Ambulatory Phlebectomy

Ambulatory Phlebectomy is a procedure used to remove varicose veins that are near the surface. An ambulatory phlebectomy done at re*be® uses a series of small incisions over the course of a superficial vein to remove the vein with a tiny hook. The procedure is done in the office and the same local tumescent anesthesia used for the laser ablation procedure is used for the phlebectomy. Ultrasound guidance is also used to assist in placing the local numbing medication. You will be wide awake during the procedure and be able to go home afterwards. Ultrasound Sclerotherapy may be done at the completion of the procedure if needed. The re*be® Vein Clinic is one of only a limited number of vein clinics in the State of Iowa able to offer this procedure! Following an ambulatory phlebectomy, we encourage you to wear prescription support stockings because these seem to make the treatment more effective as well as to minimize discomfort when walking. Repeat sclerotherapy sessions can be necessary and additional treatments will be recommended if new abnormal veins appear or if there are other lager vessels that need treatment. Physical activity is encouraged and there are very few restrictions on the things you can do after these treatments. Bruising, staining, pain and scarring can and will occur following this vein treatment however most unsightly changes gradually get better and fortunately are not common. An Ambulatory phlebectomy done at re*be® uses small incisions to locate and remove a larger vein. This procedure is done under local anesthesia. This treatment is used to remove larger veins that are close to the surface. Small stab incisions are made in the skin and the veins are pulled out of these incisions with a small hook. There will be many small incisions in the skin. These will incisions will leave small scars. The incisions may be left open, closed with small pieces of tape or occasionally sutured closed. Occasionally a slightly larger incision will be needed to remove larger veins or in the presence of scar tissue making the dissection more tedious. The pain is usually minor and little scarring is anticipated. A relatively short recovery following the procedure can be expected. The veins being treated are generally removed in one treatment. Additional veins can develop in the areas treated but the vessels removed will not come back. On the day of your Ambulatory Phlebectomy procedure, staff at The re*be® Skin Clinic will answer any last minute questions you might have, and prepare you for the procedure. The skin will be marked to show the location of the veins to be removed. These marks can remain visible on you skin for about 1 week rarely more than that. Hair in the treatment areas may be clipped if needed and the skin will be cleansed. You will be positioned on a power procedure table. Sterile drapes will then be placed around the treatment area. The area around the vein to be treated will then be anesthetized with a dilute local anesthesia. This is probably the most painful part of the Ambulatory Phlebectomy procedure since needle sticks are made through the skin to just outside the vein to be treated. Small stab incisions will be made along the course of the veins to be removed. A small hook will be used to locate and remove the veins from the incisions. At the end of the treatment, a thigh-high compression wrap or stocking will be applied to your treated leg. This compression must be worn continuously for 7 days. After the procedure, you will walk for 20 minutes at the clinic prior to being discharged. Activity is encouraged but strenuous exercise is not. You may need to be seen by the staff at The re*be® Skin Clinic for follow up at 1 week, 1-month, and 3-months following this treatment. If any concerns or problems before your follow up appointment, you are requested to contact The re*be® Skin Clinic at (712) 332-6001. In the event of any emergency please contact your nearest emergency room to assist you and us in obtaining your needed care. Following sclerotherapy and ambulatory phlebectomy, we encourage you to wear prescription support stockings because these seem to make the treatment more effective. Repeat sclerotherapy sessions can be necessary and additional treatments will be recommended if new abnormal veins appear. Physical activity is encouraged and there are very few restrictions on the things you can do after these treatments. Bruising, staining, pain and scarring can occur following this vein treatment however most unsightly changes gradually get better and fortunately are not common.

Stop taking aspirin or ibuprofen (Advil® Motrin® and other NSAID names)

Medication such as Ibuprofen especially right after a phlebectomy can protect cause more bleeding problems and if sclerotherapy was done protect your veins from the treatment. These medications should be stopped a week or more before your treatment and not started back for 3 or more days after the procedure.

Be sure your skin is clean.

Ambulatory Phlebectomy involves injections with very tiny needles and small incisions. A break in your skin will need to heal and as with any cut can lead to infection if not kept clean. Showering the morning of your appointment with antibacterial soap is a good idea.

Do not apply cream or lotion.

Several days before your visit it is a good idea not to cream or lotion your legs. Cream and lotion contains many substances. The needle passes through your skin during the procedure. Any lotion on the skin surface can be injected under the skin causing unexpected reactions. This generally is not harmful just more irritating and can cause tiny red bumps that persist for several weeks after the procedure.

Shaving your legs is not necessary.

We will prepare your skin with alcohol based solution and fresh shaving scratches can be uncomfortable. No one at re*be® will be offended by a day or two of leg hair growth. If you have heavy hair growth (men particularly), we may need to clip your hair prior to the procedure.

Wear clean and washable clothes and underwear.

Patients are checked for more serious varicose vein problems using a diagnostic ultrasound especially on your initial visit. We will use a water based ultrasound gel to do this exam and it can get on your clothes and underwear.

Bring your compression stockings.

After the procedure if you compress the veins the treatment is more effective. Firm support stockings should be worn for one week after a phlebectomy and two weeks after the procedure if sclerotherapy has been done. Those of us at re*be® prefer to use thigh high or panty hose prescription strength (Class II 30-40 mmHg). We will try to sell you a pair if you do not already have some. The non-prescription socks will work but the compression is not as complete. If you are planning on needing several sclerotherapy sessions after the phlebectomy, owning a pair of compression stockings is a good investment.

Wear comfortable walking or running shoes.

After your procedure we will ask you to walk on our treadmill for 20 min. You may choose to walk outside or in a shopping mall as well. Walking after the procedure is important to get your circulation moving, get your socks comfortable and to reduce the chances of a deep vein clot.

Bring your insurance cards and insurance plan information.

Ambulatory phlebectomy on the legs is likely to be covered by your insurance. The doctors at re*be® will examine you and take a medical history. If other conditions that are covered by insurance are recognized, you may be offered treatment for them. It is common to find an abnormal skin mole and a Skin Biopsy be needed. This done on this at the time of your phlebectomy visit.

Wear your socks.

Wear them three days, night and day. You may shower with your socks on. Wash them with soap and water like your skin, rinse them off. They will dry in about 20 min. Sclerotherapy greatly irritates the inside of the vein. It is very important to stop the flow in the blood vessels that were treated with sclerotherapy. Flow that returns to the treated veins can cause the sclerotherapy not be effective. The compression stockings are designed to stop the flow in the treated veins and also serve to support them after treatment. This makes the treatment more effective and comfortable.

Do not apply cream or lotion.

Several days after your visit it is a good idea not to cream or lotion your legs. Cream and lotion contains many substances. When the tiny scabs over the needle pokes come off creams and lotions can then be safely applied. This will usually be 2-5 days.

Shaving your legs is not necessary.

Wait until the tiny scabs over the needle pokes come off before shaving can then be safely done. This will usually be 2-5 days.

Tylenol® works well for the minor pain.

After the procedure we will have you walk for 20 minutes. Walking with support stockings on works well. Medication such as Ibuprofen will not be a good idea for the first three days after the procedure. These compounds can actually protect the veins from the sclerotherapy and reduce the effectiveness of the treatment.

Walk.

After the procedure if you compress the veins the treatment is more effective. Firm support stockings should be worn when walking for two weeks after the procedure. Walking is good for you, helps with the pain and may reduce swelling somewhat.

Do not wear high heels.

The muscles in your calf and foot need to relax to pump blood effectively through the deep veins in your leg. High heels do not allow this pump to work effectively.

Do not tan.

After a phlebectomy staining of your skin from the breakdown of the blood and treated veins produce iron oxide. Iron oxide is commonly known as rust and is a brown color. Sun damage can cause staining of your skin like a tattoo with the iron oxide. Sun damage causes numerous other health problems and should be avoided for those reasons as well. Sun tanning after the bruising, redness and discoloration from the treatment is resolved will be less likely to cause staining. Spray tan or cream lotion tanning is not a problem once the needle pokes have healed.

Avoid alcohol.

After an ambulatory phlebectomy or sclerotherapy alcohol will dilate the veins. Blood that is allowed to reflow in treated veins can defeat the treatment and the veins can return. Alcohol is not recommended for this reason. This recommendation should be followed for at least the two weeks the socks are warn. Alcohol is bad for you anyway for many other reasons.

Avoid warm bath or showers.

After these procedures, warm water will dilate the veins. Dilated veins can allow the blood to flow through the treated areas and this can cause the veins to return. Cooler than normal shower is recommended for this reason. This recommendation should be followed for the two weeks the socks are on.

Stay out of lakes, rivers, and public Jacuzzis® and pools

The tiny scabs over the needle pokes and incisions can come off when you are in the water. The risk of an infection from these sources is very low. This will usually be 5-7 days when this recommendation should be followed.

Redness.

There is minor tissue trauma with the procedure and some degree of redness is expected in the immediate areas of the incisions. The medication for sclerotherapy is irritating and is designed to be that way. It is normal to get hive-like swelling in the area around the injections sites. These hives usually clear within hours and are much less irritating as soon as your compression socks are on. Treated veins close to the surface of your skin also will get red. This clears with time but can take several weeks.

Lumpy sore veins.

Ambulatory phlebectomy stops the flow in the veins as does sclerotherapy. This clots the vein and the lumps you feel are these inflamed clots. These lumps can be tender and can get red. They also can appear out of nowhere even several weeks after a procedure. The lumps generally resolve over weeks to months. If they are very uncomfortable or the skin over the lump swells, turns black or gets shiny draining the lump can be necessary. These lumps are clots but because their path back to the heart and lungs is gone they are not considered very dangerous.

Bruising.

Some of your injection sites will develop bruising. This is normal and does not indicate a problem. It will be more intense and the bruises bigger if you are taking aspirin or ibuprofen or some other blood thinner. Bruising should generally clear in 2-3 weeks or less.

Swelling.

Swelling after these procedures should resolve quickly. The swelling also should be around the immediate area of the treated veins. Swelling that involves the entire foot, calf or ankle is not normal and could indicate a deep blood clot. Deep clots are dangerous and should be checked by a Doctor.

Staining.

Staining after sclerotherapy or an ambulatory phlebectomy should resolve over time. Minor staining in very surface veins is normal also should be around the immediate area of the treated veins. Staining that lasts longer is more common in individuals with heavier pigmented skin. Unfortunately there is no good treatment for this type of staining but most cases do get better with time. Again avoiding sun exposure especially soon after the treatment can minimize this problem.

Some veins will remain.

The treated vessels will go away and follow up sessions are necessary for further clearing of any unwanted veins.

Numb spots.

Numbness after sclerotherapy or an ambulatory phlebectomy should be rare and is likely due to the needle poke bruising or cutting small nerves in the skin. This type of numbness should be in the area just at the treated vein or below it. As the numbness resolves, the nerves get very irritable just before they recover completely. Tincture of time is the best treatment usually.

Fever >100.5°.

The medication and procedure are irritating and one if the signs of irritation is a low grade fever. A temperature of 100.5° or less is usually not an indication of a serious infection. If you have a fever higher than this in the week after the procedure especially when associated with redness and marked pain a more serious infection can be present. This would require medical attention.

Redness.

The ambulatory phlebectomy is irritating and some degree of minor redness is expected. It is normal to get hive-like swelling and red in the area around the injections sites. Redness that spreads way beyond the injection site or incisions especially when associated with marked pain that is not relieved by walking or Tylenol® can be a sign of an infection. This requires medical attention.

Lumpy sore veins with shiny or black skin over them.

Ambulatory phlebectomy leaves clots in the remaining veins and the areas where the veins were removed. This causes lumps. These lumps can be tender and can get red. Lumps that do not resolve, or you cannot get comfortable with can need to be drained. If the lumps cause enough painful pressure on the overlying skin that the skin turns dusky or dark generally will do better if the vein is drained. This is a minor office procedure but does require medical attention.

Bleeding.

Some of your injection sites and incisions will develop tiny amounts of drainage. Bleeding after an ambulatory phlebectomy that does not stop is not normal and does indicate a problem requiring medical attention.

Skin wounds.

In the past and in those clinics that are still using a lot of hypertonic saline injections ulcers of the skin were common following sclerotherapy for any reason. With the switch to soap based foams for the sclerotherapy solution ulcers can and still do occur but are usually rare, small and heal with little or now difficulty. If you do get an ulcer or scab at an injection site that is slow to heal we would like to see this at your next visit. Ulcerations unfortunately can leave small scars on your skin that are difficult to improve once they are healed.

Swelling of your lower leg or foot.

Swelling after an ambulatory phlebectomy should resolve quickly. Swelling that goes way beyond the treated veins is not normal and can be a sign of a more serious problem. Swelling that involves the entire foot, calf or ankle could indicate a deep blood clot. Deep clots are dangerous and any significant swelling after these procedures should be checked by our staff at re*be®.

Spider veins fail to clear.

Ambulatory phlebectomy is very effective for removing large veins and these veins will not come back. If an abnormal number of veins fail to clear this can be an indication of more significant problems in veins that are deeper and do not show on the surface. It is important to go to an ICAVL certified peripheral venous diagnostic center like re*be® to check for abnormal vein valves.

Severe Staining.

Staining after an ambulatory phlebectomy or after sclerotherapy should be minor resolve over time. This photograph is a foot that was sunburned during a trip to Mexico shortly after sclerotherapy. The deep dark stains are rust (iron oxide), they behave like a tattoo. This is expected to lighten up eventually but takes much longer (1-2 years maybe more).

Numb spots.

Numbness after an ambulatory phlebectomy or sclerotherapy should be minimal and is likely due to the needle poke or stab incision bruising or cutting small nerves in the skin. This type of numbness should be in the area just at the treated vein or below it. As the numbness resolves, the nerves get very irritable just before they recover completely. Tincture of time is the best treatment usually however if the irritability gets worse with time and it is not possible to get comfortable medical attention is necessary. A condition called reflex sympathetic dystrophy is very rare but treatment early can make a difference so medical attention is a good idea.