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 small 1–3 mm needle punctures in the skin, rather than the traditional 12.7–25.4 mm scalpel incisions for vein stripping, hence the term “ambulatory micropuncture phlebectomy.” In our practice, we refer to this as ambulatory phlebectomy or AP.
After removing larger varicose veins, the puncture marks are so small, they do not require stitches. 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 are very pale with no freckles or skin pigmentation.
It is very important to note that AP 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 underlying refluxing veins. For this reason, most insurance companies cover AP only after the EVLT procedure is performed. Therefore, phlebectomy should be considered as an associated procedure to EVLT. And as one might expect, the benefits and risks of AP 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 clinician while using fine-tip instruments through the micropuncture skin opening. Usually only 10–20 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 tell Dr. Lee the extent to which you want your veins removed, and that will determine how many treatment sessions it will take to remove your veins.
At Advanced Vein Care Center, our experienced surgical physician assistant or surgical nurse practitioner performs most phlebectomy procedures, while Dr. Lee performs most 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 AP is less than that after EVLT. This is difficult to say because most phlebectomy procedures are done within days of EVLT procedures. Other patients say that recovery pain after phlebectomy is more than that of EVLT. Even so, pain after AP is usually only mild to moderate discomfort. On average, however, it is less than that after EVLT (see the Q&A on this topic in the 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. While the AP procedure will not impair your ability to walk, the local anesthetics and wrapping of your leg make it best not to drive immediately after the procedure.
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 48 hours after EVLT, then yes. If your appointment is less than 48 hours after EVLT, you can take a quick shower two hours before the appointment. Shower with the gauze dressing/tape still on your leg and 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.
We recommend ibuprofen. Following the initial endovenous laser treatment, you may already be taking this anti-inflammatory medication, which you can continue.
Please let us know if you:
- Have a prior history of inability to take over-the counter anti-inflammatory medication because of a stomach ulcer or reflux condition.
- Have a kidney condition or are prone to inadequate kidney function.
- Are age 65+.
- Have a liver condition. Do not take Tylenol (acetaminophen).
If you are taking “baby-aspirin” daily as part of your usual regimen, you should stop taking this medicine for the days you are taking the anti-inflammatory medication. You should also stop taking vitamin E pills, herbal or home remedies. Multivitamins are okay. If you have any questions 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. If you have any questions about this, please call us immediately.
AP 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 stop taking your blood thinners, and if so, for how many days prior to the procedure. Please call us immediately if there is any question on this matter.
Daily low-dose aspirin: While we have performed AP safely on patients on a 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 phone or a similar device to listen to music. 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 iTunes library.
You can bring your iPad, Kindle or even a book. During the EVLT procedure, our patients have been known to do all kinds of parallel activities, including online shopping, reading a book, catching up on their office e-mails, texting or tweeting. One patient even studied for her state licensure exam during our procedure. (She passed the exam three days later.)
Use the restroom while in the waiting room before your appointment. A medical assistant will bring you into the procedure room. You will undress from the waist down except for underwear.
The medical assistant will instruct you to stand on your feet for a 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 them readily to mark for removal. You should bring reading material or music to listen to keep you occupied during this time. After 5–15 minutes of standing on your feet, the medical assistant will return to discuss the procedure and mark the areas of the leg to be treated.
Our surgical physician assistant or nurse practitioner 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.
When I stood up, there was enough oozing that it soaked right through the gauze pad and stained the compression stockings.
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.
- Simply resume recumbent (lying down) position.
- Elevate your leg to a 45-degree to 90-degree angle position on multiple pillows or against a wall.
- 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.
- 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.
- 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 48 hours, you may shower. The same instructions as following EVLT apply to after your phlebectomy. Do not remove steri-strips; they will fall off gradually. Do not scrub over the steri-strips when showering. Avoid water directly hitting the incision areas. After showering, pat the steri-strips 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
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.