the vein that remain in the body and have scarred down and become hard. With time, the body will absorb and soften these areas but some may persist. Skin ulceration: Post injection therapy at the site of injection, a skin ulcer may develop. This is a rare complication. In the event of a skin ulcer it may takes months for the area to heal. Skin Burns: Laser therapy carries a small risk of skin burns, which may require further treatment. 10

11 Nerve trauma: Occasionally there can be trauma to surrounding nerves, which can result in a transcient numbness that will resolve on its own with time. In rare instances the localized numbness may be permanent. Reoccurrences of new veins: When a patient has varicose veins it is usually an ongoing problem. Several years after the vein has been treated the body will attempt to repair itself by taking veins that were insignificant and make them significant. We recommend a yearly follow up with ultrasound so that we can detect any new problems and treat them accordingly as they arise. I am aware that in addition to risks listed above, there are other risks that may accompany any surgical procedure, such as loss of blood, infection, and inflammation in the venous system with formation of a thrombus (clot), postoperative bleeding, and nerve trauma that may lead to temporary or permanent numbness. Alternative Treatments: Because varicose veins and spider veins are not life-threatening conditions, surgical treatment is not mandatory in every patient. Some patients get adequate relief of symptoms from wearing graduated support stockings. Surgical stripping may also be used to treat large varicose veins. This usually requires a hospital stay and usually is performed while the patient is under general anesthesia. Risks of vein stripping are similar with the additional risk of the general anesthetic. The other option is to receive no treatment at all. Informed Consent: By signing below, I acknowledge that I have read the foregoing information and understand the risks and possible side effects, alternative methods of treatment and I hereby consent to the treatment of Laser Endovenous Closure. I consent to the local anesthesia to be administered. I am aware that risks are involved with the administration of local anesthesia such as allergic or toxic reactions to the anesthetic and cardiac arrest. I know the practice of medicine and surgery is not an exact science, and therefore, reputable practitioners cannot guarantee results. While the overwhelming numbers of patients have noted gratifying symptomatic and cosmetic improvement, we cannot promise or guarantee any specific result. Patient Signature: Date: Patient Name: Witness Signature: Date: 11

12 Endovenous Closure and Ambulatory Phlebectomy PATIENT INSTRUCTIONS Pre-op Instructions You will not be able to drive home following the procedure. Please arrange for someone to drive you home. You will be in the office approximately 11/2 hours. Please bring your compression stockings with you the day of your procedure. If you are on blood thinners please notify us immediately so we can adjust dosing as needed. Do not come to the office on an empty stomach. You will not be having general anesthesia. We encourage you to have a small meal 1 to 2 hours prior to arriving at the office. Post-op Bandages You will have a compression bandage in place when you leave the office. Leave this bandage on for twenty four (24) hours. Remove this bandage on the first day after your procedure and begin wearing your compression stockings daily. Remove them only at night or to shower. Wear the stockings for the next two weeks. You may shower once the compression bandage is removed. Post-op Pain You may have some discomfort following surgery. Walking after the procedure helps relieve this discomfort. We recommend that you take Ibuprofen 800mg every 8 hours for the first four days and then use the ibuprofen just as needed after the first four days. If you are having extreme discomfort or bleeding notify the office immediately. Some bruising and inflammation along the course of the treated vein are not unusual and are part of the healing process. Walking, wearing the compression stockings, and taking the Ibuprofen will help relieve any discomfort you are having. Post-op Bleeding You may have several areas on your dressing where blood shows through. Some bleeding is normal. Do not be alarmed. Elevate the leg and wrap the bleeding area with an ace wrap. If the bleeding continues and the dressing becomes soaked, call the office. We will change the dressing if needed. Post-op Activity We would like you to continue to keep moving and maintain a normal level of activity. Avoid strenuous exercise such as aerobics, weight training, or running for one week. Avoid hot baths and hot tubs for one week. You may resume all other activities the day after the procedure. You may drive and return to work the day after the procedure. Post-op Follow-up We will see you in one week for a follow-up visit with venous duplex exam at that time to assess the closure of the vein. Please call the office if you have any questions or problems following your procedure. After hours call our answering service at (269)

13 Ambulatory Phlebectomy for Treatment of Varicose Veins This is a minimally invasive treatment to remove the bulging varicose vein branches of the leg. This treatment can not be used to remove the greater saphenous vein on the thigh. The greater saphenous vein needs to be either stripped or occluded using endovenous closure. Once the greater saphenous vein is occluded, we will then proceed with stab phlebectomy. Removal of the veins is done through small stab incisions that are 2-3mm in size. The procedure can be done in the office with only local anesthesia. Most patients return to work and near normal activities the very next day. Description of Procedure Prior to the procedure the varicose veins will be marked with a skin marker while you are standing. This allows us to see all the bulging varicosities that need to be removed. You will then have the leg cleansed and draped sterilely. Local anesthesia is injected around the area of the varicose veins. During the injection of the local anesthesia you will feel some mild pain and burning from the injections. This only lasts a few seconds. Once this is completed you will not feel any pain. During the procedure you may feel some pulling and tugging sensation, but it should not be a painful sensation. Once the procedure is started the varicose veins are removed through the small stab incisions. We make multiple stab incisions, often10-30 incisions, and use a small vein hook to hook the veins and pull them out through these small incisions. Once the procedure is completed the leg is wrapped with a compression bandage to give compression over the entire area that has been treated. The leg will be wrapped from the toes to above the area of the phlebectomy. The bandages stay on for twenty four hours. On the first day following the procedure you will remove these and start wearing a thigh-high compression stocking. The stocking will be worn daily and taken off only at night or to shower. We recommend that you have someone drive you home following the procedure. We will let you resume all activity the following morning. You can drive and return to work the next day. You can expect a small amount of pain following the procedure. Usually ibuprofen is adequate for pain control. You can expect bruising over the area of the Phlebectomy. This slowly resolves over 2-4 weeks. You will have a follow-up appointment at one week following the surgery. 13

14 Informed Consent for Ambulatory Phlebectomy Ambulatory Phlebectomy is a safe and effective surgical procedure to treat varicose veins. This is performed using small stab incisions which will close without suturing. The veins are pulled out using a surgical vein hook. This procedure is done utilizing a local anesthetic. After the procedure is completed a dressing will be applied to your leg followed by a compression bandage. This compression bandage will stay in place for twenty four hours. One to two weeks after surgery we will evaluate your results at a follow up office visit. If we find any branches remaining we can perform a limited repeat ambulatory phlebectomy, or close them with a procedure called ultrasound guided sclerotherapy. This is done utilizing ultrasound to visualize the varicose vein on a screen and the Physician uses this technology to guide the placement of a needle directly into the diseased vein. A sclerosing agent is injected directly into the veins. This causes an irritation to the inner lining of the vein resulting in closure of the vein. Varicose Veins and Spider Veins are chronic and recurrent conditions. The proposed treatments will not offer a cure, but rather a control of the condition. Surgically removed veins cannot come back, veins that are sclerosed will not return. However, your tendency towards developing new veins will not be relieved by this or any other form of treatment. Potential Risks and Side Effects: All surgical interventions carry an inherent risk of infection, allergic reaction, bleeding and anesthetic complications including cardiopulmony complications. Below are possible risk and side effects that are specific to the proposed treatment outlined above. Allergic Reaction: Very rarely, a patient may have an allergic reaction to the anesthetic agent or the scleroscent agent. The risk is greater in patients who have a history of multiple allergies. Pain: Post operatively your leg will be tender touch. There will be a significant amount of bruising which will resolve in approximately two weeks. We will prescribe a mild pain reliever which will help alleviate the discomfort. Swelling: You may experience some swelling in the lower leg post operatively. It will usually resolve in a few days but may last a few weeks, especially after treatment of large varicose veins. Wearing the prescribed compression hose lessens ankle swelling. Deep Vein Thrombosis: is a very rare complication. The dangers of phlebitis include the possibility of pulmonary embolus (a blood clot carried to the lungs) and post phlebitic syndrome, resulting in a permanent swelling of the leg. Nodularity: Nodularity at the site of vein removal may persist for up to a year. This occurs when there are pieces of the vein that remain in the body and have scarred down and become hard. With time, the body will absorb and soften these areas, but some may remain. Nerve trauma: Occasionally there can be trauma to surrounding nerves, which can result in a transcient numbness that will resolve on its own with time. In rare instances the localized numbness may be permanent. Reoccurrences of new veins: When a patient has varicose veins it is usually an ongoing problem. Several years after the vein has been treated the body will attempt to repair itself by taking veins that were insignificant and make them significant. We recommend a yearly follow up with ultrasound so that we can detect any new problems and treat them accordingly as they arise. 14

15 Alternative Treatments: Because varicose veins and spider veins are not life-threatening conditions, surgical treatment is not mandatory in every patient. Some patients get adequate relief of symptoms from wearing graduated support stockings. Surgical stripping may also be used to treat large varicose veins. This usually requires a hospital stay and usually is performed while the patient is under general anesthesia. Risks of vein stripping are similar with the additional risk of the general anesthetic. The other option is to receive no treatment at all. Informed Consent: By signing below, I acknowledge that I have read the foregoing information and understand the risks and possible side effects, alternative methods of treatment and I hereby consent to the treatment of Ambulatory Phlebectomy. I consent to the local anesthesia to be administered. I am aware that risks are involved with the administration of local anesthesia such as allergic or toxic reactions to the anesthetic and cardiac arrest. I know the practice of medicine and surgery is not an exact science, and therefore, reputable practitioners cannot guarantee results. While the overwhelming numbers of patients have noted gratifying symptomatic and cosmetic improvement, we cannot promise or guarantee any specific result. Patient Signature Date Patient Name: Witness Signature: Date: 15

16 Endovenous Closure and Ambulatory Phlebectomy PATIENT INSTRUCTIONS Pre-op Instructions You will not be able to drive home following the procedure. Please arrange for someone to drive you home. You will be in the office approximately 11/2 hours. Please bring your compression stockings with you the day of your procedure. If you are on blood thinners please notify us immediately so we can adjust dosing as needed. Do not come to the office on an empty stomach. You will not be having general anesthesia. We encourage you to have a small meal 1 to 2 hours prior to arriving at the office. Post-op Bandages You will have a compression bandage in place when you leave the office. Leave this bandage on for twenty four (24) hours. Remove this bandage on the first day after your procedure and begin wearing your compression stockings daily. Remove them only at night or to shower. Wear the stockings for the next two weeks. You may shower once the compression bandage is removed. Post-op Pain You may have some discomfort following surgery. Walking after the procedure helps relieve this discomfort. We recommend that you take Ibuprofen 800mg every 8 hours for the first four days and then use the ibuprofen just as needed after the first four days. If you are having extreme discomfort or bleeding notify the office immediately. Some bruising and inflammation along the course of the treated vein are not unusual and are part of the healing process. Walking, wearing the compression stockings, and taking the Ibuprofen will help relieve any discomfort you are having. Post-op Bleeding You may have several areas on your dressing where blood shows through. Some bleeding is normal. Do not be alarmed. Elevate the leg and wrap the bleeding area with an ace wrap. If the bleeding continues and the dressing becomes soaked, call the office. We will change the dressing if needed. Post-op Activity We would like you to continue to keep moving and maintain a normal level of activity. Avoid strenuous exercise such as aerobics, weight training, or running for one week. Avoid hot baths and hot tubs for one week. You may resume all other activities the day after the procedure. You may drive and return to work the day after the procedure. Post-op Follow-up We will see you in one week for a follow-up visit with venous duplex exam at that time to assess the closure of the vein. Please call the office if you have any questions or problems following your procedure. After hours call our answering service at (269)

17 Ultrasound Guided Sclerotherapy for Treatment of Varicose Veins This is a minimally invasive treatment used to close varicose veins using a sclerosing agent. It is used to treat veins that are not visible and that are deeper in the legs. Venous Ultrasound is used to identify the veins and guide a needle into the veins where the sclerosing agent is then injected. This is often used to complement endovenous ablation and stab phlebectomy. Description of Procedure Prior to the procedure a venous duplex is performed to identify the vein to be treated. The vein is marked. This area of the leg is cleansed and draped. Using ultrasound guidance a needle is placed in the varicose vein to be treated. Once the needle is in the vein we inject the sclerosing agent into the vein. Once the injection has been completed, the leg is wrapped with a compression bandage for compression of the area. This is applied from the toes to above the area of treatment. This will stay on for two days. After the bandage is removed the patient will then wear compression stockings on the leg daily for two weeks. Follow-up will be in the office at one to two weeks following sclerotherapy. A venous duplex will usually be done to verify closure of the treated vein. 17

18 Informed Consent for Ultrasound Guided Sclerotherapy Ultrasound Guided Sclerotherapy is a very effective method of treating varicose veins. Utilizing ultrasound the varicose vein is visualized on a screen and the Physician uses this technology to guide the placement of a needle directly into the diseased vein. A foam sclerosing agent is injected into the veins. This causes an irritation to the inner lining of the vein resulting in closure of the vein. The injections are done along the course of the vessel as needed, usually 4-5 injections per leg. The number of treatments varies depending on the severity of your condition. The majority of persons who have Ultrasound Guided Sclerotherapy performed have satisfying results. Unfortunately there is no guarantee that this procedure will be effective for you. In rare instances the patient s condition may become worse after treatment. The number of treatments needed differs from patient to patient, depending on the extent of the problem. Risks and Side Effects Associated with Ultrasound Guided Sclerotherapy Transient hyperpigmentation associated with Sclerotherapy: Patients who have had ultrasound guided sclerotherapy may notice a discoloration after treatment. This discoloration is almost always transient and will resolve in approximately 3 months. In rare instances this darkening of the skin may persist for up to one year. Skin Ulceration associated with sclerotherapy: In rare cases a blister may form, open, and become ulcerated. Healing occurs slowly over a few months. After healing, this will usually leave a scar. Allergic Reaction: Very rarely, a patient may have an allergic reaction to the sclerosing agent. The risk of this is greater in patients who have a history of allergies. Deep Vein Thrombosis: Deep vein thrombosis is very rare complication; the dangers of deep vein thrombosis include the possibility of pulmonary embolus (a blood clot carried to the lungs) and post phlebitic syndrome, resulting in a permanent swelling of the leg. Vision Loss: This is an uncommon complication of foam sclerotherapy. It is usually transient lasting from only a few minutes up to an hour. There is usually no long term adverse effect. Nodularity: Nodularity at the site of vein removal may persist for up to a year. This occurs when there are areas of the vein that have scarred down and become hard. With time, the body will absorb and soften these areas but some may persist. Most Common Side Effects: The veins may be tender to the touch after treatment, and an uncomfortable sensation may run along the vein route. This discomfort is usually temporary. Bruising is very common and to be expected. Some patients complain of an itchy sensation after treatment, which is also very normal. Trapped blood may cause a discoloration, which can be flushed out, although this may leave hyperpigmentation for up to one year. Alternative Treatments Varicose veins are not life-threatening conditions, treatment is not mandatory. Some patients get adequate relief of symptoms from wearing graduated support stockings. The other option is to receive no treatment at all. 18

19 Informed Consent By signing below, I acknowledge that I have read the foregoing information and understand the risks of Sclerotherapy and Laser therapy. Alternative methods of treatment, and the risks of not treating my condition, and I hereby consent to vein treatment with Ultrasound guided sclerotherapy. The practice of medicine and surgery is not an exact science, and therefore, reputable practitioners cannot guarantee results. While the overwhelming numbers of patients have noted gratifying results from Sclerotherapy, we cannot promise or guarantee any specific results. Note: The medication we use is Polidocanol, a scleroscent recognized and used worldwide and throughout the USA. It has not yet received FDA approval for use in the USA. By signing the consent below I acknowledge having been informed of the above. Patient Signature Date Patient Name Date Witness Signature Date 19

20 Patient Instructions for Ultrasound Guided Sclerotherapy After your ultrasound guided sclerotherapy, we recommend that you leave the compression bandage on for twenty four hours. After that remove the bandage, and start wearing your compression stockings daily for 1-2 weeks. Remove them only to shower and at night while sleeping. You may experience discomfort such as aching or throbbing for the first day of two after your initial treatment. Walking will help to dissipate this sensation. If discomfort continues, Ibuprofen 800mg every 8 hours may be taken with food. Also the vessels may appear to turn dark in color and/or be slightly tender. This could be an entrapment of blood in the closed vessels, resulting in a hard lumpy feeling under the skin. This is a normal response to the procedure. Significant bruising may occur after your treatment. Do not be alarmed, this is a normal process. Avoid: Hot tubs, saunas and long hot baths are not recommended for one (1) week following treatment. Postpone shaving for two days to avoid further irritation. Sun exposure is not recommended for 7 days after your treatment. Areas that have been treated will be tender and more likely to burn and may contribute to hyper pigmentation changes. Avoid high impact aerobics and any heavy weight lifting for 7 days. Permitted: You may apply lotions as desired. Exercise is an important part of the healing process. A 20 minute walk or bike ride once a day is best for the healing process. It is important to remember that is has often taken years for these veins to develop, and the treatment plan we have outlined for you will take time. Please be patient and allow time for healing to occur. Bring shorts to wear during your treatment. Please bring your compression stockings with you the day of your procedure. Call the office with any questions you may have about your treatment. 20

21 Sclerotherapy for Treatment of Small Varicose Veins and Spider Veins This is a minimally invasive treatment to close or occlude veins. It works best on very small veins. It has been found to be very affective on spider veins and small varicose veins on the legs. Description of Procedure The spider veins and/or varicose veins to be treated are selected with the patient standing. These areas are cleansed with alcohol over the area to be treated. Using a very tiny needle the sclerosing agent is injected into the spider vein or varicose vein. This is done in multiple locations to get medication throughout all the visible veins. During the injection you will experience a little stinging or burning sensation. Each injection only lasts a couple of seconds. During each treatment session we will treat one leg. We will try to treat all areas of spider veins and varicose veins on that leg during that session. However, sometimes we will be limited by the maximal safe dosage for the session. Results Some of the treated veins will disappear within one to two days. However, some will become inflamed and may take four to twelve weeks to disappear. Some veins will not disappear completely and we will need to repeat the treatment to fully remove the veins. Some veins will develop a clot within the vein and appear very dark at one to two weeks following the procedure. Repeat treatments of some areas will be required to fully eliminate the veins. Usually repeat treatment of an area already treated will not be done for approximately four weeks or more to allow time to see the full affect of the previous treatment. The response to sclerotherapy will vary from patient to patient. Not all veins will respond to sclerotherapy. In most cases it will improve the overall appearance of the legs by reducing the number of spider veins and small varicose veins. We usually can t remove all spider veins. Based on experience a reasonable expectation is that we can expect to obtain a 50-75% reduction in the number of spider veins on the legs. Not all patients will get this good of a result. Some patients will get a better result. We can t guarantee a result prior to treatment. Following the sclerotherapy treatment you will leave the office wearing compression stockings. These will be worn daily and removed only at night or to shower. These will be worn for 5 days. We ask that patients always bring the compression stockings with them to the office for treatment sessions, as the stockings are required to perform the treatment. If the stockings are not available we will have to reschedule the sclerotherapy treatment. 21

22 Informed Consent for Sclerotherapy Sclerotherapy is a very popular method of eliminating small varicose veins and spider veins in which a solution, called a sclerosing agent, is injected into the veins. This causes an irritation to the inner lining of the vein resulting in closure of the vein. A small gauge needle is used to perform the injections and most patients relate the discomfort to an ant bite. The majority of persons who have Sclerotherapy performed have satisfying results. Unfortunately there is no guarantee that Sclerotherapy will be effective for you. In rare instances the condition may become worse after Sclerotherapy treatment. The number of treatments needed differs from patient to patient, depending on the extent of the problem. Potential Risks and Side Effects: Transient Hyperpigmentation: After sclerotherapy you may notice some discoloration (dark streaks) after treatment. This occurs when the blood gets trapped inside the vein after it closes down. We can usually flush the trapped blood out on your next visit. If the flushing does not alleviate the discoloration it will fade on it s own in 4 to 12 months. In rare instances this darkening of the skin may persist for years. Skin Ulceration: In rare cases, a blister may form, open, and become ulcerated. Healing occurs slowly over a few months. After healing, this will usually leave a scar. Allergic Reaction: Very rarely, a patient may have an allergic reaction to the sclerosing agent. The risk of this is greater in patients who have a history of allergies. Deep Vein Thrombosis: This is a very rare complication. The dangers of phlebitis include the possibility of pulmonary embolus (a blood clot carried to the lungs) and post phlebitic syndrome, resulting in a permanent swelling of the leg. Most Common Side Effects: The veins may be tender to the touch after treatment, and an uncomfortable sensation may run along the vein route. This discomfort is usually temporary. Bruising is very common and to be expected. Some patients complain of an itchy sensation after treatment, which is also very normal. Trapped blood may cause a discoloration, which can be flushed out, although this may leave hyperpigmintation for up to one year. Alternative Treatments: Varicose veins and spider veins are not life-threatening conditions, treatment is not mandatory. Some patients get adequate relief of symptoms from wearing graduated support stockings. The other option is to receive no treatment at all. Proposed Treatment Results: The practice of medicine and surgery is not an exact science, and therefore, reputable practitioners cannot guarantee results. While the overwhelming numbers of patients have noted gratifying results from Sclerotherapy, we cannot promise or guarantee any specific results. Informed Consent: By signing below, I acknowledge that I have read the foregoing information and understand the risks of Sclerotherapy, alternative methods of treatment, and the risks of not treating my condition, and I hereby consent to treatment with Sclerotherapy. Note: The medication we use is Polidocanol, a scleroscent recognized and used worldwide and throughout the USA. It has not yet received FDA approval for use in the USA. By signing the consent below I acknowledge having been informed of the above. Patient Signature: Date 22

23 Patient Instructions for Sclerotherapy After each treatment is completed, we recommend that you wear your support hose for 5 days taking them off only at night. You can never wear them too much. You may experience slight discomfort such as aching or throbbing for the first day or two after your initial treatment. Walking will help to dissipate this sensation. If discomfort continues; Ibuprofen 800mg every 8 hours may be taken with food. Also the vessels may appear to turn dark in color and/or be slightly tender. Bruising may occur, especially after the first treatment. Do not be alarmed, this is a normal process. Avoid: Hot tubs, saunas and long hot baths are not recommended for one (1) week following treatment. Postpone shaving for two days. Sun exposure is not recommended for 7 days after your treatment. Areas that have been treated will be tender and more likely to burn Avoid high impact aerobics for 2 days. Permitted: You may apply lotions as desired. Exercise is an important part of the healing process. A 20 minute walk or bike ride once a day is best for the healing process. If you are already involved in an exercise program, we encourage you to continue. It is important to remember that is has often taken years for these veins to develop, and they will not disappear overnight. Around the same time that your bruising resolves (10 days - 2 weeks), you will also begin to see the fading and lightening of your spider veins. Please be patient and allow time for healing to occur. Always bring your compression stockings to your appointments. Bring shorts to wear during your treatment. Call the office with any questions you may have about your treatment. 23

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