Varicose veins are caused by failure of the saphenous vein trunks (GSV and SSV). There are valves in these veins designed to allow blood flow in one direction. These tend to fail primarily for genetic reasons and blood tends to pool in these veins. The blood then subsequently back fills into the veins under the skin and may become visible – so called varicose veins. These saphenous main trunks may not be visible themselves, rather it is the varicose veins which they cause that are seen. Treatment usually involves dealing with the main trunks and the varicose veins, hence most treatments involve two component parts. In Ireland these tend to be done at the same time but can be staged over two sittings. The most common treatment for the main saphenous trunk is thermal ablation, with laser being the most commonly used in Ireland. This is called Endovenous laser Ablation (EVLT). Over 15,000 cases have been performed in Ireland since 2006 with my personal series of over 2,000.
Once the saphenous trunk has been dealt with attention turns to the varicose veins themselves. The main choices of treatment here are to remove these veins through a series of small incisions using a hooking technique, this is called phlebectomy. Alternatively these veins can be treated by injection using a sclerosing agent A recent trend has been to delay treatment of these veins following the initial treatment of the saphenous trunk. The patient is then reviewed after a few weeks often by which time the veins have become less visible. The staging of the treatment has the advantage of potentially reducing the need for the number of phlebectomies or injections. The disadvantage however is that it is a second stage and requires another visit to the doctor. In the UK and Ireland both components of the venous operation tend to be a single procedure. The choice between phlebectomy and sclerotherapy depends on both patient and operative preference with each having particular consideration.
These procedures are performed almost exclusively as day cases with a recent trend of treating some patients in an ambulatory setting, where the patient walks in to a treatment area in a clinic rather than to an operating theatre. This does not suit every patient and a variety of factors have to be considered when deciding what is the best option. Generally after treatment patients are discharged on the same day with compression hosiery and some discharge instructions.
The laser fibre is introduced into the main saphenous trunk in the lower leg and passed up through the vein using ultrasound as a guide. Fluid containing local anaesthetic is placed around the vein again using ultrasound guidance. This has the combined effect of isolating the vein allowing it to be safely heat-treated and producing pain relief through the local anaesthetic. The laser fibre is withdrawn slowly sealing the vein off and blocking off the blood which causes the visible varicose veins.
Other alternatives to thermal ablation are glue or injection treatments and open traditional open surgery where the main vein is removed through groin surgery. Glue, is a new treatment which is promising, producing excellent results, however, it is expensive and as a result it is not widely used in Ireland at present. This however is likely to change in the near future. Injection treatment (Sclerotherapy) is popular in Australia, UK and other parts of Europe. However in Ireland it tends to be used in combination with other treatments rather than just in isolation. It can be used in combination with a mechanical device designed to aggravate the vein and hence enhance the effects of the injection.
Traditional open surgery has become less popular in recent times as recovery tends to be longer. However it is an excellent treatment with good long term results. Some patients who have a larger calibre of vein at the groin area or are particularly thin are often less suitable for thermal ablation. In such cases open surgery maybe their best option.
POST OPERATIVE COMPLICATIONS
Venous surgery is generally a safe procedure and it is well tolerated. The significant side effects are very infrequent. The most significant potential complication is called venous thromboembolism (VTE). In such cases a blood clot forms in the deep veins of the leg and may or may not partially break off and travel to the lung. These conditions are called deep venous thrombosis and pulmonary embolus. Post op instructions are almost exclusively designed to reduce the risks of VTE to as low as is possible. These include wearing compression hosiery, taking regular exercise, keeping well hydrated and avoiding being immobilised, either during a long car or plane journey. In addition people get an injection of a blood thinning agent at the time of surgery once again to try and reduce the risk of VTE to as low as possible.
After surgery most patients generally develop some bruising which can be quite extensive if they have had particularly bad varicose veins and required extensive phlebectomy. Other complications tend to be less significant.
Varicose veins can recur with significant recurrences in about 20% of patients. Patients might develop thread veins after surgery and may, as a result have some areas of reduced sensitivity. Thread veins can be treated with injection and the reduced sensitivity tends to be only transient in nature.
POST OP INSTRUCTIONS
You will be discharged from the hospital in either a temporary dressing or stocking. This will be left untouched for several days after which you will change to a standard class 2 compression stocking. It may be provided by the institution or may require purchase in advance. When the original bandage or stocking comes off you will notice some sticky dressing on the leg. These dressings are waterproof and may start to come off once you have started to shower. If however they do not come off you should leave them for a week before you actively try to remove them. Class 2 compression stocking should be worn during the day until the bruising subsides. This varies from patient to patient and really depends on how extensive the veins are. It can be necessary to wear them for several weeks. The stocking can be taken off at night. I ask patients to perform about four 15 – 20 minute walks per day spread fairly evenly throughout the day. The emphasis is on short regular walks to promote a constant mobility and activity however I do not restrict walking and if a patient wants to walk further that is fine. I do ask the patients to defer from gym work for about two weeks.