Varicose Veins Treatment
Management options for varicose veins in the last few years have changed drastically. In particular we have seen the explosion in endovenous options that permit patients to pursue more minimally invasive options than ever before. Despite this, there is still a role for open surgery in some patients, and some patients are not best treated with endovenous options. Consequently, the vascular surgeon is still best to advise patients on best course of action going forward.
Do I need to have my veins treated?
We very rarely insist that someone needs to have any treatment for varicose veins, but only offer them to you if you find them unpleasant enough or if they cause major problems such as skin staining, ulcers and bleeding. Some people have no symptoms from varicose veins, but others have a wide variety of symptoms from swollen ankles to eczema and ulcers. Compression stockings are an effective alternative treatment.
There are several treatment options for varicose veins, and importantly not one single treatment options is suitable for every single patient. Further, the landscape for the treatment of varicose veins is rapidly evolving with newer techniques being developed with equally rapid pace. Despite this, there are several well established practices in place that consistently produce good results for patients and are well supported by the current medical literature.
Patients may encounter one of several options
- Traditional open surgery (often called high ligation and stripping)
- Radiofrequency ablation (see below)
- Endovenous laser ablation (EVLA)
- Ultrasound guided sclerotherapy
A current Cochrane Review Cochrane Review (Whing 2021) compares the various surgical treatment options available and compares their relative efficacy. The findings can be summarised as follows.
- Laser versus radiofrequency ablation: comparable results at 5 years
- Radiofrequency ablation versus surgery: similar early results, with a potential for better long term benefits.
- Surgery versus sclerotherapy only: surgery generally produces mroe succesful results.
- The primary goal in treating superficial venous insufficiency is closure of refluxing superficial veins, which alleviates symptoms and prevents complications.
- The most proximal point of reflux should be treated first. An additional goal of the treatment of telangiectasias and reticular veins is the attainment of satisfactory cosmetic results.
- Patients with saphenous reflux may also exhibit varicosities, enlarged reticular veins, or telangiectasias. Currently there is debate as to whether adjunctive procedures to treat these varicosities and telangiectasias should be performed at the same time that truncal reflux is eliminated or in a staged fashion.
- The Society for Vascular Surgery (SVS) and the American Venous Forum (AVF) have compiled evidence-based recommendations for the care of patients with chronic venous disease.21 Both EVLA and RFA are considered safe and efficacious and are recommended equally for the treatment of saphenous reflux.
- Both are recommended in preference to open surgery because of reduced convalescence time and a decreased incidence of postprocedural pain and morbidity.
- Liquid or foam sclerotherapy is recommended for the treatment of telangiectasias, reticular veins, and varicose veins.
Radiofrequency Ablation (RFA)
RFA is a modern, minimally invasive treatment option for varicose veins. It involves passing a long catheter into the main vein, and applying controlled heat along its length to allow it to collapse. The catheter and system is named “ClosureFAST”
Generally, the results of RFA are excellent and almost comparable to open surgery. Most people can generally undergo RFA, and this can even be sometimes performed in the rooms.
- The current RFA technology uses the “segmental ablation” method employed by the Venefit procedure using the ClosureFAST catheter. It is designed for treating both the long and short saphenous vein.
- The ClosureFAST catheter is constructed such that it must make direct contact with the vein wall to deliver radiofrequency energy.
- Contraindications to the use of RFA include superficial venous thrombosis (SVT), deep venous thrombosis (DVT), venous aneurysm, and an ankle-brachial index of less than 0.9 (low arterial pressure to the ankle).
Venaseal is another excellent treatment option for varicose veins. Like radio frequency ablation, it is another minimally invasive treatment option. However unlike radiofrequency ablation or endovenous laser ablation it does not use heat. Rather, a glue is injected in the vein to prevent further blood flow within it. Therefore one of its key advantages is to not require cooling fluid to be injected around the vein prior to being heated. Also, compression stockings are generally not required. Results are also excellent and it is a relatively successful procedure.
However, as a downside many patients can palpate the cord like structure in the thigh from the setting of glue. Some patients do not mind, while others are bothered by this. Similarly, in younger patients who may have decades of life yet, the long term viability of the glue is not know and one cannot adequately predict what the glue may do in 40 or 50 years! Thus venaseal seems to be a better option for older patients who cannot tolerate sedation and cannot adequately wear stockings.
Sclerotherapy is a non surgical treatment for varicose veins. Sclerotherapy is used to injure the veins and cause them to become irritated and stick together. This leads to damage of the veins, but in doing so causes them to scar and shrink. The veins eventually disappear altogether.
What do you use for sclerotherapy, and how does it work?
There are different chemicals and substances used for sclerotherapy. Generally these are various substances that are injected directly into the vein under ultrasound guidance as a foam solution.
What are the risks of sclerotherpay?
Why sclerotherapy is generally very safe and very well tolerated, there are some risks to consider.
Ulceration and skin damage
Hyperpigmentation – this is where areas of the skin appear brown and discoloured. One in three people will experience this and it will eventually disappear in most people
Nerve injury – extremely uncommon. This involves nerves being damaged by the injections.
Sometimes people experience chronic pain or burning.
Deep vein thrombosis (DVT) or blood clots.
Extremely rare complications such as stroke and migraine have been reported to happen with large doses of sclerotherapy. We typically use safe doses only to minimise major complications.
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© Sam Farah 2022