Vein Treatments
What treatments are available?
Since varicose veins are not dangerous there is a choice about whether to treat them.
Doing nothing is an option. If aching is the main problem then support stockings or tights can often go a long way to relieving discomfort although they will not get rid of the veins themselves.
However, in my experience, most people who bother to see their GP or a specialist are fed up with their veins and want something doing about them. Treatments available are described below together with an idea of their pros and cons.
Newer Less Invasive Methods of treating varicose veins; VNUS Closure and EVLT (Laser Surgery)
See Mr MacSweeney doing a local anaesthetic VNUS procedure on BBC News.
Click on: http://news.bbc.co.uk/2/hi/uk_news/england/7524339.stm
The vein which runs down the inside of the leg from the groin to the ankle (long saphenous vein) is the commonest vein to allow blood to flow in the wrong direction and to need treatment (see “varicose veins” for an explanation).
Traditional surgery involves making a cut in the groin to tie this off and then removing it (“stripping”). While this is effective, it requires a general anaesthetic and produces a significant amount of bruising which takes time to recover from.
Newer treatments aim to deal with this vein in a much less invasive way so as to avoid a cut and often the need for a general anaesthetic, they also produce much less pain and bruising, so that recovery is faster.
There are two basic ways of dealing with the vein, either by feeding a very fine device up within the vein from below and using it to heat up the vein from the inside (VNUS catheter ablation or Endovenous Laser therapy) or by injecting foam into the vein (foam sclerotherapy).
VNUS catheter ablation
Click on links for a patient information video explaining the procedure www.vnus.co.uk For detailed information on the newest “Closurefast” local anaesthetic method see www.closurefast.com.
In the “Closurefast” procedure, some local anaesthetic is placed over the vein to be treated, usually just below the knee, a small tube is inserted into the vein, and the VNUS catheter is inserted via this tube into the vein and passed up inside the vein until it reaches the top of the vein in the groin.
An ultrasound scanner is used to monitor the position of the catheter inside the vein. Once positioned more local anaesthetic is placed around the full length of the vein to be treated. The catheter is then switched on and this heats up a 7cm section of the vein at the end of the catheter which shrivels it up, the catheter is then withdrawn another 7cm and the next section treated and so on until the entire vein has been treated.
The catheter is removed, a support stocking or bandage is placed on the leg, and the patient gets up and goes home. Mr MacSweeney did the first VNUS procedure in Nottingham in 2002, the first hundred cases were followed up by ultrasound scan and the procedure was successful in 99%.
The improvement in terms of post-operative recovery was striking bur the original procedure was performed under general anaesthetic. The new Closurefast system is an excellent development because it can be done under local anaesthetic.
Please view or download this PDF - Patients Guide To VNUS Closurefast
Laser treatment (EVLT)
The VNUS catheter uses radiofrequency energy to heat up the inside of the vein, EVLT uses laser energy to do it. The basic idea is the same as VNUS, with the laser fibre being passed up the vein from the knee to the groin under local anaesthetic, and the vein being heated up and shrivelling away.
The main difference is that the tip of the laser fibre is much hotter than the VNUS catheter and while this is effective at shrivelling up the vein it tends to burn little holes in it which can cause bruising and post operative pain.
Recent research suggests that while both methods are very effective at eradicating varicose veins, and are good techniques, laser treatment causes more post operative pain and bruising than VNUS. In my opinion while laser sounds marvellously high tech, VNUS is better for this reason.
Foam Sclerotherapy: What is Foam Sclerotherapy? (Varicofoam)
Sclerotherapy involves injecting a substance (sclerosant) into the varicose veins which seals off the varicose veins, preventing blood flowing through them. While this works fine for small veins, the sclerosant is inactivated by blood and does not work well for large veins.
Recently it has been discovered* that if the sclerosant is mixed with air to form foam, then it pushes the blood out of the vein. This makes it much more effective at treating larger veins and makes it a more useful treatment.
The other difference between foam sclerotherapy and standard sclerotherapy is that an ultrasound scanner is used to observe the foam and check that the entire vein is treated. This also helps to make it more effective. Once the vein has been treated, it is compressed using a combination of bandages and elastic stockings. This is an important part of helping to seal off the vein.
What should I expect after foam sclerotherapy?
After treatment, you will need to wear bandages and a stocking for five days and then a stocking for two weeks. This means it is difficult to have a shower or bath for the first week. Wrapping the bandaged leg in cling film or in a bin liner can allow showering without wetting the leg and bandages.
After the treatment, it can take several months for the veins and bruising to disappear completely.
Some people, especially those with large varicose veins, can get pain in the area treated caused by phlebitis. This can be treated with pain killers like Ibuprofen.
Are there any complications associated with Varicofoam?
All procedures carry some risks. The particular risks of Varicofoam are reactions to the injection which are very rare. It is possible that blistering of the skin can occur. There is a risk of Deep Vein Thrombosis (DVT), although this risk is very small and there is also a DVT risk with standard surgery.
Transient visual disturbance has been reported as a very rare complication. In my opinion the major downside of foam sclerotherapy compared with the VNUS and EVLT is that if plebitis occurs, it can take weeks or even months to settle down fully. Pigmentation of the skin (a brownish area) can occur, and while it usually settles this too can take several months.
* Like so many “new” discoveries, this was recognised years ago but forgotten about. Actually it is a rediscovery.
What does the traditional operation involve?
If the newer less invasive methods are not available to you locally, or if your veins are not suitable for them, then you will require a "traditional" operation. There is nothing wrong with this and it works well, but it does take longer to recover from that the newer methods. Please note that the details of an operation, for example, what kind of stitch or bandage is used may vary from surgeon to surgeon.
Most commonly, the source of the problem is at the top of the leg (groin). In this situation you will require a cut in the groin and small nicks over the veins in the leg and calf. The varicose veins will be removed. You will have some self-absorbing stitches in the cut in the groin and usually no stitches are required in the other small incisions.
The leg will be bandaged up at the end of the operation. If the main source of the problem is behind the knee then the cut will be here. Occasionally both the groin and the back of the knee are involved.
What will it be like after the traditional operation?
Normally you come into hospital on the day of the operation and go home the on the same day (day case) or on the following day. The leg will be bandaged up. There is bound to be some bruising and although every effort is made to minimise this the amount of bruising varies from person to person and according to how many and large the veins are.
You will be able to walk around from the day after the operation and are encouraged to do so. You are welcome to walk as far as you like but are not obliged to walk miles as people used to be advised many years ago. You would certainly be expected to walk around and mobilise several times per day as a minimum.
When you are not walking around it is a good idea to try and keep the leg up, for example when watching television put the leg up on the arm-rest of the sofa as avoiding hanging the leg down reduces any tendency to swelling or bruising.
At the end of a week the bandage is removed. You can have a bath at this time. You will notice some bruising in the leg. This will gradually fade over a period of time just like any other bruise.
To start with the places where the veins were may feel a bit hard and lumpy under the skin. The stitches in the groin are self-absorbing and do not need to be removed.
It is recommended that you get a compression stocking or support tights prior to your surgery and you wear these once the bandage has been removed. This will make the leg more comfortable. The compression stocking only needs to come up as far as the knee but if you prefer a full length one, that is perfectly acceptable.
How long do I need off work after a traditional operation?
People vary quite considerably as to how much bruising they have in their leg and how this affects them. It is certainly recommended that you should have a week off following your surgery during which the bandage is in position.
After this time you will be more mobile but there is bound to be some bruising of the leg. People vary as to how much they feel able to do at this point. You would certainly be able to walk around and are encouraged to do this. You may be well enough to go back to work a week after your surgery but most people prefer to take some more time before going back to work.
If your job is particularly physical and you need to be in very good physical condition before going back to work then you may require several weeks off. If both legs are operated on at the same time, again it may take a little longer.
A few people are able to go back to work after a week. Most are able to go back after a couple of weeks, but if there are very extensive varicose veins, both legs are operated on, or you need to be particularly fit for major physical activity, you may require a couple of weeks longer still.
When can I drive?
The important thing is to be able to drive as safely following your operation as you did before it. You should certainly not drive for 48 hours after a general anaesthetic and I would recommend you not to drive for the first week while you have your bandage on.
After this you may drive providing your leg is comfortable and you can do an emergency stop, etc. I would recommend that you wear a support stocking for driving and try to avoid long drives early on as this tends to mean that you are sitting with the leg down which encourages swelling.
Are there any risks to an operation?
All operations have a risk. If you want a zero risk then do not have an operation. The traditional surgery will normally require a general anaesthetic the risk of which in otherwise well people is nowadays extremely small.
As with any operation there is the potential for bleeding or infection but the risk of this happening is low. As mentioned above, bruising is inevitable to some degree as the veins which are removed have some blood inside them.
People sometimes worry about getting blood clots (deep venous thrombosis) following varicose vein surgery. Although it is natural to consider this as the surgery involves the vein it is in fact an unusual complication. Nonetheless, it is prudent to stop the combined contraceptive pill six weeks prior to surgery as being on the pill slightly increases the risk of a blood clot.
HRT is acceptable but it is helpful to know if this is being taken. If people have a past history of deep venous thrombosis it is very important that this is brought to the surgeons' and anaesthetist's attention as special precautions will need to be taken.
The veins sometimes runs very close to a nerves supplying the skin around in this situation removing the vein can sometimes produce some numbness in the skin. This does not usually trouble people and often they don't notice it, but if it is looked for there will be some degree of numbness around the ankle approximately once in every ten operations. It usually recovers to some extent but not totally.
This is not intended to be a comprehensive list of everything possible that could happen but merely to cover more common problems or the ones that are more commonly asked about. It is worth pointing out that the large majority of people having varicose vein surgery have no complications.
Can the veins come back? Getting the right operation done
Although your doctor will wish to examine your varicose veins, examination alone is not always a reliable way to work out which veins are causing the problem. If the choice of operation is based solely on physical examination then there is bound to be an element of guesswork involved.
One of the advantages of seeing a specialist vascular surgeon is that he/she is more likely to have access to more specialised techniques such as Doppler or venous duplex scanning (see picture).
A duplex scan is an ultrasound test (like the ones used to scan babies inthe womb). It gives clear pictures of the veins and shows whether they are damaged and whether the one-way valves in the veins are working properly.
This helps the surgeon make sure that the correct veins are removed at the time of the operation. It is obvious that if the choice of operation is based on an element of guesswork, then there is more chance of having further veins after the operation. However, no matter how well your operation is planned and performed, it is unrealistic to expect every single vein to be removed every time, particularly if you have large numbers of veins.
Making new varicose veins
The veins that have been removed at the time of your operation are physically taken away and cannot come back. However, the tendency to form varicose veins is part of the way you are, otherwise you would not have varicose veins in the first place. Having had a varicose vein removed from one part of your leg will not prevent you forming a new varicose vein if that is what you are destined to do. However, once the major feeding veins are dealt with, the chances of the veins being as bad as they were originally are small.
Only about one in ten people ever get further varicose veins that are bad enough to require a second operation. In other words, sooner or later, you almost certainly will form some further varicose veins and the operation should not be regarded as a cure. On the other hand, the chances are that the varicose veins will not be as bad as before your operation and probably won't require anything doing about them.
It is important to realise that varicose vein surgery, no matter how well it is done and which method is used, is not perfect. It is certainly not a permanent cure for varicose veins. Provided people are aware of that the aim is a major improvement over a reasonable period of time rather than perfection for ever, most people are satisfied with their operation and report an improved quality of life.
How will the blood get out of my leg once the veins have been removed?
This question is often asked; because there are two systems of veins in the leg and the operation only involves some of the veins on the surface, the deep veins which are by far the most important are left untouched.
In fact since the varicose veins are allowing blood to flow in the wrong direction they are actually making the venous circulation slightly worse and varicose vein operations if anything improve the return of blood to the heart rather than making it worse.
Please note that this website is intended to give you some background information and answer some of the more commonly arising questions about varicose veins. It is not supposed to cover every possible aspect of venous disease or every possible complication. If you have any further questions you should discuss them with your specialist.
What treatment is best for me?
Sometimes the variety of treatments on offer can seem confusing, it is worth pointing out that they are all effective ways of treating varicose veins. The best choice depends in part in the type of veins you have, for example very large veins do not do well with foam sclerotherapy, it may be difficult to pass a catheter up a very wiggly vein.
So some people may not be suitable for all the various treatments. If you are suitable then it is to some extent a matter of personal preference. The great thing about Closurefast and foam is that they do not require a stay in hospital, are done under local anaesthetic and normally have a very rapid return to full activity. In general both local anesthetic Closurefast and foam sclerotherapy can be done on only one leg as a time, so if you have extensive veins on both legs you may wish to choose a general anaesthetic and have both legs done in one go.
Some people just do not like the idea of an operation under local anaesthetic and it is perfectly possible to have a general anaesthetic. Closurefast is more reliable than foam sclerotherapy, and is less likely to cause phlebitis and skin staining. It is also somewhat more expensive as it requires more equipment and time to perform. In many people the varicose veins which are obvious to see are branches arising from the major veins.
Treating the main feeding vein will make these branches disappear about 75% of the time. However, if they do not disappear a further session of treatment may be needed. Again, people under severe time pressure or coming from abroad may decide to get all their veins treated in one go under a general anaesthetic.
The most important thing is to discuss which treatment is best for you with a specialist who can do all of them, then you can decide between you which option is the best for you as an individual.