Varicose vein questions

Questions that seem to come up often when we are discussing the symptoms, diagnosis, treatment and after care for varicose veins at re*be®

What is Phlebology?
Phlebology is the study of venous disease and in today's use of this term refers to vein disease if the face neck, chest, arms, thighs, abdominal wall, legs, and feet.
What is sclerotherapy?
Visual sclerotherapy refers to injection of surface veins that are visible to the naked eye. Some veins that need to be treated are below the surface of the skin and cannot be injected safely without the aid of ultrasound imaging assistance. Sclerotherapy is the treatment of varicose veins by injection of the veins with chemicals that cause destruction of the veins. Many patients who select this treatment option for cosmetic reasons notice improvement in the way that their legs feel after treatment.
Will my varicose veins ever be completely gone, forever?
Varicose veins are a problem that can be treated but the like many medical problems it needs chronic management and for that reason you may never hear 'you're cured'. The treatment we have for varicose veins does not affect the actual reason you got them in the first place. We encourage a lifetime of follow up for your veins and anticipate the need to do additional treatments in the future. A 3-4 year follow up after your treatments is considered a good idea. At re*be® we like to see you back in 2 years once all your initial treatments are complete.
How soon can I return to work after my varicose vein procedure?
Photo of re*be?® patient working hard in his dairy 2 hours after surgery

'AI'ing dairy cow 2 hours post op.

We try to have you up and walking for 20 minutes after the procedure. Many patients return to work immediately after surgery. The photo to the right is one of our patients with a very active dairy farm, who is now 2 hours after his laser vein procedure and a phlebectomy. Several of our nurses have had the procedure done at re*be®. One of our nurses was the second patient on a day when we had 6 laser vein ablations. After helping with the first patient, she laid down on the table and had her vein fixed. She got up cleaned up the room and then helped with the next 4 procedures. I know she was a bit sore but did drive herself home and came back to work the next day. Everyone's results are different. There have been a few people that have had to take some days off of work to recover. Women generally do a little better than men. Go figure.....
What are the usual symptoms of bad veins?
  • Bulging leg veins
  • Painful leg veins
  • Leg ulcers
  • Ankle stains
  • Leg and ankle swelling
  • Restless legs
  • Tired aching legs
  • Labial varicose veins
Am I doomed to get ulcers if I don't get these fixed?
A skin ulcer is caused by a venous reflux disorder that is called a venous stasis ulcer. Early signs that a venous stasis ulcer may develop include a darkening of the skin in the area of the ankle. Gradually, the skin may become leathery or waxy in appearance. Without treatment of the venous disease, the skin may breakdown and bleeding may occur.
Only one leg hurts?
If you really only have symptoms on one leg we will concentrate our efforts on that leg. What happens often however is that many people come back and then notice symptoms on the other leg that heed attention. If you have symptoms on both for a variety of reasons it is reasonable to treat them both but on separate days.
If I need heart surgery and my veins are gone now what?
Heart surgery is done much less frequently than it was twenty years ago. The veins from the leg were 'harvested' to make new blood vessels for the heart. Bad varicose veins that were thick walled and stretched out were never considered very good to make new heart vessels. There now is new approaches for the heart using the artery inside your breast bone or taking veins from your arms if needed. These vessels have better size match and are better choices than diseased varicose veins. We do not believe many people will ever miss or have needed to use the veins in their legs to fix the heart.
Phlebotomist and Phlebologist which is which, what are you?
Dr. Kolegraff is a phlebologist, a doctor that specializes in the diagnosis treatment and study of diseases of the veins. A phlebotomist is a person who is trained to draw blood for lab tests, usually a technician and based in a big clinic or hospital and not a doctor. Unfortunately the words are very similar and there is confusion. If you need your veins fixed you want to see a doctor who specializes in varicose veins If you need your blood drawn for lab tests find a phlebologist.
How much does it cost?
The cost of this procedure is variable but based on the number of Veins that are bad and the number of follow up treatments needed. The bill going to your insurance company for the laser ablation procedure is about 3500-4000 depending on exactly what we do that day. re*be® participates in most insurance plans available in our area. Based on the contract we have with your insurance company what we get paid is always less and usually set by the insurance company. Every person's out-of-pocket expense depends on the plan you have with the insurance company. Check with your insurance company and with us after your consultation and we can usually get a pretty good estimate of what things will run.
Does the doctor do the procedure?
Yes. I am not aware of very many clinics where the individual doing the procedure is not a doctor. There are a very few clinics in the country that are very busy and a nurse or nurse practitioner may administer your tumescent local anesthesia. At re*be® in Okoboji currently Dr. Kolegraff does the procedure.
Does it hurt?
No not very much. Of course every patient is different but most people do surprisingly well. The tumescent local anesthesia is very good at numbing up the tissue. Your experience will depend somewhat on the experience of your doctor. Dr. Kolegraff is experienced with tumescent anesthesia and has done thousands of procedures using this technique for varicose veins. When done properly you will feel the initial poke of the same tiny needles. Once the surface of the skin is numb the fat under the skin does not have much sensation and numbs up quickly as well. You will notice some tugging, pulling and hear the sizzling of the vein and vibrations under the skin. If you do have discomfort it is easy to give some more local anesthesia which usually fixes the problem quickly.
What kind of anesthesia do you use?
We use tumescent anesthesia with a combination of Lidocaine and epinephrine and sodium bicarbonate to numb your tissue. This is a very dilute local anesthesia in much lower concentrations than your family doctor or dentist might use. By diluting the local anesthesia we can use it to treat a much larger area and volume of tissue than would otherwise be possible. It is this tumescent local anesthesia that makes the procedure much safer than a similar procedure done in the hospital operating room under general anesthesia. Keeping the procedure in well-equipped doctor's offices is safe because of this anesthetic technique. It is estimated to be 1000 times safer than general anesthesia. Reduced anesthesia costs make the procedure more affordable as compared to the alternatives in the hospital. We do not encourage the use of sedatives but if you have had experience to need them in the past for other things we will provide you with some.
Can my friend watch the procedure?
We will on occasion allow friends or family members to watch your procedure but we want you to consider and be aware of our concerns too. Our procedure rooms are state of the art, air filtered and ultra violet light treated clean rooms which were expensive to build. We feel the cost of providing this type of place to do the procedure is well worth the expense especially if it reduces the chances of a serious infection. The more people we bring into the room the more bacteria come into the room. We like to limit the number non medical people observing to one for this reason. If your friend or family member understands sterile technique and is familiar with what goes on in the procedure like this it is better. Someone unfamiliar with anesthesia or surgery can get light-headed and need assistance themselves. This will require an interruption in your procedure as the staff will need to assist them. We already have one patient in the room adding another one is not a good idea. The procedure is pretty 'naked' meaning that you are quite exposed especially the areas we are working on. This can be just as uncomfortable for your friend as it is for you. The procedure is done in phases and there are short interruptions but will get very boring for most friends and family members. If you must have an observer we would recommend they bring a book to read or something to do because watching you have this done may not be as interesting to them as you think. The bottom line is we would like to discourage observers especially non medical people but on occasion will allow one if you and they understand our concerns.
Do I have to have my pictures on the internet?
No. re*be® is a busy medical clinic and we would love to be able to use your photos to demonstrate what we have done for you to others. If you do not want your photos used they will not be. If you give us permission to use your pictures on the website and later change your mind we will remove them at the next opportunity. If you give us permission to use your photographs and they make it into our billboards or our print material removing them is much more difficult.
Why do we get varicose veins?
Increase in the diameter of a vein results in the malfunction of valves inside of the vein that are designed to prevent blood from flowing backward in the vein. An inherited weakness of the vein wall (genetic) and circulating hormones that relax the smooth muscle of the vein wall are the most common causes. Females have high levels of such a hormone, the hormone progesterone. Pregnancies, obesity, hormone replacement therapy, the use of female oral contraceptives as well as occupations that require a standing position are additional causes of varicose veins. Since females usually have multiple risk factors for the development of varicose veins. About three fourths of the people who have varicose veins are women. Men have the remainder and usually wait significantly longer (have much worse symptoms) when they come in for treatment. Varicose Veins are veins that become abnormally swollen and large, usually due to defective valves in the vein and possibly abnormalities in the vein walls too. Varicose veins are sometimes blue, protrude from the surface of the skin, and frequently have a winding or worm-like appearance. There are significant numbers of people that have no visible external evidence of varicose veins but truly have disabling symptoms from very high pressure in abnormal veins. These need treatment the same as the visible ones.
What can go wrong?
The worst complication is death but is very rare and almost never related to the tumescent anesthesia. Interestingly the experience and background of the doctor doing the procedure plays a role. Credentials and Board certifications are difficult for your doctor to get but do not seem to correlate with safety as much as those of us with credentials and board certifications would hope. Death from liposuction has been reported from the laser poking through the muscles and hurting the intestine inside the belly. This has been reported when non surgeons are just beginning to learn to do the procedure. Small lumps in your skin that do not resolve after 3-6 months may need to be touched up. There are places in this country where the doctor even a non surgeon has taken a weekend course bought a machine and started doing liposuction. Bleeding after the procedure can occur but so far not been a problem for us. The epinephrine constricts the blood vessels and the laser seems to close them up making both bleeding and blood loss from the procedure much less than traditional liposuction. You can get fat.
EVLA, EVLT®, VNUS, Laser, Radiofrequency ablation, Closure Fast®?
Light energy (laser) or electrical energy (radiofrequency) similar to microwaves can be used to heat up and seal shut the veins that are causing your symptoms. All of these treatments generate heat and it is the heat that changes the vein and closes it up. Usually treatment of the abnormal veins starts at or below the knee. Closure Fast® uses Radiofrequency ablation to generate the heat and is a registered trademark of Covidien corporation. EVLT® uses light energy to heat up the vein and is a registered trademark of AngioDynamics, Inc. as VenaCure EVLT®. Ultrasound guided injections may also be used in addition to the above methods to seal the abnormal veins.
What can I expect after the procedure?
You will be tired the evening of the procedure. This occurs because of the adrenaline you release and the epinephrine we give you as well as the disruption in your routine. Severe pain is unusual but aches that wake you up at night are not. The best thing to do for the pain is get up and walk around. You will drain clear to slightly red fluid from the small holes in your skin for 24 to 48 hours usually. There may be a small amount of drainage on the gauze dressings placed over your needle puncture wounds. You will be sore. Moving your leg assists in reducing the swelling and also helps with the discomfort. The numbing medicine we use to do the procedure will wear off in about 4-6 hours and this will remind you of the procedure you had earlier. The skin over the treated areas can be somewhat numb to very numb. This can last many months but generally gets better with time. It may never be absolutely normal but real problems with numbness are rare. There will be small scabs around the needle poke sites that will come off in a week or two. As you heal the treated area will become uneven. This occurs because of fluid shifts and We have seen some real improvement in the appearance of cellulite doing laser liposuction at re*be®. It appears that breaking up the connective tissue between the fat lobules will cause improvement to the surface of the skin resulting in improvement in the cellulite appearance. Elevating your leg while in bed may help a bit but this does much the same thing as compression stockings and will not be expected to do much if you have your socks on. Elevating your leg with compression stockings on can be dangerous for someone with hardening of the arteries. If you get more pain elevating your leg, put your leg down below the level of your heart, as this can be due to poor arterial circulation. Limited circulation can be made worse by the combination of graduated compression stockings and elevation. You may get bruising along the course of the veins that were treated. Swelling and red areas along the course of the treated veins is common but this should not be much warmer than the surrounding skin. A minor post treatment increase in your temperature is expected but these temperature changes are usually trivial. Any fever over 100.5 especially with redness in your leg can be an indication of a more serious problem and should checked out by us.
What is all the ultrasound about?
The venous duplex examination permits your phlebologist to see the anatomy and check the flow characteristics of the veins beneath your skin. Useful information is gathered that your physician can use to adequately diagnose your specific vein problem and to plan and guide treatment.
Can I just take medication?
For minor symptoms due to varicose veins this approach is very acceptable. If you are developing swelling and staining in your legs medication will not address these problems. There is a product in the health food stores called beta-aescin more commonly known as horse chestnut seed extract. There have been recently enough studies to convince most of us that it does work to reduce leg pain from varicose veins and may give you some relief. if your leg problems are not too bad trying this product may be worthwhile providing temporary relief. Claims that escin works for hemorrhoids too are based on the fact that hemorrhoids are varicose veins but there are questions about this claim.
What do they do in Europe?
For the treatment of the visible veins to last a long time, the source that may not be visible to the naked eye must be controlled as well. From a practical standpoint, some insurance carriers will not pay for treatment of smaller branch veins if an abnormal main trunk is not treated at the same time or before the branches are treated. In order to control the backward flow of blood in these large veins, the vein that is the source of the visible bulges must be sealed shut or removed. The vein may be sealed shut using a laser, or radiofrequency energy, electrical energy, or by ultrasound guided sclerotherapy injections.
I am on a blood thinner?
Generally we do the procedure leaving your coumadin levels in the safe range. Some newer blood thinners also do not need adjustment. If you can have your blood thinner stopped safely it may be advisable to do so but not always necessary. Be sure to share this information with the doctors caring for you.
Is anyone still doing vein stripping?
Yes. Generally, these are older institutions and doctors but their numbers are decreasing and the reasons for choosing the older vein stripping are becoming less. Vein stripping will be offered if we are unable to close your veins with the ablation and sclerotherapy procedures.
I hate my socks?
The properly fitted gradient compression stocking can temporarily reverse the effects of vein disease and lessen the discomfort as well as skin damage. Many insurance companies require a trial of stocking use before approving definitive therapy.
What is a phlebectomy vs a microphlebectomy?
The term phlebectomy means to excise or remove a vein. A phlebectomy in the legs is now a minor procedure where the physician makes cuts in the skin and removes the veins. This is in some ways similar to the old vein stripping to those familiar with that procedure of the past. Vein stripping is an aggressive form of a phlebectomy and was done under general anesthesia. A microphlebectomy is currently a very popular procedure to remove the more superficial larger bulging veins. A microphlebectomy is done through a series of small cuts usually less than 1/4 inch under local anesthesia to remove these larger veins. Scarring from a microphlebectomy is minimal especially when compared to the scarring left in the past from vein stripping.
How does taking my veins out help my circulation?
How will the blood in my veins get back to my heart after all the abnormal veins are removed or destroyed? The backward flow of blood in varicose veins and main superficial trunks, the great saphenous vein (GSV) and lesser saphenous (LSV) vein actually interfere with the normal venous return of blood. Removal of these areas of abnormal circulation actually improves circulation of blood in the treated limb. It is this improvement in limb circulation that causes improvement of symptoms of tiredness and heaviness in the limb.
Is this all safe?
Most patients do not experience any complications from sclerotherapy. However, some patients develop changes in skin pigment in locations where the veins are injected. Some patients may experience chemical burns of the skin over a treated area. Rarely you can develop an allergy to the medication. Serious complications such as deep vein blood clots and unintentional arterial injection occur rarely.
What are spider veins?
Spider veins are small purple to red blood vessels that occur just under the surface of the skin. There is often a central core of a larger blood vessel that fills the arms of the spider. These are often an indication of broke valves in veins deeper in the leg. In the absence of deeper veins that actually reflux treating spider veins only is considered cosmetic and not covered by insurance. We treat them with cosmetic sclerotherapy and with laser light surface vein ablations and anticipate being able to make considerable improvement in their appearance.
Why do you use laser treatments at re*be® instead of radiofrequency?
The primary reason is cost. The radiofrequency catheters can only be used for one person and are very expensive. The results long term seem to be identical for people who go to properly trained physicians. Doctors who only do a few treatments or who are just learning will be able to get better results early using radiofrequency catheters. A busy vein practice however will quickly learn that a laser in trained hands leads to more versatility and expanded treatment options at less cost. We have done several thousand laser ablations and did try the VNUS/ClosureFAst® device. Both work well. We own three excellent Sciton® laser systems at re*be?® and know how to use them. Our choice for you is endovenous laser ablation over radiofrequency ablation.
How will you treat my varicose veins?
At re*be?® we use a procedure called endovenous laser ablation to treat your veins. The procedure is done under local anesthesia with you awake. We do not like to give you medication to make you sleepy as many of our patients are able to return to work after the procedure. An intravenous catheter (IV) is placed into the vein in your leg that needs to be treated using ultrasound guidance. The area around the vein is numbed with local anesthetic similar to what your dentist uses only very dilute. The laser fiber is positioned inside the vein to the upper part of your leg. The laser is turned on and the inside of the vein is 'cooked' with the laser energy as the fiber is slowly removed. This causes the vein to shrink and the blood flow in that vein to stop flowing. Your body then over the course of the next several months turns the vein into a fine thin cord. The veins inside the muscles take over returning the blood to your heart from your legs.


The re*be® Clinic has been extensively remodeled and purchased state of the art new equipment to be able to offer endovenous laser vein ablation as well as a very complete line of varicose vein treatments both those covered by insurance and cosmetic procedures. The doctors at re*be® have combined experience that now numbers into the several thousands of vein ablations. This gives re*be® a huge experience to draw from and makes re*be® an excellent local and regional choice for advance vein care.
Rebe Skin and Vein Clinic
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