Varicose Vein Treatment

By Karen Appold

Various treatments offer patients relief from the leg pain and swelling that are characteristic of varicose veins.

Varicose veins cause a broad range of symptoms—from aching, swollen ankles, and pain, which is typically worse after long periods of standing, to the more esoteric symptoms of restless legs at night, throbbing veins, and itching/burning sensations. "A fraction of patients seek treatment based upon the appearance of varicosities in the legs; however, this tends to be the minority," says Jonathan Bath, MD, RPVI, assistant professor of surgery at the University of Cincinnati.

When venous hypertension has been in place for some time, this may lead to skin changes, pigmentation of the gaiter area (just above the ankle bone), and skin breakdown as venous ulceration. "Usually these patients have already been treated for some time at a wound center and already have established venous wounds by the time they seek treatment," Bath says.

Treatment Types
There are three types of treatments for varicose veins: surgery, ablation therapy, and chemical injections (sclerotherapy). Here's a look at each type.

Surgery, or vein stripping, is performed by making small incisions over the veins and then pulling them out of the body. "This is especially effective for very large superficial veins and works quickly to get rid of many veins," says Ellen Dillavou, MD, FACS, RPVI, director of Venous Services, University of Pittsburgh Medical Center (UPMC) Division of Vascular Surgery.

According to Bath, surgery is typically reserved for patients for whom an office-based procedure is less appropriate. "This may be due to intolerance of the procedure (which is rare) or more often for a combined procedure to strip the great saphenous vein in conjunction with phlebectomy (direct removal) of the bulging branches of the saphenous vein," he says.

Bath typically offers this procedure when the bulging branches are too large to be dealt with adequately with foam sclerotherapy or if he expects that the varicosed branches will not improve following simple ablation of the great saphenous vein.

Disadvantages of surgery are that small incisions are made in the groin crease and in the upper calf, and most patients require sedation or general anesthesia for the procedure.

Ablations of veins, performed via laser, radiofrequency, or chemical foam, is a relatively new method of varicose vein treatment. The in-office procedure closes dysfunctional saphenous veins. It is effective in closing veins in more than 95% of procedures and generally lasts a lifetime, Dillavou says. Following ablation, other varicose veins may require injection or surgical removal depending on the size and symptoms.

Bath offers radiofrequency ablation (RFA) because it involves less post-procedural discomfort for patients than laser therapy. "The methods of treatment are almost identical," he says.

Under local anesthesia the great or small saphenous vein is entered under ultrasound guidance. A small sheath is placed into the vein and a catheter is inserted to the top of the vein, Bath explains. A diluted lidocaine solution is infused into the tissue surrounding the vein (tumescent anesthesia) to collapse the vein and protect the patient from the heat from the catheter tip during treatment.

The advantages of this approach include avoiding sedation or general anesthesia and a percutaneous rather than surgical approach to treatment. "In our practice patients do not have to stop taking medications prior to the procedure, including anticoagulation or antiplatelet agents," Bath says. "Therefore, it is rare that a patient would not be a candidate for this procedure, even with multiple comorbidities and medications." 

The injection of a chemical sclerosants (sclerotherapy) is most useful for spider veins and reticular veins (small varicose veins measuring one to three millimeters in size) and is often combined with ablation or surgical procedures following treatment of the great or small saphenous vein. Sclerotherapy can be performed on very small (spider) veins, or can be used to treat larger veins. For larger veins, the sclerosant is typically foamed to better fill the target vein. The foaming procedure uses very small amounts of 1% polidocanol or sodium tetradecyl sulfate mixed with air or carbon dioxide by means of a fine filter in order to produce foam, Bath explains. The foam is then injected with a small needle directly into the vein. This increases the contact time with the venous endothelium in order to induce more damage to the treated vein.

For the treatment of difficult venous wounds, following great or small saphenous vein treatment, ultrasound-guided foam sclerotherapy can be used for treatment of perforating veins (veins that connect the deep and superficial venous systems) in the region of the wound, Bath says. Superficial veins that are demonstrated to feed into large perforating veins are accessed using ultrasound and foam sclerotherapy. The foam can be traced into the perforating vein with limitation of entry into the deep venous system. Although this technique to easy to perform in the office, it is not 100% effective, and ablation of perforators, either by laser or radiofrequency, has become an important tool for venous ulcer therapy.

The three treatment options are complementary, and the approach should be tailored to each patient. "The principles of venous disorders and hierarchy of treatment are important when offering patients the most effective form of treatment," Bath says. "The general applicability of RFA to virtually every patient makes this an attractive first line mode of treatment; however, there are some patients who may be inadequately treated by this approach alone and may, in fact, require some combination of all three modalities in order to obtain excellent durable results."

Treatment Candidates
Although most patients are candidates for open traditional surgery, a few are not. These include individuals with groin infections or wounds, individuals with wound-healing complications who would benefit from a percutaneous rather than surgical approach, and patients who might be unable to tolerate anesthesia. "Generally these patients carry severe significant medical comorbidities that elevate the risks associated with surgery," Bath says.

Almost all patients can be considered for ablative therapy, unless the vein to be accessed is too small or filled with thrombus, or is simply too tortuous (twisted) to pass the RFA catheter into. "These are relative contraindications, however, and there are techniques that can be used to straighten out tortuous veins and navigate the catheter through areas of thrombus or scarring," Bath explains. In very small veins where ultrasound access has failed, a direct approach to access the vein through a tiny skin incision can almost always be used successfully to guide a wire into the vein and then the treatment catheter.

Foam sclerotherapy can be broadly applied to any patient with veins between one and 10 millimeters in diameter. "The procedure is extremely safe when performed by a specialist knowledgeable and competent in foam sclerotherapy injections," Bath says. Side effects such as temporary visual disturbances and anaphylactic reactions have been described with an incidence of less than 0.2% and may be more frequent when larger sclerotherapy volumes are used. While there have been very rare instances of stroke described with sclerotherapy, this is exceedingly rare. General recommendations to minimize this small risk are that patients receive no more than 10 to 15 cc of foam at one treatment to limit the amount of air or carbon dioxide entering the system.

Recovery Rates and Expected Results
Surgery is performed as an outpatient procedure; patients are discharged following a brief monitored period of recovery from anesthesia. Usually post-op activity is restricted to avoid soaking incisions, swimming, or bathing until the two-week follow-up visit, according to Bath. In addition, optimal results require avoidance of lifting more than 20 pounds or engaging in intense physical activity for at least two weeks post-op. Compression wraps, worn for the first 24 to 48 hours, can then be exchanged for prescription compression stockings to be worn through the follow-up period. Relief of symptoms can be expected shortly after surgery and mild pain and bruising that is usually treated with over-the-counter analgesia can be expected over the site of vein stripping or phlebectomy.

RFA or laser ablation is performed as an office-based procedure that takes approximately 45 minutes. Like conventional surgery, it carries similar instructions on avoiding soaking, swimming, and the like. Compression wraps are exchanged for prescription compression stockings after 24 hours. Relief of symptoms is expected shortly after the procedure and some mild pain and bruising can be expected over the ablation site following the procedure. Patients are ambulatory immediately following the procedure with very little recovery time.

Sclerotherapy is performed as an office-based procedure and follows a similar set of post-procedural instructions to ablation therapy. Localized bruising is expected over the treated veins and patients are advised to avoid sun exposure for two weeks following the treatment to minimize the risk of skin pigmentation due to ultraviolet exposure to the products of vein breakdown. Compression wraps are exchanged for prescription stockings after 24 hours and are recommended for at least two weeks following the procedure.

Treating extensive veins may require many sessions and some bruising and discoloration may persist for a few weeks, depending on the size of the treated vein, Dillavou adds.

Ultrasound-guided foam sclerotherapy to perforating veins predicts a 70% association with a healed ulcer when perforator vein thrombosis occurs. Unna's boot compression or standard compression wrapping is continued immediately following the sclerotherapy session and may need to be repeated if ulceration is persistent.

New and Anticipated Procedures
Venous disorders have been studied with more intensity in recent years, leading to a much deeper understanding of the pathophysiology of venous reflux and venous hypertension, Bath says. This has prompted rapid expansion in the technology available to treat venous reflux with a tectonic shift from surgery toward catheter-based treatments.

"Newer trials of foam sclerotherapy for great and small saphenous veins treatment has shown some promise, but has not yet lived up to the durability of ablative or surgical procedures," Bath reports. A device that combines an infusion of sclerotherapy agent with mechanical abrasion of the vein lining is available for use in the United States (Clarivein, Vascular Insights) and is currently being evaluated against RFA and laser treatments.

Closure of saphenous veins with a new chemical foam (Varithena, BTG) has recently become available. Use of a medical grade glue (Sapheon, Covidien) is expected to secure FDA approval early in 2015. "These new treatments are exciting as they do not require any tumescence at the time of the procedure and may not require compression to be worn afterward," Dillavou says.

— Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.