By the time Teri Moreno began to consider surgery for her varicose veins, her ankle had swelled to 12 inches in diameter.
She wouldn't have believed it either. But her husband measured it.
Pain from the swelling forced her to sit on a bench instead of playing with her children in the park. She hauled a barstool into the kitchen so she could sit while cooking dinner. She walked around in oversized sneakers, the laces untied.
But the prospect of conventional vein-stripping did not offer a realistic solution for the 38-year-old mother of three, who said she could not afford to spend a week or more recuperating.
"I just learned to deal with it because I was caring for the kids," said Moreno. "I was taking a ton of Advil and Tylenol just to get to sleep."
Until recently, the options were limited for Moreno and the estimated 25 million others who suffer from bulging leg veins that are not dangerous but can be painful.
They could wear support stockings, elevate their legs at the end of the day or go to the hospital for a 100-year-old vein-removal technique called stripping that works but causes pain and difficulty walking while the patient heals.
"How can you tell a young woman to elevate your legs at the end of the day when your toddler is pulling at the stove?" asked Dr. Lori L. Greenwald.
Greenwald, a vascular surgeon with offices in Avon and Manchester, Conn., recently repaired Moreno's veins with one of several new, less invasive procedures that could someday make support hose and stripping obsolete.
The techniques rely on radiofrequency- or laser-generated heat to collapse damaged veins and seal them shut.
Varicose veins should not be confused with spider veins, those thread-like red and blue or purple blood vessels that sometimes appear on the thigh or ankle. Those are usually harmless.
Instead, varicose veins bulge, sometimes appearing like a knotty rope just beneath the surface at the skin. They are caused by defects in the walls of the superficial leg veins, tube-shaped vessels that carry blood from the legs back to the heart.
Blood must fight the force of gravity as it travels up the legs. In healthy veins, tissue-paper-thin valves close behind it, keeping the blood from slipping backward. Varicose veins occur when the valves fail, allowing blood to leak and pool, causing bulging, swelling and often pain.
Heredity is the most common cause of varicose veins, although pregnancy, obesity, weight lifting and long hours of standing also can create or worsen vein problems.
In the past, surgeons removed malfunctioning veins by making incisions along the leg, disconnecting the veins from the body and literally yanking them out. It worked well, but it hurt, and patients often needed to be off their feet for four to seven days and wear support stockings for weeks afterward.
Lasers and radiofrequency heating devices are rapidly replacing stripping. Research shows the less invasive techniques can work well, with less pain or swelling and faster recovery time.
Moreno went to Greenwald's office in February for the radiofrequency technique, known by its trade name, Closure.
With guidance from ultrasound, Greenwald used an indelible marker to map Moreno's damaged veins. After numbing the area with local anesthesia, she punctured a spot on the side of her patient's knee and threaded a catheter through the damaged vein up to the groin.
At the end of the catheter, a small fan of electrodes was heated to 185 degrees. The heat sealed the vein, collapsing its walls and stopping the flow of blood. Deeper veins can easily handle the redirected blood flow, Greenwald said. In time, the destroyed vein shrinks down to scar tissue and is eventually reabsorbed by the body.
Moreno said the procedure was painless, and she walked out of Greenwald's office afterward, drove home to East Windsor, Conn., and cooked dinner -- without the stool. "Forty eight hours after surgery, I had my sneaker on, and I was able to tie it," Moreno said.
"This has really turned a fairly painful procedure into pretty much a piece of cake," Greenwald said.
In the hands of an experienced surgeon, that may be true, said Dr. Gabriel Goren, a vascular surgeon who prefers a less invasive surgical stripping technique that he uses in his Los Angeles office.
He said insurance companies pay surgeons only about $400 for the conventional stripping and may pay $2,000 for radiofrequency or laser treatment. Because it is lucrative and apparently easy to perform, doctors in many specialties are buying the machines.
"That's what I am afraid of: Popularizing it spreads it also into the hands of people who are not equipped to use it," said Goren. "I know of podiatrists who have used it."
Several surgeons who use laser and radiofrequency also caution that large varicose veins still must be surgically removed after they have been collapsed by heat.
But pulling out the flattened vein through a small skin puncture does not increase the pain or recovery time, said Dr. R. Anthony Carabasi III, director of the division of vascular surgery at Thomas Jefferson University School of Medicine in Philadelphia.