Varicose Vein Treatments

Varicose vein treatments in the 21st century

Treatment of varicose veins is undergoing major change. During the 20th century varicose veins were treated by either conventional surgery or sclerotherapy. The types of surgery, involving sapheno-femoral ligation or short saphenous ligation, with or without stripping and phlebectomies, has changed little for the best part of 100 years. Sclerotherapy was introduced about 50 years ago and although there was some early enthusiasm it was found to be associated with a high recurrence rate. It remains the best treatment for thread veins.

Recently, the widespread use of duplex ultrasound to thoroughly assess both the deep and superficial venous systems has provided a more focused approach to treatment, as well as the possibility of less traumatic and less invasive ways of treating varicose veins.

Investigations

If varicose veins are causing worry or troublesome symptoms then assessment by a vascular specialist is recommended. A careful medical history and direct examination of the legs is necessary. Duplex ultrasound is now used to more accurately define the source and details of the varicose veins.

Duplex ultrasound

This is a large complex machine which combines the ability to assess the direction and speed of blood flow, with a direct ultrasound picture of the enlarged veins. This clearly maps the distribution of veins and hence enables the best treatment to be planned.

Surgical treatment ligation and stripping

Your surgeon makes an incision in the groin, or behind the knee, at the top of the main affected vein. This vein is tied off (ligation) and then carefully removed (stripping).

Individual varicose veins are removed using small incisions along the leg. You may sometimes need to stay in hospital overnight after ligation and stripping. Your legs will be bandaged and you will need to wear elastic stockings for three weeks. You will also need to plan time off work, usually one or two weeks and avoid strenuous exercise for several days, although plenty of walking is good for you. You should refrain from driving until you are confident that you can perform an emergency stop without discomfort (this will probably be about 1 week).

The main disadvantages of conventional surgery for varicose veins have been the need for hospital admission, general anaesthesia and the extent of bruising and discomfort post operatively requiring time off work as well as restricted activities. Although considerable efforts have been made to refine surgical as well as anaesthetic techniques to increase the proportion of cases performed in the day unit, nevertheless most surgeons still recommend at least 1-2 weeks off work.

New techniques

New techniques have been developed to treat major incompetent superficial venous trunks (long or short saphenous vein). These fall broadly into three categories. The first uses a laser fibre (EVLA) fed up the main saphenous vein to destroy the inner lining of the vein. The second uses radio frequency energy (VNUS) to achieve a similar objective. The third is rather different and involves a development of conventional injection treatment (ultrasound guided foam sclerotherapy).

EVLA/VNUS

These procedures close the thigh vein without stripping from the body. No groin incision is needed and the operation can be performed under local anaesthetic. A laser (EVLA) or radio-frequency fibre (VNUS) is passed along the abnormal vein under ultrasound guidance and then heated to destroy the vein.

What are the advantages?

  • No scarring
  • No incision in the groin
  • Less bruising
  • Faster recovery
  • Can be done under local anaesthetic
  • No overnight hospital stay needed

What are the drawbacks of EVLA/VNUS

The adverse events have been relatively few. The vein has to be isolated from surrounding tissue which involves injecting about 500 ccs of fluid which can be painful. Occasionally, patients get some redness of the skin of the thigh. Immediately after the operation the vein in the thigh is occasionally felt through the skin like a tender 'cord'. This settles over the course of a few weeks as the inflammation subsides. Rarely, some patients get a feeling of numbness or altered sensation over the vein. In some cases neither EVLA, nor VNUS treatments can be performed because of the tortuosity of the vein preventing passage of the guide wire. In most cases the prominent below knee veins require separate treatment either by surgical removal or foam injection. The treatment is useful for recurrent veins.

Thermal ablation techniques (EVLA and VNUS) are recognised by the National Institute of Clinical Excellence (NICE) as an effective treatment for varicose veins. Long term follow up suggests recurrence rates at least comparable, if not better than, conventional surgery.



Rehabilitation


The medical information provided here is intended solely for patients of the London & Surrey Vascular Clinic, it is general information only and should not be used as a substitute for personal advice received when consulting your own surgeon face-to-face.