Varicose veins are enlarged visible veins on the leg. They are often cosmetic problems but can be symptomatic. Varicose veins are part of venous insufficiency syndrome, where poorly functioning valves allow blood to flow in the wrong direction and pool.
Studies have shown that the condition affects somewhere between 10 and 30% of the world, and is more common in women than men, especially women who have had multiple pregnancies or obese women. As studies in Japan and France have shown, a family history of venous insufficiency also increases the chances of the condition. Other associations include occupations involving prolonged periods of standing, smoking and pes planus (flat feet).
Associated symptoms are
- Pain, itching, leg heaviness, and cramps in lower limbs
- Infection of the skin
- Distress over cosmetic appearance
- Skin pigmentation
The onset of varicose vein disease is insidious with slow progression. Patients often have significant disease prior to presentation. Rapid progression of varicose vein disease is rare but can be associated with other pathologies including iliac vein stenosis/compression (e.g., May Thurner stenosis), pelvic venous disorders, prior history of DVT etc.
CEAP Classification for Chronic Venous Disorders
CEAP stands for Clinical (C), Etiological (E), Anatomical (A), and Pathophysiological (P) evaluation of venous disease. This was first introduced by the American Venous Forum in 1994 and revised in 2004.
Varicose Vein Pathophysiology
Venous reflux disease develops when the valves stop working properly and allow blood to flow backward (i.e., reflux) and pool in the lower leg veins.
Whilst there are multiple ways to treat varicose veins, there is no definitive cure, and any treatment has a chance of recurrence. The main methods of treatment are compression stockings, varicose vein surgery – surgical ligation, stripping, avulsion; injection sclerotherapy, endovenous laser treatment, endovenous radiofrequency ablation and endovenous glue ablation.
Stockings are offered as a first line of treatment. Most patients will be advised to use them for around 2 to 6 weeks, and they often get adequate symptom control. In order to be as effective as possible, they should reach the thigh at least. Compression stockings however have relatively low compliance rates due to patient discomfort, particularly in hot weather as well as cosmetic appearances
Surgical Ligation, Vein Stripping/Avulsion:
SL is a procedure where smaller veins are closed with ties via small incisions in the affected areas. VS follows a similar process, but instead of being tied off, the damaged veins are removed. This process is usually done on larger veins. Avulsion, similar to VS, is the use of very small incisions to focally enlarged varicose veins. Surgical treatment requires hospital admission and general anesthesia. Whilst they are documented to be effective at preventing future recurrence, they are less efficient than the more recent percutaneous treatments. Potential side effects include skin numbness, inflammation, bruising in the targeted area and limb edema in addition to potential complications of general anesthesia.
Minimally invasive therapies for VV
More recently, several minimally invasive treatments are available for varicose vein disease. These include endovenous laser ablation (EVLA), endovenous radiofrequency ablation (EVRFA) and endovenous cyanoacrylate glue injection. Injection sclerotherapy is to supplement all varicose vein treatments and in selected situations as a stand-alone treatment.
Patients are required to use compression stockings for a short period of time after EVLA, EVRFA and injection sclerotherapy.
There is no statistical difference in patient outcomes with EVLA and EVRFA. Glue injection therapy is relatively new and shows promising results. However, the long-term efficacy compared to more established treatments needs to be evaluated further.
The main advantages of minimally invasive therapies compared to surgical treatment are
- Reduced procedure and recovery times
- No requirement for hospital admission
- Reduced rate of complications
- Reduced procedure related costs
Endovenous Laser Ablation (EVLA):
EVLA works by using energy from laser fibers to close the problematic veins, allowing blood to start flowing in healthy, non-compromised veins. EVLA is performed as a day case procedure under local anesthesia. If desired mild conscious sedation can be administered to increase patient comfort during the procedure. Tumescent anesthesia is administered by injecting dilute local anesthetic solution around the target vein.
Some side effects include thrombophlebitis, hematoma, ecchymosis, skin discoloration, DVT (deep vein thrombosis), burns on the skin around targeted areas and nerve damage. Any burns must be monitored for infections and treated appropriately.
Endovenous Radiofrequency Ablation (EVRFA):
EVRFA is another method of closing off problematic veins, this time using heat via radiofrequency catheters. The procedure is performed similar to EVLA and requires tumescent anesthesia. Potential complications are also similar to EVLA
Case Example for Thermal Ablation (EVLA/EVRFA)
Endovenous Glue Ablation (EGA):
EGA is performed by injection of cyanoacrylate glue under ultrasound guidance. The glue is injected at the entrance to the problematic veins, which results in closure. This treatment is a relatively novel one, only becoming common within the last few years, Early research has shown this to be a safe and effective method of treatment. Research has also shown that it is less painful than other treatments, although patients may experience mild discomfort and pain. Some side effects include bruising, blood clots, DVT and skin irritation in the targeted areas. Recent literature suggests potential foreign-body granuloma formation within 2–12 months of the procedure. Cyanoacrylate adhesive closure is not advised in patients with uncontrolled inflammatory, autoimmune or granulomatous disorders (e.g. sarcoidosis). Caution should be exercised in patients with significant active systemic disease or infection and alternative therapies such as thermal ablation and foam sclerotherapy should be considered. Ongoing data collection and research is required to establish long term safety.
Sclerotherapy involves injection of sclerosant medication, often in the form of foam, directly into the abnormal vein resulting in inflammation of the vein wall causing the vein wall to stick and eventually result in obliteration of the target vein. Evidence shows that foam sclerotherapy is more effective than liquid sclerotherapy. Injection sclerotherapy is rarely effective as a stand-alone treatment of advanced varicose vein disease and is often used in conjunction with other therapies. The incidence of side effects for sclerotherapy is low. Potential side effects include bruising, stinging, inflammation, skin pigmentation, raised red areas, and general discomfort in the area. More significant side effects include an allergic reaction, ulceration of the skin in the surrounding area, blood clotting in the targeted and deep veins, and skin infection.