Non operative treatment: Patients with varicose veins usually request treatment for two reasons:
a) cosmetic or
b) because the varicose veins are causing problems.
Compression stockings: These can relieve symptoms, hide veins and slow down deterioration of skin changes. They need to be worn every day – summer and winter. Many people find this irksome. Stockings need to be replaced every six months since they wear out. They need to be graduated – with the highest pressure at the ankle, dropping to 75% at the calf and 50% at the thigh. Most people only need the below knee stockings which are easier to wear than full length ones.
Varicose veins developing during pregnancy.
Patients who have varicose veinsbut don’t want or are unfit for surgery. Also patients who do not have any symptoms due to the veins.
Patients with secondary varicose veins.
Sclerotherapy: This procedure involves injecting a sclerosant solution into varicose veins. This irritates the inside of the vein wall which is then compressed with a bandage which cause the wall to stick together and obliterate the lumen ( that part through which the blood flows) of the vein. Sclerotherapy is easily done in the consulting room without anesthetic. Bandages remain on for 10 days to 2 weeks and patients are encouraged to walk for about an hour a day until next seen at the clinic. Sclerotherapy is usually around Rs5000/- per session, per leg.
Sclerotherapy has fallen out of favour for treatment of larger veins because of almost 100% recurrence at 4-5 years after the procedure.
Most vascular surgeons feel that patients with incompetence of the long and short saphenous veins and their major branches should have surgery instead of sclerotherapy since the recurrence rate is less.
Sclerotherapy works well for patients with isolated varicose veins and thread veins. It is less satisfactory for short veins above the knee than below the knee, since they are more difficult to compress.
Complications of sclerotherapy include – discoloration/skin pigmentation in the injected site ( this usually fades ) and mild pain in the injected vein (usually requiring paracetamol for a week or two). Most people can go back to work the next day. Rarely a varicose ulcer may develop at the site of injection, and this needs advanced wound care for healing.
Surgery: Most varicose vein surgery can be done as day surgery or short stay surgery. It can be done under general, regional or local anesthetic. I prefer the former two methods.
Following surgery I prefer to keep a compression bandage on for 48 hours. This can be replaced by a stocking until the first clinic visit one week later, and then dispensed with. In case perforator veins are operated then due to stitches on the legs, stockings are given only after removal of stitches.Following surgery patients can walk, carry on with their social activities, go shopping etc. Driving can be undertaken once there is no groin tenderness. Surgery is associated with very little pain or tenderness. Most patients can commence work 4-5 days after surgery or less.
For patients with long saphenous vein incompetence the standard procedure involves a small groin incision. The long saphenous vein is tied off and divided from the femoral vein (together with surrounding branches ). It may then be stripped down to just below the knee (under the skin) or not. The varicose branches (which are premarked before surgery) are avulsed through a series of stab incisions about 2-5mm in length. The lesser saphenous vein is similarly dealt with except that the incision is behind the knee where this vein drains into the popliteal vein.
EVLT : Laser Treatment for Varicose Veins: Endovenous laser ablation is now available. This involves passing a laser catheter up the long saphenous vein. The laser catheter is then activated and slowly withdrawn down the vein. This heats up the inside of the vein wall causing it to stick together thus obliterating the inside of the vein. This procedure avoids a groin incision. Stab incisions are however still necessary. Patients can be back at work after 36 hours.
VNUS : This is the use of Radiofrequency to also heat up the vein and thereby close it. It also entails use of a catheter inserted in the vein.
Both EVLT & VNUS procedures are very similar except for the technology used, in one it is LASER energy and in the other Radio Frequency Waves are used.
With advances in technology both the procedures are being used and have similar results. Preference is basically surgeon dependent. However long term results in various series with recurrence rates of anywhere from 10 – 20%.
Recurrence in the same vein can happen with any treatment of varicose veins, however the rate of recurrence with surgery is currently lower. Veins are known to grow back even after they are cut.
The drawback of EVLT or VNUS is that they do not treat the perforator veins which most people just treat with sclerotherapy – after having done laser/RFA treatment to the main vein in the thigh -which as you already know has a 100% recurrence rate at 4-5 years.
In my opinion the best and long lasting results for varicose vein treatment are by surgery which has to be carried out after a thorough color Doppler examination & any other required investigations, of the venous system of the leg.
Thread veins. These can occur on their own or in association with long or short saphenous vein incompetence. In the latter case the main superficial vein incompetence should be dealt with surgically. Then the thread veins can be injected. This may involve several treatments. Thread veins can also be treated with laser therapy but this may also involve many treatments and may also leave areas of skin pigmentation.
REGULAR FOLLOW UP after any treatment for varicose veins and the use of Compression Stockings for life is the mainstay of treatment. New sites of venous reflux can develop over time and cause future problems. So prevention with graduated compression stockings should be used by all patients who undergo any form of treatment for varicose veins
It is recommended that patients should carefully weigh the benefits and risks with their doctor before deciding on the best treatment strategy. It is NOT TRUE that ONE SIZE FITS ALL…especially in the case of varicose vein treatment. The optimum treatment plan keeping in mind the cause and the degree of damage to the legs is what leads to better long term results.
Patient compliance in the way of regular follow up as per doctors guidance is also important to prevent emergence of symptoms.