Overview
The cause of varicose veins isn’t certain so the aims of treatments are the removal or destruction of enlarged visible veins (varicose veins) and visible surface veins, skin care for those with venous skin changes and minimise the risk factors that seem to cause more veins to come (prolonged standing, body weight gain).
Conservative Management
This is available to all patients. The key aspects are skin care which usually involves application of Sorbolene cream (e.g. Hydraderm). Patients with specific skin rashes or ulcers will be given specific advice.
Support Stockings
These empty the varicose veins and reduce the pressure they place on the skin (venous hypertension). This can lead to symptom relief and may retard the progression of the disease. Support stocking can be lightweight e.g. Kolotex Sheer Relief pantyhose from Safeway or Coles or medical grade e.g Venosan Leg Line 20, Leg Line 30, 4002. From commercial suppliers a range of colours and custom stockings are also available. Patients need to wear the stockings during the day especially at work.
Vein Surgery
This is a traditional treatment for large varicose veins. It will usually involve an incision in the groin or behind the knee to tie off the leaking vein(ligation), passage of a catheter down the vein to pull the main vein out (“vein stripping”) and small cuts on the legs to pull out the varicose veins(avulsions). This may be a day patient admission for single legs or overnight for double leg operations. Anaesthesia can be spinal or general anaesthesia. Residual and small veins may be treated by follow up injections.
The results of this surgery can be particularly good for those patients without the need for sclerotherapy (many men) or those with large veins (over 7-8mm diameter). There is a small risk with anaesthesia and there is a requirement for about 5 to 10 days off work and about 4 weeks off sport. There is a high and increasing hospital fee for non-insured patients and a moderate out of pocket fee for insured patients.
The surgery for recurrent varicose veins is more challenging and the results can be satisfying but more modest. Wound complications and injuries to nerves of the leg are much more frequent in redo surgery.
Sclerotherapy
This procedure is the injection of varicose veins and is traditionally applied to small varicose veins e.g. 3-5 mm. These are usually treated after surgery in several sessions as a room’s procedure. A newer version is microsclerotherapy which involves injections of veins smaller than 2mm. Newer sclerosants (eg Aethoxyskerol) and meticulous techniques are required. Multiple sessions are required. Sessions are typically 6 – 8 weeks apart. It is necessary to wear Grade 1 support stockings for about 2 weeks after each sclerotherapy session.
With the options of surgery and sclerotherapy most patients can be managed in a conventional fashion with a reasonable outcome. Some patients can’t be and it can be difficult to identify these patients unless careful examination is combined with a specialist vascular ultrasound and the knowledge of new options for vein treatment as described below.
Ultrasound Guided Sclerotherapy (UGS)
This is the use of specialised vascular ultrasound to guide the injection of varicose veins. The visible veins can be injected but more importantly the sclerosant can be directed into non-visible feeding veins in the upper thigh and behind the knee which would normally require surgery. This is a specialised technique requiring specific knowledge but with care it can be a highly effective alternative to surgery. Patients may wear bandages for several days and support stockings for up to one month but can potentially avoid hospital costs and the risks of anaesthesia in surgery. There is a moderate cost for each session. This is an ideal treatment for patients with recurrent veins or for those with primary veins who could not manage several weeks off work but could manage several afternoons for injection treatment. Veins up to 6mm can be treated. It is necessary to wear Class 2 support stockings for about 2-4 weeks after each UGS session. Follow-up conventional sclerotherapy for small veins is required.
Endovenous Laser Therapy (EVLT)
This is a newer technique in which a small nick is made in the lower leg and a disposable laser fibre is fed into the large feeding vein (great/long or lesser/short saphenous veins) to the varicose veins. The laser is then activated and the vein is then destroyed by laser heat action. This procedure is performed in the rooms and takes 1 hour. Bandaging is required for a couple of days and then support stockings for a couple of weeks. Below knee varicose veins and small surface veins will require subsequent sclerotherapy. The aim of this procedure is to remove very large veins for which surgery is traditionally recommended. Ultrasound guided sclerotherapy can be used for some such veins but beyond about 6mm diameter ultrasound guided sclerotherapy becomes much less effective even with repeated sessions. Currently, the laser is probably an ideal treatment for long or short saphenous veins greater than 6mm. There is currently no Medicare/Private Health Insurance rebate and therefore there is a moderately high cost for the laser treatment.
Ovarian Vein Coiling
Some patients have varicose veins which are not due to leaking from vein junctions in the groin but rather from pelvic veins. A left ovarian vein draining down into the pelvis and causing varicose veins in either leg is one recognised entity. This can be treated by a day in hospital procedure requiring the insertion of a plastic catheter into a groin vein (venogram). Specific metal coils can be placed in the ovarian vein to cause it to block (thrombosis). Subsequent ultrasound guided sclerotherapy or conventional sclerotherapy for leg veins will probably be required. This is a specialised technique which is applicable to a small but under recognised number of patients with this syndrome. Read more…
Other Techniques
There are other techniques such as laser treatment of surface veins and removal of surface veins under local anaesthetic (ambulatory phlebectomy) that are currently not widely available.
Conclusions
Treatments for varicose veins should be individualised. A plan of management encompassing several techniques with a proposed time course and estimated cost should be provided to the patient.
Options in treatment for a particular patient should be discussed. There is rarely any urgency to decide on treatment so time for consideration and discussion is important.
It is our policy to provide all of these as a specialist private practice. We are emphasising non-surgical options but will provide surgery as appropriate.
Time and cost estimates are routinely provided. If costs are an issue various options are available.
We wish you well in the treatment of your veins.
GREG SELF
Vascular Surgeon
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