Varicose veins are characterised by thick, swollen veins that usually appear in the legs.
Varicose veins transport blood out of the leg and back to the heart, and thus have valves in them to prevent backflow of blood. Varicose veins are strongly genetic, and are caused by a weakening of the vein walls, causing them to dilate and thus rendering these valves incompetent. Blood then backflows (refluxes) and the veins distend. Fluid may exit the veins with resultant swelling of the legs and in some people the skin and underlying tissue is affected causing other visible changes such as skin pigmentation, hardening of the skin and in advanced disease, ulceration (wound).
The condition can be painless, but generally, symptoms include pain, swelling and itching in the legs. One may also experience a heavy feeling and fatigue in the legs, especially after prolonged periods of standing or sitting.
The leg may visibly have varicose veins, mild to severe swelling (oedema), brown pigmentation, hardened skin and even ulceration.
The treatment of varicose veins has advanced significantly over the past couple of decades.
Treatment is aimed at relieving symptoms, preventing progression of disease and getting rid of unsightly veins.
A non-surgical option is medical compression stockings. These will not cure the veins, but will halt the progression of disease. For successful compression treatment, stockings need to be worn daily and replaced every six months.
Traditional treatment was invasive surgery that involved vein stripping with long recovery periods. However, these have largely been replaced by minimally invasive (endovenous) techniques that can mostly be done out of main theatre, under local anaesthetic and without the need for skin incisions or sutures.
Radiofrequency Ablation (RFA)
Radiofrequency ablation is a minimally invasive treatment for varicose veins that uses radiofrequency energy to heat to seal off the main vein that the visible varicose veins are attached too.
In the same way that Radio Frequency Ablation uses heat to seal off the veins, laser uses laser thermal energy for sealing.
Mechanochemical Ablation (MOCCA) or ClariVein
Mechanochemical ablation, is a treatment for varicose veins that combines mechanical destruction of the vein wall with a sclerosing agent to seal the main vein off instead of heat.
Veneseal is a type of glue that is inserted into the veins to seal them off.
One advantage of non-thermal treatments are that the leg can be treated all the way to the ankle if there are incompetent veins in that region. This cannot be done with thermal ablations due to the risk of nerve damage.
Pro’s of Endovenous Procedures
Endovenous procedures are operative procedures that also address the refluxing vein with the same outcomes as surgery however, they:
- Do not require hospital admission
- Do not require a general anaesthetic
- Do not require surgical incisions to address the vein
- Allow the patient to go home the same day
- Allow the patient to return to normal activities the same day
- Decrease pain and discomfort post procedure
There have been 4 randomised controlled trials comparing RFA to open surgery and RFA was significantly better in all of the following:
- less post-operative pain
- quicker recovery
- higher quality of life scores
- less bruising
UltraSound Guided Foam Sclerotherapy
Ultrasound-Guided Foam Sclerotherapy Foam is used to treat varicose veins and involves an injection made of sclerosant medication in foam form to seal veins off. This is usually used in addition to an endovenous procedure for more tortuous veins or where a catheter-based treatment is not anatomically possible.
Phlebectomy refers to the removal of varicose veins. This is done for the visible branch varicosities on the legs, and is also usually an adjunctive procedure to an endovenous procedure. These veins are removed through tiny incision made in the leg.
As with any procedure, there is a risk of complications. These are very uncommon and if they do occur, they are usually temporary.
The following complications have been reported:
- Deep Vein Thrombosis – This is probably the most significant complication and requires active treatment, should it occur.
- Bruising along the inner-thigh
- Numbness / pain along the inner thigh
- Heat injury along the inner thigh
- Pigmentation along the inner thigh
- Thrombophlebitis (inflammation or redness of the vein)
Although varicose veins surgery can have excellent results in terms of symptoms improvement, wound healing and aesthetic appearance, there is the risk of recurrence and new veins may develop over time. Veins are not curative ( only problematic veins are removed out of the circulation), and vein health thus needs to be maintained.