New treatments for varicose veins

Recent press reports have generated considerable
interest in new techniques for treating varicose
veins, claiming major advantages over conven­
tional surgery. Their main aim is to reduce operative
trauma and bruising associated with stripping, leading
to quicker postoperative recovery. All these methods
depend on the use of duplex ultrasound scanning
during surgery to monitor obliteration of the vein
lumen. Evidence about these new techniques is limited
to case series and registry data, largely in private practice
settings. Many vascular surgeons have therefore
regarded the claims for their success with some
scepticism, especially when press reports have portrayed
conventional surgery in a falsely unfavourable light. The
new methods may well offer some advantages, but they
need further stringent evaluation.
Surgical stripping of the long saphenous vein is by
far the commonest form of treatment for varicose veins,
with more than 60 000 operations each year in England
alone. The reasons for treatment range from complica­
tions like bleeding or ulceration to the much commoner
complaints of discomfort or unsightliness. Indications
for specialist referral are the subject of recent advice
from the National Institute for Clinical Excellence.1 Sup­
port hosiery can control symptoms but many patients
dislike support stockings or tights; while injection
sclerotherapy is inappropriate for most symptomatic
varicose veins, because recurrence is common if there
are incompetent valves in the long saphenous vein.2 3
The established treatment for long saphenous vari­
cose veins is surgery,2 3 in the form of saphenofemoral
ligation and stripping, which involves an incision,
2­5 cm long, in the groin and a short incision, less than
1 cm, near the knee, with tiny incisions, 2­5mmlong, to
remove the varicosities (phlebectomies). Various
techniques are in use for stripping the long saphenous
vein, aimed at reducing the incidence of postoperative
bruising, and some surgeons ligate veins or use a tour­
niquet when doing phlebectomies. Compression
bandaging is standard practice, and many patients suf­
fer little bruising or discomfort. Some, however,
develop extensive bruising, lumpy haematoma, and
pain, especially in the context of large varicose veins,
obesity, and heparin prophylaxis. In the long term at
least one third of patients develop further varicose
veins, in either the treated or the untreated leg.
Three new methods have been promoted to close
off the long saphenous vein under ultrasound control,
avoiding a groin incision and gaining access to the vein
by a small incision or puncture near the knee. Radio­
frequency ablation4–6 involves use of a radiofrequency
probe to obliterate the vein by controlled thermal
injury. The probe is pulled slowly down the vein from
the groin with simultaneous application of pressure to
close off the lumen. The long saphenous vein can also
be obliterated using a laser probe.7 8 These techniques
can sometimes be used for veins other than the long
saphenous vein,5 but varicosities are usually removed
by phlebectomies in the traditional way.
A third new method (“varicose veins cured by a sin­
gle injection”) is a novel application of sclerotherapy, in
which sclerosant is mixed forcibly with air to produce a
foam that spreads rapidly and widely through the veins
after injection.9 Ultrasound monitoring prevents spread
of the foam into the femoral vein, although it seems that
the passage of small amounts into the deep veins is sel­
dom harmful. Sclerosant foam also fills many of the
varicose tributaries, so a single injection with subsequent
compression can obliterate these as well.
Proponents of all these techniques claim several
advantages over conventional surgery—in particular
reduced bruising and discomfort, with quicker return
to normal activity. Many surgeons undertake these
procedures under local anaesthesia, but general anaes­
thetic is necessary if there are extensive varicosities.

Source : bmj.com

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