Vein disease is poorly understood, even among health care providers. Spider and varicose veins are treated by a wide spectrum of providers including vascular surgeons, plastic surgeons, general surgeons, dermatologists, radiologists, primary care doctors and others. While any vein specialist with proper skills theoretically can provide excellent care, this diversity is sometimes at odds with coherent and consistent care and has led to confusion among those seeking treatment. This brief primer reviews the basics of vein pathology.

Spider veins are very small reddish or purplish veins located just beneath the skin surface measuring 1 to 3 mm in width. Also called telangiectasias, they can be limited to a few areas or occur extensively on any part of the legs, or other areas of the body. Reticular veins are blue-green in color and are slightly larger than spider veins and can often be seen connecting to a cluster of spider veins. Varicose veins are larger, dilated veins that often bulge from the skin surface.


Spider veins and varicose veins are not normal. In fact, their presence frequently indicates a problem with the larger veins beneath the skin surface called the superficial veins. The largest superficial vein runs from the groin to the ankle and is called the great saphenous vein. The small saphenous vein runs from the back of the knee down the leg. These veins contain valves that help direct blood upward toward the heart. When the veins become stretched or the valves are damaged, blood moves backward – a condition known as reflux or venous insufficiency. This back pressure leads to bulging varicose or spider veins.

Often reflux is accompanied by a constellation of symptoms including leg pain, achiness, heaviness, fatigue, itchiness or restlessness. Typically the symptoms progress over the course of the day, particularly with periods of prolonged standing or inactivity. When untreated, chronic venous insufficiency can lead to significant disability. Sluggish blood flow in these superficial veins and varicosities can cause localized blood clots to form with tender areas of inflammation referred to as thrombophlebitis. Increased venous pressure also can lead to skin erosion or chronic wounds.



Treatment begins with a thorough evaluation. Vein disease can range from small, unsightly spider veins to painful, disfiguring and debilitating varicose veins, or even bleeding or skin breakdown. Regardless of the severity, the treatment goals are similar: to reduce the symptoms and longterm sequelae associated with chronic venous insuffciency and to make the legs appear as beautiful as possible.

Your initial consultation usually takes about an hour and includes a thorough medical history and physical exam. In all patients, it is essential to look beneath the skin to assess the blood flow in the superficial veins of the legs. This exam is performed painlessly with color duplex ultrasound and makes it possible to determine the source of the abnormal visible veins on the surface. This roadmap is critical at directing treatment for varicose and spider veins.



Sclerotherapy involves the injection of a solution called a sclerosant into the visible spider or varicose veins of the legs. The veins are visualized under special polarized light and a tiny needle is placed allowing the solution to fill the veins. The sclerosant irritates the vein lining causing the vein to collapse and be reabsorbed by the body over time.

Each treatment session concentrates on a specific area of the leg, and usually several treatment sessions are planned depending on the extent of the abnormal veins. Patients are asked to wear compressive stocking for a few days after treatment. All normal activities can be resumed after treatment.



Sclerotherapy alone does not provide long-lasting results when the abnormal veins are due to back pressure caused by venous insufficiency. If ultrasound examination shows significant backflow (reflux) in the veins beneath the surface, it is essential to treat this root cause.

Endovenous ablation has revolutionized this treatment making it possible to close off the abnormal vein under local anesthesia in the office setting. Under ultrasound guidance, a catheter is placed into the abnormal vein and radiofrequency or laser energy is used to heat the vein to make it seal shut. Over the course of several months, the body reabsorbs the vein and it disappears.

Compression stockings are worn initially, and patients can resume most normal activities immediately after the procedure.


Larger, bulging veins are sometimes best treated by direct removal instead of sclerotherapy. Often at the same time as endovenous ablation, the larger veins are directly removed through tiny nicks in the skin, hence the term “microphlebectomy.” The small incisions usually do not require stitches and the marks from the skin nicks fade in a few months.