The Women's Journal

Spider Vein Treatment: A Three-Tier Approach

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Nadiv ShapiraBy Nadiv Shapira, MD, FACS, FACPh

Many patients with Spider veins expect that a few injections will cure them. But even though they may look innocuous, Spider veins are often indicative of venous insufficiency in deeper and larger veins. Venous Insufficiency results from defective valves within the veins allowing blood to flow backward, pool inside and distend them. For this reason, the underlying problem contributing to spider veins must be addressed first. Ultrasound examination should often be done to rule this out.

Venous insufficiency at different levels my cause spider veins!

Tier I.  Spider Veins (SV’s) – red / purple / blue fine lines appearing in starburst-like or web-like clusters at the surface of the skin, 1.2mm in diameter or less. Usually caused by venous insufficiency involving deeper veins.

Tier II. Reticular Veins (RV’s) – larger (1.5-2.5mm) blue/purple veins located beneath the skin. They may protrude and form areas of unattractive bulging clusters. SV’s are usually associated with incompetent RV’s. RV’s may be indicative of deeper vein’s insufficiency.

Tier III.  Deeper vein insufficiency may involve the great saphenous vein, small saphenous vein, accessory saphenous veins and/or perforating veins. They often result in varicose veins (enlarged, swollen, bulging, rope-like veins that occur on the surface of the legs).

Treatment tailored to the tier!

Treatment options ( office procedures done under local anesthesia with no “down time”):

1. Sclerotherapy – injection of SV’s with a chemical solution (sclerosant) which causes inflammation, makes the walls of the veins stick together, scar up and eventually reabsorbed. Ideal for 0.8-1.2mm spider veins.

2.  Ohmic Thermolysis (“VeinGogh”) – relatively new, done by placing a tiny needle and focusing heat energy (radio frequency) on the SV. Best for purplish SV’s 0.8mm or smaller.

3. Intense Pulsed Light (IPL) – Effective for smaller veins in fair skin types and new tiny veins formed around treated areas.

When underlying venous insufficiency is not found (tier I), a combination of 1-3 modalities hastens and improves the resolution and the cosmetic results.

4.  Foam Sclerotherapy – Foam is made by mixing a sclerosant with C02. Applicable for sclerotherapy of RV’s.

5.  Mini-Phlebectomy – Since sclerotherapy of bulging RV’s or SV’s may cause an unsightly staining, mini-phlebectomy (a delicate surgical removal of these bulging small veins) is the preferred treatment for these.

6.  Endo Venous Laser Ablation – closure of incompetent tier III veins from the inside by heat emitted from a small laser fiber.

7.  Ultrasound Guided Sclerotherapy – applicable for closure of incompetent perforating veins.

When underlying venous insufficiency is found (Tier II or III), treatment by modality #4,5,6 and/or 7 is done before addressing cosmetic concerns.


Dr. Shapira, who is a very personable man, took the time to thoroughly explain the entire procedure and reassured me of the benefits of proceeding with it.  The procedure was quick, painless and without complication.  Finally, I have the much-needed relief from the discomfort I had been living with for so long thanks to Dr. Shapira and his wonderful staff.    – Alinda R. S.

I have worked as a flight attendant for many years and was at the point where my legs ached every time I went to work. My ankles were always puffy and my legs discolored due to unhealthy veins.  Dr. Shapira carefully evaluated my condition and explained what my treatment options were as well as what I could expect. Supported by an extremely caring and compassionate team, Dr. Shapira has gently and affectively treated my condition. My legs no longer ache, they don’t feel full and heavy, my ankles are much less puffy, a great deal of the discoloration is gone or reduced and they generally look and feel much healthier. I can’t thank Dr. Shapira and his staff enough for all of their care.   -Jodi P.

Nadiv Shapira, MD, FACS, FACPh, an adult cardiac and thoracic surgeon for over 20 years in the Christiana Care Health System, DE recognized the need for improvement in the care of venous disease.  He recently established First State Vein and Laser Spa, utilizing minimally invasive treatment modalities for all forms of venous diseases, including spider veins, large and small varicose veins, leg swelling and skin ulcerations. He is a diplomat of the American Boards of Surgery and Thoracic Surgery, fellow in the American College of Surgeons, the Society for Thoracic Surgery and the American College of Phlebology. He is a member of Vein Affiliates and Vein Experts.