Treatments for Varicose Veins

Support stockings

If properly measured and supplied by a specialist company to give 'graduated support' to the leg, medical support stockings can give some help - this is discussed more fully on the support stockings page of this site.

Therefore by understanding that varicose veins or venous reflux problems are caused by the failure of the valves in the veins and the subsequent malfunctioning of the veins, it becomes obvious that treatment requires a physical destruction of the bad veins, preventing the reflux from flowing the wrong way down the affected veins.

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High tie

- In the 1890's, a man named Trendelenberg suggested cutting the vein in the groin and tying the vein off, stopping the blood from refluxing. Although this seems to make sense, it didn't work in a great many patients for 3 main reasons:

• the material used to tie the veins dissolved and the veins re-connected
• the vein below the tie was still refluxing blood from tributaries feeding into the vein below the level of the tie
• most patients have other causes of venous reflux that aren't corrected by a simple tie in the groin

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High tie and Stripping

During the next 50 years or so after Trendelenberg, vein surgeons found they could improve the results of the high tie if they then stripped the vein out to below the knee - and sometimes to the ankle.

However, although there was a little improvement, most veins still came back (recurred). One of the main reasons for this was discovered in prize winning research in 2005 by The Whiteley Clinic when we showed that the act of stripping the veins stimulates the healing process, resulting in veins that were stripped to grow back again.

When you add the failure of this treatment to permanently get rid of the veins to the facts that the high tie and strip usually:

• is very painful
• results in 2 weeks off of work
• leaves big scars (compared to the new keyhole surgery)
• needs a general anaesthetic
• has a risk of DVT
• has a risk of nerve damage

then it is not surprising that venous specialist have been moving away from this old technique towards the new walk-in walk-out local anaesthetic procedures for vein surgery, listed below.

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Walk-in walk-out local anaesthetic procedures for veins

There are a host of these new 'keyhole' procedures for varicose vein surgery - many of which work very well although most work better in some veins than in others.

The whole idea of 'keyhole' surgery for varicose veins started in the UK on the 12th March 1999, when Mark Whiteley and Judy Holdstock performed the UK's first keyhole operation for varicose veins using radiofrequency ablation.

The procedure was carried out in Guildford and the whole operation was guided using Duplex Ultrasound - making sure that exactly the right vein was treated and that it was fully closed by the operation.

This operation started all of the current interest into 'keyhole' surgery for varicose veins - and Mark Whiteley and The Whiteley Clinic have stayed at the forefront of this new specialty - developing new procedures, inventing new ways of doing operations and continually improving these new techniques.

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Radiofrequency Ablation (RFA) of varicose veins

The first such device in the UK was the VNUS^® Closure^® device. It was the original VNUS^® Closure^® catheter that we used for our first keyhole operation for varicose veins in March 1999. At the time we liked this early device as it did not get hot, but worked instead by passing electric current into the vein wall at radiofrequency rates, making the vein wall itself heat up. The outside of he device then had a temperature measuring thermocouple making sure the vein wall was heated to the optimal temperature - 85 degrees centigrade.

The VNUS^® Closure^® catheter underwent a few changes and on 5th March 2007 Mark Whiteley performed the first VNUS^® Closure^® FAST^® procedure in the UK.

The FAST^® catheter worked in a different way to the original VNUS^® Closure^® device. Whereas the original device passed electric current at radiofrequency rates into the vein, making the vein heat up itself - the VNUS^® Closure^® FAST^® device has a long 7cm end that gets hot itself. This 7cm end is heated by radiofrequency current, but the vein - or any other tissue touching this hot end - is heated by simple contact (ie: conduction). Therefore experts in the field question if this is actually radiofrequency ablation at all any more, or just thermo-ablation - closing the vein with heat.

At The Whiteley Clinic we have moved away from this device as the 7cm end reduces the flexibility of the catheter and the number of veins it can be used in. Surgeons and clinics dealing with simple veins can probably use this device in many patients. However, a great many people who come to see us at The Whiteley Clinic for our expert help have complex veins with very small diameters or recurrent varicose veins with many very short lengths that need treating - and so these cannot be treated with this device.

Since 2009 we have been using the RFiTT^® device by a company called Celon, who are associated with Olympus. This is a true radiofrequency device similar, but more powerful, than the original VNUS^® Closure^® catheter. It has a short working end which can be placed precisely by ultrasound and it can deliver a variable amount of energy to optimise the closure of many sizes of veins.

Unfortunately, when RFiTT^® was first launched, the power settings that were recommended did not tally with our experience of keyhole surgery for varicose veins and so we would not use it at The Whiteley Clinic. However, we have now completed our research to show how to modify the power settings to overcome the problems that the original RFiTT technique had, and we are now using it very successfully with our own treatment settings and protocol.

The RFiTT^® device used with The Whiteley Clinic settings and protocol is now our preferred method of RFA (Radiofrequency Ablation).

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RFA for Incompetent Perforator Veins - (Transluminal occlusion of perforators - TRLOP)

Perforating veins are veins that take blood from the surface veins deep down through the muscle, into the deep veins of the legs from where the blood gets pumped back to the heart. If these perforator veins lose their valves, they become incompetent perforator veins (IPV) which can then leak blood.

As the pressure generated in the deep veins has to be large enough to pump the blood back up to the heart, then a leak in this system means very high pressure blood can flow out of an IPV causing varicose veins or skin damage - another 'hidden' cause for thread veins, varicose veins or associated complications.

Our research has demonstrated that 40% of patients with varicose veins have IPV's and 63% of patients have recurrent varicose veins - so an effective treatment is needed.

In 1999, Mark Whiteley and Judy Holdstock invented a procedure called TRLOP that uses RFA to close IPV's. Under ultrasound control, a special RFA catheter is put into the IPV - we used to use a VNUS RFS device but now use the RFiTT device. Under local anaesthetic the current is switched on and the IPV is closed permanently in seconds.

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Endovenous laser ablation (also called EVLA, EVL, EVLT^® and many others)

Endovenous laser ablation of varicose veins appeared the year after RFA using VNUS^® Closure^®. It was invented by a Spanish doctor C. Bone, but was popularised by Dr. R. Min from the USA (see www.evla.co.uk).

Endovenous laser is often called by a variety of names - such as EVL or EVLA. However some names, such as EVLT^® are often incorrectly used to mean any endovenous laser whereas they are registered trademarks and refer to only one company's product. Therefore the correct term to use for all endovenous laser ablation is EVLA.

EVLA is similar to RFA in that they both involve a tiny 'keyhole' incision into the vein lower in the leg, made under ultrasound guidance. As with RFA, the EVLA catheter is passed up the vein, guided precisely by Duplex Ultrasound.

Local anaesthetic is placed around the vein and the laser is fired, closing the vein permanently.

At The Whiteley Clinic we started using EVLA for many of our local anaesthetic walk-in walk-out varicose vein operations on 19th May 2005. By the beginning of 2010 we had performed over 2000 successful EVLA procedures.

Although there are many different wavelengths and devices that can be used in EVLA, our general findings are that EVLA is a very successful technique to close the truncal veins that cause varicose veins and other venous problems and it is particularly useful in big veins or irregular veins where the RFA catheter might not have good contact with the vein wall.

However, unlike RFA, EVLA often makes holes in the vein at it treats it, meaning blood can leak out causing more discomfort and bruising. This is very variable and many patients do not get this - however a significant do.

Therefore at The Whiteley Clinic we do use EVLA on many patients - but we only recommend it to people whose veins are best treated by EVLA rather than one of the other methods that are available.

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Foam Sclerotherapy - or Ultrasound Guided Foam (UGF) or Endovenous Chemical Ablation (EVCA)

Sclerotherapy is a technique for injecting veins with a liquid substance that destroys the vein wall, getting rid of the vein. However, experience and research shows that it is only really useful for very small veins (thread veins or very small green veins).

In 1935 the first paper was published about making the liquid into a 'foam' by mixing it with gas. The reason for making a foam is that when liquid sclerosant is injected into a larger vein, the liquid sclerosant mixes with the blood and causes a clot. This clot turns that overlying skin brown and can give a bad result.

By making the sclerosant into a foam (with a consistency like shaving foam) and then injecting the foam into a vein, the foam physically pushes the bloodout of the area to be treated, leaving just the sclerosant fluid in the vein to kill the vein wall.

Foam is only a collection of small bubbles and so as they pop, the foam disappears. Outside of the body, foam can be seen to last up to about 4 minutes. When injected into veins, some of that time has been lost and so the foam lasts for about 2 minutes inside the vein. Therefore after injection, compression bandages need to be placed over the vein, holding it shut, stopping any blood flowing back into the treated vein. If it did, blood getting into the dead vein would clot, leading to a painful lump and brown stain.

As it takes 14 days for the dead vein to be absorbed by the body, the compression needs to be worn continuously for 14 days and nights for the best results.

Air should not be used to make foam. Air is about 80% nitrogen and bubbles of nitrogen injected into the blood stream can go through the heart and in about 1 in 4 people, can cross the centre of the head and go to the brain.

At The Whiteley Clinic we use a combination of Oxygen and Carbon Dioxide to make the foam. These gases are easily absorbed by the body and so the risks of nitrogen bubbles are virtually eliminated.

Although foam sclerotherapy has been widely publicised as the 'alternative to surgery' research and experience has shown that although it worked very well in small veins, the results are much worse the wider the diameter of the veins.

In summary, foam sclerotherapy is a very useful addition to our armoury for use against varicose veins - and is particularly useful in complex veins through scar tissue in recurrent varicose veins or in hard skin around ulcers at the ankles - but it isn't as good as RFA or EVLA for large truncal veins.

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Clarivein closure of varicose veins

Clarivein is a very new and very different technique for closing truncal varicose veins. It is an alternative to radiofrequency ablation (RFA) and endovenous laser ablation (EVLA) which both use heat to close the vein.

Clarivein is inserted into the vein under ultrasound control, just like RFA and EVLA. However, instead of using heat, Clarivein has a small wire that rotates at very high speed, damaging the wall of the vein from the inside. As the vein is damaged by the wire, a steady trickle of sclerotherapy solution is passed out of the end of the wire, treating the cells in the wall that are not destroyed by the rotating wire.

One of the major advantages is that there are far fewer injections of local anaesthetic needed as there is no need cool the vein down.

However, Clarivein is very new and so there are no medium or long term results proving that it is effective in the medium or long term. Although we know that the heating of the RFA and EVLA systems penetrates the whole wall and permanently destroys the veins that they treat, there is no evidence available at the moment as to how much of the vein wall is destroyed. Therefore although Clarivein is available, we are currently only offering it to patients who accept that we cannot be as certain of the long term results as we are with the other keyhole techniques that we use.

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Coil Embolisation under X-ray control

Platinum metal coils can be put in veins through very fine tubes (called catheters) to permanently close the veins. In vein surgery, we only use these in pelvic veins for pelvic vein reflux. Because these veins are very deep, they need to be placed under X-Ray control.

Please see www.vulval-varicose-veins.co.uk and www.vaginavaricoseveins.com.

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Phlebectomies (hooking out of veins)

For bulging surface veins, sometimes the best treatment is local anaesthetic phlebectomy - especially if very big. Almost always deeper veins will have been treated first with RFA, TRLOP or EVLA before the phlebectomies will have been performed, or foam sclerotherapy will be needed afterwards for underlying complexities - but in a few patients phlebectomies alone might be needed.

The bulging varicose veins are marked when standing up or with Duplex Ultrasound at the time of surgery. Local anaesthetic is infiltrated around the veins using a tiny needle and a pump, and then the veins are hooked out through tiny 2mm incisions.

A compression stocking is worn for 2 - 3 days and then everything is usually healed.

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Liquid Sclerotherapy - Microsclerotherapy

Sclerotherapy has already been discussed above, under 'Foam Sclerotherapy'. As noted, sclerotherapy only really works if the blood can be removed from the vein, leaving just the sclerotherapy solution in contact with the vein wall.

For very small veins (like thread veins) liquid sclerotherapy is injected which then flushes the blood out of the vein, leaving the ideal conditions for vein destruction, after compression for 14 days and nights.

Any vein that is to big to flush the blood out, doesn't do well with liquid sclerotherapy.

Therefore at The Whiteley Clinic, liquid sclerotherapy is now only really used for thread veins treatments on the legs - a procedure called Microsclerotherapy (see www.thread-veins.co.uk).

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