Unfortunately, when patients have had Sclerotherapy at another clinic, the results are usually less than impressive. As a consequence the patient thinks that Sclerotherapy doesn’t work for them. The reason for this poor result is usually simple – the reticular veins, the veins that feed into the spider veins, have not been treated PRIOR to treating the spider veins (“telangiectasia”). This is the most common mistake that is made by doctors with the invariable result that either the spider veins do not go, they are made worse or they come back very quickly (less than 1 year). Sometimes the cause for a poor result is that the patient has an underlying deeper problem (that can only be determined by an Ultrasound examination) but this situation is less common. The reason why doctors don’t treat the reticular veins is because they don’t understand the significance of these veins or that they find treatment of these veins too technically difficult. The reason why the underlying incompetence is not diagnosed is because there is often not a high enough “index of suspicion” about the cause of the problem. These issues are addressed by having your veins treated by a doctor who has had accredited training through an established organisation like the Australasian College of Phlebology.

  

I have often been told by patients that they need surgery to fix their varicose veins. This statement is usually made after the patient has seen either a general practitioner or vascular surgeon. The statement may have been true 20 years ago but has not been correct for the past 20 years since Ultrasound Guided Sclerotherapy (UGS) was first used. UGS is used to treat the underlying incompetent vein that is responsible for the varicose veins that are seen on the surface. More recently, Endovenous Laser Ablation (EVLA) has been used an alternative to UGS to treat the underlying incompetent veins. EVLA is used for the more severe situations and UGS for the less severe cases. These two procedures have now essentially replaced surgery in America and are progressively replacing surgery in the rest of the world.

The reason for these two non–surgical approaches replacing surgery is simple: they have less complications at the time of the procedure and a lower rate of recurrence of varicose veins in subsequent years. Many doctors who have been trained in the traditional surgical technique of vein “stripping” have been slow to adopt these new techniques because of the costs of equipment (ultrasound and laser machines) as well as the time and financial cost of training to be able to perform these new techniques. I believe that to deny patients access to these procedures is bordering on incompetence.

The short answer is a qualified yes.

Varicose Veins: If someone presents with varicose veins I can guarantee that I will get rid of the varicose veins. I can also guarantee that it will be very unlikely that they will ever get any varicose veins related to the underlying vein that I have treated (provided they come in for the scheduled reviews after their initial treatment).

Spider Veins: For cosmetic spider vein concerns I can guarantee that I will significantly improve the current situation.

If a patient has had multiple previous treatments, that have been unsuccessful and have resulted in an even worse situation, then the expected improvement is obviously not as good as if I had the opportunity to treat the legs initially. Of course I cannot guarantee that spider veins or varicose veins will not occur in other areas as this is the result of genetic coding. Treatment of the underlying incompetent veins by Endovenous Laser Ablation or Ultrasound Guided Sclerotherapy does not affect whether veins will occur in other areas.

  

Spider veins are invariably treated with Sclerotherapy whereby a small amount of solution (the sclerosant) is injected into the abnormal veins to close them off. The body then dissolves these treated veins. Laser treatment of spider veins has produced inferior results to Sclerotherapy. As with all medical treatments the skill of the treating doctor is a critical component to achieving a successful result. The Australasian College of Phlebology has a register of doctors credentialed to perform certain procedures. Varicose veins are increasingly being treated less with surgery (“vein stripping”) and more with the “non-surgical” procedures of Ultrasound Guided Sclerotherapy (UGS) and Endovenous Laser Ablation (ELA). Some Phlebologists still perform adjunctive surgery (ambulatory phlebectomies) in association with one of the non-surgical techniques. Whether UGS or ELA is used depends on many factors with the most important being the size of the vein being treated. The larger the veins are more likely to be treated with ELA.

Compression stockings

These come in a variety of compression strengths ranging from support pantyhose to Class 3 medical compression stockings. In between are the compression stockings that are useful in the prevention of DVT’s when flying and the anti-embolism stockings that are often work in hospital. After Sclerotherapy it is usual for a Class 2 stocking to be worn from 3 days to 2 weeks depending on which vein was treated. As an adjunct to wearing stockings it is important to do as much walking as is possible.

Endovenous techniques (radiofrequency and laser)

In many countries Endovenous Laser Ablation (ELA) is replacing, or has replaced, the traditional surgical “stripping” of veins. The reasons for this are that ELA can be done as an office procedure (walk-in, walk-out) and has less risk than surgery. It also does not have the recovery time associated with surgery. The long term results of ELA are excellent. Importantly the recurrence rate of new varicose veins after surgery, which is often very concerning for patients, is avoided by performing ELA. The technique of ELA consists of placing a small laser fibre up the middle of the vein. This fibre is then very slowly withdrawn from and the laser energy from the tip of the fibre then heat seals as it is withdrawn. The laser is introduced via a 3-4 mm cut (done under local anaesthetic) and the procedure itself is also done under local anaesthetic. Normal walking is possible straight away as the local anaesthetic is not into the muscles but only placed around the vein being treated. The actual laser treatment is painless although some patients report a buzzing sensation.

  

The answer depends first on the size of the vein and second on issues of affordability. Generally, for veins that have a diameter greater than 5 or 6 mm’s, most Phlebologists believe that Laser is a better form of treatment. Sclerosant injection into veins of this size is challenging because the large amount of blood in these veins will dilute the sclerosant and make it difficult to get adequate concentrations of the sclerosant. This effect is not substantial for veins less than 4mm. Once veins are greater than 8mm the number of treatments that would be required generally make UGS an inefficient way of treating veins of this size.

ELA is however a more expensive procedure so the inconvenience of multiple visits may be preferable to the extra cost of ELA. Provided the veins are not over 8mm (which makes it extremely difficult to effectively close veins with UGS no matter how many treatments) after the initial occlusion is established the results are similar when patients are reviewed several years after treatment. However, the use of large quantities of sclerosant makes pigmentation more likely because of the large amount of blood that is trapped when very large veins are treated with UGS.

  

Questions or comments about vein treatments

Are you concerned about your treatment or have any additional questions about this article? Leave a question below.

If you have your legs treated by a well trained and experienced practitioner you can expect to not require further treatment for many years. The actual time will depend mainly on your genetic predisposition, your age, the number of pregnancies that you have after treatment and your occupation. To a less extent it will depend on your weight and whether you wear high heel shoes. For example a lady who is 40 years old with little in the way of family history, no more pregnancies and a job that involves sitting down, can reasonably expect 5-10 years between sclerotherapy treatments. Younger girls can expect to be closer to the 5 year timeframe and older ladies closer to the 10 year timeframe. This of course assumes that your legs are properly treated in the first place meaning all reticular veins are treated prior to any telangiectasia (spider veins) being treated.

Questions or comments about vein treatments

Are you concerned about your treatment or have any additional questions about this article? Leave a question below.

The traditional surgery for varicose of “stripping” has been around for a long time and for many doctors it has been the only vein procedure that they are familiar with. For many older style surgeons, it was what they were taught when going through Medicine and it is what they have always done for their patients. Whilst some patients have been happy with “stripping”, many more have found it to be a procedure associated with significant pain at the time of operation, sometimes anaesthetic problems or difficult to manage hospital infections and a recovery time that was longer than they anticipated.

These issues are however are not the most troubling aspect for many patients. What many patients are more concerned about is that they develop new varicose veins soon after their surgery. The origin of these veins was not clear until we started doing Duplex ultrasound examinations on these patients and often found that these new veins were growing from the stumps of the veins that had been previously removed. This process of “neovascularisation” is now widely accepted as the main cause of new varicose veins after surgery. It means that vein “stripping” should be renamed vein “pruning”. Despite this knowledge, unfortunately it is often hard to teach “old dogs new tricks” and some surgeons just persist doing what they have always done despite evidence of the problems associated with the procedure.

Questions or comments about vein treatments

Are you concerned about your treatment or have any additional questions about this article? Leave a question below.

If the varicose veins are large then invariably they are the result of a deeper problem. This deeper problem is a malfunction of very small one way valves within the deeper vein. These valves normally allow blood to go up the leg veins back to the heart but prevent blood flow down the leg. The malfunction of these valves is that they are permanently open and so cannot prevent flow back down the leg. This increased flow / pressure finds escape routes (= varicose veins) that appear on the surface of the leg. The implication of this mechanism is that treating the visible varicose vein will be inadequate unless the deeper vein is also treated. Otherwise there would be very early recurrence of the varicose vein. The ways of treating the deeper vein are by Ultrasound Guided Sclerotherapy or Endovenous Laser Ablation. The traditional method of “stripping” has been replaced by these non-surgical methods because these procedures have less risk, less (no) downtime and the long term results are better. If the varicose veins are small then they may just be surface veins with no underlying problem. In this case treatment with standard sclerotherapy will be adequate.

The short answer is no. In the past (and sadly still now) some surgeons claimed that if the veins were very big then surgery was the only treatment that worked. This is not true. When Ultrasound Guided Sclerotherapy was the only non-surgical treatment available, it could be said that it was an inefficient was of treating very large veins because multiple treatments would often be required to get the desired result. This has all changed with the advent of Endovenous Laser Ablation where the size of the vein is not a limiting factor because of the way the vein is treated.