TREATMENT for VENOUS DISEASE.
GENERAL MEASURES
Many patients improve with simple measures, some of which have been discussed above.
1. EXERCISE.
Walking, running, cycling and swimming are all beneficial. Walking is the simplest to do and using the calf muscles directly pushes blood up the veins of the leg improving the circulation.
2. AVOID standing still for long periods of time.
3. ELEVATE the legs whenever possible. Any elevation will help but if you can raise the feet above the level of the heart (chest) this will be particularly beneficial.
4. If you are OVERWEIGHT, try to reduce this down towards your ideal/target weight.
5. Use firm "graduated" SUPPORT STOCKINGS on the legs during the day. These can be brought at chemists or obtained on prescription. The pressure in the stocking is designed to be greatest at the ankle level and gradually decrease up the leg. This assists the return of blood up the veins. A below knee stocking is often sufficient unless you have painful veins in the thigh.
All these measures should be used before moving on to the specific treatments below.
DILATED VEINS
The treatment for dilated veins depends upon the size and the number of veins involved. With larger, truly varicose veins (>4mm) involving a significant part of the superficial venous system (as assessed with doppler/Duplex scans) surgery is often required. Smaller localized problems (flares, thread veins, spider veins) may be treated by injection or laser.
VARICOSE VEIN PROCEDURES
1. Foam Sclerotherapy
What is sclerotherapy?
Sclerotherapy or injection of varicose veins is a procedure designed to reduce the size or remove your varicose veins. The veins are injected with a solution called a sclerosant which damages the internal lining of the vein. This damage to the vein leads to scarring which reduces the vein size and may even block the vein completely. If blood mixes with the sclerosant it clots within the vein. This causes phlebitis where the vein is inflamed and sore for 2-3 weeks. However the end result is often the same with the vein reducing in size or disappearing with time. The solution normally used for this procedure is called sodium tetradecyl sulphate (STD) and is available in different concentrations depending on the size of the vein being treated.
What is foam sclerotherapy?
Normally STD is injected as a solution directly into the vein to be treated. Foam sclerotherapy involves making small volumes of the solution into foam by rapid mixing and agitation with a small volume of air. This can then be used to treat some of the larger underlying abnormal veins which would not normally be treated with conventional sclerotherapy. This is performed under ultrasound control. The foam solution causes intense spasm of the vein and a greater volume can be injected without using too much of the STD solution. The foam is less likely to mix with blood and cause phlebitis.
Is foam better than conventional sclerotherapy?
The initial results with foam sclerotherapy are very promising and this method of treatment offers a possible alternative to surgery. However it should be emphasised that this is a new treatment and at present the long term results are not yet known and it is not possible to say how this treatment compares in terms of results with conventional surgery in the long term (2-5 years).
Are my veins suitable for foam injection sclerotherapy?
Varicose veins involving isolated veins in the leg or involving the long saphenous vein or short saphenous vein are suitable for this form of treatment i.e. most varicose veins. If you have very extensive and very large varicose veins then you may do better with surgery rather than sclerotherapy. If you have any underlying blood clotting tendency it may not be advisable to have sclerotherapy.
What does the procedure involve?
Depending on the number of varicose veins you have you may need 2 or 3 sessions of treatment, and occasionally more than this. The main surface vein to be treated will be marked on your leg initially using ultrasound scanning. Local anaesthetic will then be injected into a small area of skin, usually in the lower thigh or mid calf and a needle will be placed into the vein, again using ultrasound scanning. This will be flushed with a salt solution containing heparin, a blood thinning agent, just to keep the needle open. Two or 3 smaller needles (called butterfly needles) will then be inserted into the visible varicose veins in the leg and these will be similarly flushed.
Your leg will then be elevated above the couch and the foam solution will be injected in small volumes at a time into each of the needles. Whilst this is being done you will be asked to bend your ankle up and down in order to increase the blood flow in your deep veins. You may experience some slight stinging as the foam is injected but it is usually painless. The passage of the foam in the vein will be monitored by ultrasound scanning and the foam injections into each needle will be repeated 2 or 3 times.
Once enough foam has been injected the needles will be removed, pieces of sponge will be applied to your leg followed by a bandage in order to compress the treated veins. An elastic compression stocking will then be put on your leg. This will feel tight but should not be so tight as to make your foot discoloured or painful.
What happens after treatment?
You should keep the sponge, bandage, and stocking on continuously for 7 days. After this you may remove the sponges and bandage and then replace the stocking which should be worn for a further 7 days. During this 7 day period you may remove the stocking to shower and you may remove it at night if you wish. If you find the stocking comfortable and wish to wear it for longer this may be helpful. Please bring your stocking back with you to your next visit as it may be possible to reuse it if you have further injections.
You should do plenty of walking and may generally do most normal activities without any problem. If in doubt ask your doctor.
Will I need further treatment?
It is possible that some of your varicose veins will remain after one set of injections and you may need 1-2 repeat treatments. You will be seen again in 4-6 weeks time and further injections can be performed at that stage if necessary.
What are the complications?
Superficial thrombophlebitis
If the varicose veins become hard, tender, and red this is due to blood clotting in the vein causing thrombophlebitis. This is nothing to worry about but may be associated with inflammation and discomfort. If this occurs anti-inflammatory pain killers (nurofen, ibuprofen) may help. These lumps will eventually subside and disappear but this may take several weeks. This process may be hastened by your doctor inserting a needle into the lumps and aspirating the clots after a few weeks.
Brown pigmentation of the skin
This can occur following superficial thrombophlebitis described above and can be permanent. However it will usually fade for a period of several months and may disappear completely.
Deep venous thrombosis
If the solution passes into the deep veins there is a risk of thrombosis of the deep veins. This may be very minor with no symptoms or a major blood clot with a risk of a pulmonary embolus (passage of a blood clot to the lungs). It is for this reason that only small volumes of the foam are injected at a time and the ankle is exercised in order to maintain good flow in the deep veins. Surgery also carries a risk of deep vein thrombosis.
Recurrent and residual varicose veins
If you have any remaining varicose veins it is usually possible to inject these at your next visit. However if you have a lot of very small varicose veins it may not be possible to eradicate all of these. It is possible that the treated vein could reopen. At present the risk of this is not known and only long term follow up data will provide this information. If this does happen it would be possible to treat the vein again, either by further injection or by surgery.
Skin ulceration
If the solution does not go into the vein but goes into the surrounding tissues it can cause a small ulcer of the skin. This will heal up but this may take several weeks and will leave a scar. The use of ultrasound to guide the injection reduces the risk of this to a low level.
Allergic reaction
Allergy to the solution used is rare but can occur. If you have any allergies you should inform your doctor.
Visual disturbance
There are reports of temporary visual disturbance with foam injections. This is thought to be due to the air bubbles rather than the solution injected.
Stroke
There have been 2 reported instances of a stroke occurring after foam sclerotherapy. However this is out of many thousands that have been done and there may have been particular reasons why this occurred in these cases, including a high volume of foam injected.
2. Venous Ablation
EVLA and VNUS CLOSURE
Two “ablation” techniques for treating varicose veins have been introduced, VNUS and EVLA. These aim to replace the “stripping” part of the standard operation. They are therefore used when the varicose veins are connected to the long or short saphenous veins. (see diagrams)
Both these techniques aim to remove the long or short saphenous vein from the circulation by blocking or ablating the vein. Both techniques use heat to achieve this, a type of “cautery” of the vein. EVLA uses laser deliver heat (EndoVenous Laser Ablation) and VNUS uses radiofrequency to generate controlled heat. The heat alters the structure of the vein wall and causes the vein to shut down. No wounds or “stripping” are required. Instead a catheter is placed into the vein in the lower leg via a needle. The catheter is then passed up the vein under ultrasound control and positioned at the junction between the saphenous vein and the deeper veins (femoral or popliteal).
Both VNUS and EVLA are similar in many ways and achieve similar results with the faulty saphenous vein being removed from the circulation. Both techniques are suitable for use under local anaesthetic in appropriate cases. Once the vein has been closed, avulsion of varicosities may still be required. This can also be done under local anaesthetic but if there are lots of varicose veins to remove then general anaesthesia may be a better option.
These techniques are designed to reduce post operative discomfort and enable a faster recovery rate. After the standard open operation the groin wound can be a source of discomfort. Bruising in the thigh after stripping of the vein can also lead to more discomfort and delay return to normal activities.
ADVANTAGES OF EVLA AND VNUS CLOSURE.
- No groin wound. Less discomfort, no risk of infection.
- No stripping of thigh vein. Less bruising, less discomfort.
- Experience to date suggests that the above leads to a faster return to normal daily activities and work. This can be achieved on average in 2-3 days. Sporting activities can be resumed at one week on average.
- Very suitable for day case surgery.
- Local anaesthesia a possibility for selected cases.
DISADVANTAGES.
- New technique, therefore long term (>5year) results unknown yet. It is possible that the recurrence rate beyond 5 years may be higher with this new technique. Up to 5 years however, the results have so far been as good as standard surgery.
- The electrical current or laser used to “close” the vein may cause damage to surrounding skin nerves. Numbness in the thigh may occur (5-10%) but this is usually temporary. A misplaced catheter could potentially damage the deeper veins in the groin, leading to a stenosis or deep vein thrombosis. With careful ultrasound monitoring this complication is rare (<1%)
- More expensive. The equipment required for this technique is more expensive and therefore the charge for this procedure is higher than for traditional varicose vein surgery. Currently EVLA and VNUS closure are largely performed privately. Most insurers now cover the procedure.
The National Institute of Clinical Excellence (NICE) have recognised both EVLA and VNUS closure as safe and acceptable procedures when performed by trained surgeons.
3. VARICOSE VEIN SURGERY
There are two aspects to varicose vein surgery. The most obvious is to remove the lumpy, distended varicosities and this is usually done through a series of small cuts (2-4mm). The terms "avulsions" or “phlebectomies” are used to describe this. The veins are removed in sections (avulsed) through each of the incisions.
The second aspect of the operation is to remove or close any superficial veins with reflux in the leg, since if these are left in place they are a source for new varicose veins forming.
Two systems are commonly involved, first a vein called the Long Saphenous Vein (LSV) running up the inside of the leg to the groin. Second, is the Short Saphenous Vein (SSV) running up the back of the leg to behind the knee. The standard open operation involves tying off these veins either at the groin or knee. The long saphenous vein may be removed in the thigh by a process of "stripping". This involves pulling the vein out under the skin down to the knee level. New techniques for closing down the long saphenous vein are now becoming more popular since painful stripping of the vein is avoided (see EVLT/ VNUS Closure).
Complications (specific to vein surgery)
Removing varicose veins inevitably produces some bruising and soreness. The severity depends on how many veins are removed. Most of this resolves in 1- 2 weeks but it may take longer for the leg to fully return to normal. Small venous flares may develop in areas where the bruising was most extensive. Wound infections occur in approximately 2-3% of cases. Small nerves next to the veins can be disturbed leading to patches of numbness in the lower leg and foot in 10% of patients. This slowly resolves but is occasionally permanent. A thrombosis can occur in the deeper veins of the leg but this is not common, affecting less than 1% of patients. A number of precautions are taken to prevent this.
Post Operative Instructions
Much varicose vein surgery is performed on a day case or overnight stay basis. Some form of bandage or stocking is used to try and reduce post operative swelling, bruising and the risk of thrombosis. This support should be used during the day for 1-2 weeks.
Aim to either rest with the leg elevated moving the ankle, or be up on the move around the house and garden. Avoid standing for any long period of time; avoid crossing your legs. A daily walk of up to 1- 2 miles will be beneficial. If at any time there is some bleeding do not worry. Elevate the legs, apply some pressure for 10 - 20 minutes and it will stop.
You will probably need 7-10 days off work, returning when you feel comfortable. Avoid driving for 4-7 days. Return to all other activities when you feel comfortable and confident. With common sense and a gradual return to activities it is extremely unlikely that you will damage any part of the operation.
VENOUS INJECTIONS (MICRO-SCLEROTHERAPY)
Some superficial veins can be treated by injections
How does Sclerotherapy work ?
A chemical that irritates the wall of the vein is injected via a small needle. Following this pressure is applied with a pad and a bandage or stocking. The vein is compressed and emptied of blood. The walls of the vein become inflamed and stick together preventing the vein from opening up again so that it is no longer prominent under the skin.
What are the Complications ?
1. If too much chemical is injected outside the vein the inflammation can cause some pain and redness. This can lead to permanent brown marking of the tissues which is visible beneath the skin.
2. If there is a severe reaction outside the vein to the chemical an ulcer can develop.
3. A generalised allergic reaction can occur. If you have several allergies or very bad asthma injection therapy may not be advisable. Your physician will advise you on this.
4. A thrombosis can form in the vein. Occasionally this may spread to the deep veins of the leg and cause an embolus.
These complications are not common (1%).
Is It Successful ?
Injections are most successful in treating small veins, (2-4mms diameter). A series of injections (commonly 2 – 4) may be required to remove the veins depending on how widespread they are. Other dilated veins may form in the future.
What is involved ?
The injections are performed with you sitting or lying on a couch. The needle is very small so that most people do not experience any significant pain. It is common for the area to itch or sting afterwards. Several different veins can be injected at the same time. A pad is placed over the injection site followed by a firm bandage or stocking. This should be worn for 3 – 4 days depending on the size of the veins which are injected. Initially there may be some bruising, and this will take longer to fade.
LASER TREATMENT
Some very small spider/thread veins can be treated by laser
How does Laser treatment work ?
The energy from the laser is absorbed by the vein which heats up. The vein is damaged and the blood within it coagulates. Commonly a red reaction to the laser appears, sometimes a fine white grey line is all that is left. The ability to focus exactly the right amount of energy on the vein prevents significant damage to surrounding structures so that the end result is removal of the vein only.
What are the Results and Complications?
1. Redness and swelling frequently develop and convert to a “Cat-scratch” scab for 2-3 weeks. This fades away leaving one of the following:
• Veins are gone
• “Trapped” blood in some of the veins. This will be absorbed over 2-3 weeks.
• Scarring of the overlying skin, as a white line, may occur.
• No change or lighter coloured veins. A re-treatment may be necessary or sclerotherapy may be an option. It is common for 2 or more laser treatments to be necessary.
What is involved ?
Avoid aspirin or other anti-inflammatory medicines before treatment because they thin the blood slightly and increase the risk of bruising. Recent sun exposure to the treated area reduces the effectiveness of the laser. The treatment is carried out with you lying on a couch with standard laser safety precautions. A local anaesthetic cream can be used to reduce discomfort. During the laser treatment cold gel is applied. The average duration of treatment is 20 - 30 minutes.
After treatment avoid hot showers or baths for 3 days. No vigorous exercise for 3 days, avoid high impact sport for 4 weeks. Apply a moisturiser to any dry and flaky areas until healed. Also avoid significant sun exposure for 4 weeks. If swelling is a problem elevate the leg and apply ice wrapped in a soft cloth.