This guide aims to provide an in-depth understanding of all the available options for minimally invasive treatment of varicose veins. Treatment options include a range of different techniques, and the guide explains each one step by step. It is hoped that patients will acquire enough information to select the treatment that best suits their needs. The symptoms, causes, and long-term effects of varicose vein will be discussed so that patients can make an informed choice about treatment. This guide is also intended for medical professionals who would like to expand their knowledge in the field.
The decision to treat varicose veins depends not only on the extent and severity of the vein problem but also on how much related symptoms affect a patient’s quality of life. Symptoms vary between individuals and are the principal reasons for treatment. In manyThis guide aims to provide an in-depth understanding of all the available options for minimally invasive treatment of varicose veins. Treatment options include a range of different techniques, and the guide explains each one step by step. cases, symptomatic varicose veins are a chronic medical condition, and it does not mean that they are permanently cured by treatment. Symptoms can recur after treatment, and further treatment may be required. A small proportion of patients will go on to develop more severe problems over time if varicose veins are left untreated. This is because high pressure in the veins, which is the cause of the varicose veins, can also affect the overlying skin, causing dermatitis and, in the long term, skin damage. More rarely, patients can develop phlebitis with painful tender lumps and swollen legs. The most severe form of vein problem can lead to the formation of leg ulcers.
Varicose veins are a common, often hereditary condition, which can cause significant discomfort, not to mention psychological distress for those who live with them. Traditionally, the only means of treating varicose veins was surgery (vein stripping), which necessitated a hospital admission, a general anesthetic, and several weeks off work. In the past 15 years, however, there has been a quiet revolution in the investigation and treatment of vein problems. This has been driven by the development of less invasive methods of treating varicose veins. Most of these new techniques are included in the field of “interventional radiology”. This involves treating the patient under image guidance with X-rays using a catheter (tube which goes inside the body) or, more recently, a probe which emits sound waves. These methods are much less invasive than surgery, and nowadays an estimated 85-90% of varicose vein treatments can be performed using these newer techniques.
Understanding Varicose Veins
This chapter offers a comprehensive understanding of varicose veins, the disease that is being treated. Because it is the nature of people to be more compliant with any treatment when they are well informed of the significance of their disease, this information is seen as an important aspect of the book. Often, health care providers are perceived as not having the time to explain things to patients in a way they can easily understand. The result is a patient who is not very compliant because he does not see the significance of the disease and therefore does not see the reason for getting the often expensive and uncomfortable treatments. This chapter is meant to provide a sufficient understanding for the patient or any health care provider involved in the care to comprehend the significance of their disease. This chapter is also meant to help categorize the different classes of venous disease in a way to enable the selection of the most appropriate treatments for different patients. Most insurance companies require treatments of varicose veins to be medically necessary for coverage. This information could also prove helpful for any health care administrator in justifying the treatments as medically necessary. This can also act as a resource for medical students or residents working in fields involving care for elderly people such as family practice, internal medicine, or pediatrics. Often, the significance of varicose veins in elderly patients is overlooked because the cause is simply thought of as a cosmetic problem which is part of normal aging.
Causes and Risk Factors
Varicose veins are not something that can be compared equally in all people. The majority of those affected will only suffer a mild case, usually causing no more than aching and discomfort. How severe varicose veins become is dependent on many factors and still not completely understood. It is known that varicose veins are more common in women than in men. This is due to hormonal influences in pregnancy and menopause and the fact that females generally have a greater prevalence of weaker vein walls. It has also been shown that multiple pregnancies are a risk factor, with each pregnancy increasing the likelihood of getting varicose veins.
Venous insufficiency – the condition of weak vein walls and valves failing to propel blood flow adequately in the right direction – is the root cause of varicose veins. Normal leg veins have valves that prevent blood from flowing backwards as they move up the leg. If an individual’s vein walls lose their natural elasticity due to age or other influences, the valves become incompetent and allow blood to flow back down the leg. This reverse flow, called venous reflux, causes pooling in the veins, resulting in increased vein pressure. This increased pressure often causes the very same veins to dilate and become varicose. High pressure in a vein commonly causes the vein to bulge, and the increased force on the skin results in the formation of discolored and often painful ulcers on the leg.
Symptoms and Complications
People with varicose veins have an increased incidence of leg deep vein thrombosis compared to the general population. In the past, it was thought that most DVT was a result of propagation of calf vein thrombosis into the deep veins at the level of the knee or below. It is now recognized that most DVT is unrelated to propagation of calf vein thrombosis and that varicose veins associated with obstruction to venous outflow are a risk factor for above knee or common femoral vein DVT. This has important implications for the treatment of DVT in patients with varicose veins. The main concern of varicose vein complications is the development of venous leg ulcers, which affect up to 1% of the population and are costly to the NHS. They cause much patient morbidity with pain, smell, and social disablement.
Complications of varicose veins are less frequent than the symptoms. They are caused by longstanding, severe, untreated varicose veins and include swelling, pigmentation, eczema, lipodermatosclerosis, atrophie blanche, superficial thrombophlebitis, varicose pattern deep vein thrombosis, and leg ulcers. Ankle swelling is a frequent problem, often worse after prolonged standing. Superficial thrombophlebitis is painful and makes repeating bouts of inflammation and phlebitis more likely.
Pain is a common symptom of varicose veins. It is a dull, aching pain which is usually worse after prolonged standing and relieved by rest or by elevating the legs. Throbbing or muscle cramping in the legs, particularly at night, can also occur. In some patients, symptoms may be severe and include muscle aching and burning. Occasionally, the skin over the varicose veins becomes inflamed. More severe inflammation causes phlebitis, which is an indication for medical intervention. In addition to the symptoms, some patients, especially women, are concerned about the cosmetic appearance of bulging varicose veins. Measures of the severity of varicose vein symptoms usually focus on pain, resulting in some discordance between clinical importance and severity categories. Varicose vein symptoms can also cause a great deal of social and economic disruption, for example, lost working days.
Traditional Treatment Options
Surgical procedures have been performed for over 100 years with the aim of removing or occluding the saphenous vein, as well as extirpation of varicosities. Numerous different procedures were described during the last century and have been subject to a Cochrane review. The most recent of which suggests that there is no strong evidence to favor one surgical method over another. The one common theme is that surgery using ligation and/or stripping of the saphenous vein has a high incidence of recurrence rates of >60% at 5 years. Furthermore, the incidence of complications is moderate to high, with reported rates of 4-10% for deep vein thrombosis and 20% for postoperative ecchymosis. Recurrence, usually indicated by the reappearance of visible and symptomatic varicose veins, can range from 25-80% in 3-5 years. This is likely attributable to the fact that surgery does not address the underlying cause of reflux, and most patients with clinical C varicose veins have an incompetence of the saphenofemoral junction. Although recurrence rates show no statistical difference between high tie and below knee stripping, and surgery does improve symptoms, quality of life scores tend to be worse in the varicose vein population undergoing surgery compared to the normal population. This paradox can be explained by the fact that by removing large truncal veins and varicosities, postoperative rates of numbness and tightness are 37% and 24%, and 17% and 19%, respectively.
Several treatment options have been described and are well-established in the management of varicose veins. These include compression therapy, various surgical procedures, and sclerotherapy. The use of compression therapy alone is rarely, if ever, used to treat varicose veins. Conversely, it is generally used as an adjuvant therapy at various stages in the nonsurgical procedures, as well as the mainstay of treatment of superficial thrombophlebitis and prevention of recurrent varicose veins, regardless of the mode of treatment.
Surgical Procedures
Both techniques are often performed together and under general anesthesia, with the patient usually able to go home the same day. Surgery can also be performed on incompetent superficial veins with hook phlebectomy or transcatheter radio-frequency ablation. There is also the option of more invasive surgical techniques for deep vein reflux. Overall, surgical procedures have good success rates for abolishing main vein reflux but are associated with significant morbidity and often slow return to normal activities for the patient. Due to this and much-improved minimally invasive treatments, surgery should be reserved for more severe cases of varicose veins.
Varicose vein surgical procedures have been the mainstay of treatment for many years, and although minimally invasive methods are becoming more popular, surgical procedures are still popular amongst doctors and patients. This may be because of the many surgical techniques that can be employed to treat varicose veins. Surgery can be performed on the main truncal veins with techniques such as ligation and stripping. Ligation is where the saphenous vein at the top of the leg is tied off and divided. EVLT has since become more popular for this. Stripping involves the removal of the vein by threading a special wire through it and then removing the vein by pulling it out.
Sclerotherapy
The only deficit in using Aethoxysklerol and performing this method of sclerotherapy is that it is not practical for larger varicose veins, where the typical result is inflammation caused by the leakage of the solution from the vein and the formation of a solid, lump-like clot. This usually dissolves into the body. For larger veins, the use of ultrasound in conjunction with a needle catheter may be used to guide the injection. This is so the exact location of the solution being injected can be visualized to achieve the best results from the treatment.
This method of sclerotherapy takes longer to perform as the solution is injected slowly, and the vein is ‘milked’ while being visualized to maximize the contact of the solution with the vein wall. Polarized light is used post-treatment to detect any remnants of the injected vein and treat it immediately to avoid any adverse effects. The patient is then required to wear bandages (compression for larger veins) as long as possible post-treatment to maximize the results gained from the procedure.
Sclerotherapy is a well-proven procedure and has been used since the 1930s. Various solutions are used for sclerotherapy. The most common include hypertonic saline and sotradecol. However, these solutions carry a greater risk of skin irritation and hyper-pigmented staining. The most favored solution in current practice is called Aethoxysklerol. It is an anesthetic-based solution, so there is little to no discomfort for the patient during the treatment and minimal discomfort post-treatment. Aethoxysklerol also carries a reduced risk of adverse effects (skin irritation, staining) compared to the previously common solutions.
Sclerotherapy is a common method for treating spider veins and smaller varicose veins. The treatment involves the injection of a solution into the affected veins. The solution irritates the lining of the blood vessel, causing it to swell and stick together. Over a period of weeks, the vessel turns into scar tissue that fades from view.
Minimally Invasive Treatment Options
Radiofrequency ablation is similar to endovenous laser therapy; however, it uses radiofrequency energy to heat the vein. The catheter is inserted into the vein, and as it is withdrawn, the vein is heated using a controlled amount of energy. The vein closes and seals, and blood flow is rerouted to healthy veins. This is a highly effective method done under local anesthesia and has been used for over a decade to treat chronic venous insufficiency. This has a 92% success rate at 5 years and produces minimal discomfort, with patients being able to return to normal activities almost immediately.
Endovenous laser therapy is a treatment that uses laser to cauterize the vein, causing it to close. A fine catheter is inserted into the vein, usually around the knee and threaded up to the problematic vein under ultrasound guidance. As the catheter is slowly withdrawn, it emits short bursts of laser energy to the lining of the vein, causing it to close. The vein will then be gradually absorbed by the body. This treatment is done under local anesthesia and has a 95% success rate. It is slightly more painful than the other methods, and patients with large or highly symptomatic varicose veins often opt for one of the methods.
Section 4 of the book further expands on treatment options for varicose veins, which in the past often required many days of admission to hospital and a slow and painful recovery. Modern technology has given rise to minimally invasive options that can be done in the doctor’s rooms in under an hour with no post-operative downtime. All of these techniques are done under ultrasound guidance and provide much more comfortable alternatives to the traditional surgical options for varicose veins.
Endovenous Laser Therapy (EVLT)
Foam sclerotherapy has been found to be more effective than older methods of sclerotherapy and can provide good long-term results, particularly in treating smaller varicose veins and recurrent varicose veins from previous treatments. With this technique, a special detergent sclerosant is mixed with air to create the foam, which is then injected directly into the vein. The foam displaces the blood from the vein while causing inflammation and closure of the vein. It is particularly useful for veins below the knee where other treatment modalities may not be suitable.
In RFA, the doctor inserts a catheter into the vein and applies radiofrequency energy to the vein wall, heating it. As the catheter is withdrawn, the heat closes the vein. Endovenous Laser Therapy uses laser energy applied to the wall of the vein through a catheter, causing the vein to close. The ELT procedure is usually associated with less discomfort and bruising than RFA; however, both techniques are effective with good long-term results and a low incidence of recurrence.
Sclerotherapy, which includes both laser and foam sclerotherapy, RFA, and ELT, are minimally invasive techniques that have gained popularity in the treatment of varicose veins. They are less invasive than surgery and have a lower risk of complications or side effects. With both techniques, the doctor uses ultrasound to map out the vein and then injects an anesthetic and/or a tumescent (dilute local anesthetic) around the vein.
Radiofrequency Ablation (RFA)
Radiofrequency ablation (RFA) is a minimally invasive treatment method that treats vein reflux by delivering radiofrequency energy to the vein wall, causing it to heat, collapse, and seal shut. The ClosureFast™ procedure is a type of RFA, but currently, there are no other RFA devices that are approved for use in Australia. RFA is usually performed in a clinic or day surgery facility using local anesthetic, and patients are encouraged to walk immediately afterward. RFA is a technique that uses a catheter inserted into the vein to be treated and ultrasound imaging to position the catheter in the right place. The catheter delivers radiofrequency (RF) energy to the vein wall. As the RFA catheter is withdrawn, the vein is heated using RF energy, causing contraction of the collagen in the vein wall and eventual vein closure. The RFA technique has proven to be very effective in achieving complete vein closure and has a low incidence of nerve injury because the procedure is targeted purely at closing the vein and does not cause any damage to surrounding tissue. RFA has shown to be more effective than surgery and with quicker recovery times. RFA provides a good alternative for treatment that will reduce patient post-operative pain and bruising compared with laser or surgery and is the treatment of choice for small saphenous reflux.
Foam Sclerotherapy
The first method involves drawing the sclerosing agent into a syringe and agitating it by forcefully injecting it back and forth between two syringes connected with a three-way tap until a good consistency of foam is achieved. The second, and more technically advanced method, utilizes a mechanical pump to produce the foam. The advantage of the pump method is that it is more reproducible, and the resulting foam has a more consistent and durable microstructure. The foam is directly visualized with ultrasound, which is used to guide a fine needle into the vessel to be treated and to monitor the dispersion of the foam within the lumen of the vein to ensure no deep vein thrombosis or paradoxical embolism occurs. The ability to obtain foam inside the vessel lumen rather than blood/sclerosing mixture is achieved by using foam to displace the blood column in the vein, a technique known as double or multiple puncture. Treatment success and the volume of foam retained in the vein can be further enhanced by external vein compression or specific positioning of the patient during or after treatment. The foam is left in the vein for a few minutes to cause occlusion, and displaced blood is then emptied from the vessel to prevent staining of the skin. During this time, the patient is usually advised to exercise the limb to encourage uptake of oxygen from the surrounding tissues, although it is important to note that foam sclerotherapy can be used for veins in any part of the body and not just the legs.
The principle of sclerotherapy involves the injection of a sclerosing agent into a vein to produce a local inflammatory response, which causes the vein to occlude and fibrose. Standard sclerotherapy has been used for many years to treat varicose veins, primarily small veins (spider veins) and occasionally larger veins that are not suitable for endovenous thermal ablation. The introduction of foam sclerotherapy has sparked a recent surge of interest in the treatment for both small and larger veins. Foam sclerotherapy involves the production of a microfoam from a sclerosing agent, which is achieved by one of two methods.