Varicose veins are a symptom of venous insufficiency. They are most often caused by insufficient valves in the main trunks of the superficial veins - in the great and small saphenous veins. Venous insufficiency is usually genetic. Incorrect structure of the vessel walls causes a loss of elasticity and a tendency to stretch them. The choice of varicose vein treatment method has an impact on its effectiveness, safety and cosmetic effect.
Varicose veins treatment methods can be divided into two groups:
The first group includes the oldest surgical methods - stripping and miniflebectomy. This kind of technique was used for the first time in 1905 by William Wayne Babcock, where he had to remove the saphenous vein part using a flexible, special probe. Due to the small number of relapses and a relatively low percentage of serious complications, this method has been carried out until today. It is complemented by so-called miniflebectomy, i.e. a surgical operation to remove varicose veins using punctures or small skin incisions. The surgery is most often performed under either spinal anesthesia (an anesthetic injected into the central canal of the spinal cord) or general anesthesia.
There can be, however, one very serious complication using the stripping method. The deep vein or arterial system can be severly damaged as well as its nerve trunks. This can lead to permanent paralysis of muscle groups or sudden numbness affecting a certain skin area. Furthermore, postoperative wound infection occurs in 2-3% of the cases. Paradoxically, after classical surgery, there may be an increase in limb swelling caused by impairment of lymph nodes and lymphatic vessels.
While the long-term results of classic operations are quite good, in the postoperative period the pain is significantly worsened. This is caused by extensive hematoma in the canal where the vein was pulled out, but also by postoperative wounds, skin stitches and sensory nerve damage. It usually takes a few to several weeks to get back to normal physical activity.
According to the recommendations of most international phlebological societies, traditional methods of treatment, such as stripping or miniflebectomy, should be kept to a minimum required because they are associated with a high rate of complications, longer hospitalization and a significantly longer period of postoperative recovery.
Minimally invasive endovascular methods
Less invasive treatments, so called intravascular methods, are very safe and can be used on an outpatient basis, which means that the patient can return home on it’s own after the procedure and the recovery period is very short. In the vast majority of cases, patients do not require any painkillers and do not have to limit their normal physical activity. The effectiveness of these procedures is at the same time much higher than that of traditional methods, because the use of ultrasound during the procedure avoids most of the technical errors made in classical operations.
The number of complications after endovascular procedures is negligible and is usually limited to minor pain along the closed vessels as a result of the surrounding inflammation that irritates the nerve endings of the skin. Lumps in the subcutaneous tissue and skin discoloration usually disappear within a few to several weeks after the procedure.
Minimally invasive methods can be divided into thermal and chemical. EVLT is one of them. It is a method with the best documented efficacy and safety. The method involves closing inefficient venous trunks using thermal energy generated by laser light. The optical fiber is inserted into the vein by puncturing the skin. The whole procedure is performed under local anesthesia (so-called tumescence) and is also ultrasound-guided [performed with the aid of ultrasound imaging throughout the procedure]. The use of laser light with a wavelength of 1470 nm (compared to the older 980 nm type) and optical fibers with a radial structure, reduced the risk of thermal damage to the adjacent tissues. The usage of disposable fibers reduced to a minimum all the complications resulting from fiber fragment damage or distortion.
Another thermal method is a Radio Frequency plasma method (RF). The healing effects of this method are similar to a laser. Another method involves the use of steam, although it hasn’t found wide application yet. The effectiveness of this method is lower compared to the one of laser or RF methods, and additionally, the skin burns may occur more often after such the procedure.
Among the chemical methods, sclerotherapy is the oldest. It involves the injection of a chemical substance into an insufficient vein in the form of a liquid or foam. By this method we are damaging the vessels endothelium inducing inflammation and fibrosis, which eventually leads to venous atrophy. This method works well when closing small varicose veins or spider veins. When closing large venous trunks however, the method has relatively low efficiency and as we know, when both the concentration of a sclerosant is too high and the volume is too large, it can be the reason for deep vein thrombosis and even pulmonary embolism. Recently, it is used as a mechanical-chemical method. Sclerosant in a combination with a catheter is working mechanically on the vessel wall and additionally damages the vascular endothelium mechanically. This increases the effectiveness of the procedure.
Recently another chemical method has appeared, consisting of applying cyanoacrylate glue and gluing the walls of the vessel. Research indicates that this method is more effective than sclerotherapy, however, the thickening of the superficial veins is long-lasting and the adhesive itself can cause allergic reactions.
The common advantage of chemical methods is that the anesthesia does not require to be administered, which significantly shortens its course. In addition, the usage of a chemical may reduce the discomfort after the surgery. However, in the light of current research, the most effective and best studied method is laser ablation with 1470 nm light using a radial fiber. The effectiveness of vein occlusion using this method over a one year period is estimated at 99.7%, over a 3 year period at 98% and over a 5 year period at over 96%.
The choice of varicose vein treatment method depends mainly on the anatomical conditions in the venous system and the specialist’s experience. The possibility of combining several methods during one treatment gives a wide range of therapeutic options that are effective and safe, while leaving a beneficial cosmetic effect. Thanks to the use of modern intravenous methods, the procedure is performed on an outpatient basis, and patients can return to normal physical activity immediately after the procedure.