Meet Our Doctor
Maged S.Mikhail, M.D, R.V.T.
Varicose Veins
Spider and Reticular Veins
Causes of Venous Insufficiency
When to Seek Treatment
Treatment of Varicose Veins
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Endovenous Ablation
Treating Varicose Branches
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When do need to go to the doctor if I have varicose veins?
Although often considered just a cosmetic problem, varicose veins reflect chronic venous insufficiency (CVI), a potentially serious condition. Tissues need normal venous drainage as well as normal arterial flow. Anything that interferes with either one can lead to symptoms and tissue damage.
Once varicose veins appear or significant symptoms develop, patients should have an evaluation that includes a detailed ultrasound examination. Symptoms do not always correlate with the severity of the problem. It is especially important to seek treatment if there is any sign of skin damage, because once it occurs it is often irreversible.
Fortunately for most people, serious complications from chronic venous insufficiency take a long time to develop. Complications generally correlated with the duration and severity of the problem. The bad news is that disease severity can only be assessed reliably with ultrasound examination.

Will my health insurance pay for varicose vein treatments?
Most health insurance plans, including Medicare, cover treatments for symptomatic venous disease but medical necessity must be established. They may require a trial of conservation treatment with graduated compression stockings and life style changes. Accepted criteria for medical necessity include:

  1. Troublesome leg pain
  2. Leg edema
  3. Skin damage (pigmentation or dermatitis)
  4. Leg ulcer
  5. Vein rupture and bleeding
  6. Phlebitis

What is new in the treatment of varicose veins?
Varicose vein treatments are now individualized and based on each patients specific anatomy and physiology. Treatments are primarily nonsurgical, minimally invasive, and require expertise in ultrasound. Endovenous ablation, foam sclerotherapy, and microphlebectomy are now the standard of care in varicose vein disease. They have replaced older painful and often disfiguring surgical procedures such as saphenous vein stripping surgery and stab phlebectomy. Ultrasound imaging has clearly shown why the old one treatment fits all, saphenous vein stripping surgery approach often fails.

Why is endovenous ablation superior to vein stripping surgery?
This procedure is a major advance in the treatment of varicose veins because it:

  1. Requires only local anesthesia
  2. Immediately relieves symptoms
  3. Results in minimal pain or discomfort
  4. Allows patients to immediately get up, walk, and resume normal activity>
  5. Results in no scarring
  6. Long term results are the same or better than surgery
  7. Provides new treatment options for patients with recurrent varicose veins
  8. Allows treatment of patients who previously could not tolerate surgery or anesthesia.

Are all endovenous ablation systems the same?
No. There are many systems currently used and clear advantages to some, We believe the CoolTouch CTEV system which uses a 1320 nm laser is by far the best in terms of safety, most versatility, and effectiveness. Other endovenous laser systems appear to be associated with more pain and bruising. The radiofrequency system (Vnus) was the first endovenous ablation technique but long-term results with the first system were not as good as the CoolTouch 1320 nm laser (Dr. Robert Weiss, Baltimore MD). Short term (1-2 year) results are better with the newer ClosureFast radiofrequency system but many doctors are concerned about its safety, and there is a relatively high number of adverse events reported to the FDA with this system (

How is endovenous ablation performed?
During endovenous laser ablation a very small laser fiber is placed into the diseased vein through a slightly larger small intravenous catheter. The ablation catheter is then positioned precisely with ultrasound. A local anesthesia solution is injected around the vein to make ablation painless and protect surround tissue. The heat generated during catheter activation permanently closes the vein and functionally removes it from the circulation. Endovenous laser ablation has only a 5-10% long-term (after 3 years) failure rate compared to the 20-40% short and long term failure rates that have been reported following surgical ligation and stripping.

Is endovenous ablation the only treatment necessary for varicose veins?
Varicose veins on the skin surface are the branches of the diseased saphenous vein. Large varicose vein branches should always be treated at the time of endovenous ablation with either microphlebectomy or sclerotherapy. When left untreated, these branches often clot and become painful afterwards. Untreated varicose branch veins can also be a source of residual symptoms, remain cosmetically unattractive, and increase the chance of future varicose vein problems.

Some physicians who perform endovenous ablation unfortunately do not treat large varicose branches until problems arise. In such instances, patients often go through needless discomfort and require additional procedures later. We treat all large varicose branches at the time of the endovenous ablation. Those just under the skin are removed through small needle holes that heal without scarring (microphlebectomy), while deeper ones are treated with ultrasound-guided sclerotherapy.

How is microphlebectomy performed?
Microphlebectomy is used after endovenous ablation to remove large ropey branches of saphenous or perforator veins. During the microphlebectomy, which is typically performed with local anesthesia on the same day as endovenous ablation, the ropey veins are removed with tiny hooks through 2 to 3 mm openings along the path of the branch veins. The holes are made with a needle or small blade. They do not require suturing because they are very small and normally completely heal without leaving a scar like the older stab phlebectomy procedure. The results are gratifying because the cosmetic improvement in leg appearance is much quicker than with sclerotherapy alone.

How is sclerotherapy performed?
Sclerotherapy involves injecting abnormal veins with one of several sclerosant medications, depending on the size of the vessel. The ultra fine needles used are virtually painless. Sclerosant medications cause veins to spasm and permanently close over the course of days to weeks. Some veins close with a small blood clot inside that temporarily makes them more prominent until the clot is absorbed by the body. The majority of patients need 2-4 injection sessions spaced 4 weeks apart. One or both legs may be treated during each session. In the first session, injections are mostly into incompetent, feeder reticular veins. These vessels frequently can only be visualized with a special bright light (Veinlite). Injecting only surface spiders and leaving feeder vessels intact decreases the efficacy of treatments and results in only short term improvements. Once feeder veins are closed, injections are primarily direct at any remaining spider veins.

Before & After
The Los Angeles Varicose Vein Center is one of few clinics in Southern California that specialize in minimally invasive treatments for varicose veins.
We offer expertise in problems ranging from complicated cases, such as recurrent varicose veins after stripping surgery, perforator vein reflux, and advanced chronic venous insufficiency to simple cosmetic spider veins.
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