Results of a new technique, developed at UCLA by Peter Lawrence, M.D., were published in the October 2007 issue of the journal The American Surgeon. The technique was developed to remove branch varicose veins from the thighs, calves and ankles by combining two varicose vein-removal procedures. For the new technique, Dr. Lawrence combines powered phlebectomy and stab phlebectomy, which remove veins through a small incision in the skin. He also uses transillumination to light up the veins under the skin -- making them easier to see and easier to remove. Finally, the technique also involves the use of crochet hooks -- size 7 crochet hooks to be exact. There is minimal, if any, scarring. Dr. Lawrence says, "We can essentially leave the leg looking like it's been untreated or at least not treated surgically and yet, we've removed all the veins."
Dr. Lawrence does the procedure with the lights in the operating room turned off -- to maximize the benefit of transillumination. He makes a tiny incision next to a varicose vein and uses a crochet hook to pull the vein through the opening. The vein is then dislodged from the skin. A separate incision is made to remove each vein. Dr. Lawrence says, "The recovery phase is very, vey rapid and the discomfort is minimal because they are just tiny little incisions." When compared to other procedures, Dr. Lawrence says, "Virtually all patients said it was an easier procedure to go through with better cosmetic results. They seem to prefer this to virtually anything else that had been tried on them."
Dr. Lawrence's study shows the technique resulted in quick vein removal, minor bruising and excellent cosmetic outcomes in the more than 260 patients who received it. Patients were followed for about a year after their procedures. During that time, researchers found few early postoperative complications such as infection or pain that required additional pain prescriptions. A larger study is the next step for the research.
Peter F. Lawrence, M.D., a vascular surgeon, explains light-assisted stab phlebectomy (LASP), a new procedure for removing varicose veins.
What are varicose veins?
Dr. Lawrence Varicose veins are abnormal dilated veins or blood vessels that become visible to the naked eye and are often associated with, not only visible dilated veins, but also with symptoms. They look like a vein that's larger than normal, and often, as it becomes larger, it becomes tortuous. It's like a meandering river that's going through a valley or something. It starts getting more and more tortuous to the point where it then becomes dilated and raised. We see it visibly when it's both above the skin surface or pushing on the skin surface and very often blue.
Why are varicose veins bothersome?
Dr. Lawrence Some people get mild symptoms of heaviness and aching which is the most common thing. This is very common disease and, in fact, some people say it's not a disease but a condition because 40 percent of adults have varicose veins. For every 10 years of age, the risk of getting them goes up by at least 10 percent. So when you get into your 70s and 80s, at least 60 to 70 percent -- maybe even 80 percent -- of senior adults have varicose veins. Therefore, it's extremely common to have the heaviness and aching that people find uncomfortable. They usually get used to it, but it's often associated with fatigue at the end of the day. Sometimes, it's improved with support hose, but often it isn't. I must say though, quite honestly for many of our patients the biggest issue for them is cosmetics as well. Most patients have a combination of both discomfort and cosmetic concerns when dealing with varicose veins.
Margaret mentioned earlier that she always felt left out when she went out with her girlfriends and they all wore skirts. She said she wanted to be fun and flirty, but she felt she couldn't because she had to wear pants and knee-high boots to cover her varicose veins. She felt very self conscious.
Dr. Lawrence Well, one of the most common stories is a female patient who comes in and there are many more women than men, not so much because varicose veins are that much more common in women, but because women tend to adhere to the western culture of shaving their legs and wearing shorter skirts. So women will be much more conscious of it. I've had so many people say, “I decided to have this fixed when I went to the beach, and a little kid came up with their mother and father and said, ‘oh, mommy or daddy, what is that on her leg?" For them, it becomes something they realize is visible. For many patients, at that point, they want to have it fixed.
Before this procedure, what were some ways to fix varicose veins?
Dr. Lawrence Just over the last 25 to 30 years, we've moved from the classic stripping, which is a technique where we move the major veins, the saphenous vein, or lesser saphenous, or short saphenous vein, by passing a tube or plastic catheter up the veins from the ankle, to the groin and then tying a suture around it and pulling it out, essentially turning it inside out, or stripping it out like each branch has just broken off. It's like if you take a tree and just take the trunk out and leave the branches that would fall, so every branch is left behind. Consequently, there's some discomfort after that from the bleeding from those branches. Also, the process of stripping is not that comfortable because there are two sensory nerves that run along side it that sometimes get irritated. That was the traditional approach to big varicose veins. There were some modifications on it, like turning it inside out, as opposed to standard stripper. Then, for the branches, we would make incisions over the vein and directly go after the vein and take a clamp and scissors and cut and tie the vein. The problem with that approach was that it had some post operative discomfort associated with it, and the incisions that were made for the branches often were a quarter of an inch to an inch long. So the patients were trading the appearance of varicose veins for the appearance of multiple incisions. If you put 15 or 20 incisions in a leg, patients would no longer have those blue, tortuous veins, but have incisions that were long enough that to be very visible. They felt like they were trading one cosmetic defect for another. So even though we took care of their symptoms, they had something that was essentially untreatable after that, which are multiple incisions on the leg. No matter what you do once you've made the incision, it's very hard to get rid of it.
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Varicose veins
There's a new less invasive procedure that doctors feel is a sure shot way to get rid of varicose veins.
 
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How has the treatment of varicose veins advanced?
Dr. Lawrence I got involved and interested in this maybe 15 years ago, when a Brazilian surgeon visited, who became a lifelong personal friend. I still communicate and visit with him and his family in Brazil and he said, "Why are making such big incisions? Why don't you use smaller incisions?" And I said, "Well we really don't have the instruments to do that." He made me a set of instruments while I was at the University of Utah and showed me how to take a simple crochet hook and modify it. From that, I've just started making the hooks myself. In the mean time, there has been simpler ways of treating the saphenous vein. No longer does it need to be stripped, although in some patients it's still the best approach for very large veins, or ones that are very close to the surface; however, for most people, we can close the vein by just putting a simple equivalent of an IV in a vein just below the knee and then running a catheter up inside and closing the vein without any incision. So that's an incision-less approach to the big vein. Then we'd learn how to get the smaller veins out, which are sometimes called tributaries or reticular veins. We've been able to remove the smaller veins with these micro incisions so we can essentially leave the leg looking like it's been untreated, or at least not treated surgically while removing all the veins.
Can you explain how the new LASP procedure involving micro incisions works?
Dr. Lawrence Essentially, it combines multiple things that I've learned over the past 25 years. LASP stands for light-assisted stab phlebectomy, which involves a tiny incision. We make a tiny incision no longer than a millimeter or half a millimeter by using a blade that has a sharp point to it. In fact, the incision is so short that it doesn't require a stitch to close it. Then, we have access to the veins and we can see the veins to make sure we've completely removed them by using a trans-illumination. A trans-illumination is a light that's placed through a tiny little canula, underneath the veins, to make the incision. The analogy would be very similar to a hand puppet show where a curtain would be put up with a light behind it and then someone's fingers would make different types of animals. You can trans-illuminate, or shoot through the sheet, and on the other side you can see very easily the hand. The same thing can be done in the leg. We take a small little canula with light on it and shine it from underneath the vein and I can actually see the vein and see the entire path of the vein very easily. Then using these tiny little crochet hooks to catch the vein once we see where the vein is going we make a tiny little incision next to the vein to remove it. It's not that there's anything revolutionary about the equipment or instruments, it's just putting together a lot of things that have been done over many years into a single procedure.
The other thing you might be interested in is that we try to remove as much vein as possible through a single incision, but sometimes we have to make multiple incisions because if it's a fragile vein it could break off. I have, through a single incision, removed a 31 centimeter or 14 to 15 inch vein. It's remarkable how much vein you can get out through a single tiny incision that's only a millimeter in diameter.
How do your patients respond when you tell them you are using crochet hooks to remove their veins?
Dr. Lawrence The response is fascination. Patients try to help you as a physician and I've had several patients who've both brought me crochet hooks, or other types of knitting tools they think might be better than crochet hooks, to see if I wanted to try them. The crochet hooks are something that really fascinates them and yet it makes sense. Many of these patients are women and many of them have done knitting or crocheting and so they understand how you can use a tiny little hook to catch something deep and it's common sense to them to use it to remove a vein.
Are there any risks to the patient in doing this procedure?
Dr. Lawrence The veins we're taking out are varicose and therefore the blood is generally flowing the wrong way in the vein, so it's not as though they are contributing a lot to the good flow of blood out of the leg. The deep veins in the leg carry 90 percent of the blood supply so the large surface veins like the saphenous veins can be used for heart bypasses and leg bypasses. Those veins are not treated with the LASP procedure, but with a closer technique instead. Patients are worried about whether or not they need these big veins to save them for a heart bypass, but we point out that we would never do a heart or leg bypass with a varicose vein because it would just get dilated and very large. Therefore, it's safe to take out the abnormal varicose veins and certainly the branch veins or these tributary veins we use the LASP procedure on because they are not contributing to the significant amount blood supply in the leg.
Is the LASP procedure done on all varicose veins or just certain types?
Dr. Lawrence It's done typically on the calf veins and any vein other than the very large veins, because that's a different procedure. Spider veins, which are in the same category of abnormal veins, are too small for LASP so they are better treated usually with injection or a laser treatment.
So LASP couldn't be used for spider veins?
Dr. Lawrence That's correct, although the treatment we're talking about is not for the spider veins, but I think of varicose veins as being sort of an overall umbrella of problems of the large veins in the leg, the medium sized veins and even the small veins. The analogy we like to use with patients is that it's somewhat like a tree that has leaves, which would be the spider veins. It has twigs and branches, which would be the reticular or the tributary veins, and then it has the larger branches or the trunk, which would be the saphenous vein or the lesser saphenous, short saphenous veins. Any one of them can become varicose and they all contribute to the venous system.
Describe the recovery for a patient who has a LASP procedure?
Dr. Lawrence One of the surprising things for many patients is the recovery is actually quicker with doing a small surgical procedure. Depending on the number of veins we are removing, we wrap the leg fairly tightly and some patients go directly back to work or some of them take off a day or two to elevate their leg to keep the bruising down. Within two days, patients are back to their normal activities. There are no sutures to remove and the recovery phase is very rapid, and the discomfort is minimal because of the little incisions. The length of the incision sometimes determines how much recovery and how much pain there is with recovery. The little incisions tend to be very well tolerated by patients.
Tell me about your study published in The American Surgeon.
Dr. Lawrence There were two papers that were published and we are completing the third, which is a long term result. The first thing we wanted to do was to report on the technique, to tell people how we've evolved into doing it and just sort of the steps of the technique. In The American Surgeon, the early outcomes about how patients did are described. We wanted to make sure they were number one with no excessive pain associated with the procedure. We asked them to compare the LASP procedure with other procedures they had done. We wanted to know whether we had relieved their symptoms and how complete the veins had been removed. I think one of the differences between our technique and others is that the LASP technique allows me to see virtually all of the veins. Sometimes patients come to me and say, "I've had this procedure done two or three or five years ago and I've had reoccurrence. I have new veins." A lot of times, I sense these were really not new veins, but they were original veins that had just been missed on the original procedure. We wanted to see how many patients had not only good cosmetic results, but also how many reoccurrences people had, which in my opinion could be missed veins.
What did your study show about the results of the LASP technique?
Dr. Lawrence We found the patients reported a very quick recovery back to normal activity with minimal pain. A significant percentage of patients took no medication and a few, after the procedure, took a very mild oral pain medication. Most returned to work or to other activities quickly and were very pleased initially with their cosmetic result. When the LASP technique was compared to other procedures, virtually all patients said it was an easier procedure to go through, with better cosmetic results than the previous treatments they have received. Their previous treatments could have been a variety of different treatments, but they seem to prefer LASP to virtually anything else.
How common is the LASP treatment and where can people get it?
Dr. Lawrence I think there are more places that offer it than we realize. One of the purposes of publishing the study was to make other physicians aware. Everybody has the technical ability and the equipment to do it. When I presented this at one of our national meetings in New York a month and half ago, after I gave the talk, about three people came up to me and said, "It's amazing. I was thinking about doing it with the equipment that you are talking about," or "I tried it in a couple of patients and it worked great." I think that most physicians, mainly vascular surgeons, have the equipment at their institution. I actually get the clamps from my friend from Brazil, when I visit him every couple of years, for an international meeting. I usually bring back as many as a dozen clamps that cost 14 dollars apiece. I buy the crochet hooks in clothing or knitting stores, and they will cost two to three dollars. So with very inexpensive equipment, I can do a lot of procedures. The only thing that costs a little bit more is the light source -- the trans-illumination -- and the canula, but that's available in most surgery centers and operating rooms.
When you go into buy those crochet hooks, do they know why you are buying them?
Dr. Lawrence It's interesting because they are very fascinated by it. When this study came out recently, one of the stores called me and asked if I would mention the name of their store, because they found this as a new potential market. The reality is that we use these over and over again, and it takes me a half an hour to an hour to file the tip of them so we can use them. The hooks are not disposable, so I try to use them as much as possible. Maybe once or twice a year I'll go into a knitting store and buy crochet hooks.
Is there anything else you would like to add?
Dr. Lawrence I think the main thing is patients equate the number of incisions with the cosmetic results and part of it is getting them to shift their thinking. You have to explain that it's not the number of incisions -- it's completely removing the vein and the more completely we can remove it, the better their symptom relief will be and the better they'll look cosmetically. We can make such tiny incisions that they almost have a hard time showing you where they are. A year later, I challenge my patients to come back and show me where we did the procedure. For most people, it depends on the pigmentation and they have a really hard time showing me the incision. Most patients can only come up with three or four or five incisions that they can see on their leg. I document the number of incisions so I know that how may I've done. Small incisions and more of them are actually better cosmetically than making a few large incisions, and it's sort of leap of faith that patients have to be convinced that making lots of small incisions and completely removing the vein is better cosmetically, as well as for symptom relief, than making a few big incisions.
