6 Reasons Why Leg Veins Pop Out?

Feb 28, 2022

Eliminate Spider & Varicose Veins
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Best Vein Treatment For Spider  and Varicose Veins

FIND YOUR VEIN CLINIC

Developing veins that bulge and pop out on your legs can make you feel self-conscious and even limit your activities. As you might expect, this is a physically and mentally unhealthy outcome. With up to 50% of individuals experiencing some degree of vein disease, we want to help patients understand the development of dilated veins and how they can be best managed.

Bulging veins can happen for a variety of reasons both benign and serious. Sometimes it is as minor as exertion after exercise. When you exercise, your veins expand to increase your blood flow and regulate your body temperature. This is a healthy temporary response. Abnormal veins on the other hand are chronic and progressive due to an underlying condition such as venous insufficiency.

Your veins must work against the force of gravity as they move your blood from the bottom of your legs back to your heart. For this task, our veins contain tiny valves that help prevent the backflow of blood.

If the valves weaken, blood flow is impaired and blood falls to the bottom of your legs with gravity. The pressure inside your leg veins increases and leads to spider veins and varicose veins popping out from your legs.

Varicose veinsVаrісоѕе vеіnѕ, аlѕо known as “vаrісоѕіtіеѕ”, are еnlаrgеd and unhealthy veins that usually arise due to high pressure in veins slightly deeper within the leg. They may be large or twisted, and may bulge from under the skin. You’ll find that they can be red or purple in color. Varicose veins can appear anywhere on the body; however, they are most commonly found on the legs.

Venous Insufficiency – Inside the superficial veins in the legs are a series of valves, that are essentially one-way doors that prevent blood from falling back down towards the feet. If the valves stop working properly, blood leaks downwards and the veins below the valves become full of excess blood. The increased pressure in these veins can lead to spider veins and varicose veins over time.

Phlebitis – Inflammation of a vein. When caused by a superficial blood clot, it is called thrombophlebitis sensed as warm, painful lumps or redness.

Age – As we age our veins and valves weaken and are more likely to form varicose veins.

Pregnancy – During pregnancy the blood flow to the legs and feets can decrease from the pressure on the pelvis causing varicose veins.

Temperature Regulation – Our veins help cool our bodies with dilation. For this reason, during exercise or warm weather, it is common to see more prominent veins

Do you know how to pick a vein treatment clinic for the best results?

When Are Bulging Leg Veins Normal?

Usually bulging leg veins are no reason to worry. The most common reasons are not serious and can resolve on their own or with some minor adjustments.

You can expect veins to naturally bulge under the following circumstances:

  • Thin body frames
  • Normal Aging
  • Temperature Regulation
  • Increased activity during and after exercise

Although bulging veins can be prominent in these conditions, they are not likely to be dangerous or cause symptoms. Pregnancy veins and those seen after exercise will often improve on their own. Your vein specialist should be made aware if you are experiencing:

  • Pain
  • Discomfort
  • Heaviness in the legs
  • Tenderness on palpable veins
  • Leg swelling
  • Skin discoloration or eczema

How To Get Rid of Abnormal Veins

Our vein treatment guide provides valuable information into the best practices for spider and varicose vein treatment. It summarizes up to date literature on vein treatment and our own experience in treating patients. Interested patients can use this guide to advance their knowledge on vein disease and make the best decisions on their vein treatment.

Do you know how to pick a vein treatment clinic for the best results?

Vein Treatment Overview

“Each patient has to be evaluated individually to establish a vein treatment plan tailored to the individual patient using the best combinations possible as proven by our experience and current guidelines.”

Endovenous Vein Ablation

By Dr. Faisal Siddiqi

VenaSeal

By Dr. Simon Smith

Sclerotherapy

By Dr. Claudia Rios-Datta

Ultrasound Guided Sclerotherapy

By Dr. Claudia Rios-Datta

Ambulatory Phlebectomy

By Dr. Alissa Brotman-O’Neill

Echotherapy

Similar Procedures: Endovenous Laser Vein Ablation (EVLA)

Varicose Vein Treatment: Endovenous Radiofrequency Vein Ablation (EVRFA)

By Dr. Faisal Siddiqi

Radiofrequency ablation is a minimally invasive treatment for varicose veins.  During ablation, thermal energy is used to heat tissue and create scars that collapse unhealthy veins.  This technique uses radiofrequency energy (instead of laser energy) to heat up and damage the wall inside a vein.  RF vein ablation is now the gold-standard of varicose vein treatment replacing surgical stripping.

To treat a varicose vein, radiofrequency energy is applied from a small catheter inserted through a leg vein.  Most highly skilled vein specialists can do this with a simple needle puncture under local anesthesia.   It can be done in an office setting or ambulatory surgical center (ASC) and the entire procedure can take 30 minutes in skilled hands. You will be able to resume your normal activities shortly after the treatment.  

After treatment, you will wear compression stockings until your follow-up with the treating doctor. An ultrasound is performed at the follow up visit to ensure adequate treatment.

An experienced vein specialist can safely perform an ablation with minimal risks.  Possible side effects of radiofrequency ablation include:

  • Skin burn (rare)

  • Nerve irritation or skin sensory disturbance (usually temporary)

  • Phlebitis 

  • DVT (rare with a trained vascular doctor)

These side effects are rare and should be discussed ahead of time with your vein specialist.

Radiofrequency ablation is the gold standard for treating venous insufficiency and has a success rate equal to 95%.

In the rare instances, a vein does not collapse with vein ablation, repeat treatment can be offered versus an alternative treatment like VenaSeal or foam sclerotherapy.

  • Gold-standard of vein disease treatment for underlying venous insufficiency
  • Local Anesthesia only
  • No downtime, No sutures, No scars

Covered by medical insurances for medical necessity

  • RF vein ablation is not intended for spider veins or visible veins directly on the surface.

  • Sclerotherapy is often performed in conjunction with RF vein ablation to target large varicose veins on the skin and spider veins.

The simple answer is yes.  However, there are many contributing factors to the development of recurrent varicose veins.
  • New sites of venous insufficiency

  • Incomplete treatment of varicose veins

  • Incomplete preoperative planning

  • Perforator disease

Despite many years of experience, there is still a disappointingly high rate of varicose vein recurrences.  Being selective about your vein doctor and having a complete examination before treatment is critically important towards minimizing risks of recurrences.  Inadequate investigation before vein treatment and high rates of recurrences are linked to inexperienced vein clinics.  The vein doctor must have accurate information using duplex ultrasound to identify all sites of incompetence to plan successful individualized treatments.

If you are considering a procedure or surgery for varicose veins, ask the following questions before proceeding:

  • How much does the exam and treatment cost?

  • How many treatments does the doctor think you will need? 

  • What are the risks of each specific vein treatment? 

  • What are the expected results with varicose vein treatment and how soon can you see symptomatic improvement? 

  • What are my alternative options to vein ablation?

For additional reading on selecting the best vein clinic, click here

  • Vein Ablation is the gold standard for treatment of venous insufficiency

  • Vein Ablation is minimally-invasive and can be performed with local anesthetic

  • Recurrence rates can be unacceptably high with inexperience vein centers

  • Complete ultrasound examination and interpretation are critically important to planning successful vein treatments

Do you know how to pick a vein treatment clinic for the best results?

Similar Procedures: Medical Adhesive, Venous Glue

VenaSeal Vein Glue

By Dr. Simon Smith

The most recent innovation in the treatment of varicose veins is VenaSeal, otherwise known as vein glue.  

VenaSeal is developed by Medtronic and used to seal saphenous veins in the thigh or calf region. Once the vein has been treated, it will harden and gradually be absorbed by the body. The procedure is minimally invasive similar to endovenous vein ablation.

The VenaSeal procedure involves the percutaneous placement of a small catheter through the skin using minimally invasive techniques.  In place of heat energy, the catheter delivers small amounts of vein glue to the targeted segments of the saphenous vein under ultrasound guidance.  Once the affected vein is closed, blood is immediately re-routed through other healthy veins in the leg.  Because VenaSeal does not use any heat energy, there is minimal need for even local anesthesia during the procedure.  Stockings are usually not necessary after VenaSeal treatment. This provides an added comfort for patients and sooner returns to normal activities.   

The published success of the VenaSeal closure procedure is equal to other endovenous procedures including laser ablation (EVLA). 

VenaSeal has been independently studied in the United States and Europe over the last decade.  In addition to effective treatment of saphenous veins, published results show a low risk of complications.

VenaSeal is a treatment that involves the implant of cyanoacrylate, a medical-grade glue. It is a quick, minimally invasive procedure that takes approximately 30 minutes in experienced hands.

Interesting properties of VenaSeal that make it particularly useful in vein treatment include:

  1. It rapidly polymerizes on contact with blood resulting in an immediate effect on the vein walls. 

  2. The glue displaces the blood inside the vein and seals the walls shut.  As a result, compression stockings are not required after vein treatment.

  3. Has an “anti-microbial” effect against bacteria on the skin

Advantages of VenaSeal

  • Treatment is performed without any delivery of heat energy eliminating risk of injury to skin or nerves

  • Increased comfort for procedure versus traditional surgery and endovenous ablation

  • No need for compression stockings after vein treatment

  • Quick recovery with no downtime

Disadvantages of VenaSeal

    • Small, rare intolerance to the adhesive 

    • Implant lacks long term data for efficacy

    • VenaSeal has limited insurance coverage at this time

Do you know how to pick a vein treatment clinic for the best results?

Similar Procedures: Cosmetic Sclerotherapy, Cryosclerotherapy, Liquid Sclerotherapy

Sclerotherapy

By Dr. Claudia Rios-Datta

The gold standard treatment of spider veins is sclerotherapy, which can treat a large variety of small and large veins.  Laser vein removal is limited to facial veins or very fine veins on the legs or particularly feet. 

Sclerotherapy is used to treat and remove spider veins and varicose veins on the legs, ankles, and feet.   Sclerotherapy can also be used for some facial veins, breast veins and hand veins.

Sclerotherapy involves the injection of a medicated solution, called a sclerosant, into spider veins. The sclerosant irritates the lining of the blood vessels and causes them to collapse. Over subsequent weeks and months, the body gradually absorbs the vein.  Each treatment can be associated with 50-60% improvement with multiple treatments required for 80-90% improvement.

Sclerotherapy can be augmented with several advanced techniques including:

Cryosclerotherapy is an additional measure to enhance patient comfort. The whole procedure is done using a cryo unit that produces a continuous flow of cold air to the sites of application of sclerotherapy injections. The result is the cold air anesthetizes the skin so the treatment is relatively painless. This is especially helpful for the treatment of spider veins in sensitive areas like the behind the knees and thighs.

  1. All patients with spider veins are assessed for underlying venous insufficiency.  In some instances, a reflux ultrasound may be requested by your vein specialist to identify any abnormal veins beneath the skin contributing to symptoms and spider veins.  

  2. Any underlying venous insufficiency is considered for vein treatment prior to sclerotherapy.  

  3. Foam sclerotherapy is often reserved for large surface varicose veins or patients with residual vein disease from prior vein treatment.

  4. The most effective sclerosants include polidocanol and sodium tetradecyl sulfate (STS).  Hypertonic saline is an older technique associated with increased risks for hyperpigmentation and skin injury.

  5. The concentration of sclerotherapy is planned by your vein specialist based on the size of target veins.

  • Your usual medications can be continued prior to treatment (hormonal therapy, birth control, iron supplementation should be discussed ahead of time)

  • Do not apply lotions on the day of treatment

  • Do not shave your legs immediately prior to your treatment

  • Any travel plans should be discussed ahead of time with your physician

  • Patients who smoke should consider stopping before any treatment

  • Understandably, some patients are anxious about spider vein treatment and needle pricks.  We can assure you that most patients have very little discomfort from sclerotherapy.

  • A typical procedure lasts between 15 minutes to 30 minutes

  • Multiple sessions may be planned depending on the condition of your veins

  • Larger veins are addressed first down to the smaller veins

  • Specialized equipment including vein-lites, magnification and cooling techniques may be utilized

  • A topical steroid can be immediately applied post-treatment for any skin irritation at the discretion of the vein doctor.

Following each treatment session, patients may benefit from compression stockings. Sun exposure after treatment should be avoided for at least 4 weeks or until bruising has subsided.  Read more about sclerotherapy aftercare.

Complications can occur even with the best possible technique and attention to detail.

  • Deep vein thrombosis (DVT). Clots are a recognized complication of vein treatment, however rare inexperienced vein clinics. Increasing pain or leg swelling after treatment deserves immediate attention.

  • Allergic reaction. The most common reaction is a skin wheal similar to mosquito bites.  No treatment is required however topical cortisone may alleviate any itching.  More serious reactions are extremely rare and immediately recognized as difficulty breathing or a change in health status.  On-site treatment with steroids or epinephrine is required.

  • Skin ulceration or tissue necrosis is another rare complication, especially with newer sclerosants. It occurs mainly because of inadvertent injection into the dermal capillaries and arterioles. In our experience, most injection ulcers are small and will heal without scarring, however early attention is warranted for optimal resolution.

    • Mild Discomfort after sclerotherapy is more often related to compression stockings.  The stockings can be removed for periods of time to provide some ease.  

    • Darkening of Spider Veins. Some treated spider veins may darken in the initial weeks after treatment due to trapped blood.  This is a sign of successful spider vein treatment and the area will gradually fade with time.  

    • Bruising is seen more often with treatment of larger veins with ablation or phlebectomy. 

    • Hardened, Lumpy Veins are another sign of successful vein treatment.  The hardened veins do not require any further sclerotherapy and will be gradually reabsorbed by the body.  Trapped blood can be removed with a few needle pricks. 

    • Hyperpigmentation represents hemosiderin deposits released from the treated veins. Prevention is the best course of action with meticulous technique and using the lowest concentration of sclerosant for effective results.  Early evacuation of trapped blood is recommended.  Most hyperpigmentation resolves spontaneously by 6-12 months.

    • Telangiectatic Matting occurs 4-6 weeks after treatment and resolves spontaneously.  They appear as tiny, fine new capillaries on the surface of the skin particularly near sites of injections. Spontaneous resolution is expected, however, identification of any larger refluxing veins is recommended.  For most patients undergoing cosmetic sclerotherapy, very few symptoms are expected with treatment.

    • Phlebitis. Inflammation of the treated veins can occur during the healing process. It will appear as redness and tenderness over treated veins.  Treatment goals are comfort provided by compression stockings, warm compresses, and NSAIDs.  Regions of associated coagulum can be removed with simple needle drainage.

    • Sclerotherapy is the preferred treatment for spider veins in comparison to laser vein removal

    • Many patients require staged treatments with the expectation of 80-85% improvement

    • Several enhanced techniques can enhance the effectiveness of treatment

    • Side effects are rare

Do you know how to pick a vein treatment clinic for the best results?

Similar Procedures: Foam Sclerotherapy, Pre-mixed Foam Sclerotherapy

Ultrasound Guided Sclerotherapy

By Dr. Claudia Rios-Datta

Ultrasound Guided Sclerotherapy (UGS) is a highly specialized procedure for treating varicose veins that are hidden beneath the skin.

Not all varicose veins are visible and some feed directly into the spider veins on the surface of the skin.  In these cases, ultrasound is used to identify the target vein and the medication is injected into the desired segment.   Vein doctors adept at ultrasound technique are best suited to perform this advanced technique for vein removal.

A detailed ultrasound examination is performed prior to sclerotherapy to create a road map of the lower leg veins. This map precisely displays all abnormal veins and helps the vein doctor identify the root cause of the visible spider veins and varicose veins.

Using ultrasound guidance, the doctor can accurately guide the needle and inject the sub-surface veins underlying visible ones.  The ultrasound also helps identify regions of deep venous connections (perforator veins) that are carefully monitored during treatment. Once injected, the treated vessel will collapse and gradually be absorbed by the body, disappearing with time.

Foam sclerotherapy is well visualized on ultrasound and allows for real time monitoring of treatment.   The foam is better suited for larger varicose veins than liquid sclerotherapy as it maintains better contact with the vessel walls.  Additional safety enhancements include pre-formulated compounds with O2:CO2 mixtures that micronize bubbles leading to more uniform treatment. 

In our vein clinic, we routinely perform ultrasound guided sclerotherapy for large visible varicose veins, neovascularization, and residual segments of saphenous veins that are tortuous or in close proximity to vulnerable structures like skin and nerves.  It is used in conjunction with vein ablation for the best results.

  • The target vein segments are mapped with ultrasound.  Entry sites and perforator veins are marked on the skin for special attention. 

  • The target vein(s) is accessed using ultrasound guidance and the sclerosant is injected into the vein

  • Foam sclerotherapy is visualized in real-time to monitor treatment response.  Additional injections are given based on this information.  The leg is often elevated during the injection to increase the treatment response

  • Smaller spider veins may be treated during the same session or during follow up for cosmetic sclerotherapy

The treatment usually takes half an hour with some additional time allotted for ultrasound examination, patient preparation, and discussion. Following the procedure, patients are fitted with grade 2 graduated compression stockings and foam padding.  Most routine activities can be immediately resumed after treatment.

Patients return to the vein clinic in one week following the UGS procedure. At this follow-up appointment, focused ultrasound is performed to ensure that the treatment was successful.

A randomized controlled trial comparing foam sclerotherapy to laser ablation and surgery found that laser ablation and surgery had better outcomes, and that laser had the fewest procedural complications.

We reserve the use of foam sclerotherapy for necessary adjunctive treatment of saphenous vein segments following vein ablation or prior surgical therapy, large surface varicose veins, and segments of neovascularization.  In our practice, vein ablation is the preferred treatment for most vein segments.

Complications can occur even with the best possible technique and attention to detail.

  • Deep vein thrombosis (DVT). Clots are a recognized complication of vein treatment, however rare in experienced vein clinics. Increasing pain or leg swelling after treatment deserves immediate attention.

  • Allergic reaction. The most common reaction is a skin wheal similar to mosquito bites.  No treatment is required however topical cortisone may alleviate any itching.  More serious reactions are extremely rare and immediately recognized with symptoms of difficulty breathing or change in health status.  On site treatment with steroids or epinephrine is required.

  • Skin ulceration or tissue necrosis is another rare complication especially with newer sclerosants. It occurs mainly because of inadvertent injection into the dermal capillaries and arterioles. In our experience, most injection ulcers are small and will heal without scarring, however early attention is warranted for optimal resolution.

For most patients undergoing ultrasound guided sclerotherapy, few common symptoms can be expected and are good to know ahead of time.

  • Mild Discomfort can be related to the normal healing process after vein treatment.  Our vein clinic will monitor your treatment with an ultrasound 1 week after the injection.

  • Bruising is not uncommon after vein treatment

  • Lumps and bumps are another sign of successful vein treatment.  The hardened veins do not require any further sclerotherapy and will be gradually reabsorbed by the body.  Trapped blood can be released with needle drainage if appropriate. 

  • Hyperpigmentation represents hemosiderin deposits released from the treated veins. Prevention is the best course of action with meticulous technique and using the lowest concentration of sclerosant for effective results.  Early evacuation of trapped blood is recommended.  Most hyperpigmentation resolves spontaneously by 6-12 months.

  • Telangiectatic Matting occurs 4-6 weeks after treatment and resolves spontaneously.  They appear as tiny, fine new capillaries on the surface of the skin particularly near sites of injections. Spontaneous resolution is expected, however identification of any additional refluxing vein segments should be treated.

  • Phlebitis: During the healing process, the treated vein segment can become inflamed and tender to touch. Treatment goals are comfort provided by compression stockings, warm compresses and NSAIDs.  Regions of associated coagulum can be removed with simple needle drainage.

    • Ultrasound-guided sclerotherapy or Foam Sclerotherapy is an effective vein treatment for subsurface varicose veins

    • Best used in conjunction with vein ablation 

    • Reduced risks of injury to skin or nerves

    • A smooth and successful procedure is dependent on having a vein specialist experienced in vascular ultrasound technique (RPVI, RVS or RPhS credentials)

Do you know how to pick a vein treatment clinic for the best results?

Similar Procedures: Microphlebectomy

Ambulatory Phlebectomy

By Dr. Alissa Brotman-O’Neill

Ambulatory Phlebectomy is the surgical removal of bulky, large varicose veins on the skin surface, through tiny incisions.  It is a minimally invasive procedure with patients returning to many of their normal activities the following day.  Ambulatory phlebectomy should not be confused with vein stripping or surgical stripping procedures. 

The procedure eliminates varicose veins through a series of tiny incisions directly over the varicose vein segments, removing them in a single setting.  Before phlebectomy is performed,  any underlying reflux should be identified and treated first with vein ablation or ultrasound guided sclerotherapy. 

  • Ambulatory phlebectomy is performed on an outpatient basis under local anaesthesia

  • The procedure can be performed in 30-60 minutes depending on the location and severity of varicose veins.

Phlebectomies are carefully evaluated against sclerotherapy and generally reserved for larger veins. While sclerotherapy is more simple, it can be associated with longer recovery periods as it takes time for the veins to absorb.  Not all large varicose veins are suited for foam sclerotherapy.  Ambulatory phlebectomy is notable for more immediate results and higher levels of patient satisfaction in the right settings.

In our vein clinics, both Dr Alissa Brotman and Dr Claudia Rios perform ambulatory phlebectomies in select cases.

No, in most instances the phlebectomy incisions are so small that no stitches are required. For the very same reason, scarring is much less likely, however, certain skin types may be more vulnerable.

Ambulatory phlebectomy is a safe and effective therapy for many patients with large visible  varicose veins.  The procedure is best managed by vein specialists who also routinely perform ultrasound guided sclerotherapy to weigh the pros and cons of each treatment choice.  In some cases, a hybrid approach is appropriate for obtaining the best results.

Absolutely not! Modern spider vein and varicose vein treatments have completely revolutionized. This means no cuts, no sutures and no downtime.

The Vein Specialist Centers utilize cutting-edge tools including RF vein ablation, VenaSeal, phlebectomy and advanced sclerotherapy techniques to heal even the most difficult veins.

Your vein doctor will customize a treatment plan based on your symptoms and personal goals.

    • Ambulatory Phlebectomy is a useful tool to treat large, bulky varicose veins on the surface of the skin

    • Most varicose veins will be treated with a combination of ablation and sclerotherapy

    • In our experience, phlebectomy is a reserved tool associated with high patient satisfaction in the right setting

The Future of Vein Treatment

ECHOTHERAPY

The surgery-free treatment using therapeutic ultrasound

Discover the only non-invasive “vein treatment”: No scars and no incisions.


TREATING VARICOSE VEINS WITHOUT SURGERY

SONOVEIN® is currently available in select European countries after receiving CE-mark approval.   It was recently approved by the FDA for clinical trials in the United States.[8]  These studies are ongoing and will provide the necessary safety and efficacy data before approval in the US.  SONOVEIN® represents the first robotic solution for a 100% non-invasive treatment of varicose veins. Unlike current endovenous procedures, the treatment is performed completely outside the body.  There are no catheters, incisions or post procedure scars.  SONOVEIN® is directly operated by the vein specialist without any significant preparation.  Patients can resume their normal daily activities immediately after treatment.


HOW ECHOTHERAPY WORKS

Vein ablation by echotherapy and radiofrequency have identical tasks – the elimination of source (feeder) veins into symptomatic varicose veins.  The main benefit of echotherapy over current therapies available in the US is being completely non-invasive.

The high-intensity ultrasound beam (HIFU) is focused on the vein.  A pulse of therapeutic ultrasound is then delivered for a few seconds at the target segments of the diseased vein. As the thermal energy is delivered, the vein shrinks and is sealed closed, similar to other endothermal methods – but non-invasively.  Pulses are provided until the complete target area is treated.

What Is The Best Vein Treatment For Me?

A consultation with experienced vein specialists at the Vein Specialist Centers will provide insights to help you decide on the best vein treatment plan.

It’s important to have a treatment plan tailored to your specific condition. Varicose veins and spider veins do not fit just one pattern.  Conservative measures such as compression stockings and exercise continue to be important tools in treatment. For individuals with persistent symptoms or more advanced disease, minimally-invasive treatments are available and preferred.

Do you know how to pick a vein treatment clinic for the best results?

References

  1. Beebe-Dimmer JL, Pfeifer JR, Engle JS, et al. The epidemiology of chronic venous insufficiency and varicose veins. Ann Epidemiol 2005; 15: 175–184. [PubMed] [Google Scholar]
  2. Beebe HG, Bergan JJ, Bergqvist D, et al. Classification and grading of chronic venous disease in the lower limbs. A consensus statement. Eur J Vasc Endovasc Surg 1996; 12: 487–492. [PubMed] [Google Scholar]
  3. Eklöf B, Rutherford RB, Bergan JJ, et al. Revision of the CEAP classification for chronic venous disorders: consensus statement. American Venous Forum International Ad Hoc Committee for Revision of the CEAP Classification. J Vasc Surg 2004; 40: 1248–1252. [PubMed] [Google Scholar]
  4. Vasquez MA, Wang J, Mahathanaruk M, et al. The utility of the Venous Clinical Severity Score in 682 limbs treated by radiofrequency saphenous vein ablation. J Vasc Surg 2007; 45: 1008–1014. [PubMed] [Google Scholar]
  5. Vasquez MA, Munschauer CE. Venous Clinical Severity Score and quality-of-life assessment tools: application to vein practice. Phlebology 2008; 23: 259–227. [PubMed] [Google Scholar]
  6. Todd KL, Wright DI, the VANISH-2 Investigators The VANISH-2 study: a randomized, blinded, multicenter study to evaluate the efficacy and safety of polidocanol endovenous microfoam 0.5% and 1.0% compared with placebo for the treatment of saphenofemoral junction incompetence. Phlebology 2014; 29: 608–618. [PubMed] [Google Scholar]
  7. VANISH-1: Phase III Study of Polidocanol Endovenous Microfoam on the Appearance of Varicose Veins. Podium presentation by Theodore King, Am Coll Phlebology, Florida, November 2012.
  8. https://echotherapie.com/echotherapy-treatment-by-therapeutic-ultrasounds/