Recurrent varicose veins - Why do varicose veins come back after surgery or other treatments?
It is commonly said that varicose veins always come back after treatment. This is probably true with the old way of dealing with patients by:
- examination with eyes and hands
- standing the patient up and using a tourniquet or a little hand held Doppler to 'decide' where the veins are
- then tying and stripping the veins - or injecting them with sclerotherapy
However, with the new techniques, many introduced into the UK by The Whiteley Clinic or invented or developed at The Whiteley Clinic, we can now expect only a very small number of people to develop new varicose veins after our treatments - approximately only 3% per year.
To understand why, it is necessary to understand why varicose veins come back after the traditional approach.
Why do varicose veins recur (come back) after traditional treatment?
There are 3 main reasons that varicose veins recur after traditional treatments:
- The underlying cause of the varicose veins wasn't indentified and therefore the wrong operation of treatment was given
- The surgical technique used, or treatment given allowed the veins to re-grow ('neovascularisation') or to re-open
- Normal veins, that were working at the time of the original procedure, lose their valves and start to allow blood to reflux - called new or 'de novo' reflux
It is by understanding these causes and addressing them where possible, that has allowed The Whiteley Clinic to reduce the risk of recurrent varicose veins, after their treatments, to as low as it is possible to get.
To take these in order:
1 - Identifying the underlying cause of varicose veins (or venous reflux) - Missed veins
It is now obligatory for anyone who thinks that they might have varicose veins or a venous problem, to have a colour flow Duplex Ultrasound, performed by a venous specialist.
These non-invasive ultrasound machines that show the flow of blood using a technique called 'colour coded Doppler' have revolutionised venous surgery.
When performed by an expert, the blood flow in all of the veins in the leg and the pelvis can be seen - and veins with valves that aren't working and that are allowing blood to reflux the wrong way - can be identified.
Many clinics only use hand-held Dopplers, or very small ultrasound machines that the surgeon uses themselves - unfortunately these rarely identify all of the underlying problems in venous disease - leading to incomplete surgery or treatments and refluxing veins being left behind - hence a major cause of recurrent varicose veins - veins missed at diagnosis and surgery.
A proper venous Duplex Ultrasound will be performed in a darkened room by a vascular technologist or some other imaging professional who scans veins for almost all - if not all - of their working day. Anyone who scans occasionally - ie: surgeons scanning between consultations and operating, other imaging professionals that perform multiple other services and just a few varicose veins sporadically throughout the week, are highly unlikely to be able to reach the same level of diagnostic skill as a fully fledged venous trained vascular technologist.
The Duplex machine used must be of a high specification, and an adequate examination will take even a very experienced vascular technologist over 30 minute - usually 45 minutes. 1 in 5 women who have had a vaginal delivery in the past will also need a transvaginal scan of the veins in the pelvis - and so both the Duplex Ultrasound machine and the technologist must be able to perform these examinations.
In the same way that a car driver needs to use their eyes and a map (or GPS) to find their way to their destination, a venous surgeon needs Duplex during the procedure to see the veins as they operate on them, and a 'map' drawn by the vascular technologist at diagnosis, to show which of the veins need treatment. Therefore Duplex Ultrasound has become the 'eyes' of the venous surgeon - and an inadequate Duplex scan (or no scan at all) means that it is virtually impossible to plan or perform the correct venous treatment.
How The Whiteley Clinic deals with this:
At The Whiteley Clinic, every patient has a diagnostic Duplex Ultrasound scan performed by a specialist vascular technologist who has been trained to The Whiteley Clinic standards for veins. Scans take 30 - 45 mintues (or longer in complex cases) and may include a pelvic scan if needed.
By performing such thorough scans, all the veins in the legs are examined and so veins can be missed.
In addition, all of The Whiteley Clinic procedures are done under ultrasound control. This means that during the treatments, all of the veins that need treatment are identified by Duplex Ultrasound in the operating theatre and treatment of each is guided by the Duplex Ultrasound. Once treated, the veins are then checked before the end of the operation to make sure that all of the veins have been treated and none have been missed.
2 - Re-growth ('neovascularisation') or re-opening of varicose veins after stripping and other traditional treatments
Although it would seem logical to think that veins that have been tied and stripped away would be gone forever, nothing could be further from the truth.
Our bodies have evolved to heal. If you get cut, your skin and underlying tissues heal. If you look a these wounds scientifically you find that the veins first bleed, then clot, and then the veins grow back stimulated by the clot.
The same happens after the old stripping away of veins. The removal of the main vein leaves two open ends (one of which is tied) and many side branches (or 'tributaries') which are also open and living. At first the open ends all bleed, giving the pain and bruising that tying and stripping is well known for.
After a while, the blood clots - many surgeons try to bind the leg to reduce the bleeding and hence this painful clot - or 'bruise' - but although this may reduce the pain and bruising a little, it doesn't change the biology of the healing process.
The clotted blood next to the open ends of the veins stimulates the lining of the veins (the 'endothelium') to re-grow - a process called 'endothelial budding'. Even the top end that has been tied does this - and usually the surgeon has used a dissolvable tie that has disappeared within a few weeks of the surgery.
The 'endothelial buds' or growth of vein cells from the vein walls connects them all together again, directed by where the bruising and the clot lies. In other words, the very bruise caused by the stripping of the vein directs the body where to heal it again!!
When the solid endothelial buds from different veins meet up and connect, they join and open up into being new veins - but without any valves. This new growth of veins is called 'neovascularisation'.
Therefore new veins but without valves are now just new varicose veins!!!
Another treatment for varicose veins that can lead to the same varicose veins coming back again is Sclerotherapy. This is the injection of a liquid or foam into the veins, that kills the vein wall.
Although sclerotherapy can be very successful when used correctly, large studies have shown that sclerotherapy is only really successful in the longer term if used in smaller veins. It has been shown that veins smaller than 3mm diameter respond very well to foam sclerotherapy if it is used properly - and veins of 4 - 5mm stay closed in about 80% of cases at 3 years. However veins larger than 5mm regularly re-open after treatment.
The reason for this is not really the size of the vein - but the thickness of the vein wall. Larger veins have thicker walls. Thicker walls do not let the sclerosant kill all the layers - leaving the outer layers of the wall alive after treatment, ready to heal and re-open the treated vein.
How The Whiteley Clinic deals with this:
At The Whiteley Clinic, we introduced the 'keyhole' approach to varicose veins into the UK in March 1999, showing that by heating the veins, the vein could be killed permanently. As the vein is not removed, the dead vein withers away as the body reabsorbs the dead tissue - preventing any regrowth or 'neovascularisation'.
As far as the reopening after sclerotherapy is concerned, this is prevented by making sure that liquid sclerotherapy is only used for tiny thread veins, and foam sclerotherapy is only used in veins smaller than 3 mm diameter.
3 - 'de novo' varicose veins - veins that were normal at the time of surgery can go on to lose their valves
No-one is born with varicose veins. Research performed by Mark Whiteley in 1994 showed that children and teenagers lose the valves in their veins progressively as they get older. The research showed that by the age of 9 years, 1 in 20 girls had lost the valves in their veins, and by the age of 18 years, 1 in 9 had.
Therefore we know that every year, about 3% of people who did have normal veins, develop venous reflux (the underlying cause of varicose veins) by their valves stopping working.
This is a natural deterioration and is due to people's genetic make-up. As such, it is impossible to prevent this deterioration and so everyone has about a 3% chance of developing new vein reflux (or 'de novo' reflux) which can then cause varicose veins, just by being alive.
Surprisingly, some surgeons and clinics claim to have recurrence rates after varicose veins surgery of less than 3% per year!!! This if course is impossible as it means that their surgery has somehow stopped the natural deterioration of the body's healthy veins!!!
How The Whiteley Clinic deals with this:
There is no way known to prevent the deterioration of the valves in people who have the genetic predisposition to develop venous reflux and varicose veins.
As such, at The Whiteley Clinic, we specialise in treating all of the problem veins, leaving all of the working veins to keep the patient's leg healthy.
As such, our recurrence rates after surgery have been measured to be 3.3% per year - and all of the recurrent veins that we have found in our patients are 'de novo' or newly refluxing veins. Therefore using our techniques, we have the lowest possible chance of developing recurrent varicose veins in the future after our treatments.