FAQs of endovenous treatment of varicose veins
- Will the treatment hurt?
- Will they come back?
- Are there any side effects?
- When will I notice improvement?
- Cosmetic improvements can take longer depending on many factors
- Can I drive/fly after treatment?
- Can I exercise?
- Do I have to walk 3 miles a day?
- Is there any harm in getting rid of the veins? (Where will the blood go?)
- How much does it cost?
- I have had my veins stripped before, is laser treatment still possible?
- When can I go back to work?
- Can I be treated with just foam sclerotherapy?
- My approach to managing varicose veins
- Pros and cons of the various treatment options
- Post-treatment follow-up
RF and laser are both very similar. They are undertaken as an outpatient often in a doctor's office rather than a hospital. Using local anaesthetic a needle is inserted into the vein which needs treating and exchanged for the laser fiber or RF probe which is threaded up the vein. More local anaesthetic is injected to numb the area and the device fired up and slowly withdrawn down the vein. This heats and destroys the vein wall and stops blood flowing through it.
All the endovenous ablation methods are undertaken under local anaesthetic. This is administered though tiny needles so you will feel the prick of the needle as it enters the skin but most people find this slightly uncomfortable but not painful. A tight feeling can be experienced as a large volume of anaesthetic solution is injected. The actual heating whether by RF or laser is painless.
Compared to surgery which has a high recurrence rate of at least 20% experience with EVLA and RF over the last 9 years shows a recurrence rate of about 3%.
With any effective medical treatment for any condition there is always a risk of unwanted side effects and complications which need to be weighed up against the potential benefits of the treatment. Endovenous ablation of varicose veins is remarkably free of significant problems.
Laser, which is the commonest treatment in the West, causes some mild discomfort in the region of the treated vein usually around the 5th day and some bruising which has usually settled by the time the compression stockings are removed. There is some evidence that the degree of discomfort and bruising is influenced by the wavelength of laser used to heat the vein; the longer wavelengths causing less problems. Some patients develop thread veins around the site of insertion of the laser fibre. These can be treated easily by injections or thermocoagulation techniques like Veinwave. Potential serious side effects from laser like eye injuries, skin burns, deep venous thrombosis (DVT), pulmonary embolus, nerve injury, lymphatic damage are virtually unknown.
RF is becoming popular with some doctors as it has less stringent regulatory requirements than laser and causes less bruising and discomfort. Serious side effects especially DVT, nerve injuries and skin burns are however more frequently reported with RF.
Foam sclerotherapy is rarely used to treat major venous incompetence although there is a minority of doctors who use it for all patients. Most specialists prefer the reliability of RF and laser and reserve foam sclerotherapy for residual varicosities remaining after endovenous thermal ablation. Serious side effects are rare. Temporary disturbance of vision like a migraine attack occurs in about 1% of patients. It lasts about 10 minutes and has never been permanent. Allergic reactions do occasionally occur but are very rarely more than slight redness and swelling at the site of the injection. A brown staining of the skin is the commonest complaint. It is not possible to predict who will get it but in most it resolves with time but it can take many months and occasionally never goes completely.
Symptoms like heaviness, itching, aching and ankle swelling usually resolve quickly after both RF and laser and most patients report significant improvement if not complete resolution by the time of their first follow up appointment. This improvement cannot be guaranteed however and occasionally the symptoms may be due to another cause.
If microavulsions are carried out at the same time as the endovenous ablation then a good cosmetic result should be noticeable by the time the compression stockings are removed at 2 weeks. You may see tiny red marks at this stage from the skin nicks.
If foam sclerotherapy is undertaken at the time of initial treatment you may notice some hardening and soreness of the injected veins which can last a few weeks.
In most cases just endovenous ablation is undertaken at the first treatment session. In these cases there is a spectrum of cosmetic improvement in the first few weeks ranging from complete disappearance of varicosities to no improvement at all. Most patients see significant change by first follow up but still require some further avulsions or foam sclerotherapy injections. Women more often require this ancillary treatment than men.
It is inadvisable to fly long distance for a few weeks after any venous treatment due to the inherent risk of DVT. Most doctors accept short haul flights within Europe.
You can undertake any normal exercise as long as it does not involve wetting or significantly dirtying the compression stockings.
This is a common question as so many patients have had surgery before and were advised to walk 3 miles a day after surgery. It is not necessary to walk any particular distance after endovenous ablation; just get on with normal life.
The veins which are removed by endovenous ablation are abnormal and not performing any useful function. There are plenty of other veins to carry the blood back to your heart and in fact these will have to work less hard once the refluxing veins have been removed.
Costs vary, sometimes quite dramatically, between providers and in different parts of the country. Expect to pay between £2000 and £8000 for full treatment to both legs.
It is always possible to treat recurrences following stripping without surgery and the commonest treatment option is laser. In some cases foam sclerotherapy or microavulsions will suffice.
It should be possible to go back to work as usual the day following treatment.
There are a few vein specialists in the UK who treat all types of varicose vein using foam sclerotherapy injections and it is possible to get good results in some with that treatment strategy. However most doctors accept that the recurrence rate after foam sclerotherapy is much higher than with thermal ablation and the initial success rate at closing off the refluxing veins is lower. It is much more likely that treatment will fail and you will need multiple treatment sessions using a strategy of foam sclerotherapy alone.
This will be dealt with in more detail in forthcoming articles but in brief my approach is as follows.
I try to make the process as efficient as possible whilst giving all patients as much information as they need to decide what treatment if any is right for them. This is the patient's decision following my assessment and information. As a doctor it is important not to bring one's own prejudices into the decision making process. All patients should be treated equally regardless of their size, age or reasons for requesting treatment.
Initial questions by potential patients are answered either over the phone or by email. Patients are then given the opportunity to book in for just a consultation or for both consultation and treatment at the same time. If they choose the latter I request but do not insist upon a letter of referral from their GP before the visit and a detailed explanation of the commonest treatments (laser, foam sclerotherapy and microavulsions) is sent by post or email so the patient is aware of what to expect from the treatment and has time to consider carefully the right course and if they wish discuss it with their GP.
The consultation involves taking a brief but relevant medical history, a physical examination and crucially a duplex ultrasound scan of the legs. All sources of reflux are detected and treatment planned on this basis. Discussion of the merits and drawbacks of all possible treatment options then takes place and the patient encouraged to ask any further questions. I make every effort to be open and honest about the likely outcome. Managing expectations is a vital part of the management of patients with varicose veins. In some it is reasonable to expect a good result quickly but others, especially those with extensive thread and reticular veins, need to be made aware that treatment may take many sessions over many months. 30 minutes is scheduled for this consultation.
Treatment can follow on immediately or at a later visit. I aim to ablate all refluxing veins starting with the largest and highest and working down in size and position. This normally involves undertaking EVLA laser ablation of the great or small saphenous veins first but occasionally higher reflux eg. in ovarian veins, needs to be dealt with first by an outpatient technique called embolisation. Most patients have 3 or fewer main refluxing veins and normally all 3 (both legs) can be treated at the same session. Rarely two laser treatment sessions are required. The EVLA takes between 15 and 30 minutes per leg. Some patients also have significant reflux in incompetent perforator veins and these need to be ablated using an RF device.
Patients can then go home after a 15 minute walk around.
The total time for consultation, scan, discussion and treatment is 90 minutes.
I see them for follow up after about 6 weeks when further treatment of residual varicosities, if needed, is undertaken under local anaesthetic using either microavulsions or foam sclerotherapy.
Again this will be dealt with in greater detail in later articles but to summarise:
- Do nothing. This is a reasonable option for those who are not significantly troubled by symptoms and not bothered by the cosmetic appearance. They should keep an eye out however for skin changes (eg discolouration around the ankle) which may mean that treatment would be advised to prevent further damage and ulceration.
- Compression stockings can help symptoms but do not cure varicose veins or improve the cosmetic appearance. They are uncomfortable and I have yet to meet a patient who has been pleased to be offered that treatment option.
- Surgical stripping is never required nowadays although is a reasonable alternative in a minority of patients. It requires general anaesthesia, a stay in hospital, time off work, cuts and scars, greater risk of complications and a high recurrence rate.
- Foam sclerotherapy as a sole treatment requires multiple treatment episodes, has unpleasant side effects, particularly skin staining, fails to ablate large veins in up to 40% of patients and has a high recurrence rate.
- RF (VNUS) is virtually pain free, works very effectively in the majority of patients but is not suitable for at least 10% of patients. It is expensive and has a higher incidence of serious side effects compared to laser.
- Laser (EVLA) causes slightly greater discomfort in some patients after about 5 days, but is equally as effective as RF (VNUS), can be used in almost all patients, is cheaper, and has fewer serious side effects.
All patients are seen for follow-up after about six weeks. This delay gives the greatest chance for any residual varicosities to settle naturally and minimises the need for any further treatment. If there are cosmetically unattractive varicosities remaining at this follow up the patient is given the option of removing these by either foam sclerotherapy injections or microavulsions.
Varicose veins are very common, often cause distressing symptoms and NHS treatment is denied to many.
Surgery by stripping was until recently the gold standard treatment but now has been superseded by endovenous methods especially laser and RF.
These new treatments can be carried out under local anaesthetic in a doctor's office rather than a hospital, allow the patients to return to work straight away, cause very little pain and few complications. Most patients get excellent symptom relief and cosmetic improvement.