Vascular (Varicose Veins) Patient Advice in Essex, UK

Vascualr surgeon for varicose veins, renal and general surgical conditions and procedures

Patient Advice and Information

Adjuvant & New Treatments In Varicose Veins
by Dr Panayiotopoulos, Consultant Vascular and General Surgeon Essex.

VARICOFOAM SCLEROTHERAPY, VNUS & EVLT

Mr Panayiotopoulos would be happy to discuss these options with you further, if you wish to.

You should remember that the aim of surgery in varicose veins is:

To stop the communication with the deep veins at the points were this takes place, in order to stop the waterfall blood reflux
To remove or block all the incompetent superficial veins [the visible venous clusters] that are fed by the main trunk [usually not visible]

A. Vnus [www.vnus.com] Closure [Radiofrequency heating]

1. How is VNUS performed?

VNUS can achieve the first aim with open groin incision, by introducing a special wire into the vein at about the knee level and is passed up to the groin where it is positioned under ultrasound guidance. A radiofrequency generator produces heat [85C] destroying the vein from the inside. The wire is moved gradually down the leg to heat the remaining main trunk.

At the end of the procedure, the leg is bandaged for 2-6 weeks. VNUS can achieve the first aim without opening up the groin and without stripping the main vein trunk [LSV].

To achieve the second aim, avulsions [small incisions to pull out the veins are carried out the normal way.

2. Who is suitable for VNUS treatment?

VENUS cannot be used for people with short saphenous incompetence [communication with the deep veins behind the knee], perforator incompetence and the most of recurrent varicose veins, where there is still a main branch communicating with the femoral vein at the groin. Most patients with small to moderate primary varicose veins originating from the groin [LSV incompetence] can be treated this way. Overall, 50-60% of patients with primary varicose veins may be suitable for VNUS

3. What are the good points?

· Avoids the groin incision and the stripping of the main vein.

· The post-operative discomfort is less than open surgery

· May be performed under local anaesthaesia in people with small varicose veins that do not need avulsions [It is usually done under general anaesthaesia].

· There is less bruising in the thigh compared to EVLT and open surgery.

· Patients return to normal activities slightly sooner than open surgery [4-5 days compared to 7-10 days]

4. What are the disadvantages?

It still needs the avulsions [incisions] to remove the clusters of varicosities, which implies general anaesthaesia in most of the cases [or combination with sclerotherapy].
It cannot be used for large, winding veins
Heating can cause damage of the nerves that follow the main vein trunk and this is the reason why it is not suitable for short saphenous surgery, as the sural nerve lies in close proximity to the venous trunk.
It does not disconnect all the tributaries from the main vein at the groin, the presence of which is the commonest form of recurrence of the varicosities.
It cannot be used in most cases with recurrent varicose veins.
There is a risk of a cord tissue development along the course of the long saphenous vein. If that happens, the patient feels a tightness in the thigh when he walks and crosses his legs.
There is also a small risk of skin burn and a slightly increased higher risk of deep venous thrombosis compared to open surgery and stripping
It is more expensive that surgery, due to the cost of the equipment and laser fibre. The VNUS special catheters cost Ł600.00, and an ultrasound machine and a vascular technician have to be present.

5. What are the results of VNUS?

The long-term outcome is not yet established, and trials are still in progress. Time will tell. However, the short-term outcome seems to be similar to EVLT but worse than open surgery, with 80-90% recurrence rate at 1-2 years.

B. Endovenous Laser Treatment [EVLT]

1. How does this treatment work?

The procedure is similar to VNUS. With ultrasound guidance, a laser probe is inserted into the vein at about the knee level and is passed up to the groin where it is positioned. The laser is fired to heat the vein, which is destroyed near the end of the probe. The wire is moved gradually down the leg to heat the remaining main trunk. Avulsions [small incisions to pull out the veins are carried out the normal way.

At the end of the procedure, the leg is bandaged for 2-6 weeks.

2. Who is suitable for this type of surgery?

Most patients with small to moderate primary varicose veins originating from the groin can be treated this way. However, it cannot be used for people with short saphenous incompetence [communication with the deep veins behind the knee], perforator incompetence and the majority of cases with recurrent varicose veins.

3. What are the advantages?

· May be performed under local anaesthaesia in people with small varicose veins that do not need avulsions.

· Avoids the groin incision and the stripping of the main vein, causing somewhat less discomfort for the first couple of days following surgery.

· There is somewhat less bruising in the thigh compared to open surgery.

4. Are there any bad points?

Heating can cause damage of the nerves that follow the main vein trunk and this is the reason why it is not suitable for short saphenous surgery, as the sural nerve lies in close proximity to the venous trunk.
It still needs the avulsions [incisions] to remove the clusters of varicosities, which implies general anaesthesia.
It is more expensive that surgery, due to the cost of the equipment and laser fibre.
It does not disconnect all the tributaries from the main vein at the groin, the presence of which is the commonest form of recurrence of the varicosities.
It cannot be used in most cases with recurrent varicose veins.

5. Is it effective?

The long-term outcome is not yet established, and trials are still in progress. However, the short-term outcome seems to be acceptable, with 80-90% recurrence rate at 1-2 years. Proper classical surgery has a better short and, certainly, long-term outcome with 10% recurrence rate for primary varicose veins in a life’s time.

C. Varicofoam Injection Sclerotherapy Under Ultrasound Guidance

Ultrasound guided varicofoam sclerotherapy is an alternative to surgery [open, VNUS, EVLT]. It is a modification of the old technique that seems to be more effective.

1. What is the varicofoam and how does it work?

Varicofoam is the traditional sclerosant [chemical] mixed with air to create babbles, like a mousse. If the pure chemical is injected, it gets easily diluted and the effect is less satisfactory. With the air [which is absorbed and is safe to inject it when there is no central flow], the foam displaces the blood and fills the vein, allowing the sclerosant to act. In fact, less chemical has to be used if it is mixed with air. Once the vein is injected, it is compressed to stop blood flowing and let the walls stick together.

2. How is it done?

With careful ultrasound monitoring, the needle is carefully positioned into the vein and the foam is injected. The veins are checked with the ultrasound to see if they are filled with foam and when all the superficial veins are filled, the main vein at the junction with the deep veins is compressed, to avoid entering the foam there. A firm bandaging is then applied to the leg, aiming to compress the veins and not allow blood to enter them while the patient stands. The bandage is usually kept on for a week, followed by another 1-2 weeks of elasticated compression stockings. If there are any remaining visible varicose veins, they are treated by further sclerotherapy at the outpatients follow-up 3-4 weeks later.

3. Who is suitable for foam sclerotherapy?

Most patients with small or moderate primary varicose veins can be treated by injections. Patients with extensive or large varicose veins are better treated surgically, to obtain a more rapid result.
Overall 50-60% of patients with varicose veins can be treated by foam sclerotherapy.
Patients with recurrent varicose veins, if they do not have a main communication [reflux point] with the deep veins, can also be treated by sclerotherapy, something that may be easier than redo surgery.
Varicofoam injections are not suitable for small veins in or under the skin. Other techniques can be used for that, including Photoderm, an intense pulsed white light that causes coagulation of the intradermal veins, Laser treatment or injections with special chemicals [sclerotherapy].

4. What are the advantages?

The main vein is not tied and stripped, avoiding thus the incision at the groin or behind the knee and the thigh bruising that follows surgery. The risk of groin infection with open surgery [rare, less than 1:1000] is also avoided.
It can be performed under general anaesthesia, and in fact, it is the only method that does so.
It is the only method that does not have the risk of nerve damage.
Recovery time is less than surgery, with many patients not taking any time off work.
It is less expensive than surgery.

5. What is the catch? Are there any disadvantages?

The treatment usually causes a mild leg discomfort for a month.
A tight bandage should be kept on the leg for a week.
Although there is less bruising following treatment, the end appearance evolves over several months rather than the 6 weeks of open surgery.
In about 10-20% of cases there are residual veins that will need further treatment on an outpatient basis.
Small veins under the skin of even large protruding veins are better not treated with foam as brown discoloration of the skin over the treated vein may occur more often than the 1% risk of skin discoloration reported for the normal deeper veins treated by varicofoam.
The risk of deep venous thrombosis is slightly greater than surgery
Quite often multiple session may be needed, especially for patients with medium or extensive varicose veins.

6. Are the results better than surgery?

As an overall approach, no. Sclerotherapy has some limitations while surgery does not and can be applied to all patients with varicose veins.

However, varicofoam sclerotherapy is useful to patients who want to avoid surgery altogether. The final result takes longer [a number of months] to evolve than surgery [usually 6 weeks] and the long-term outcome is worse than surgery [recurrence rate of 10-20% at 1 year compared to 10% in a lifetime], however, it does not cause nerve damage and anaesthesia is not necessary. On the contrary there may be prolonged mild leg discomfort for a month and there is also the chance of skin staining with a brownish appearance [1%] and many sessions of sclerotherapy may be necessary in order to get rid of the bulky veins. Surgery deals with all of them at one sitting.

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Please note:
A written referral from a general practitioner is helpful but is not essentially required in order to make an appointment to see a consultant specialist.

This page was last updated on 01/10/2006