Varicose veins are defined as swollen and tortuous leg veins that tend to bulge and protrude from the surface of the skin. They are very common and affect women more frequently than men. In many patients they produce no symptoms but in others they may give rise to pain, itch, swelling, irritability, heaviness and damage to the skin of the leg.
Many sufferers also find that they are embarrassed by the appearance of their varicose veins and often avoid exposing their legs. Varicose veins will tend to worsen slowly but more serious problems only occur in about one in ten of those affected.
Veins collect blood from the tissues and return it to the heart. The leg contains deep veins embedded within the muscles and superficial veins which lie in the fat plane beneath the skin. There are two main superficial veins – the long saphenous vein which runs up the inner part of the calf and thigh and the short saphenous vein which is located at the back of the calf. The saphenous veins contain valves throughout their length. Failure of the valves will allow blood to reflux ie run back down towards the foot. This abnormal downflow increases the pressure within the saphenous vein and this in turn causes the side branches to become engorged, swollen and tortuous - varicose veins.
A duplex scan identifies the location of the leaking or “incompetent” valves and allows the surgeon to plan the most effective treatment. This is designed to obliterate the incompetent section of saphenous vein, usually by the application of heat energy - VNUS closure. This is normally done under local anaesthetic, does not need a surgical incision or stitches and allows a return to work next day, with a minimum of pain. The procedure takes about one hour including recovery time. There can be no doubt that this is a great improvement compared to traditional surgical stripping and is definitely our preferred method.
Varicose veins can also be treated by daycase surgery or sclerotherapy (the injection of chemical foam). At Castle Quay Veincare we are able to offer the full range of treatments for varicose veins either under local or general anaesthetic, according to your preference. We will provide straightforward advice about the most suitable treatment for you as an individual patient, because there is no single method which is superior in all circumstances.
The relief of symptoms and a good cosmetic outcome are always paramount.
VNUS closure uses heat generated by a thin radio frequency catheter to obliterate the incompetent saphenous veins. The failure of valves within the truncal (saphenous) veins causes their side branches to become enlarged and tortuous ie varicose veins. VNUS closure is used to bring about thermal obliteration of the long saphenous vein on the inner aspect of the thigh and short saphenous at the back of the calf.
VNUS closure is just as effective as endovenous laser therapy and several studies have reported that patients suffer significantly less pain and bruising. It is therefore our preferred option.
VNUS closure is used as an alternative to traditional ligation and stripping. There are several advantages when compared to surgery, such as avoidance of general anaesthesia and a groin incision, much more rapid return to normal activities because of less pain and bruising and a more reliable obliteration of the saphenous veins with less risk of recurrence of varicose veins in the future. A pre-treatment duplex scan is always required in order to determine suitability for endovenous treatment.
VNUS closure is not suitable for some patients with recurrent veins and may not be possible if the saphenous vein is thin, kinked or scarred by previous phlebitis. Furthermore, if the varicose veins are related to abnormal venous reflux down a tortuous anterior thigh vein, then surgery is still the best option. At Castle Quay Veincare we find that more than nine out of ten of our clients are suitable for treatment by VNUS closure rather than surgery. The success rate of these endovenous techniques is an impressive 98%.
VNUS closure can be done easily under a local anaesthetic and, after a cup of tea, the patient is able to go home with a minimum of discomfort. Treatment usually takes about forty minutes for one leg and about one hour for two. After endovenous treatment most patients, but not all, may return to work the following day. We assess all our patients six weeks after VNUS closure We have reviewed our results and find that 90% of our patients who had VNUS closure under local anaesthetic were completely happy with the results of treatment and did not need any further therapy for residual varicose veins. Total obliteration of the treated vein is achieved in about 98% of cases following VNUS closure compared with about 80% who have surgical stripping. Please note, however, that in some cases varicose veins will persist and need further treatment. This can be done by foam sclerotherapy, which is relatively inexpensive although the results of treatment are variable and occasionally marked unsightly pigmentation of the skin can occur. This may be permanent. We are therefore not very keen on this option and in general prefer removal of residual veins by phlebectomies.
VNUS closure is a straightforward procedure which starts with a duplex scan of the leg from groin to calf. Local anaesthetic is then injected and the long saphenous vein entered with a needle, just below the knee. The slim VNUS catheter is then passed up the inside of the vein to the level of the groin. The tip is positioned very precisely with the assistance of the duplex scanner. Local anaesthetic is then injected along the line of the vein in order to numb the area to be treated. The VNUS catheter is then activated over a period of three minutes and the saphenous vein obliterated along its entire length by the emitted heat energy. This part of the procedure is painless.
Over the past ten years the new endovenous methods such as laser and radiofrequency have revolutionised the treatment of varicose veins so that surgery is now rarely needed. We strongly recommend VNUS closure under local or general anaesthetic as the best starting point of treatment. In some situations it is a good idea to combine VNUS closure with the removal of varicose veins through tiny skin incisions – phlebectomies. This is a controversial area in vascular opinion as the majority of patients will get a good result from the VNUS closure procedure alone. The decision on whether or not to carry out some phlebectomies is best based on an individual bespoke assessment. For example if the patient is seeking relief of pain and swelling rather than cosmetic perfection, then VNUS closure alone would bring about the desired result. Conversely where a perfect cosmetic result is required then concomitant phlebectomies will be the best option. Surgery may occasionally be the more appropriate treatment for some patients with recurrent varicose veins and those whose varicosities emanate from an incompetent anterior thigh vein.
Occasionally, avulsion of varicose veins or "phlebectomies" without VNUS closure may be a good option in purely cosmetic cases (usually small, unsightly varicose veins), but only if there is no evidence of leaking valves in the major saphenous veins. Phlebectomies can be done under a local anaesthetic and is often combined with microsclerotherapy for associated thread veins. The cosmetic outcome is extremely good but there will be a degree of bruising, although that will settle over two to three weeks. The incisions used to remove varicose veins are tiny and become virtually invisible with time. We never use stitches but close the skin with sticky paper strips “steristrips”.
You will be advised about the most suitable option for your condition by Mr Williams. Surgery is no longer the preferred option for varicose veins but still has a place in the range of possible therapies.
Foam sclerotherapy is a safe treatment which involves the injection of chemical foam into one or more varicose veins. An elastic compression stocking is then fitted and worn for four weeks. It is essential to do plenty of walking during this period. Foam treatment is straightforward and very well tolerated by our clients who are able to walk out of the clinic a few minutes later.
The success rate, meaning obliteration of the entire length of the saphenous vein, is about 50 to 60% from the first treatment, rising to 70 to 80% following a subsequent injection of foam. Occasional complications include phlebitis – inflammation and soreness of the treated vein - and pigmentation (brown staining of the skin) which may either resolve over a few months or sometimes persist. Very occasionally the brown pigmentation may be marked and unsightly which, to many, is the main disadvantage of this method.
Foam sclerotherapy produces good overall results but in some patients the results may disappoint. Abolition of downflow in the saphenous veins is achieved more reliably by VNUS closure or surgery, but these are more major interventions requiring general or local anaesthetic and a greater recovery time.
Foam sclerotherapy is less expensive but more than one session of treatment may be necessary. It is best suited to the treatment of recurrent varicose veins, short saphenous veins and varicose veins that have caused bleeding.
At Castle Quay Veincare we will discuss the advantages and possible drawbacks of each form of treatment to help you make the best decision.
To find out more about foam sclerotherapy download our information sheet here