Varicose Veins: Management in the New Millenium

Varicose veins has traditionally been treated by surgery, possibly sclerotherapy, and support stockings. The results of treatment varied widely and was reflected in some patient dissatisfaction especially with surgery. Scarring, nerve injury and recurrence are the main issues. recurrence is quoted as 0-30% at 5 years.

0%=the patient went elsewhere. 30%= the surgeon left some varicose veins that he/she did not detect by followup ultrasound exam and attend to by sclerotherapy including ultrasound guided sclerotherapy.

Recurrent varicose vein surgery is an operation for the specialist surgeon only and even then is attended by a higher rate of complications than first time surgery. Recurrence rate are similarly higher.

Variability of longterm control of varicose veins by surgery was originally attributed to variations in specialist expertise (patient selection, technique of operation) and to a degree this is still true. However, numerous studies of patients with varicose veins who were treated by experts, using recognised or standardised treatmnets and assessment tools has proven that other, more subtle factors apply.

Patients can grow new veins (“neovascularisation’). Leaving residual smaller veins can promote the growth of new varicose veins (“Veins up” vs “veins down” theories). Leg veins can be due to pelvic vein incompetence including left ovarian vein reflux. Some patients seem to do well despite the type of treatment.

Worldwide there is a strong trend away for surgery as the mainstay of treatment.

Endovenous laser treatment (e.g. www.evlt.com.au) can deal with most primary long and short saphenous vein reflux. Other manufacturers has developed high energy ultrasound probes with similar efficacye.g. VNUS.

Ultrasound guided sclerotherapy (UGS) treats smaller or tortuous varicose veins. The most effective technique is to mix the sklerosant solution with air or carbon dioxide to create a foam for injection. Aethoxysklerol (generic name: polidocanol) is approved for treatment of veins up to 6mm diameter in Australia. It is highly effective and has few major side effects compared with Fibrovein (generic name: STS, Sodium Tetradecyl Sulphate).

Treatments such as ambulatory phlebectomy, left ovarian vein coil embolisation, Veno-cuff implantation (Rod Lane), vein valve transplantation (Raju) remain niche procedures. The occurence of so many procedures indicates that none are completely satisfactory. In fact they are complimentary and patients are best treated in a clinic where expertise for several options exists. Caveat emptor.