Phlebectomy: What You Need to Know

Phlebectomy is not a first-line treatment for all varicose veins.

The procedure is usually performed on large, ropey veins that likely won’t respond to sclerotherapy, a noninvasive treatment that works by injecting an irritating chemical into a vein, causing it to collapse, explains Dr. Ramandeep Sidhu, a vascular surgeon in Seattle and medical director of Vein, Vascular & Aesthetic Associates (VIVAA). “In my practice, if the veins are too big and we know sclerotherapy either wouldn’t work or would require too many sessions, then stab phlebectomy would be ideal.” 

The term varicose means abnormally swollen or dilated, and superficial veins become this way when the blood pressure inside increases. 

Veins have one-way valves inside of them that open and close to keep blood flowing toward the heart. If the valves become weakened or damaged, some of the blood flows in the wrong direction (towards the feet) and pools in the veins there. The backflow of blood is known as venous reflux or venous insufficiency. Left untreated, this pooling puts excess pressure on the veins and leads to their expansion and the appearance of bulging veins, along with symptoms associated with them. 

Your provider will determine if venous reflux is the root cause of your varicose veins via duplex ultrasound. This technology shows a detailed picture of the venous network of your legs, helping your provider detect the source of the problem and determine the type of treatment that best suits your condition. 

For instance, malfunctioning valves in the great saphenous vein (GSV), the long vein that runs from the ankle bone along the inside of the leg, are a common culprit. The high pressure and blood flow reversal in this vein can damage the normally small tributary veins near the skin's surface and cause them to bulge. Without first shutting down this source of reflux, treatments like this one are likely to fail and result in new varicose veins.

Moderately bulging veins can sometimes occur without any underlying venous reflux. In these cases, your vein doctor can treat these veins alone with procedures like a microphlebectomy.

Sometimes, phlebectomy is performed after a laser or radiofrequency treatment (like radiofrequency ablation) is used to shut down the GSV. While treating the GSV can provide a dramatic improvement, sclerotherapy or phlebectomy is often needed to fully treat other damaged veins.

Pros

• This vein procedure provides immediate cosmetic results and eliminates symptoms associated with the removed varicose vein. Removing the malfunctioning vein reroutes the blood to other healthy veins.
• An ambulatory phlebectomy procedure is usually performed in a doctor’s office under local anesthesia.
• While this is technically surgery, it's not an invasive procedure. It’s performed through very small incisions and involves minimal discomfort and downtime. Most people return to work and normal activities the day after their procedure. 
• It’s considered safe for most people in good health. 
• Complications are rare.
• If the procedure is deemed medically necessary (not just cosmetic), it may be covered by your medical insurance.

Cons

• New vein problems can crop up over time, so additional treatments may be necessary. 
• The procedure leaves small but permanent scars.
• Like other varicose vein treatments, this one isn’t likely to be successful when other leg veins aren’t working well. It’s important for your provider to treat venous reflux prior to a phlebectomy.
• Possible complications include short-term skin color change, infection, pain, and the creation of spider veins.

Good candidates include “anyone who has venous reflux that’s been addressed and has large ropey veins, where sclerotherapy is not ideal,” says Dr. Sidhu. 

It may not be an appropriate choice if you suffer from certain health conditions, such as blood clotting disorders.

When performed for appropriate indications, the procedure has a long-term success rate of 90% or greater.

The procedure itself is performed under local anesthesia, sometimes with light sedation, so you won’t feel any pain or discomfort during the procedure. 

The anesthetic is given through a series of small injections around the veins that are being removed. These injections may sting or feel hot or cold, or like a strange sensation, depending on the area of the leg being treated. 

You may feel some tugging or pressure while the veins are being removed, but the procedure is virtually pain-free.

Ambulatory phlebectomy is usually performed in the office under local anesthesia, so you’ll be awake and alert during the surgery. The procedure will take 30 minutes to two hours, depending on the number and complexity of the areas being treated. 

While you stand up, your doctor will mark the veins to be removed with a pen. You’ll then lie on a table in a position that allows the best access to the treatment area, which will be numbed with a local anesthetic. 

The surgeon makes several small incisions (1–3 mm) along the vein and inserts a phlebectomy hook (which resembles a sharp crochet hook) under the surface of the skin to gently tease out the vein through the tiny incisions. 

Depending on the size of the veins, anywhere from three to four micro-incisions may be necessary.

Once the veins are removed, blood flow will naturally redirect to surrounding healthy veins.

The tiny incision sites are typically closed with surgical glue or Steri-Strip bandages. In rare cases where large veins are removed or the patient is in on blood thinners and more prone to bleeding, they will be closed with sutures.

After the procedure, your leg will be wrapped in a compression bandage, or you can wear compression stockings over the dressing. “We typically leave the compression on for 48 hours. Then the patient can shower and continue with compression for two weeks at least,” Dr. Sidhu explains. Compression encourages healthy blood flow and prevents fluid build-up as you heal.

The procedure involves minimal downtime: the majority of patients returning to work and regular daily activities the day after the procedure.

Most discomfort can be managed through ice packs and over-the-counter medication like ibuprofen. 

“There are no significant limitations except that you have to wear medical-grade compression stockings and try to avoid doing any activity that results in a lot of sweating,” says Dr. Sidhu. 

Strenuous activities, including exercise, will be limited for about two weeks.

Your provider will likely ask you to schedule a follow-up appointment after 10–14 days, to ensure you're healing well.

The results are seen right away, but there can be a lot of bruising for a few weeks after the procedure. “For perfect results, you have to wait for complete healing of the stabs,” says Dr. Sidhu.

Once the damaged veins are removed, they’re gone forever. 

Just be aware that new veins in the general vicinity may enlarge over time. “Vein disease is genetic, so there’s a good chance that you may develop additional vein issues in the future,” says Dr. Thomas Wright, a venous and lymphatic medicine specialist in Fallon, Missouri. 

Other factors that increase the risk that varicose veins will develop and return after treatment:

• Age. Bulging veins usually develop after the age of 30 and become progressively worse over time.
• Gender. Women are more likely than men to develop them. This is often related to hormonal differences, and the risk can increase with pregnancy, the use of birth control pills, and hormone replacement therapy.
• Obesity. The stress placed on the body by extra weight can put additional pressure on the leg veins.
• Prolonged standing. Occupations that require prolonged standing may increase your risk, especially if you have other predisposing factors.

Exercising, losing weight, and wearing compression stockings can help prevent recurrences.

This is a very safe procedure, and serious complications are extremely rare.

Like all surgical procedures, it carries a small risk of temporary side effects, including an allergic reaction to the local anesthetic, numbness, inflammation, bruising, and infection.

Occasionally, a blood clot can develop after the procedure. It usually causes a tender, swollen, red area under the skin. Redness typically resolves after a week, while lumpiness can linger for several months. 

Because the blood clot is located in a superficial vein, it rarely lead to serious or life-threatening complications, but be sure to report any concerning side effects to your provider.

“There will be permanent scars at each and every stab site,” reports Dr. Sidhu. “For those who don’t do the procedures for aesthetic reasons the scars might not matter, but they are seen forever.” 

The good news: the incisions and the scars they leave are very small: 2–3 mm. Initially, they look like tiny red scabs, and over time, they often heal to a point of near invisibility.

If you’re prone to scarring, limit exposure to the sun, which can increase hyperpigmentation and make scars more visible. 

Talk to your provider about scar treatment products like silicone gels or sheeting, to help speed healing and minimize scarring.

This vein surgery can be performed by a number of specialists, including:

• Vascular surgeons, who manage veins and arteries in every part of the body except the brain and the heart. 
• Phlebologists, who specialize in diagnosing and treating vein conditions.Interventional radiologists. In interventional radiology (also called IR), doctors use medical imaging to diagnose conditions in arteries and veins and then treat them using minimally invasive techniques.
• Dermatologists, who specialize in the medical and surgical care of the skin, hair, and nails.

The underlying condition that causes varicose veins is progressive, so it’s best to speak with a vein specialist who can carefully evaluate your veins and discuss all of your treatment options.

Vein stripping is an old-school technique that’s rarely done anymore, since there are better, less-invasive options for most patients, including laser treatment like endovenous laser ablation (EVLT). 

Vein stripping is used to remove the great saphenous vein (GSV), the long vein that runs from the anklebone along the inside of the leg and thigh. 

The procedure usually takes about 60 to 90 minutes, and it's both more invasive than a phlebectomy and more expensive. You may receive either general anesthesia, in which you will be asleep and unable to feel pain, or spinal anesthesia, which will make the lower half of your body feel numb.

During the procedure, the surgeon makes small incisions near the top and bottom of the damaged vein. A thin, flexible plastic wire is then inserted into the vein through the top incision, tied to the vein, and then pulled out through the bottom incision. The incision is then closed with stitches. 

Patients are usually able to return home the same day, but you'll need several days of downtime and up to four weeks to fully recover from vein stripping surgery.

This procedure may be covered by health insurance. “It depends on the insurance company, but some providers do consider treatment of varicose veins as medically necessary,” says Dr. Sidhu. 

Medicare also covers some of the costs of vein treatment like ambulatory phlebectomy if varicose veins are causing health issues.

If your provider can't provide documentation showing that the procedure is medically necessary, you'll need to pay out of pocket, as with other cosmetic treatments.