The venous system consists of the deep veins and superficial veins. This is sometimes a source of confusion for patients. Many patients are concerned about "blood clots" in the veins and their potential dangers. It is true that blood clots are serious, but it is the blood clots in the deep vein system, especially those above the knee,that are dangerous and life-threatening and require treatment with blood thinners (see Deep Venous Thrombosis). Blood clots in the superficial system are in general not dangerous and are usually associated with a common disorder known as phlebitis (tender, inflamed vein). Phlebitis and blood clots in the superficial system, though tender and painful, are usually self-limiting and not life threatening.

The superficial system is where varicose veins arise. The superficial system is comprised of two large veins (great saphenous vein and small saphenous vein) and all the branches that arise from these two large veins. The great saphenous vein is a large vein that runs from your groin to your ankle. The small saphenous vein runs from the back of your knee to your heel. The great saphenous and small saphenous veins are encased in a fibrous sheath and are not visible to the eye. They give rise to many smaller veins that branch out and drain blood from the leg. Like branches of a tree, these vein branches in turn give rise to smaller and smaller branches that arise more superficially in the skin. The varicose veins that you can see are typically these branches of the great and small saphenous veins, and become varicose because of an underlying reflux problem in the great or small saphenous vein. As a matter of definition, a vein is considered "varicose" only if it bulges out from the skin.

The smaller, more superficial branches of these veins, found just under the skin, are the reticular veins. When reticular veins become enlarged and varicose, they often feed a network of spider veins.

The return of venous blood from the legs back to the heart is accomplished by numerous valves which are located in the veins, and the leg's "muscle pump." Normal veins contain one-way valves that permit the blood to flow from the periphery back toward the heart. These valves are necessary because of our upright posture, and the effect of gravity, which would otherwise cause the blood to pool in our feet and legs every time we stand. The "muscle pump" is made up of muscle groups in the calf. When these muscles contract, blood is forced upward toward the heart, through the one-way valves. The blood cannot flow "backwards" toward the feet, because of the presence of the valves. When the muscles relax, the valves prevent the blood from flowing back down to the feet. The empty veins in the feet and legs can now accept new blood coming from the feet, and the process repeats.

Large varicose veins are formed when the valves in the legs malfunction. The valves become "incompetent," and begin to leak. As a result, blood can leak back down to the feet and legs, because of the action of gravity. This causes the veins to become distended, which causes further valves to leak because of the increase in size of the vein channel. Over time, these veins become large, "ropy," and visible to the naked eye. The word "varicose" comes from the Greek word for "cluster of grapes," which these veins can come to resemble. Varicose veins can cause discomfort, and typical symptoms include pain, burning, heaviness, or tingling.

Superficial, small blue or red-blue spider veins, also called telangiectasais, are a result of reflux into tiny venules in or just below the skin. Reticular veins, also called feeder veins, often supply such telangiectasias. Spider veins may cause symptoms of pain--especially pain which is aggravated by prolonged periods of standing--as well as itching or tingling sensations.

One way that varicose veins are treated is through an open surgical procedure. In this procedure, a surgeon makes an incision and ties off or removes ("strips") the varicose vein. This is typically done in a hospital under general anesthesia.

Another very successful technique for treating varicose veins involves using a liquid chemical compound known as a "sclerosant". The sclerosant, which is mixed with air and prepared as a foam, is injected into the vein with a small needle. This chemical interacts with the inner lining of the vein wall and causes the vein to spasm and close. The foam property of the chemical causes it to stay in contact with the vein wall, rather than washing away with the venous blood flow. In the ensuing hours, the vein channel clots and permanently closes. Foam sclerotherapy is a very simple procedure that takes about an hour, is done in a doctor's office, and involves minimal discomfort. Following foam sclerotherapy, the patient must wear compression stockings for several weeks. Foam sclerotherapy is typically performed on the small and medium sized varicose veins.

EVLA and Ultrasound-Guided Chemical Ablation are covered by Medicare and most PPO insurance plans.

Graduated compression stockings are an important treatment for varicose veins. They work by compressing the superficial veins and forcing blood to be re-routed to the deeper, non-diseased, veins. This reduces the inflammation in the superficial varicose veins. In this way, the stockings reduce the pain and swelling associated with varicose veins. A disadvantage to the stockings is that they are a temporary solution, as the symptoms of varicose veins recur when the stocking is removed. Graduated compression stockings are prescribed by your physician and come in various strengths or levels of tightness. Typical strengths for treatment of varicose veins are 20-30 mmHg or 30-40 mmHg.

Graduated compression stockings are also an important step following treatment for varicose veins. By compressing the veins after EVLA, Ultrasound-Guided Chemical Ablation, or Sclerotherapy, they help assure complete closure and healing of the varicose veins.

Prior to having EVLA or Ultrasound-Guided Chemical Ablation, patients typically undergo a Vein Mapping ultrasound procedure, to study the vein anatomy and assess the function of the venous valves.

Diagnostic studies used to evaluate venous insufficiency prior to or as part of treatment may include the following:

• Handheld Doppler - A portable handheld device which uses Doppler ultrasound to detect reflux flow in the veins with an audible flow signal.
• Ultasound Vein Mapping - A comprehensive study performed in the Vascular Ultrasound Laboratory which provides a complete assessment of the vein pattern and connections, size of the veins, valve function, direction and magnitude of blood flow, and presence or absence of thrombus. A complete vein mapping study takes about an hour.
• Vein Light - A handheld device which transilluminates the veins by using a bright light held against the skin. This allows visualization of veins up to about 5mm below the skin surface.
• Vein Viewer® - A portable device that uses an infrared signal to identify the veins and project an image of the underlying veins onto the skin. This allows visualization of veins up to about 8mm below the skin surface.