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Varicose Veins, Available Surgical Techniques.

  • What options are available for treatment of varicose veins?

    Broadly speaking, varicose veins can be treated in two main ways:
    • Conservative treatment of varicose veins.
    • Surgical management of varicose veins
    a) Traditional open surgery
    b) Minimally invasive surgery (Laser EVLT or Radiofrequency VNUS or foam sclerotherapy techniques)

  • What are the conservative or medical treatments of varicose veins?

    The main way to help is to reduce the high pressure of the blood in the veins. This will help prevent your veins getting worse and relieve your symptoms. There is nothing that you can do to permanently remove the veins.
    • You can leave varicose veins alone; many people have varicose veins for many years without almost any ill effect. The NHS websites indicate that most varicose veins require no treatment but it goes on to reveal that "varicose veins rarely cause complications".
    • Some people decide to wear support stockings (hosiery) for their varicose veins. Hosiery provides external pressure to the vein and encourages the blood to travel up the leg. It may be helpful if you are unable to avoid standing for long periods of time. Medical compression hosiery is also available in made to measure standards.
    • Exercising regularly causes the muscles in your thigh and calf to contract, which helps the blood move along the vein and up your leg. Walking is a good exercise to help the veins. Sitting or standing for long periods of time puts extra pressure on your veins as the muscles are not contracting as much. Raising your feet when possible uses gravity to drain the blood out of the veins.
    • Losing excess weight reduces the work that your heart has to do which in turn reduces the pressure on your veins and arteries.
    • Look after your skin and prevent excessive dryness by using water based creams such as E45. Only moisturise after washing and drying the skin.

    Where possible, worried patients with varicose veins should seek the opinion of their general practitioner or vascular surgeon. 

  • What are the benefits of surgery over conservative management?

    Conservative measures mentioned above such as compression stockings will control symptoms and may prevent progression of varicose veins. They do not, however, treat the condition and require a lifelong of adherence to the wearing of the compression stockings. However, some patients would rather not have an operation and are quite happy wearing support stockings; equally even the minimally invasive endovenous surgery may not be appropriate for the very elderly or those with multiple medical problems. However, the vast majority of patients with varicose veins are suitable candidates for one or other form of surgery. They will gain benefit from treatment of their veins, long lasting improvement of symptoms, and the prevention of possible skin ulceration.

  • What surgical or minimally invasive surgical options are available for the treatment of varicose veins?

    Nowadays, modern varicose vein treatment is less invasive. It means that varicose veins can often be treated effectively under local anaesthesia in an outpatient setting with much improved results.
    The success of any procedure is measured by:
    • Effective removal of the varicose veins responsible for symptoms
    • Early complications (such as infection, bleeding, pain, deep vein thrombosis, haematoma)
    • Late complications (numbness, scarring, discolouration, nerve damage, and recurrence of veins)
    • Acceptability by patients
    It is very difficult to ascertain the exact complication rates of open surgery as up till perhaps a decade ago many operations were also performed by general surgeons not specialised in vascular surgery.  Since then, most of the varicose vein operations are being performed by vascular surgeons. In fact, before proceeding to varicose vein surgery it is imperative that all patients ensure their procedure is being carried out by a vascular surgeon (with sufficient experience especially if considering minimally invasive surgery).

  • Is there a relationship between varicose veins and deep vein thrombosis (DVT)?

    Deep vein thrombosis (clot in the deep veins ; or so called “economy class syndrome") results in pain and swelling and may result in long term ankle swelling, discomfort and skin problems. The risk of DVT after varicose vein surgery is small, but may be higher if you have had DVT in the past or have a familial tendency for excessive clot formation. Use of oral contraceptives and hormone replacement therapy is said to increase the chances of DVT after any surgery. For these reasons some patients would be advised to receive an injections of anticoagulant (blood thinner) medication prior to surgery and are encouraged to move around soon after surgery.

    Patients with varicose veins do not per se develop a DVT. There are, however, rare circumstances in which extensive an DVT can make varicose veins worse.

  • What are the surgical options for treatment of varicose veins?

    • Traditional open surgery for varicose veins:
    The traditional procedure of choice is sapheno-femoral ligation (or sapheno- popliteal junction) and stripping of the long saphenous vein (or short saphenous vein) with or without multiple stab avulsions of the tributaries of these main truncal veins. It is otherwise known as high tie, strip, and avulsions. This is performed under a general anaesthetic and the procedure duration is approximately 20 – 60 mins depending on the extent of surgery required, whether one or both legs are being treated, and whether first time surgery, or a re-do operation is carried out.

  • The procedure of high tie, strip, and avulsions

    The procedure involves a horizontal incision in the top of the leg approximately 1-2 inches (2.5 – 5 cms). The sapheno-femoral junction is then dissected out and divided with ends of veins suture closed. The long saphnous vein is then stripped out through the lower end of the thigh by making a small (1/4  inches or 0.5 cm) incision to allow delivery of the vein. A metal or plastic stripper is required for this purpose which is passed through the vein lumen down the thigh and grasped through the small incision previously made in the lower thigh.

    Once the main trunk of the vein is removed, the tributaries of this vein can be avulsed through stab incisions (1-2 mm) and hooked out using a special instrument. The number of these stab incisions depends on the number of these tributaries present and how extensive the varicosities are.

    Following surgery, the wounds are closed (with absorbable sutures), the leg is bandaged in a compressive dressing and patient then transferred to the recovery area to come through the general anasethetic. The recovery process is varied depending patient’s susceptibility to anaesthesia and may take ½ hour to several hours. Most procedures carried out in the morning allow patients to return home the same day. Prior to discharge, the bandage is replaced by compression stockings which should be kept on for around 2 weeks. It is possible to take a shower after about 2 to 3 days following surgery. A follow up visit is arranged around 4-6 weeks after discharge to ensure quality control. It is expected that the legs will develop a variable amount of bruising which will settle with time.

  • Pros and Cons of open surgery

    The advantage of open surgery is in its long term history of success. It is a very effective and durable and safe procedure in hands of experts that has proven success and history of decades of experience. It also confers the advantage of removing all the veins that contribute to symptoms in one operation; also, it can be applied to any patient with varicose veins.

    The disadvantages are that the surgery requires a general anaesthetic and an incision in the top of the leg is needed (both are avoided in minimally invasive techniques – see below).

    Newer anaesthetic techniques have made modern general ansesthesia a very safe practice which means the vast majority of people will have no serious ill effects from the anaesthetic; however, less serious side effects still can be encountered such as nausea and vomiting.

  • Complications of open surgery

    Broadly speaking, the nature of these is similar to minimally invasive procedures. The techniques vary however, in the frequency of the complications.

    The success of any open surgery procedure is measured by:
    • Effective removal of the varicose veins responsible for symptoms
    • Early complications (such as infection, bleeding, pain, deep vein thrombosis, haematoma)
    • Late complications (numbness, scarring, discolouration, nerve damage, and recurrence of veins)
    • Acceptability by patients

    It is argued that adequate removal of long saphenous vein (stripping main truncal superficial vein) in expert hands along with avulsion of tributaries results in effectively treating the cause of high venous pressure (and hence varicose veins) within the leg. What’s more this can all be done during the same procedure if carried out under general anaesthetic.

  • Infection following surgery

    Any wound can become infected and this also applies to surgical wounds. However, because the theatre environment is clean and experienced surgeons are careful with the handling of tissues and wound closure, the incidence is very low indeed. To further lessen the chance of infection we give a dose of prophylactic antibiotics during the procedure and advise patients to avoid soaking in a bath or Jacuzzi for a week after the operation – brief showers are fine from the second or third day after surgery. 

    Methecillin Resistant Staphylococcus Aureus or MRSA is a common cause for concern specially with patients being  treated in hospitals. Colonisation of skin with MRSA is frequently found in the population and this bacteria causes no harm on intact skin. If it contaminates a surgical wound however, it can delay healing or even cause an infection which is more serious and can be life threatening if it gets into the blood to cause septicaemia. With procedures such as varicose vein surgery it is very uncommon for patients to develop problems with MRSA as hospital exposure is quite short (mostly day case treatment). Most people are nowadays screened for MRSA prior to their surgery and if found on skin or nose, surgery can be postponed for eradication prior to re-scheduling the operation. Eradication can sometimes be difficult to achieve and in those circumstances a decision needs to be made to whether proceed to surgery given the small potential risks. 

  • Bruising and pain

    Post-operative bruising and lumpiness is the norm – especially where there have been many varicosities. This clears completely with time. Sometimes a tender red line may appear on the inside of the thigh in the first week or two after the operation. If it appears following open surgery it is related to bleeding into the space that the long truncal vein (the long saphenous or the short saphenous veins) occupied causing a haematoma (collection of blood). In the context of minimally invasive  surgery it is due to thrombophlebitis. In either case,  it can be a source of pain or discomfort but will settle in about 2 weeks. It is not an infection – merely the body’s reaction to blood clot in the strip track or the residual vein which has been treated by LASER or VNUS Radiofrequency.

    Also, given the more invasive nature of open surgery, some patients experience pain from the surgical site. Careful surgery and the use of long-acting local anaesthetic injections in the wound allows better post operative pain control and permits the all-important early mobilization.

  •  Late complications

    Occasionally, tiny skin nerves may be bruised, leading to numb areas; but this usually clears in the months after the operation. It is most unusual for experienced surgeons to damage the larger nerves - the saphenous and sural nerves - to the extent that there are permanently numb areas. With difficult redo surgery behind the knee there are reports of damage to a nerve in that area (the common peroneal nerve) which results in permanent weakness to some of the muscles to the foot.

    Deep vein thrombosis is a reported major but thankfully rare complication. The patients are encouraged to elevate their legs (when not walking) and to wear support stockings until they are fully mobile to reduce risks of DVT further.

    Recurrence of varicose veins is a perennial problem no matter which technique is used. Now a days, and in the context of open surgery performed by an experienced vascular surgeon, this should be a much reduced event. Never the less, this still happens more often than should. Recurrence rates of 13% after 2 years and 62% after 6.5 years have been observed. Most of these are only manifest on ultrasound scanning and may not necessary indicate a return to initial symptoms.
    There is evidence to suggest that it is caused in most cases by a process known as neo-vascularisation. This simply refers to a process of new vessel formation following injury (or trauma of surgery) to allow improved healing in damaged tissues. However, this is an unfavourable outcome in the setting of varicose vein surgery as it can result in re-establishment of the connections between the superficial and the deep veins. Ultimately, it can lead to re-appearance of varicosed tributaries (side branches) as a consequence of increased pressure within the superficial venous system.

  • Acceptability by the patients

    Beyond the first 2 weeks following varicose vein surgery, most patients report very satisfactory results with surgery in terms of removal of the varicose veins and the source of their symptoms. Most return to normal daily activities and work within 10 days to 2 weeks, able to function without the dull, dragging pain associated with varicose veins. However, in circumstances where both legs have varicose veins, most patients choose to deal with one leg at a time to reduce the postoperative discomfort.

  • What are the comparisons of open surgery and minimally invasive endovenous techniques?

    Over the recent years the surgical procedures for varicose vein treatments have been modernised. Examples are smaller incisions, use of ultrasound in ensuring stripping of the truncal vein, and performing the procedure under local anaesthetic infiltration. Successful treatment of varicose veins regardless of method requires meticulous attention to symptoms and removal of all sources of incompetence or reflux. This for example includes ablation of the long saphenous vein down to the lowest point of reflux which in some cases may be well below the knee. Some have also reported combining open surgery (high ligation) and EVLT to the truncal vein although we have no experience of this.

    We have compared the minimally invasive endovenous techniques with open surgery under the following headings:

  • Comparison of VNUS radiofrequency technique and open surgery

    In well conducted studies comparing radiofrequency (RF) obliteration (VNUS)to standard surgery (such as the EVOLVeS study*) the clinical results of VNUS were at least as good as conventional open surgery.

    However, if quality of life outcomes are looked at (loosely equates to patient acceptability), endovenous surgery has the upper hand. In a small randomized study of patients having both legs treated for varicose veins one leg was treated with conventional surgery and the other with laser treatment. Following surgery the patient satisfaction questionnaires indicated that 70% preferred laser to surgery and only 10% reported that there was no difference. These results also reflect the conclusions in the EVOLVeS study with an earlier return to physical activity and return to work in patients undergoing VNUS treatment for their varicose veins. What is more interesting is that the differences between patient satisfaction scores in favour of VNUS persisted even 2 years after initial treatment.

    In another (similarly controlled) trial VNUS took longer to perform compared to surgery but was similarly associated with less post operative pain and earlier return to work and better patient satisfaction scores compared to surgery. In this study although the cost of the VNUS procedure was higher, the advantage of earlier return to physical activity and work meant that the total economic costs involved were in fact less in the minimally invasive technique.

    In a randomised study comparing the VNUS technique with traditional open surgery, patients with bilateral recurrent veins were chosen and were treated in each leg by either of the methods at random and results analysed. Both procedures were carried out at the same time under general anaesthetic. The procedure time was quicker using VNUS technique (25min vs. 40 min) and patients experienced less bruising and pain after treatment compared to surgery.

    *Prospective randomised study of endovenous radiofrequency obliteration (closure) versus ligation and vein stripping (EVOLVeS): two-year follow-up. Lurie F, Creton D, Eklof B, Kabnick LS, Kistner RL, Pichot O, Sessa C, Schuller-Petrovic S. Eur J Vasc Endovasc Surg. 2005 Jan;29(1):67-73.

  • Comparison of Laser EVLT and open surgery

    In a robust study comparing EVLT with standard open surgery, laser achieved as good a result in terms of continued occlusion of the truncal vein (long saphenous vein) and symptom relief (and patient satisfaction) following treatment 1 year after surgery. Laser treated patients returned to normal everyday activity quicker than surgical patients despite the finding that freedom from postoperative pain was the same between the 2 groups. This is in keeping with results of others reporting shorter hospital stays with EVLT compared to open surgery but comparable outcomes in parameters mentioned above. Another study of similar nature, reported more bruising with open surgery compared to EVLT; however the authors observed no difference in terms of time taken to return to work between the groups (average around 7 days), or patient satisfaction scores, even though the open surgery patients reported higher pain scores compared to EVLT in the first 10 post operative days.

  • How do minimally invasive techniques compare to open surgery in patients with recurrent veins?

    One of the indications for minimally invasive surgery is in treatment of recurrent veins. Redo surgery involving reopening of the previous surgical scar is technically more difficult and carries higher risks of complications. With minimally invasive varicose vein therapy, reoperations in the groin are avoided.

    The recurrence rates (reappearance) after endovenous surgery is also probably as good if not better than conventional surgery. In the EVOLVeS trial the recurrence rates following VNUS treatment was 14% compared to 21% in open surgery after 2 years although the differences could have arisen because of the small numbers of patients in the study. In larger series (but not in controlled studies) recurrence rates as low as 1% has been observed after 1 year.  Laser treatment has similar recurrence rates but some have reported rates of 7% at 2 years and others as low as 3% after 3 years. It is thought that the main reason for lower recurrence rates following endovenous therapy is a reduction in the neovascularisation process which often occurs in the scarred tissue of open surgery.

  • Criticisms of minimally invasive procedures

    One of the criticisms of endovenous ablation is that if phlebectomies (avulsion of the varicosed tributaries of side branches) are also required, a more extensive procedure needs to be planned possibly in an operating suite using general anaesthetic. If numerous, the avulsion removal of these varicosed side branches will require multiple injections with local anaesthetic which most patients find unacceptable and therefore more effectively performed under general aneasthetic. Some argue however, that extensive multiple phlebectomies may not be required if they are carried out several weeks after the initial endovenous procedure. Many of these disappear once the pressure within the venous system is reduced by removing the source of reflux i.e.; the truncal vein (long or short saphenous vein). It is a point to bear in mind that the more extensive the varicosities are (specially if tortuous) the less likely that they will be suitable to endovenous methods.

    The costs associated with minimally invasive treatment of varicose veins have also been higher than open surgery relating to the cost of the equipment and the disposable RF catheters or laser probes. Although the treatment is more costly with these techniques, once the economic costs of later return to work (in open surgery) is added on to the operative costs the differences swing in favour of the minimally invasive methods.

  • What is the best method of treatment for varicose veins?

    Each case of varicose veins needs to be considered separately. However, patients who undergo the minimally invasive procedures such as VNUS or EVLT typically:
    • Can have procedure carried out under local anaesthesia.
    • Experience less postoperative pain and bruising compared to surgery.
    • Resume normal activities sooner than surgery.
    • Have better patient satisfaction scores than surgery.
    • Good cosmetic outcome with no surgical scarring in the groin.

    Endovenous techniques of laser (EVLT) and radiofrequency (VNUS) have arguably become the gold standard of treatment for truncal varicose veins, such as long saphenous or short saphenous veins.  These methods hasten patient recovery and have been used for more than ten years with proven safety and efficacy.  However, there are limitations as well as cautions to be exercised in considering these techniques for treatment of varicose veins. Most of the information from the medical literature reports comparable (if not better) short and medium term outcomes with these treatments to open surgery; but until long term data regarding durability and recurrence rates are available open surgery will remain an option in treating varicose veins.  Heat generated from minimally invasive endovenous techniques may cause skin damage or burns in patients with very thin legs or very superficial veins. Extreme tortuousity of truncal veins may prove difficult to negotiate with the laser fibre or the RF catheter.

  • Which of these methods of minimally invasive varicose vein treatments are better?

    Recently, the results of endovenous ablation with radiofrequency Closure FAST (VNUS) catheter have been compared to the conventional laser (EVLT) treatment in a controlled trial (the RECOVERY trial*). The two treatments were compared in terms of post operative pain, bruising, and complications of deep vein thrombosis, numbness, and pigmentation. The results indicated that at one month bruising was less common in patients treated with VNUS. The laser treated patients experienced more pain for up to 2 weeks after treatment but there was no difference in terms of pain levels at one month. There were no differences in terms of successful occlusion of the long saphenous vein (both 100%) , or complications such as pigmentation, deep vein thrombosis, or numbness between VNUS and EVLT. Although study is seemingly well conducted, it must be noted that it was sponsored by the company making the VNUS Closure FAST catheters. Therefore, it would be interesting to know if others can reproduce the findings of this study.

    In an earlier interesting study patients with bilateral varicose veins were treated using EVLT in one leg and VNUS technique in other chosen at random. Although the overall complication rates were the same, a higher proportion of the veins treated by VNUS technique remained closed compared to EVLT treated veins after one year follow up.

    In another (less well controlled) study, the reported complication rates following VNUS technique were 7% compared with 20% in the EVLT technique of varicose vein treatment.

    For these reasons, we recommend VNUS radiofrequency ablation to our patients for the treatment of their varicose veins. It is an effective method and can be combined with the immediate removal of tributaries (side branches) of varicose veins through tiny incisions under local anaesthetic. It offers excellent rates of long saphenous vein closure (main truncal superficial vein) with less immediate post-operative pain and lower incidence of other complications compared to the laser method. We do however, offer the full range of treatments for varicose veins including Laser EVLT, foam sclerotherapy, and open surgery. Details of these can be discussed with you during your appointment.

    *Radiofrequency endovenous ClosureFAST versus laser ablation for the treatment of great saphenous reflux: a multicenter, single-blinded, randomized study (RECOVERY study). Almeida JI, Kaufman J, Göckeritz O, Chopra P, Evans MT, Hoheim DF, Makhoul RG, Richards T, Wenzel C, Raines JK.
    J Vasc Interv Radiol. 2009 Jun;20(6):752-9.

  • How likely are my varicose veins to disappear following minimally invasive treatment?

    VNUS Radiofrequency treatment is our method of choice for treatment of varicose veins where possible. This minimally invasive technique causes an occlusion (thrombosis) of the main truncal superficial vein (long saphenous vein). This along with deliberate damage to the protein structure of the vein wall means that the vein will no longer carry any blood. Over the ensuing months there is a gradual disappearance of the long truncal vein. With the back pressure reduced, the tributaries (side branches) of the main superficial vein (what most people recognise as varicose veins) also reduce in size and in many instances are no longer visible. Those that remain can be removed under local anaesthetic.  This is a very simple procedure which we will explain to you in your appointment.

  • What are the advantages of VNUS Radiofrequency technique?

    The minimally methods (such as VNUS radiofrequency technique) of treating veins are generally less invasive and have the following potential benefits:

    • Procedure can be carried out under local anaesthesia.
    • Patients experience less postoperative pain and bruising than compared to surgery.
    • Resumption of normal activities sooner than surgery.
    • Better patient satisfaction scores than surgery.
    • Good cosmetic outcome with no surgical scarring in the groin.

  • What are the side-effects of minimally invasive endovenous techniques such as VNUS Radiofrequency:

    Any technique for treatment of varicose veins can lead to development of complications and broadly speaking these are similar between techniques; what is different is the frequency with which they can occur.

    The success of any varicose vein procedure is measured by:
    • Effective removal of the veins responsible for symptoms
    • Early complications (such as infection, bleeding, deep vein thrombosis, haematoma)
    • Late complications (pain, numbness, scarring, discolouration, nerve damage, and recurrence of veins)
    • Acceptability by patients

    Endovenous techniques produce as good a results, if not better, than conventional surgery in removing the cause of incompetent reflux (leaky vein valves) in the main superficial truncal veins (long saphenous vein)

    There has been no serious complications in the patients who have been treated with endovenous surgery by our vascular surgeon, who has routinely been carrying out this procedure for a number of years. Very occasionally there might be trouble with transient inflammation of the treated varicose veins (thrombophlebitis) which normally responds well to anti-inflammatory drugs such as Voltarol or Nurofen.

    Deep vein thrombosis is a reported complication of this procedure and might occur in any operation particularly on those which are carried out on the lower limbs. This is avoided by careful techniques and encouraging mobilization after the operation. Minimal bruising does occur but always clears with time. Occasionally patients will develop a few thread veins after treatment but these generally subside with time. If bothersome, they can be dealt with by micro-injection sclerotherapy (not the foam injection mentioned above). Infection of the needle access site can occur very rarely. Numbness in the inner thigh distribution has also been reported.

    With the removal of the head of pressure, thread veins, spider veins, and even reticular veins frequently improve, sometimes even to the point of disappearance. However, those that remain after three to six months will need to be addressed by micro-injection sclerotherapy if they bother the patient. Occasionally, thread veins may appear after the varicose vein surgery (usually just above the knee on the inside of the thigh) – this seems to be the result of blood opening up new routes to return to the heart. These fine thread veins usually settle with time, but may require micro-injection Sclerotherapy if they bother the patient.

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