There are 6 main types of minimally invasive leg vein treatment that are often required to be used in combination.
The basic principle of treatment is to select the most appropriate treatment modality for a particular vein segment. All of the treatment modalities described below may be utilised in the one treatment session.
- Microslerotherapy also called Direct Vision Sclerotherapy (DVS) – reserved for the treatment of small veins including spider veins.
- Ultrasound Guided Sclerotherapy (UGS) – reserved for the treatment of medium sized veins and bulging small varicose veins and some hidden veins.
- Microphlebectomy – reserved for the large bulging veins that distort the skin.
- Laser ablation, radiofrequency ablation and adhesive therapy (superglue) – for large hidden varicose veins previously treated with surgical stripping.
The term “sclerotherapy” comes from the Greek word “sclero” which means ‘to make hard’. The treated vein reacts to the product that is introduced to basically convert the abnormal vein into a type of bruise.
Once formed, the vein feels a little hard and this is the signal to your body’s immune system to start dissolving the vein. Eventually the vein is absorbed and disappears.
For surface veins this is considered the current Gold Standard of treatments: Surface veins are often numerous, widespread and usually require several treatments.
Sclerotherapy is considered the first choice method for the treatment of small reticular and spider veins. This involves the injection of a sclerosant detergent solution via a micro needle into the diseased vein, which causes the vein wall to collapse. The veins dissolve and disappear as the body gradually absorbs them.
For most patients with spider veins the underlying blue reticular veins, this microsclerotherapy need to be treated first.
Picture shows sclerotherapy for spider vein
Picture shows the spider vein and reticular vein before (left) and after microsclerotherapy 3 months (right)
2. Ultrasound Guided Sclerotherapy (UGS)
Ultrasound Guided Sclerotherapy (UGS) and the treatment of varicose veins UGS is a safe and effective method for the eradication of small varicose veins. Unlike the surgical option there is no need for hospitalization or anaesthetic. There is virtually no downtime. Most patients with small varicose veins are suitable for UGS.
Dr Rerkasem will determine your individual suitability during the course of the assessment. Some patients will require follow-up treatments to achieve the best results. Prior to treatment a Doppler ultrasound scan is performed to establish and map out the exact nature of the vein problem and whether there are any underlying hidden veins that are causing the appearance of the visible varicose veins. If there are hidden veins then these will have to be treated first either with UGS or if too large by using radiofrequency technology.
The UGS procedure is performed using an ultrasound unit to locate the abnormal veins and allow the doctor to accurately and safely inject sclerosant detergent solution or more recently with sclerosant detergent foam directly into the veins that are hidden below the skin at strategic locations. Once injected the veins collapse and the body’s process of absorption begins. Numerous injections may be required and can be associated with vague sensations of a heavy feeling that usually only lasts for a few minutes.
The sclerosant becomes diluted and neutralised within a short distance from the injection site. It is rapidly broken down and excreted by the liver and kidneys. The appearance of the treated veins rapidly improves over a few weeks with continued improvement still occurring for about three months.
Microphlebectomy is the physical removal of visible varicose veins under local anaesthetic using a modified procedure where the veins to be removed are firstly injected with sclerosant foam. This makes the once visible vein contract and renders them empty of blood which can then be removed via a series of tiny skin punctures (usually 1mm which results invirtually no scarring).
The procedure sounds awful but with the introduction of new ways of applying local anaesthetic the procedure is virtually painless with quick recovery and minimal discomfort. Most patients are able to return to normal activities immediately with restriction only to heavy physical activity for about a week.
Picture shows varicose vein before (left) and after microphlebectomy (right)
4. Radiofrequency ablation-RFA
Radiofrequency Ablation (RFA) for large varicose veins. RFA is a novel method for the treatment of major veins previously treated by stripping surgery under general anaesthetic. The procedure involves the placement of a radiofrequency fiber with ultrasound guidance into the abnormal vein via a tiny incision under local anaesthesia. The vein is then surrounded with local anaesthetic. The radiofrequency fiber is removed slowly whilst the radiofrequency is activated which destroys the vein wall along the treated length. The procedure involves virtually no discomfort. The published success of radiofrequency treatment is around 95 % with significantly better quality of life and faster time to return usual physical activity as compared to stripping surgery (traditional open surgery). With the addition of RFA to Ultrasound Guided Sclerotherapy it is expected that varicose vein surgical stripping will be performed less frequently.
Pictures show the process of the radiofrequency ablation in varicose vein. Left picture shows before energy activation. Varicose vein was ablated by radiofrequency energy and consequently closure (right picture).
5. Endovenous Laser Ablation (EVLA)
Laser treatment, also known as Endovenous Laser Ablation (EVLA), is a laser treatment for the removal of varicose veins. The principle is the same as doing radiofrequency waves. But the temperature of the laser machine is much higher, such as 200-300 degrees Celsius, and the device wire is relatively smaller than radiofrequency waves wire. Therefore it hurts less and travels better into constricted and tortuous blood vessels.
This is currently one of the most effective techniques for vein removal. It was developed in the 1990s in the United States. It is a new way of transmitting laser light directly to the target vein. This method of vein removal involves less incision than surgery (actually no incision, only needling) and therefore this can reduce the complication rate. It is another method that is accepted by patients and doctors around the world. This gives good results in terms of beauty. Research results in the past 4-5 years show satisfactory results in the long term of 10 years or more.
This laser vein removal procedure has been approved by the Food and Drug Administration (FDA) in the United States and Thailand. The laser technique for vein removal is significantly better than conventional surgery, which requires more trauma, painful, bleeding and a higher complication rate.
The left image shows the wire of the laser passing through the knee needling then destroying varicose veins in the groin. The right image shows the laser light at the end of the laser wire
The highlight of these methods is the treatment will take a short time. This can be treated as an outpatient in our clinic without having to go to the hospital and can be done by injecting local anesthesia without general anesthesia. The patient recovers quickly in 1-2 days after treatment. The published success of laser treatment is around 95% with marked better quality of life and faster return normal physical activity as compared to traditional open surgery (venous stripping). Most varicose veins will collapse. From the follow-up of the treatment of patients in the period of 1 years, it is found that the chance of major recurrence is about 3%, most of them are just small capillaries (spider vein), which can be treated by injection. Since varicose veins is a genetic disease, in case the patient still has risk factors such as prolong standing, obesity, multiple pregnancies, varicose veins will return with other untreated veins. There are normally hundreds of veins in one leg.
6. Adhesive therapy (superglue)
Late 2014 saw some interesting new treatments. To treat abnormally large veins using medical adhesives therapy or superglue (Cyanoacrylate) is like closing two sheets of paper together with glue. Then following this treatment in varicose vein, the veins are no longer bulged. Available data suggest that superglue closure is as effective as laser therapy. Superglue closure is not the same as laser treatment. that does not use heat energy. This means that the entire procedure can be performed with a single small injection of anesthetic, whereas laser treatment many small needling to infuse saline around to avoid burning to skin. The procedure involves the painless introduction of a small catheter through the anesthetized skin into the lumen of the vein and the correct placement of superglue within the vein. Press with hand to hold the walls of the veins together. Then there is no more abnormal blood flow in the veins. Medical adhesives, superglue, have been used for over 50 years in various medical treatment (procedures). And it’s very safe and effective. However, some patients are concerned about the treatment because the foreign matter (glue) is left behind in their body. And some people may fear that by doing so the glue will slip off to other important organs. But according to the report, the glue is very sticky. When it meets the blood, the glue hardens and sticks (polymerization) happen immediately then it stick to only the wall of treated vein.
Image showing the insertion of superglue into the varicose veins. The upper picture on the varicose veins still does not have glue. The bottom picture is when the glue is inserted through the plastic tube and the blood vessel walls are pressed against each other. This result in no more varicose veins
Supplementary treatment for varicose vein
Other complementary treatments
The following treatments are as an adjunct to the 6 above main treatment This means that the treatment of varicose veins must be treated mainly by any types of the above 6 methods.
1. Oral medication
Studies have shown that the initial mechanism of varicose veins is an inflammatory process. In the initial stage, there are white blood cells to cling to and destroy the vein valves. Thus this cause the blood to leak through the venous valves in side the lumen of the vein. It is like a water valve that is not completely closed, causing water to leak. (Picture) Several groups of oral medications, such as Diosmin (Daflon), Sulodexide (Vessel), and Aescin (Reparil), act to reduce the inflammatory process. These make the vein valves back to normal especially in a very early stage of small varicose veins Therefore, if treated in the early stages, this drug may help to recover. But if coming at the stage of varicose veins are seen from the outside, then this drug will not be enough. However in this stage, these medicine can reduce symptoms only, but they do not make the varicose veins disappear in any way. Therefore The role of these oral medications is mainly as an supplementary (adjuvant) treatment. There must be another main treatment such as using a laser to destroy varicose veins or using injection treatment to remove spider veins.
Picture shows oral medication.
2. Compression stockings
Stockings can be helpful in two phases.
- In the early stages of varicose vein, we may call it leg health stockings. Or popularly known as stockings to prevent the occurrence of varicose veins. It is stockings or long socks specially designed for vein disease. There will be a pressure that gradually increases from the feet to the calves. The compression force is highest at the ankle and gradually decreases as it gets close to the knee. The pressure at this stage is in the range of about 15-20 mm Hg. This compression will help the muscles contract to increase the pumping force of the blood better. This helps squeeze away swollen tissues (the liquid that accumulates in the legs) to collapse and help relieve pain in the legs. Stockings must be worn consistently, especially whenever you are in an erect position such as standing or sitting.
- In the late stage of varicose veins, while waiting for treatment for varicose veins such as laser treatment you can wear stockings to reduce some symptoms. But wearing stockings cannot replace varicose vein laser treatment. Because wearing stockings never makes varicose veins disappear. It does not directly solve the leaky vein valve problems. When the stockings are removed, the blood vessels leak and swell come back as before. The compression force at this stage is in the range of about 20-30 mm Hg. In addition, after treatment, whether laser or injection treatment, wearing stockings will improve the treatment results. It can reduce bruising and swelling from treatment. Doctors usually recommend wearing 1 week after treatment.
There are many types and styles of stockings on the market. Also there are several differences in colors and length (below the knee or above the knee) and different pressure. Before making a purchase decision, you will receive leg measurements and advice on how to dress from a doctor, a nurse, or a pharmacist.
The left picture shows the legs wearing over-the-thigh stockings and closed ends. The right picture shows the legs wearing over-the thigh stockings and open toe ends.
The picture shows a variety of stockings products, many brands.
3. Compression bandaging for chronic leg wound
It is often caused by severe varicose veins, which result in high intravenous pressure in the legs especially the ankle. This lead to decreased nutrition supply and oxygen supply to the skin resulting in wounds. If compared to a tree that has been in the flooded area for a long time, that tree will rot and die The occurrence of ulcers from venous disease is the same. It can have the following symptoms.
- The wound is usually found on the ankle above the inner ankle
- The wound can be so severe that it surrounds the ankle with swollen legs.
- These lesions have thick, hard black skin and varicose vein around them.
- This type of wound is wet. There is a lot of lymph coming out.
- Patients often have a long history of varicose veins.
The picture shows the appearance of the wound from varicose veins.
At this wound stage, in fact, the principle of treatment is closing the leakage point. This can be done by a laser treatment. This is quite a straightforward treatment. It can be walk in and walk out treatment. Also wounds must be applied the compression bandaging. At this stage, our clinic prefers bandaging rather than stocking because the pressure under bandaging is much higher than those under stocking. This high pressure is very important for treating chronic wound. However, when the wound is heal, our doctors will advice stocking.
This image shows bandaging of the leg
One could argue that wrapping the leg over the wound make the wound even more soggy and worse. It is not true. Good leg bandaging will make the wound dry and heal much faster. It is like having a flood of trees, we have to suck the water from around the tree, otherwise the roots of the tree will rot and die. Therefore dries out the legs, the wound heals!
The left image shows a leg wound before the leg bandaging. The right picture, the wound healed after 3 months of leg bandaging.
4. Venous stripping
Traditional treatment is surgery. Surgery (venous stripping) is the treatment of varicose veins by surgically stripping the entire problematic vein. This technique will make an incision in the groin area. The varicose vein is then cut and tied (Image A). The vein is then extracted at the knee area with another small incision (Images B and C). The operation is usually performed under general or spinal anesthesia. Most patients return home 1-3 days later. This operation has a history of more than 100 years, but in recent years it has been found that these surgeries are very painful and recurrence is high. The popularity has decreased, turning to new techniques by laser or radiofrequency treatment. The guideline in international medical societies including USA, Europe, UK and Australia, recommend laser or radiofrequency treatment over traditional surgery.
Picture shows the step of venous stripping.
Picture show the leg of a patient after venous stripping for 2 weeks. Bruising after surgery is common.