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Varicose Veins Procedures

By Mr Patrick Lintott  MBChB, MD, FRCS       Consultant Vascular Surgeon

Veins are soft blue blood vessels that return blood from the tissues to the heart. Varicose veins are extremely common and occur when the walls of the leg veins get weak and stretch, allowing them to bulge and become more visible under the skin, or even to protrude from the normal skin contour. They run in families and often are made worse by pregnancies, although men represent 30% of cases. They are frequently associated with symptoms such as aching, itching, swelling and mild eczema; while in severe cases pigmentation, thinning of the skin and even ulceration can result. Treatments have been shown to improve quality of life and reduce skin complications in the longer term; however there are now numerous alternatives.

When being assessed for varicose veins it is vital that a proper history is taken as well as an examination and ultrasound assessment of all the veins in the legs. Without this there is not only a much higher chance of early recurrance, but also a risk that the wrong vein might be treated.

The treatments broadly fall into three categories and all aim to do the same things; firstly remove the unsightly veins on the surface, but also to block / remove any dilated, connecting veins from the deep veins to these surface veins, as without this step new varicose veins can occur within months. The twp most common connecting veins to need treatment are called the “long” and “short” saphenous veins; the long runs from the groin down to the knee and beyond on the inside of the leg. The short starts behind the knee and runs down to the lower calf.

The first option is foam sclerotherapy. This uses a sort of glue that is mixed with air and looks a bit like hair mousse. This is injected into either surface veins or the connecting veins under ultrasound control and blocks them; the body then slowly destroys these blocked veins over a period of six to twelve weeks with an inflammatory process.

Its main advantage is that it is an outpatient, local anaesthetic procedure. Its main disadvantages are that it has the highest first time failure rate of any method (60% first time success rate, NICE guideline figures) and therefore often need repeating once or even twice. Secondly treating the surface veins can leave brown pigmentation as the inflammation settles, especially in pale skinned individuals. Finally there is a low risk of the foam entering the deep veins causing a deep vein thrombosis, or very rarely even a stroke. Because of this most private insurance companies will not cover it for treating connecting veins and in some cases, any veins.

The second option is “traditional” surgery, otherwise known as “stripping”. This has by far and away the most data behind it and is successful in over 98% of cases first time (NICE guideline figures). It involves a cut over the connecting vein, usually in the groin or behind the knee and then stripping out of the connecting vein. The surface veins are then removed through micro incisions, which usually heal extremely neatly and fade completely after a few months. Its main disadvantages are that it requires a general anaesthetic and in addition has the longest recovery period with most patients taking two weeks off work and four weeks for the bruising from the strip area to settle. Finally the cut in the groin can get infected in up to 5% of cases.

The third option is endo-luminal treatment, which has been around for about five years. This comes in a number of flavours either radiofrequency ablation (also known as VNUS closure) or laser (also known as EVLT or ELVuS, depending on the type and temperature of laser used). In all cases a needle is put into the connecting veins and a wire threaded up via ultrasound control. The wire is then connected to the VNUS / laser machine and withdrawn sealing it from the inside as it goes. The surface veins can then either be removed through micro-incisions or injected with foam depending on patient preference.

The advantages of this method are that it can be done under a local anaesthetic (with or without some sedation), does not require a cut in the groin or behind the knee and that the recovery period is usually a few days rather the a few weeks. The disadvantages are that it is only successful 92-95% first time (NICE guideline figures). Also there can be some surface pigmentation over the treated vein more commonly with laser. It is also more expensive than traditional surgery as the treatment fibres are single use only. In terms of comparing VNUS to laser in practice they are all pretty similar and from a patient’s perspective there is little to choose between them except for a lower risk of pigmentation and slightly less pain with VNUS or the low temperature laser.

For any sort of surgery I would always recommend seeking treatment from someone who can offer all the options so they can give unbiased advice and who operates for a local NHS provider so that you can be sure your GP will have a long working relationship with them. Before embarking on any treatment of varicose veins a patient should consider carefully what it is that is important to them and discuss this with their surgeon.