Varicose veins treatment and thread vein removal by sclerotherapy and surgery

Varicose Veins, Thread Veins, Spider Veins, PhotoDerm, Sclerotherapy, Surgery, Thrombosis

Introduction

What are They?

Investigation of Varicose Veins

Ultrasound Guided Foam Sclerotherapy

Surgical Treatment

Thread Veins & Sclerotherapy

Painful Veins

New Treatments

Traveller's Thrombosis

Photoderm Treatment

Links

BVI in the Press and on TV

Vein Clinics

Reports and Papers

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Foam Injections

Introduction

Recently several new techniques have been reported in the medical literature. The main aim of these is to avoid surgical removal of varicose veins. The idea is to avoid the need for general anaesthetic, incisions in the legs and a hospital operating theatre. One of the most promising of these is Ultrasound Guided Foam Sclerotherapy.

History

The use of injections to cure varicose veins dates back more than 100 years. In 1942 Orbach described a method of creating a foam or froth with the solution he injected. He found that this increased the efficacy of injection treatment by five times. This method was used by a small number of surgeons but never found a great following.

In 1992 Juan Cabrera, a surgeon from Granada in Spain, found that he could greatly enhance the effect of injection treatment by making a foam of very small bubbles, which he called 'microfoam'. He used ultrasound imaging to guide his injections into the main surface veins and found that he no longer needed surgical methods to treat his patients.

Over the last 15 years the use of foam injections has spread widely in France, Spain, Italy and Germany. It is now being enthusiastically taken up in several European countries, United States, South America, Australia and New Zealand. Experts in treating vein problems have used a number of different methods to create the foam that they inject but the result is the same: using a foam greatly increases the effect of the treatment without producing any additional side-effects.

Recently a pharmaceutical company, Provensis, has commenced development of a foam called 'Varisolve'. This is specifically intended to treat varicose veins. 'Varisolve' is currently only in use in clinical trials. The National Institute of Clinical Excellence has considered this treatment and published draft advice.

What is injected?

The solutions that are injected are exactly the same as those which are already used to treat varicose veins. These are mixed with air to create a mousse or foam consisting of very small bubbles. It has been shown that this is perfectly safe to inject into the veins. The air is rapidly absorbed from the veins leaving the solution to treat the veins.
Why does foam work?

When a solution is injected into a vein it is immediately diluted by the blood, reducing its efficacy. Foam pushes the blood out of the way and completely fills the vein: the foam is not diluted by the blood. In fact, far less solution has to be injected to obtain the same effect.

The treatment

Treatment is usually performed in a treatment room or ultrasound examination room, and not an operating theatre. The patient rests comfortably on a bed. Very little discomfort results from the injections so no sedation or anaesthetic is required.

In order to treat large varicose veins it is necessary to block the main vein feeding the varices. This could be done surgically, but with foam treatment all that is necessary is to put a needle into the main affected surface vein. This is the only part of the procedure which might cause discomfort and is usually performed with a small amount of local anaesthetic. The position of the needle is carefully monitored using ultrasound imaging so that it is in exactly the right place.

Next, the foam is injected whilst watching its progress using the ultrasound machine. Surprisingly, injecting the foam causes no discomfort, although the leg may ache slightly afterwards.

The varicose veins in the leg are checked to see if foam has entered these from the main surface vein where the injection was given. A few further injections are usually given through a tiny needle in order to make sure that all the varicose veins have been completely injected. The whole treatment usually takes no more than 20 - 30 minutes.

Finally a firm bandage is applied to the leg. The aim of this is to keep the veins compressed so that they do no fill with blood when the patient stands up. The bandage is usually worn for a week or two followed by an elastic compression stocking for a further week.

When the bandages are removed at the follow-up appointment it is usual to find that all the varicose veins have gone. Sometimes small lumps can be felt beneath the skin. The leg may be a little bruised, although this is usually fairly minor. Lumps present at this stage slowly resolve over several weeks. If any varicose veins have not been completely treated in the first session they are injected and the leg bandaged to complete removal of all veins.

If varicose veins are present in both legs it is standard practice to treat them on separate occasions about two weeks apart. This avoids having both legs bandaged at once.

Who is suitable for foam sclerotherapy?

Most patients with small or moderate size varicose veins can be treated in this way. Those patients with very extensive large varicose veins are usually best treated surgically to obtain a more rapid result. Some patients with large veins lying close to the skin are better treated surgically since brown discoloration of the skin over the treated vein may occur. If there has been previous surgery to the veins of the leg this does not cause any difficulty in using foam sclerotherapy. In fact, it is often far easier to treat recurrent varicose veins by foam injections than by more surgery. If varicose veins recur some years after initial treatment then it is straightforward to use the same method foam sclerotherapy again.

Who performs this treatment?

At present only a handful of surgeons in the UK are experienced in this treatment. It needs a specialist who is skilled at ultrasound imaging as well as injecting veins. By calling the BVI you can obtain an appointment with your nearest expert.

How well does ultrasound guided foam sclerotherapy work?

Several detailed clinical series have been published in the medical press. These suggest that 80 - 90% of saphenous veins (the main surface vein) are permanently occluded by this treatment when examined one or two years later using ultrasound imaging . This is similar to the success rate claimed for other new techniques such as VNUS Closure and Endovenous Laser Treatment (See: New Techniques). Surgery also has its failures and after two years further varicose veins may have appeared in about 10% of patients. Clinical trials are currently in progress which directly compare surgery and foam sclerotherapy.

Good points

Stripping of the vein is avoided and there is little or no discomfort after treatment.
There is much less bruising than following surgery.
There is no need for general anaesthetic, incisions in the leg, admission to hospital or an operating theatre.
Re-treatment for further varices is simple.

Much less expensive than surgical treatment - less than half the cost of surgery.

No time needed off work, except for the treatment sessions.

Bad points

The treatment produces mild discomfort in the leg which may last for 2 - 4 weeks. It also produces mild bruising which may last for several weeks following treatment. However, both of these features are usually seen following surgical treatment for varicose veins.
The final outcome may take a number months to evolve following treatment, and this is longer than would be taken following surgery.

Scientific publications and abstracts

Paper br Dr Cabrera (1.1MB)
Abstract from Venous Forum of the Royal Society of Medicine (0.1MB)
Abstract from Pacific Vascular Symposium (0.15MB)

Conclusions

Ultrasound guided foam sclerotherapy is a new method of treating varicose veins.
There is NO need for an operation under general anaesthetic.
The treatment only involves injections under local anaesthetic.
A treatment session is complete in 30 - 40 minutes.
The treatment is carefully monitored using ultrasound imaging.
A firm compression bandage must be worn for a week or two afterwards.
Mild discomfort and a little bruising often follow treatment. This is much less than following surgical treatment.
No time off work is needed, except to attend the clinic appointments.
The costs of treatment are much lower than for surgical methods.
Some small lumps may be felt in place of the veins after treatment. These resolve completely over several months.
Only a few specialists in the UK have experience with this technique. The BVI can put you in touch with the nearest one.

Arteries bring blood from the heart to the extremities. Veins contain one way valves and channel blood back to the heart. When there is obstruction of veins, or when prolonged pressure is placed on the veins, the valves stretch and no longer close properly. This allows blood to travel back down the veins towards the feet. The veins in the legs that are near to the surface of the skin enlarge and result in what is commonly called varicose veins. These can range from minor dilatations to large bunch of grape-like structures in the calf. Very small purple or blue veins in the skin of the legs are called "thread veins" or "spider veins" or dermal flares and often occur alongside large varicose veins. Some people are only affected by dermal flares. Both types of varicose veins are probably caused by the same factors. Varicose veins is a slowly progressive disease which if left untreated can lead to marked skin change damage or ulceration near the ankle. Why do varicose veins arise? Varicose Veins, Thread Veins, Spider Veins, PhotoDerm, Sclerotherapy, Surgery, Thrombosis Heredity is important in the development of varicose veins, thread veins and spider veins. Up to 20% of the adult population have varicose veins and experience discomfort as a result. Many people know of other family members with the same problem. A recent study showed that where both parents had varicose veins there was an 80% chance of their children developing varices. Environmental factors also play a large part in the development of varicosities, for example, prolonged standing - especially for workers such as nurses, sales assistants, flight attendants, waitresses and teachers, for example. Diet may also be a factor, and our Western diet with high content of fat and refined sugar with low fiber content may contribute to the development of varicose veins, spider veins and thread veins. Varicose veins may also become more frequent with advancing age, but may appear at any time of life and small varices are sometimes seen in school children. Although all factors such as puberty, pregnancy and the menopause also influence the course of the disease. As many as 70 - 80% of pregnant women develop varicose veins during the first trimester. Pregnancy causes an increase in hormone levels and blood volume which in turn causes veins to enlarge. Later in pregnancy, the enlarge uterus causes increased pressure on the veins in the pelvis. Approximately 60 - 70% of varicose veins due to pregnancy will disappear within a few months of delivery. Little research has been done to investigate the role of the pill and hormone replacement therapy (HRT) in the development of varicose veins. These probably have no influence on them. What are the symptoms Treatment of varicose veins and thread veins by injections sclerotherapy PhotoDerm and surgery Varicose veins may cause feelings of fatigue, heaviness, aching, burning, throbbing, itching and cramps in the legs. These symptoms are often accompanied by swelling of the ankle, which frequently appears after long hours of standing. Some people are very troubled by the aching that varicose veins produce. Even small dermal flares can result in severe aching which prevents standing for any length of time. What can I do to prevent them? Treatment of varicose veins and thread veins by injections sclerotherapy PhotoDerm and surgery Many of the things that seem to cause varicose veins are difficult to avoid such as a family history of Western way of life. Where possible standing still for long periods should be avoided. Walking is much better for the veins and helps the blood return to the heart from the legs. In occupations that require extended periods of standing then a few steps should be taken at regular short intervals to help circulation. Wearing support stockings may also reduce the likelihood of varicose veins. No creams or drugs are available to prevent varicose veins. The earlier varicose veins and dermal flares are treated the better the long term and cosmetic outcome.