Phlebectomy – Ambulatory and Micropuncture

What does the word “Phlebectomy” mean?   The word comes from combining the following Greek words.

  • “phleb-” or “phlebo-“:  meaning “vein” (from the greek verb “phlein” meaning “to flow)
  • “ek”:  meaning “out of, away from”
  • “tome”: meaning “cutting”

Phlebectomy literally means “cutting out vein”, or “removing vein”  (Pronounced: Flee•bek•to•mee) and is used to treat phlebitis.

At Advanced Vein Care Center, we perform phlebectomy on an outpatient basis with local anesthetic which is sufficient. Phlebectomy is performed through a small 1 mm to 3 mm needle punctures in the skin rather than the traditional half-inch to one inch scalpel incisions for veins stripping, hence the term, “Ambulatory Micropuncture Phlebectomy.”    After removing larger varicose veins, the puncture marks are so small, they do not require stitches.  Our phlebectomy scars are barely visible for some people, and for others, they blend in with their natural skin freckles.  They are noticeable only on patients who have pale skin color with no freckles or skin pigmentation.

It is very important to note that Ambulatory Phlebectomy is a supplemental procedure to EVLT.  Varicose veins on the skin surface arise from an underlying vein source that is refluxing.  In other words, varicose veins that are treated by phlebectomy are only the surface manifestation of an underlying venous insufficiency.  As such, it does not make sense to simply remove the varicose veins without treating the underlyling refluxing veins.  For this reason, most insurance companies cover ambulatory phlebectomy only after the EVLT procedure is performed.  Therefore, ambulatory phlebectomy should be considered as an associated procedure to EVLT.  And as one might expect, the benefits and risks of ambulatory phlebectomy are very similar to those of EVLT.

Ambulatory Micropuncture Phlebectomy: Questions & Answers

No.  Only those patients who have bumpy veins that ‘stick out’ on the skin require phlebectomy.

Phlebectomy requires total focus and concentration on the part of the surgeon while utilizing fine-tip instruments through the micropuncture skin opening.  Usually only 10 to 20 vein segments can be removed at a time, in one-hour sessions.  Some patients have a “plethora of veins” on their leg requiring more than one session.  This will be determined during your office visit when you get to tell Dr. Lee the extent to which you want your veins removed, and that will determine the treatment sessions it will take to remove your veins.

In Advanced Vein Care Center, our surgical physician assistant, Ryan MacDonald PA-C, performs most Phlebectomy procedures.  He possesses the expertise to perform this procedure in our office, while Dr. Lee mostly performs EVLT procedures.

Usually we try to schedule phlebectomy within days after EVLT, so that everything on your leg is completed within a week if possible, even if more than one phlebectomy session is required.

Before the removal of veins starts, the skin and the subcutaneous tissue over the vein will be anesthetized with a local anesthetic infusion.  This part will cause transient, mild pain as all local anesthetic injections do.  But this will render the skin and the vein painless during the rest of the procedure.  So, the removal of the vein itself does not hurt.

The vein that is removed will not come back, but there is always a chance that other veins might appear on the skin because of recurrence of other predisposed refluxing veins.

Generally speaking, most patients report that recovery pain after phlebectomy is less than that after EVLT. This may be difficult to say because most phlebectomy is done within days after EVLT. Some patients say that recovery pain after phlebectomy was more than that after EVLT. Even so, pain after phlebectomy is mostly that of mild discomfort, and sometimes, moderate. On average, however, it is less than that after EVLT (see the Q&A on this topoic in EVLT section).

For almost all patients, phlebectomy is performed within days after EVLT, and the answer to this question is the same as that given for EVLT procedure (see the Q&A on this topoic in EVLT section).  Generally speaking, the day after phlebectomy, most patients can return to work, even to a moderately strenuous activity, wearing compression stockings.

Before, During, and After Questions & Answers

Before the Procedure: Preparation

We do not recommend that you drive yourself to and from your Phlebectomy appointment. Because the procedure involves your leg which may be required for driving, we cannot be responsible for your welfare if you drive yourself.

However, some patients have taken that responsibility to drive themselves to and from their Phlebectomy appointment. If you intend to do so, we advise the following:

  • If your leg is in significant pain following the Endovenous Laser Treatment, do not drive.
  • If your driving is potentially impaired by significant pain and discomfort in your leg or by the use of compression stockings following the initial procedure, do not drive.
  • If you have chosen to take the sedative (Ativan) and therefore your driving is potentially impaired, do not drive.
  • If you are currently using any narcotic pain medication (oxycodone, Percocet, or Tylenol #3, or other opioid medication: check with your pharmacist), do not drive.
  • If you have any other condition or circumstance that might impair your ability to drive, please do not drive yourself.

We have prescribed the same sedative, Ativan (Lorazepam) 0.5 mg tablets. You may choose to take it if you feel you need the anti-anxiety effects on the night before and on the day of the procedure. (In such a case, you need someone to drive you to and from the procedure.) Or, you may choose not to take the medication if you decide after the initial procedure that you did not need it after all. This is entirely up to you.

Yes. Same principles apply as with preparation for EVLT (see the Q&A on this topic in EVLT section).

Two hours before your procedure, you should apply the prescribed EMLA cream to the area of the leg where there are visible varicose veins that are planned to be removed. This may be only in the calf, or both in the thigh and the calf, but you should apply the cream only to the area of targeted varicose veins.  Again, you should only use up to about one tube of cream to the leg, not more.

As is the case with the initial procedure, the purpose of EMLA cream is to “dull the skin to decrease discomfort during the procedure. While it is not expected to render the leg completely numb, it will make the skin slightly less sensitive to injections and manipulation of the vein during removal.

Simply remove the bulky gauze dressing/tape and proceed to apply the EMLA cream in the area of varicose veins.

If your Phlebectomy appointment is more than 36 to 48 hours after EVLT, then yes. If you Phlebectomy appointment is less than 36 to 48 hours after EVLT, you can take a quick shower 2 hours before the appointment. Take shower with the gauze dressing/tape still on your leg as you try to avoid any direct splash of water on the affected area of the leg. Then remove the wet gauze/tape. Apply the EMLA cream as instructed, and come to the appointment.

IBUPROFEN. Following the initial Endovenous Laser Treatment, you may be already taking the anti-inflammatory medication, Ibuprofen. Continue to take them if that is the case. Even if you have not, however, please begin taking Ibuprofen 600mg tablets as prescribed two days before the upcoming procedure, Phlebectomy. Taking anti-inflammatory medications prior to a procedure has been found to decrease post-procedural pain and discomfort in other surgical procedures. Be sure to take the medication with meals.

If you have a prior history of inability to take over-the counter anti-inflammatory medications because of stomach ulcer or reflux condition, please let us know. If you have a kidney condition or are prone to inadequate kidney function, or if you are aged 65 years or greater, also let us know. If these cases apply to you, you may take Extra Strength Tylenol instead. If you have a liver condition, do not take Tylenol.  Please consult with us.

If you are taking a “baby-aspirin” daily as part of your usual regimen, you should stop taking them for the days you are taking the anti-inflammatory medications. You should also stop taking Vitamin E pills, herbal or home remedies. Multivitamin pills are okay. If you have any question on these points, please call us.

Yes, this is an absolute requirement. Coumadin should be stopped 5 days prior to Phlebectomy. However, you need to consult with Dr. Lee about Coumadin prior to stopping them. If there is any question about this, please call us immediately.

Phlebectomy CANNOT be performed if your blood is still anti-coagulated on Coumadin.

Similar issues apply to other blood thinners such as Plavix, Pradaxa, etc. You must consult with Dr. Lee and also your cardiologist and/or PCP regarding whether you should, or how many days prior to the procedure to stop your blood thinners. Please call us immediately if there is any question on this matter prior to Phlebectomy.

Daily low-dose aspirin:  While we have performed Phlebectomy safely on patients with daily aspirin regimen, we prefer that this be stopped for at least 10 days prior to the Phlebectomy procedure.

For Phlebectomy, you do not have to abstain from caffeine-containing food and drinks. (Contrary to before EVLT).

Please remember to bring your thigh-high compression stockings as prescribed with you on the day of the procedure. Bring your compression stockings to all appointments. If you have a problem obtaining them prior to the procedure, be sure to let us know beforehand.

Bring loose clothing to the procedure and remove all foot/toe jewelry because these steps make the task of undressing and dressing in the procedure room much easier. Also bring an extra pair of underwear because sometimes the sterile solutions used to prep the groin area can stain or wet the underwear.

During the Procedure

Yes. We have two Restrooms for the patients you can use as soon as you arrive in our office so you do not delay your appointment time.

We do not allow someone to stay in the room with the patient because our experience has been that, despite their best intention, their presence in the room distracts from the focus and the flow of the procedure.  In special circumstances where their presence is absolutely required, we make an exception, but not commonly.

Yes, you may bring your own music on your iPod or a similar device for your private listening. However, we have a wonderful In-Room Wi-Fi on-demand music system, and you will be able to choose your own music from either Pandora or our iTune library.

You can bring iPad, Kindle, or even a paperback. During the EVLT procedure, our patients have been known to do all kinds of parallel activities, including Googling on their iPad, internet shopping, reading an e-Book, even catching up on their office e-mails, texting or Tweeting.  One patient even studied for her state licensure exam during our procedure. (She passed 3 days later.)

A medical assistant will bring you into the procedure room.  You should use the Restroom while in the waiting room beforehand. Patient takes off the pants/dress, shoes and socks, and puts on a gown over whatever clothing is comfortable for your upper body and the underwear.

A medical assistant will instruct you to stand on your feet for prolonged period of time before the procedure starts.  This is in order for your varicose veins (small and large) to enlarge as much as possible so that we can see it readily to mark them for removal.  You should bring reading material to keep you occupied during this time. After 5-15 minutes of standing on your feet, a medical assistant will return and discuss with you to mark the areas of the leg to be treated.

Our surgical physician assistant, Marianne Langlois, PA-C, will then come in, ask questions to update and confirm clinical information as needed, and proceed with the procedure.

The procedure itself consists of:

  • Sterile prepping and draping of the treatment leg.
  • Injecting local anesthetic to the skin and subcutaneous tissue directly over the varicose veins that are to be removed.
  • Removal of varicose veins that are marked.
  • Afterward, your treated leg will be cleaned and bandaged, and you will receive verbal instructions on post-procedure care.  You will continue the same pain medication as given for EVLT. The subsequent appointments will also be confirmed with you at this time.
  • And you will walk out of the room to your friend or family who is awaiting to drive you home.

After Procedure Care

Four days. After Phlebectomy, your treated leg will be placed in the compression stocking. This must stay clean and dry. Wear the compression stockings for 24 hours continuously. Afterwards, you can take off CS at night and wear only during the day, for additional three days independent of After Care instructions following EVLT. After four days of CS following Phlebectomy, follow the guideline set forth above for After Care instructions for EVLT.

At any point after the EVLT procedure, if wearing the CS causes one of the following “problems,” then CS should be removed and worn again only if the problems disappear. They are:

  • Numbness/tingling of toes, foot/ankle, or any part of lower leg
  • Skin blisters, or skin discoloration or pressure marks
  • Severe focal pain in the toes, foot/ankle, heel, or any part of lower leg
  • Undue difficulty or complications of arthritic pain in other areas incurred while donning and doffing the stockings with physical hardship
  • Other problems (call us with concerns…)

We believe that wearing the compression stockings following the procedure helpful, but it is to be considered in the context of the overall post-procedural experience of discomfort.

A small amount of oozing (a stamp size or up to two-inch sized blood stain) is normal. You do not need to replace the gauze with stained blood.

More moderate bleeding (larger than two inch sized staining) may require additional gauze. First, simply add additional gauze pad on top of the existing gauze pad and tape them on the wound(s) tightly.  (Avoid total circumferential taping of the leg.) Second, raise your leg more than 45 degrees with pillows or lie on the floor with leg elevated against the wall. Third, put direct pressure over the area. Fourth, you may call our office if the oozing does not stop. Most important is to elevate your leg at more than 45 degrees (straight vertical against a wall if need to), so that the gravitational pressure empties blood out of the vein while the blood gets a chance to clot under direct manual pressure.

Very rarely, when you stand up, you may encounter bleeding from one or more areas of Phlebectomy that soaks through the gauze requiring multiple dressing replacements and sometimes the bleeding does not stop. Do not panic. Take the following steps.

  1.  Simply resume recumbent (lying down) position.
  2. Elevate your leg to a 45-degree to 90-degree angle position on multiple pillows or against a wall.
  3. Reapply a bulky pressure-dressing directly over the area of bleeding and hold pressure manually for ten to twenty minutes.  You can do this even over the compression stockings when removal of the stockings may be cumbersome.
  4. After ten to twenty minutes, stand up again to see if the bleeding has stopped.   If it has not, then change the dressing and simply repeat the steps.
  5. If the bleeding continues despite repeated attempts of twice or more then please call our office or go to the nearest emergency department.  To be sure, the chance of this occurrence is rare, but it is a potential possibility.

At the end of the first 36-48 hours, you may shower. Same instructions as following EVLT apply. Do not remove steri-strips; they will fall off gradually. Do not scrub over steri-strips when showering. After showering, pat the steri-strips areas dry with a clean towel.

Sometimes, you may notice a “hard knot” in the area of Phlebectomy. Do not be alarmed. This is just a small hematoma in the phlebectomy wound, and this will begin to soften in 6-10 weeks and will be absorbed by the body eventually and become soft.

Generally speaking, the spider veins remain after EVLT and Phlebectomy and will require Sclerotherapy.  (See the section on Sclerotherapy.) While sclerotherapy of varicose veins (‘bumpy’ veins) is sometimes covered by insurance, sclerotherapy of spider veins (small blue/purple/red veins) is not usually covered by insurance.

Importantly, if you wish to undergo cosmetic treatment of your spider veins, please let us know at the end of your Phlebectomy appointment, so that we can make an arrangement to schedule your Sclerotherapy treatment so that you do not have to pay for a separate consultation fee.

Avoid exposure to the sun during the two weeks following the procedure. Afterward, you should wear high-SPF sunscreens with ingredients that block both ultraviolet-A rays and ultraviolet-B rays in the sun light.

In practical terms, you should wear sunscreen products with SPF-50 (which blocks 97% of ultraviolet-B rays), and with ingredients that also help to block ultraviolet-A rays (e.g., zinc oxide, titanium dioxide, avobenzone, ecamsule, and oxybenzne). Such sunscreens usually are labeled “multi-spectrum,” “broad spectrum,” or “UVA/UVB protection.”   Even better would be to wear capri pants under the sun.

The rest are the same as for AFTER-Endovenous Laser Treatment in terms of the following:

  • Pain management
  • Return to work
  • Return to activity and exercise
  • Concerns about bruising and redness
  • Travel by car or airplane for prolonged periods

Contact Us

We look forward to answering any remaining questions you may have about vein removal and ambulatory phlebectomy. Our friendly and informed Springfield, MA office can be reached by phone at 413.732.4242 or fill out the form below.