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TREATMENT for VENOUS DISEASE.
GENERAL MEASURES
Many patients symptoms will improve with simple measures.
1. EXERCISE
Walking, running, cycling and swimming are all beneficial. Walking is the simplest to do and using the calf muscles directly pushes blood up the veins of the leg improving the circulation.
2. AVOID
standing still for long periods of time.
3. ELEVATE
the legs whenever possible. Any elevation will help but if you can raise the feet above the
4.
If you are
5.
Use firm "graduated" SUPPORT STOCKINGS on the legs during the day. These can be brought at chemists or obtained on prescription. The pressure in the stocking is designed to be greatest at the ankle level and gradually decrease up the leg. This assists the return of blood up the veins. A below knee stocking is often sufficient unless you have painful veins in the thigh.
All these measures should be used before moving on to the specific treatments below.
DILATED VEINS
The treatment for dilated veins depends upon the size and the number of veins involved. With larger, truly varicose veins (>4mm) involving a significant part of the superficial venous system (as assessed with doppler/Duplex scans) a procedure to block and/or remove the veins is often required. Smaller localized problems (flares, thread veins, spider veins) may be treated by injection.
VARICOSE VEIN PROCEDURES
1. Foam Sclerotherapy
What is sclerotherapy?
Sclerotherapy or injection of varicose veins is a procedure designed to reduce the size or remove your varicose veins. The veins are injected with a solution called a sclerosant which damages the internal lining of the vein. This damage to the vein leads to scarring which reduces the vein size and may even block the vein completely. If blood mixes with the sclerosant it clots within the vein. This causes phlebitis where the vein is inflamed and sore for 2-3 weeks. However the end result is often the same with the vein reducing in size or disappearing with time. The solution normally used for this procedure is called sodium tetradecyl sulphate (STD) and is available in different concentrations depending on the size of the vein being treated.
What is foam sclerotherapy?
Normally STD is injected as a solution directly into the vein to be treated. Foam sclerotherapy involves making small volumes of the solution into foam by rapid mixing and agitation with a small volume of air (see picture above). This can then be used to treat some of the larger underlying abnormal veins which would not normally be treated with conventional sclerotherapy. This is performed under ultrasound control. The foam solution causes intense spasm of the vein and a greater volume can be injected without using too much of the STD solution. The foam is less likely to mix with blood and cause phlebitis.
Is foam better than conventional sclerotherapy?
The initial results with foam sclerotherapy have been very promising and it is certainly an improvement on conventional sclerotherapy. It can in certain cases be used as an alternative to surgery or thermal ablation. The longer term success rates (5years) with foam sclerotherapy are not as good as with thermal ablation or surgery.
Are my veins suitable for foam injection sclerotherapy?
Varicose veins involving isolated veins in the leg or involving the long saphenous vein or short saphenous vein are suitable for this form of treatment i.e. most varicose veins. If you have very extensive and very large varicose veins then you may do better with thermal ablation or surgery rather than sclerotherapy. If you have any underlying blood clotting tendency it may not be advisable to have sclerotherapy.
What does the procedure involve?
Depending on the number of varicose veins you have you may need 2 or 3 sessions of treatment, and occasionally more than this. The main surface vein to be treated will be marked on your leg initially using ultrasound scanning. Local anaesthetic will then be injected into a small area of skin, usually in the lower thigh or mid calf and a needle will be placed into the vein, again using ultrasound scanning. This will be flushed with a salt solution. Your leg will then be elevated above the couch and the foam solution will be injected in small volumes at a time. Whilst this is being done you will be asked to bend your ankle up and down in order to increase the blood flow in your deep veins. You may experience some slight stinging as the foam is injected but it is usually painless. The passage of the foam in the vein will be monitored by ultrasound scanning.Once enough foam has been injected the needle will be removed, and a bandage applied in order to compress the treated veins. An elastic compression stocking will then be put on your leg. This will feel tight but should not be so tight as to make your foot discoloured or painful.
What happens after the procedure?
You should keep the bandage, and stocking on for 24 hours. After this you may remove the bandage and replace the stocking which should be worn for a further 14 days. During this period you may remove the stocking to shower and you may remove it at night if you wish. If you find the stocking comfortable and wish to wear it for longer this may be helpful. Please bring your stocking back with you to your next visit as it may be possible to reuse it if you have further injections.
You should do plenty of walking and may generally do most normal activities without any problem. If in doubt ask your doctor.
Will I need further treatment?
It is possible that some of your varicose veins will remain after one set of injections and you may need 1-2 repeat treatments. You will be seen again in 4-6 weeks time and further injections can be performed at that stage if necessary.
What are the complications?
If the varicose veins become hard, tender, and red this is due to blood clotting in the vein causing thrombophlebitis. This is nothing to worry about but may be associated with inflammation and discomfort. If this occurs anti-inflammatory pain killers (nurofen, ibuprofen) may help. These lumps will eventually subside and disappear but this may take several weeks. This process may be hastened by your doctor inserting a needle into the lumps and aspirating the clots after a few weeks.
Brown pigmentation of the skin.
This can occur following superficial thrombophlebitis described above and can be permanent. However it will usually fade for a period of several months and may disappear completely.
Deep venous thrombosis.
If the solution passes into the deep veins there is a risk of thrombosis of the deep veins. This may be very minor with no symptoms or a major blood clot with a risk of a pulmonary embolus (passage of a blood clot to the lungs). It is for this reason that only small volumes of the foam are injected at a time and the ankle is exercised in order to maintain good flow in the deep veins. All venous procedures carry some risk of deep vein thrombosis.
Recurrent and residual varicose veins.
If you have any remaining varicose veins it is usually possible to inject these at your next visit. However if you have a lot of very small varicose veins it may not be possible to eradicate all of these. It is possible that the treated vein could reopen. At present the risk of this is not known and only long term follow up data will provide this information. If this does happen it would be possible to treat the vein again, either by further injection or by surgery.
Skin ulceration.
If the solution does not go into the vein but goes into the surrounding tissues it can cause a small ulcer of the skin. This will heal up but this may take several weeks and will leave a scar. The use of ultrasound to guide the injection reduces the risk of this to a low level.
Allergic reaction.
Superficial thrombophlebitis
Allergy to the solution used is rare but can occur. If you have any allergies you should inform your doctor.
Visual disturbance.
There have been reports of temporary visual disturbance with foam injections. This is thought to be due to the air bubbles rather than the solution injected.
Stroke.
This is very rare, again thought to be air bubles paasing through the circulation.
2. VENOUS ABLATION
EVLA, VNUS CLOSURE and CLARIVEIN
Three "ablation" techniques for treating varicose veins have been introduced, VNUS and EVLA use heat, CLARIVEIN uses a mixture of physical and chemical injury to the vein wall. These aim to replace the "stripping" part of the standard operation. They are therefore used when the varicose veins are connected to the long or short saphenous veins.
These techniques aim to remove the long or short saphenous vein from the circulation by blocking or ablating the vein. EVLA and VNUS use heat to achieve this, a type of "cautery" of the vein. EVLA uses laser to deliver heat (EndoVenous Laser Ablation) and VNUS uses radiofrequency to generate controlled heat. The heat alters the structure of the vein wall and causes the vein to shut down. No wounds or "stripping" are required. Instead a catheter is placed into the vein in the lower leg via a needle. The catheter is then passed up the vein under ultrasound control and positioned at the junction between the saphenous vein and the deeper veins (femoral or popliteal).

Both VNUS and EVLA are similar in many ways and achieve similar results with the faulty saphenous vein being removed from the circulation. Both techniques are suitable for use under local anaesthetic in appropriate cases. Once the vein has been closed, avulsion of varicosities may still be required. This can also be done under local anaesthetic but if there are lots of varicose veins to remove then general anaesthesia may be a better option.

These techniques are designed to reduce post operative discomfort and enable a faster recovery rate. After the standard open operation the groin wound can be a source of discomfort. Bruising in the thigh after stripping of the vein can also lead to more discomfort and delay return to normal activities.
ADVANTAGES OF EVLA AND VNUS CLOSURE.
1. No groin wound. Less discomfort, no risk of infection.
2. No stripping of thigh vein. Less bruising, less discomfort.
3. Experience to date suggests that the above leads to a faster return to normal daily activities and work. This 4.
can be achieved on average in 2-3 days. Sporting activities can be resumed at one week on average.
5. Very suitable for day case surgery.
6. Local anaesthesia for selected cases.
DISADVANTAGES.
1. New technique, therefore long term (>5year) results unknown yet. It is possible that the recurrence rate beyond
5 years may be higher with this new technique. Up to 5 years however, the results have so far been as good as
standard surgery.
2. The electrical current or laser used to "close" the vein may cause damage to surrounding skin nerves.
Numbness in the thigh may occur (5-10%) but this is usually temporary. A misplaced catheter could potentially
damage the deeper veins in the groin, leading to a stenosis or deep vein thrombosis. With careful ultrasound
monitoring this complication is rare (<1%)
The National Institute of Clinical Excellence (NICE) have recognised both EVLA and VNUS closure as safe and acceptable procedures when performed by trained surgeons.
CLARIVEIN
Mechanochemical ablation (CLARIVEIN) for the Treatment of Varicose Veins


What is Clarivein?
Clarivein is a procedure to treat varicose veins. The underlying fault with varicose veins is loss of function in the valves in the veins. These one way valves normally direct the flow of blood up the leg and into the deeper central veins. When they fail, the surface veins are put under pressure and varicose "bulging" veins result overtime.

The vein containing these valves cannot be repaired. Because there are other normal veins which can easily replace the function of the faulty vein, treatment involves removing or blocking the faulty vein. A number of treatments are now used to achieve this. Thermal (heat) procedures such as EVLA and VNUS closure destroy the veins by a type of cautery. Foam sclerotherapy aims to damage the vein chemically and cause it to occlude. Clarivein uses a combination of some physical disturbance and chemical injection to occlude the vein.



The solution normally used for this procedure is called sodium tetradecyl sulphate (STD) and is available in different concentrations depending on the size of the vein being treated.
Are my veins suitable for Clarivein?
Your veins will be assessed with ultrasound to detect where the faulty valves are and what size the abnormal veins are. Varicose veins connected to the long saphenous vein or short saphenous vein are often suitable for Clarivein. If you have extensive and very large varicose veins then you may require thermal ablation or surgery rather than Clarivein. Thermal ablation can occlude larger veins but is a slightly more involved procedure requiring more local anaesthetic or general anaesthesia. Clarivein is less suitable for patients on anticoagulants such as Warfarin. Patients with allergies to the chemicals used for sclerotherapy would not be suitable for Clarivein.
What does the procedure involve?
The main surface vein to be treated will be marked on your leg initially using ultrasound scanning. Local anaesthetic will then be injected into a small area of skin, usually near the knee or in the mid calf and a needle will be placed into the vein, again using ultrasound scanning. A wire and then a small plastic tube are placed in the vein and flushed with salt solution. This tube is used to guide the Clarivein catheter into the vein. The length of vein to be treated is usually from the groin to the knee or from the knee to the low calf. The Clarivein catheter is positioned inside the vein using ultrasound so that the correct length of vein can be treated. During treatment the catheter is slowly withdrawn out of the vein. When activated the Clarivein catheter has a flexible curved tip which rotates inside the vein disturbing the lining of the vein but not causing pain. Standard sclerosant chemical is injected at the same time to the exposed disturbed vein wall. As with simple sclerotherapy this chemical injection cannot be felt. This combined "mechanochemical" ablation is delivered locally to the vein wall by the catheter as it is slowly withdrawn.
What happens after treatment?
At the end of the procedure a bandage will be placed on your leg from the foot upwards to cover the treated area. This helps ensure the treated vein stays closed. The bandage is changed for a compression stocking at 24 hours. The stocking is worn day and night for 7 days but you may remove the stocking to shower or bathe. The stocking is then worn during the day for a further 7 days but can be removed at night. You should do plenty of walking and may generally do most normal activities without any problem.
Will I need further treatment?
Clarivein will successfully occlude the faulty vein in 90- 95% of cases. If the vein does not occlude the procedure can be repeated. Removal of some of the varicose veins under local anaesthetic (avulsions) may also be carried out at the same time. This will depend upon how many veins you have and their position in relation to the varicose veins. Your surgeon will discuss this with you.
What are the possible complications?
Thrombophlebitis (10%)
If the varicose veins become hard, tender, and red this is due to blood clotting in the vein causing thrombophlebitis. This is nothing to worry about but may be associated with inflammation and discomfort. If this occurs anti-inflammatory pain killers (nurofen, ibuprofen) may help. These lumps will eventually subside and disappear but this may take several weeks. This process may be hastened by your doctor inserting a needle into the lumps and aspirating the clots which liquefy again after a few weeks.

Brown pigmentation of the skin
This can occur following superficial thrombophlebitis described above and can be permanent. However it will usually fade over a period of several months and may disappear completely.

Deep venous thrombosis (DVT)
If the sclerosant solution passes into the deep veins there is a risk of thrombosis of the deep veins. This may be very minor with no symptoms or a major blood clot with a risk of a pulmonary embolism. Movement of the leg helps to prevent this complication. Regular walking and exercise of the leg are therefore very important after these procedures. With these precautions DVT is rare (<1%). The risk is not higher than with other forms of treatment for varicose veins.

Allergic reaction
Allergy to the solution used is rare but can occur. If you have any allergies you should inform your surgeon.

Recurrence of Varicose Veins

There are two main reasons for varicose veins re-appearing after treatment. Firstly new varicose veins may develop from veins that were normal at the time of your treatment. This often takes some years to develop. All treatments for varicose veins are associated with this.

Secondly, if the faulty veins are not fully removed or occluded by the treatment then the varicose veins are more likely to re-appear. This may be sooner, months after treatment rather than years.

Clarivein has been shown to successfully occlude veins up to 12 months but there is no longer term data at present.
3. VARICOSE VEIN SURGERY
There are two aspects to varicose vein surgery. The most obvious is to remove the lumpy, distended varicosities and this is usually done through a series of small cuts (2-4mm). The terms "avulsions" or "phlebectomies" are used to describe this. The veins are removed in sections (avulsed) through each of the incisions.

The second aspect of the operation is to remove or close any superficial veins with reflux in the leg, since if these are left in place they are a source for new varicose veins forming. Two systems are commonly involved, first a vein called the Long Saphenous Vein (LSV) running up the inside of the leg to the groin. Second, is the Short Saphenous Vein (SSV) running up the back of the leg to behind the knee. The standard open operation involves tying off these veins either at the groin or knee. The long saphenous vein may be removed in the thigh by a process of "stripping". This involves pulling the vein out under the skin down to the knee level.
Complications (specific to vein surgery)
Removing varicose veins inevitably produces some bruising and soreness. The severity depends on how many veins are removed. Most of this resolves in 1- 2 weeks but it may take longer for the leg to fully return to normal. Small venous flares may develop in areas where the bruising was most extensive. Wound infections occur in approximately 2-3% of cases. Small nerves next to the veins can be disturbed leading to patches of numbness in the lower leg and foot in 10% of patients. This slowly resolves but is occasionally permanent. A thrombosis can occur in the deeper veins of the leg but this is not common, affecting less than 1% of patients. A number of precautions are taken to prevent this.
Post Operative Instructions
Much varicose vein surgery is performed on a day case or overnight stay basis. Some form of bandage or stocking is used to try and reduce post operative swelling, bruising and the risk of thrombosis. This support should be used during the day for 1-2 weeks.
Aim to either rest with the leg elevated moving the ankle, or be up on the move around the house and garden. Avoid standing for any long period of time; avoid crossing your legs. A daily walk of up to 1- 2 miles will be beneficial. If at any time there is some bleeding do not worry. Elevate the legs, apply some pressure for 10 - 20 minutes and it will stop.

You will probably need 5-7 days off work, returning when you feel comfortable. Avoid driving for 3-5 days. Return to all other activities when you feel comfortable and confident. With common sense and a gradual return to activities it is extremely unlikely that you will damage any part of the operation.
VENOUS INJECTIONS (MICRO-SCLEROTHERAPY)
How does Sclerotherapy work ?
Some superficial veins can be treated by injections.
A chemical that irritates the wall of the vein is injected via a small needle. Following this pressure is applied with a pad and a bandage or stocking. The vein is compressed and emptied of blood. The walls of the vein become inflamed and stick together preventing the vein from opening up again so that it is no longer prominent under the skin.
What are the complications?
1. If too much chemical is injected outside the vein the inflammation can cause some pain and redness. This can lead to permanent
brown marking of the tissues which is visible beneath the skin.
2. If there is a severe reaction outside the vein to the chemical an ulcer can develop.
3. A generalised allergic reaction can occur. If you have several allergies or very bad asthma injection therapy may not be advisable.
Your physician will advise you on this.
4. A thrombosis can form in the vein. Occasionally this may spread to the deep veins of the leg and cause an embolus.


These complications are not common (1%).
Is it successful?
Injections are most successful in treating small veins, (2-4mms diameter). A series of injections (commonly 2 – 4) may be required to remove the veins depending on how widespread they are. Other dilated veins may form in the future.
What is involved?
The injections are performed with you sitting or lying on a couch. The needle is very small so that most people do not experience any significant pain. It is common for the area to itch or sting afterwards. Several different veins can be injected at the same time. A pad is placed over the injection site followed by a firm bandage or stocking. This should be worn for 3 – 4 days depending on the size of the veins which are injected. Initially there may be some bruising, and this will take longer to fade.
OVERWEIGHT
, try to reduce this down towards your ideal/target weight.
level of the heart (chest) this will be particularly beneficial.