What are the principles of treatment of varicose veins?
I believe that there two key principles for treating varicose veins.
The first, and most important, part is treating the source of the varicose veins (a). This is frequently valve problems in the great saphenous vein in the thigh or the short saphenous vein in the calf – a condition known as superficial venous reflux. These veins lie deeper in the leg and are often not visible from external inspection, which is why detailed ultrasound assessment of the leg is so important. Failure to deal with the cause of the problem will lead to poor results and cause the varicose veins to come back quickly.
The second part involves treating the visible veins under the skin to achieve the best possible cosmetic result (b). This usually involves phlebectomies (removal of the varicose veins through tiny incisions) or sclerotherapy (injections into the veins).
It is usually possible for me to perform both of these aspects of treatment at the same sitting.
What is the best treatment for varicose veins?
Every patient is individual and therefore your treatment needs to be tailored to you and your pattern of varicose veins, taking into account the results that you want to achieve.
Many people come to me confused by the number of treatments they have read about on the internet. Fortunately, the National Institute for Health and Care Excellence (NICE) has recently assessed all the clinical evidence on the effectiveness of different varicose vein treatments and have produced detailed guidance on the most effective treatments available. Varicose veins in the legs: The diagnosis and management of varicose veins >
In brief, they recommend that all patients with varicose veins should be assessed by a vascular specialist and that assessment should include a detailed ultrasound scan. Regarding treatment, the evidence is clear that all patients should be offered endothermal ablation as the first line treatment where possible and conventional surgery only when other options are not possible.
Treatments for Superficial Venous Reflux
This is the most popular treatment that I offer and is the treatment recommended as the most effective by NICE.
It works by using heat energy to seal off the veins that feed the varicose veins. The two most popular methods of doing this are radiofrequency ablation (Venefit™) and laser (EVLT). My preference is for radiofrequency ablation as I believe this gives the best results and causes less bruising and pain.
Endothermal ablation is a minimally invasive procedure that is performed in a treatment room under local anaesthetic, usually takes less than 1 hour to perform and produces excellent results with quick return to normal activities.
In a typical case, a small tube is inserted into the great saphenous vein on the inside of the knee and the fine Venefit™ catheter is inserted into this vein and carefully positioned just before this vein enters the main deep vein in the groin. As this is performed under detailed ultrasound control I can be certain that the diseased vein is specifically targeted. Once the catheter has been placed, I inject fluid containing local anaesthetic around this vein so that the heating of the vein is completely painless. The Venefit™ catheter is connected to a radiofrequency generator which heats the tip of the catheter as it is slowly withdrawn causing the vein to shrink and block off so that blood is unable to flow back down this vein into the varicose veins.
This treatment is also minimally invasive and is performed in a treatment room using small amounts of local anaesthetic. I use foam that is made by mixing a liquid called a sclerosant with air. This foam is injected into the great saphenous vein via a small plastic tube. The injections are performed under ultrasound control to ensure that the foam is placed safely inside the vein and that the vein is fully treated.
The treatment works by the foam displacing the blood from the vein and causing a chemical irritation of the lining of the vein which then becomes inflamed and blocks off. The vein is then slowly reabsorbed back into the body. A firm bandage and a stocking need to be worn for a week to keep this vein empty to achieve the best results.
The National Institute for Health and Care Excellence recommend the use of this as a second line treatment when endothermal ablation is not possible.
Conventional surgery (stripping) was until recently the main treatment available for varicose veins. An incision is made in the groin and the great saphenous vein causing the varicose veins is tied off flush with the main deep vein of the leg. The diseased great saphenous vein is then stripped out of the thigh to the level of the knee.
Whilst excellent results can be achieved with surgery, this treatment usually requires a general anaesthetic and as a result is more expensive than endothermal ablation. Due to the nature of the treatment, recovery times are longer and there is a greater risk of your veins coming back in the future when compared to endothermal ablation. This is the reason I reserve surgery for the small number of patients whose veins are not suitable for endothermal ablation or ultrasound guided foam sclerotherapy.
This is an exciting new treatment. It uses a medical grade ‘super glue’ to glue the great saphenous vein closed. This is done by inserting a fine tube into this vein near the knee and under ultrasound control the vein is glued closed from the level of the groin to the knee. Early clinical evidence suggests that this treatment is as effective at sealing the vein off when compared to endothermal ablation.
The main advantage of Venaseal™ is that it requires only one small injection of local anaesthetic, so it is virtually painless, and there is no need to wear compression stockings after the procedure. This makes it truly a walk in, walk out procedure!
Simply treating the cause of the superficial venous reflux by one of the methods described above will significantly improve the appearance of your varicose veins as, by removing the source, we are in effect depressurising the varicose veins. If your veins are small this may be all you require.
If your varicose veins are larger, to achieve an even better cosmetic result, I will usually remove these at the same time under local anaesthetic through tiny incisions – a procedure called microphlebectomy.
If you are worried by your veins and the appearance of your legs and want to know if one of these treatments is suitable for you then please contact us >