Patients with milder forms of varicose veins essentially have a cosmetic problem. To a doctor, these patients are sometimes viewed as low priority, and treatment is often neglected until complications occur. An understanding of the natural history, progression, and complications of varicose veins should enable physicians to decide at what stage intervention is appropriate in different patients and what to offer these patients.
It has been estimated that approximately 30% of the population have some form of varicose vein disorder, and as such, a huge number of patients present to primary care practitioners and general physicians seeking advice about the nature of the problem, whether treatment is necessary, and understanding the range of treatment options available. Primary care physicians report that they spend a large proportion of their clinical time managing varicose vein disease, and practical reports and guidelines suggest that primary care should be the focus of care for uncomplicated cases. Coordinated efforts between primary care physicians and specialists are required to translate such guidelines into effect, and patients often present with preconceived ideas about the nature of their treatment from the advice of friends and family. Thus, practitioners need a clear understanding of the range of treatment options available.
The purpose of this paper has been to attempt to undertake a review of the available treatment modalities for varicose veins in a non-systematic manner. It has been the authors’ intention to produce a practical guide for physicians to follow during the decision-making processes involved in managing varicose vein disease. As such, the authors felt that it was inappropriate to follow the usual conventions employed in the production of a systematic review, as the limitations of the evidence base made this the least helpful way to achieve our stated aim. Instead, this review seeks to answer the common questions which occur during the clinical work-up of a patient presenting with varicose vein disease.
Non-surgical Treatment Options
Of all the non-surgical treatments, the strongest evidence exists for compression therapy, and this is the recommended first-line non-surgical treatment. This involves wearing prescription-strength graduated compression stockings, which are tightest at the ankle and get looser further up the leg. Compression helps to improve the symptoms of pain, swelling, and discomfort and can also reduce ankle swelling. Studies have shown that patients can report a significant improvement in symptoms of pain and swelling with the use of compression stockings. Compression can also help in the prevention of leg ulcers. A study comparing sclerotherapy and compression stockings as treatments for varicose veins showed that the recurrence of venous ulcers was higher in patients who received only sclerotherapy, and so the compression therapy may be beneficial in conjunction with other treatments for the prevention of venous ulcers.
Varicose veins can be unsightly, and not everyone with varicose veins has symptoms. Non-surgical treatment options will not make the veins disappear but can reduce the symptoms of pain, swelling, and discomfort that can be associated with varicose veins. These treatment options are also relevant for patients before and after undergoing surgical treatment. In anyone with superficial vein thrombosis, non-surgical treatment is recommended. The non-surgical treatment options often require several months to see the benefits and usually have to be continued on a long-term basis.
Compression Therapy
One of the main barriers to wearing elastic compression stockings is the appearance and stigma associated with them, especially in warmer climates. Some patients have found Unna boots and zinc paste bandages to be effective alternatives, as they provide compression while remaining hidden and allowing normal activities with minimal inconvenience. The emergence of endovenous techniques may encourage more patients to try compression therapy, as it can be used as an adjunct before or after these procedures. Additionally, both patients and clinicians are increasingly interested in the long-term reduction of compression therapy and associated symptoms following endothermal procedures.
Compression therapy aims to reduce the diameter of affected veins and alleviate associated symptoms. Elastic compression, which applies external pressure to the calf muscle, has been the main treatment method for many years. It reduces venous reflux and venous hypertension. Stockings are commonly used, with the highest pressure at the ankle and a decreasing pressure gradient up the leg. Initial treatment typically involves class 1 (14-17mmHg) or class 2 (18-24mmHg) below knee compression for at least 6 months. However, compliance with wearing stockings is relatively low, with up to 50% of patients not wearing them as prescribed, and 20% not wearing them at all. It is crucial to maintain full compliance, as the physiological effects of compression are lost within 48 hours of discontinuation. Elastic compression has been shown to improve symptoms and promote disease regression.
Lifestyle Modifications
During the assessment of a patient with varicose veins, it is important to establish what influence their lifestyle is having on their symptoms. It may be possible to make a number of simple lifestyle changes that can significantly improve symptoms. Regular exercise such as walking or swimming helps to pump the blood out of the legs and back to the heart. This can help to reduce the pooling of blood in the veins and so reduce some of the symptoms of varicose veins. Patients should also be advised to avoid long periods of standing or sitting as this can make symptoms worse. If their job involves prolonged periods of standing or sitting, it may be worth suggesting they take regular breaks and try to move around. Leg elevation is beneficial as it improves the venous return from the legs back to the heart. Patients should be encouraged to elevate their legs for three periods of 30 minutes throughout the day and especially at the end of the day and after any prolonged standing. This can easily be achieved by lying on a settee with the legs resting on the arm and a couple of pillows. Finally, weight loss and dietary changes can also be beneficial. Studies have shown that there is a strong association between obesity and the severity of varicose veins. This is likely to be due to the increased pressure in the abdomen that is caused by excess weight. This increases the pressure in the leg veins, which can contribute to the development of varicose veins. High-fiber, low-fat diets are also beneficial as constipation is known to cause and/or exacerbate varicose veins due to the straining involved.
Medications
While not achieving the same reduction of reflux and visible varicose veins as obliterative procedures, certain medications may be useful to improve symptoms and slow the progression of venous insufficiency in patients who are not candidates for, or who elect not to undergo, compression therapy or invasive treatments. Pentoxifylline, a drug with hemorrheologic properties, has been shown in some but not all studies to reduce pain and other symptoms in patients with non-malignant chronic pain and other symptoms in patients with non-malignant chronic venous hypertension or post-thrombotic syndrome. Dosage of 400 mg, three times per day is recommended for a three-month trial; in the absence of a positive response, the drug should be discontinued. A trial of daily aspirin or other antiplatelet medication would seem warranted by the increased risk of thrombotic events in patients with LES. This practice, however, has not been evaluated in well-designed clinical studies and therefore cannot be strongly recommended. Non-steroidal anti-inflammatory drugs can be particularly effective for superficial thrombophlebitis, and may be used episodically to treat a worsening of pain, and joint exercises are a useful alternative for patients unable to tolerate NSAIDs. For symptoms of chronic venous insufficiency or isolated superficial reflux, there is evidence that Rutosides (oxerutins), a group of semi-synthetic flavonoids with long-established use in Europe, offer symptom relief. A variety of other herbal medications and dietary supplements, and numerous alternative therapies, are used in an effort to relieve symptoms of chronic venous insufficiency. As these treatments have not been well studied, it is important that patients inform their providers of any herbal supplements or alternative therapies they are trying or considering, due to the potential for drug interactions and other complications.
Minimally Invasive Procedures
The endovenous laser procedure (“EVLT”) uses a laser fiber introduced directly into a varicose vein via a small needle. Using ultrasound guidance, the needle is placed into the faulty vein and local anesthetic applied around the vein. The laser is then activated and slowly withdrawn, causing the vein to close through heat. This procedure reduces the risk of nerve or other tissue damage in comparison to the old surgical methods. After the procedure, a bandage is generally applied to the insertion site, and it is recommended that you walk for half an hour. Regular activity is recommended thereafter. Compression stockings must be worn for a period of one to two weeks. Compared to traditional surgery, the main advantages of EVLT are that it is minimally invasive and there is a lower risk of complications. At the present time, EVLT may not be suitable for more severe cases, including larger varicose veins and skin changes. As EVLT is still a relatively new procedure, there is no clarity on its effectiveness over the long term.
Ultrasound-guided foam sclerotherapy is done with the same sclerosant drugs used in the standard version of the treatment, but the foam version is more effective and is preferred in treating larger varicose veins. This is probably the most inexpensive way to treat larger varicose veins, is virtually painless, and its complications are uncommon. Ultrasound-guided foam sclerotherapy showed no difference in major complications and efficacy from surgery for treating saphenous varicose veins according to a systematic review published in the Journal of Vascular Surgery in 2012. This study showed that foam sclerotherapy had a notably lower recovery time compared to surgery, which concludes that foam sclerotherapy is a better option for treating saphenous varicose veins. Step one for foam sclerotherapy is the same as standard sclerotherapy, only instead the salt solution is mixed with a small amount of air to create a foam that looks similar to shaving cream. The doctor will then inject the foam into the desired veins while monitoring its process on an ultrasound screen. This allows the doctor to see exactly where the foam is being placed and to ensure he treats the entire length of the vein. After the treatment is done, a compression stocking must be worn for 10-14 days. This is done to keep pressure on the veins, thus ensuring that the treated area will be closed. Some common side effects for foam sclerotherapy are slight bruising, redness, and inflammation of the treated veins. These symptoms should subside after a few days. Other uncommon side effects that may occur are light headaches, migraines, and allergic-type reactions, which could all subside within a week. An aftereffect of this treatment is the pigmentation of the skin over the treated veins. This could last for a few weeks to a few months, but in rare cases, it could be permanent.
Sclerotherapy
The Royal College of Physicians guidelines recommend that prior to being treated with a thermal ablation or ligation and stripping, patients should have an ultrasound-guided foam sclerotherapy. This is a modified form of sclerotherapy using stronger solutions and is a suitable alternative to surgical ligation for some patients. The “foam” is made by mixing air with the solution, and this increases the contact with the vein wall. A small catheter is then used to place the foam into the abnormal veins under ultrasound guidance. This technique is particularly suitable for treating large veins in the inner calf, where the recurrence rate with surgery is high. It can also be used to treat recurrent varicose veins from previous surgery or other treatments. Foam sclerotherapy is felt to be cost-effective compared to the alternatives and has been shown to be as effective as surgical treatments, with significantly quicker recovery and less post-operative pain.
Sclerotherapy is a well-established treatment for varicose veins. A detergent (sclerosing) solution is injected into abnormal surface veins. It causes the veins to become less distended. The body is then able to absorb these veins and they subsequently disappear. The procedure is widely available in New Zealand as a treatment for larger varicose veins. Microsclerotherapy is a technique using fine needles to inject the solution into thread veins and is available in some areas. This treatment is most suitable for treating localized varicose veins and for preventing recurrence of varicose veins; it is not generally used to treat all veins in a leg.
Endovenous Laser Treatment
An evidence-based summary and guideline for practice published in 2008 by the Journal of the American Academy of Dermatology stated “ELT has a 92% primary efficacy at 1 year and has results similar to the gold standard achievement of US-guided endovenous thermal ablation”. As an extremely effective treatment option, it is also associated with a lower rate of post-operative complications and has been shown to be cost-effective in the long term. ELT is recommended as the treatment of choice for large truncal veins with a reflux diameter of over 7mm.
Endovenous laser treatment (ELT) is a technique utilizing laser energy delivered into the abnormal vein to close it. Using ultrasound guidance, a thin laser fiber is inserted into the vein via a catheter. As laser energy is delivered through the fiber, it is slowly withdrawn, heating the vein and causing it to close. With the vein sealed shut, blood is rerouted to normal veins. ELT can be performed in the doctor’s office using local anesthetic. The VNUS Closure procedure is an example of ELT. It is also a simple and relatively pain-free procedure which can be done in a clinical setting. By improving the techniques and using tumescent anesthetic, it has been shown to have a higher success rate with less patient discomfort. Success rates of up to 97% at one year with very little pain have been reported.
Radiofrequency Ablation
The method involves inserting a catheter directly into the vein, much in the same way as with the EVLT procedure. Once the catheter is in place, the doctor will apply local anesthesia to the patient and the vein, and the vein will be punctured. The puncture is then dilated in order to allow passage of the probe and the vein itself is also anesthetized. This is to ensure the process is without pain. The RF generator will then be turned on to activate the generator and the catheter is slowly pulled out of the vein. The generator will cause heat to be produced at the site in which the catheter is in contact, and studies have shown that RFA treatment is much less painful than 980nm laser due to the thermal protection allowing limited heat to spread uninsulated. Once the catheter is fully removed, the numbed vein will be compressed with both a bandage and a stocking and the patient will be given a 20-minute walk to seal the thermal lesion.
The final of these is a method known as radiofrequency ablation. Radiofrequency ablation is a minimally invasive procedure used to treat chronic venous insufficiency. This is a technique which is usually applied in the condition where the patient is starting to develop skin changes or even venous ulcers. It can also be applied in instances of cosmetic treatment where a patient may not like the appearance of a varicose vein. This technique can also be used to treat larger veins where other methods such as sclerotherapy have been disappointing.
Surgical Treatment Options
All of these treatment methods should be thought about carefully. In most cases, improving your lifestyle and using compression stockings will be effective enough to manage your symptoms. These treatments have side effects and can cause further pain and discomfort in the short term. The long-term benefits of these treatments are also not entirely clear. Varicose veins are very rarely a serious condition and treating them will not prevent other vein problems occurring in the future. A guideline on these treatments, produced by the National Institute for Health and Clinical Excellence, provides a set of recommendations for patients and doctors on these forms of treatment. These include the well-being of the patient and whether the patient’s symptoms are sufficiently severe to affect their quality of life. Always discuss with your GP or specialist the pros and cons of each form of treatment and whether it is the right option for you.
These are the most invasive ways of treating varicose veins and are often used as a last resort for patients that are experiencing severe pain and have skin damage due to their veins. Vein stripping involves removing long segments of veins from the body. Small incisions are made in the skin and an elastic wire is threaded through the veins to pull them out. A newer, less invasive form of vein stripping is available. This involves using a special machine to create the incisions rather than a scalpel. It is less painful and the patient can return to normal activity quicker. Endoscopic vein surgery is a minimally invasive surgery in which a thin camera is used to see inside the veins. This allows this surgery to be done through very small incisions. The vein is then removed using a second surgical tool. Both of these surgeries are generally done while the patient is under local anesthesia.
Ambulatory Phlebectomy
This microsurgical technique removes varicose veins through small incisions and is especially useful for painful varicose veins overlying bony prominences or where large scars are not wanted. It is done under local anaesthetic on a walk-in, walk-out basis. A phlebectomy is generally done alone or in combination with other treatments for varicose veins such as ambulatory vein phlebectomy or endovenous ablation. After the anaesthetic is administered, a small skin incision 2-3mm in length with a local anaesthetic is made. Small 1mm stab incisions are made over the length of the varicose vein to remove it. The varicose veins are then hooked and removed in tiny segments with a phlebectomy. Segmental avulsions are done at the point of entry to bypass bleeding and a potential hematoma. No sutures are required and the tiny incision sites are dressed with a non-stick dressing. A compression bandage or stocking is worn for a fortnight and the patient may receive a post-operative review.
Vein Stripping
Vein stripping is the surgical removal of superficial veins. It is a minimally invasive procedure and can be performed under local anaesthetic or as a day case under a general anaesthetic. The aim of stripping is to remove the cause of varicose veins and prevent recurrences. The operation involves tying off the top end of the varicose vein and then removing a segment of the vein by pulling it out with a wire through a small incision at the ankle. This is repeated segment by segment down the length of the vein until the entire length of the vein has been removed. The incisions are usually closed with Steristrips or a stitch and covered with a dressing. Patients are often advised to go for a short walk the same day and return to normal activities as soon as possible. The main downside is that, because of the removal of the vein, it can be quite uncomfortable for a few days postoperatively and is unsuitable for those with physically demanding careers. Newer techniques for stripping involve the use of less invasive methods to completely remove the vein, often reducing the discomfort and cosmetic disadvantage of traditional stripping techniques. These involve using a special type of adhesive to attach to the vein and then removing it, or by destroying the vein from within using a combination of heat and mechanical devices inserted through very small incisions. Both of these are also often done in combination with other vein treatments such as endothermal ablation.
Endoscopic Vein Surgery
Reparative strategies for venous reflux that avoid saphenofemoral junction ligation and provide an alternative to lifelong compression hose and periodic ulcer recurrence, especially those utilizing small incisions and therefore potentially providing rapid recovery and return to work, are the holy grail in the treatment of superficial venous insufficiency. In this regard, the technique of endovenous vein ablation using either laser or radiofrequency energy has held considerable promise and now has follow-up data extending to five years. Unfortunately, this approach suffers from one significant drawback: there is no consensus that elimination of saphenous reflux will prevent progression or recurrence of CEAP clinical class 2-6 disease in the limb segments that are historically recognized to be the chief source of secondary varicose veins. Furthermore, recent studies have cast doubt upon this assumption by demonstrating the high prevalence of saphenous reflux in asymptomatic limbs and questioning the clinical significance of this alone in the development of venous hypertension and/or adverse skin changes.