Varicose Veins

Varicose veins are a common problem that affect approximately 20 to 25% of all North American adults, male or female. This disorder is not limb or life-threatening but can result in adverse symptoms and an undesirable cosmetic appearance. Varicose veins are the result of venous valvular insufficiency. Veins in the lower extremity normally contain one way valves that point towards the heart. Their function is to prevent backwards flow of blood down the legs (reflux) when we stand. Valvular insufficiency (leaky vein valves) is a familial (genetic) problem. Other risk factors for varicose veins in men and women include tall stature, obesity, and occupations that require long periods of standing or sitting. In addition to these risk factors varicose veins in women are also exacerbated by pregnancy and hormonal variations that occur during a normal menstrual cycle. Hot muggy weather is also a common environmental condition that aggravates varicosities.

Reflux occurs largely in the superficial veins of the legs and over time through pressure exerted by gravity, the superficial veins of the leg slowly enlarge and become engorged. This gives the clinical appearance of large ropey veins that characterizes varicose veins.

Commonly, most varicose veins (>80%) are in the distribution of the Long Saphenous Vein, which runs from the groin down the inside of the thigh and calf to the ankle. Varicosities involve this vein itself or the many smaller tributaries of the saphenous vein. The typical clinical presentation ranges from undesirable cosmetic appearance to ankle swelling, achiness, cramping, and itchiness. Long-standing varicose veins can result in discoloration of the skin in the calf and ankle area as well as venous ulceration, scarring, and bleeding.

Since varicose veins are neither life nor limb-threatening, a variety of treatments are available for this disorder. The most conservative treatment is of course to do nothing; however, as time passes this approach will result in enlarging veins that will become more and more symptomatic over time. This is due to the constant, unrelenting effect of gravity and pooling of venous blood in the lower extremities.

The next level of treatment would be a trial of compression stockings. Compression stockings work by providing extrinsic support to the dilated veins. They will not correct the valvular problem and therefore only work when worn by the patient in a consistent fashion. Historically, this approach eventually results in a failure of patient compliance – few people wish to wear stockings on a long-term basis. In addition, even in the presence of excellent compliance, time and gravity will eventually result in progressive enlargement of varicose veins.

The next option might be a trial of injection sclerotherapy. The term 'sclerose' means to become hardened or scarred. This technique utilizes a variety of reagents including concentrated saline, dextrose, or detergent chemicals to create inflammation (phlebitis) in the vein. When combined with a compressive dressing, injections can obliterate smaller varicosities. We use the sclerotic process to cause an injury to the vein and then the bodily response is the creation of a healing response to the injury. The main limitation of this method is that although a local phlebitic reaction can occur, the valvular insufficiency still exists higher up in the groin. In essence, the cause of the problem still exists and we have only treated the effect with sclerotherapy rather than the cause. Therefore, recurrence of the varicosities is inevitable when this method is used in isolation when true venous valvular insufficiency exists.

The final category of treatments for varicose veins are surgical approaches to this disorder. Historically, surgery meant Vein Stripping. This procedure has been available for over one hundred years. It typically requires a general anaesthetic in hospital, multiple incisions down the length of the leg, and a painful recovery period approaching four to six weeks. Vein stripping historically has a recurrence rate approaching 35-40%. This recurrence rate is dependent on the anatomy of the patient and the diligence of the surgeon as well as regrowth of veins caused by the body's healing response to the invasive nature of this surgery. A common complication of vein stripping is permanent numbness along the site of the stripped vein. Vein stripping is a technique that, while still available, has fallen into disfavour due to the challenges related to prolonged recovery, complications, and a high recurrence rate.

In the last twelve to fifteen years, less invasive surgical approaches to varicose veins have been described. We call this category of surgical treatments Endovenous Surgery. The prefix 'endo' means 'from the inside' and this now describes a family of techniques that have rapidly become well accepted by both patients and their treating physicians. This approach relies on careful ultrasound imaging of the patient's venous anatomy pre-procedure and the use of ultrasound intra-operatively to make this truly an image-guided surgical technique.

The most common method of endovenous surgery is termed Endovenous Laser Ablation (EVLA). This technique is usually performed in an office or clinic setting under local anaesthetic. In essence, ultrasound is utilized to introduce a fine needle into the vein that is causing the varicosities. Through this needle a fine guide wire is passed through the lumen of the vein up to the groin. Over the guide wire a fibre optic device is positioned under ultrasound guidance. This instrument is then used to transmit LASER light energy to destroy the vein from the inside out. Since this technique is treating the vein from the inside out we term it 'endovenous'. The laser only treats the main route. Branches of the main route are usually dealt with through sclerotherapy, which when used in conjunction with LASER becomes very successful.

The advantages of this method include: no incisions, less bruising and pain, and a much quicker recovery period. Patients are usually able to return to work within two to three days and return back to the gym within three to five days. Although a quick recovery is typical, it is still a surgical procedure and complete cosmetic healing typically takes about 12 to 16 weeks. The five year outcome of this procedure has been shown to be better than traditional surgery. When markers of long-term recurrence after surgery are examined, 30 to 40% of patients who undergo vein stripping and only 2 to 3% of patients who have been treated by EVLA experience recurrences. Overall, EVLA has rapidly become a well-accepted, successful methodology for the treatment of varicose veins and represents a modern approach to an old surgical problem.

Two other Endovenous techniques also exist. These include Radiofrequency Ablation (RFA) and endoluminal bonding of the vein (Venaseal©). RFA is a very similar technique to EVLA, but utilizes a different energy source (microwave radiation) than LASER to seal the vessel wall. In a head-to-head comparison, the long-term seal rate with RFA is lower than that with EVLA.

Both EVLA and RFA utilize heat energy in order to seal the vein shut. Therefore in order to achieve patient safety and comfort, both of these techniques require the use of local anaesthetic (freezing). Freezing is placed along the length of the vein to be treated in order to provide patient comfort and also to insulate the vein being treated away from the rest of the tissues in the patient's leg. This requires a series of small needle injections along the length of the vein being treated.

In the last three years, the latest innovation that has occurred is the use of chemical bonding agents to close the vein rather heat sealing. The idea here is that using a glue-like substance would close the vein in the absence of heat, therefore making the endovenous treatment even easier to tolerate for the patient because less freezing would be required. Venaseal© is a proprietary variant of 'crazy glue' (cyanomethylmethacrylate) that has been shown to be effective in causing vein closure. However, the vein seal rate at three years follow-up is inferior to either EVLA or RFA and no long-term follow-up exists at present. Therefore, either EVLA of RFA remain the gold standard for endovenous ablation of varicose veins at present. This technique is available at the Davisville Vein Clinic if the patient desires it.