After years of hiding her legs under long slacks, Nancy Revella was looking forward to a vacation in Ocean City last summer without worrying that her kids would ask -- yet again -- "Mom, what are those bumps on your legs?"
The bumps were varicose veins -- unsightly, swollen blood vessels that had begun to bulge during her first pregnancy and had worsened during the second. Her distress was more than just cosmetic: "My legs were throbbing and restless," she says ++ now.
But that's all a memory. Beginning in September and finishing in May, Mrs. Revella, 39, of Ellicott City had a series of treatments in which a chemical was injected into the veins to make them disappear.
"My mother had her varicose veins stripped; when I looked at the scars, I knew I didn't want that," says Mrs. Revella, explaining her decision to go to Vein Clinics of America in Owings Mills where she had injection treatment -- called sclerotherapy -- instead of stripping, or surgical removal of varicose veins.
And the treatment she chose, sclerotherapy -- long used for eradication of "spider veins," which are hair-thin streaks of red or purplish blood vessels in the skin -- is just one of the newer, less traumatic treatments for varicosities.
"I haven't done a complete stripping in years," declares Dr. Frank Criado, a vascular surgeon in partnership with Dr. Luis Queral at the Maryland Vascular Institute at Union Memorial Hospital.
In stripping, the entire saphenous, or long vein in the front of the leg, is cut free and pulled out, from groin to ankle, while the patient is under general anesthesia; extra incisions are sometimes required because of kinks in the main vein or in its branches. While there are situations in which stripping may be appropriate, Dr. Criado prefers a newer technique.
This new method involves removal of the veins in an outpatient micro-surgery session that leaves people able to return to normal activities the next day.
Dr. Criado makes several tiny incisions along the route of the varicosities, and, using a crochet hook, he pulls loops of the swollen veins out through the little holes.
Shots of local anesthesia prevent pain; pressure stops the bleeding, and tape covers the wounds. They heal without stitches, and without scars, according to Dr. Criado.
"Six weeks later, you cannot even find the places," he says.
In sclerotherapy, by comparison, the vein is not removed; it's destroyed inside the body. The goal is "to injure the lining of the blood vessel so that the walls will stick together," explains dermatologist Margaret Weiss (who works in partnership in the Baltimore area with her husband, Dr. Robert Weiss).
It can be a months-long process, with several injections in a single session, and several sessions required before the vein or veins are sclerosed, or turned to scar tissue, which the body eventually absorbs. Blood, meanwhile, reroutes itself through other channels for the return trip to the heart.
With each session, the treated area is compressed with tape; patients may have to wear surgical hose as well. Dr. Weiss also encourages them to walk afterward. Compression and walking are also basic at Vein Clinics of America, where Dr. James Leo Harry, insists, "You have to be able to walk three miles a day during treatment."
Whatever the treatment, varicosities can recur; that is, you can get new ones after the old veins are destroyed. That happens because of the process that caused the original varicosities -- a failure of the one-way valves that are supposed to keep blood from slipping back down as it travels from the feet and legs and up the body on its return trip to the heart.
When valves don't close properly, blood pools in peripheral vessels, which stretch, bulge and kink in the configurations recognized as varicose veins.
"People think [varicose veins] are merely a cosmetic problem," says Dr. Criado. "But at least half the patients come to the doctor because of symptoms: They have intermittent swelling, achiness, burning, tiredness. It is not critical, but it does interfere with daily activities." Spider veins do not cause swelling, he adds; but they, too, can ache.
Varicosities can also lead to ulceration, the formation of oozing .. wounds that Dr. Harry describes as ranging "from a pinpoint in size to a ring that is circumferential around the ankle."
Distressing as the veins can be, destroying them is not entirely free of risk. Salt water, which is one of the sclerosing agents, can cause pain and cramping during injection; another of the solutions, described as a "synthetic detergent," can, in rare cases, set off an allergic reaction. And if they leak into tissue outside the vein, infection and ulceration can occur. Dr. Criado has not seen any major infection or under-the-skin bleeding in patients who have had the new surgical procedure; however, he says, they do have a moderate degree of pain for about a day afterward.
Moreover, not everyone is a candidate for treatment. Cardiovascular disease, diabetes, and other medical conditions could raise questions about the advisability of varicose vein destruction. And, according to Dr. Weiss and Dr. Criado, preliminary surgery might be required in people with a leaky valve high up in the groin. Careful pretreatment testing is therefore essential.
Costs can also be a consideration. Although some medical insurance policies provide coverage for treatment of veins that cause medical problems, you could still end up with a good-sized bill. Dr. Criado's procedure costs $1,000 or more -- depending on the extent of the problem; Dr. Weiss charges $150 to $180 for a sclerotherapy session, and Dr. Harry charges $325 per session.
With her treatments scheduled twice a week for the first several months, then spaced further apart, Mrs. Revella's charges added up to about $5,100, with $600 of it for testing, she recalls. Her insurance paid about half, and she paid the rest.
"It was the best thing I ever did for myself," she says.
The valve failure that causes varicose veins is a hereditary problem, the doctors say. Women are more likely to have varicosities than men, and are especially likely to develop them during pregnancy, which suggests a hormonal influence as well. Obesity and occupations that require a lot of standing can aggravate the condition, but have not been shown to cause it, according to Dr. James Leo Harry of Vein Clinics of America.