Varicose veins are degenerative disease of the venous wall, what leads to elongation and dilatation of epifascial veins on lower limbs, mostly great and small saphenous vein. Prevalence of varicose vein is high, up to one third of world population suffers from some form of varicose veins. There is a slightly higher number of female and prevalence gets higher with higher age. Complications in form of inflammation, thrombosis or skin changes are present in 10 % of the patients. The most severe complications are skin changes (including venous ulcers), which can be found in up to 4 % of the patients with varicose veins.

in Goldman MP, Bergan JJ, JJ Guex – Sclerotherapy: Treatment of Varicose and Telangiectatic Leg Veins: Mosby Elsevier 2007

We can divide varicose veins into two main groups based on etiology – primary varicose veins, caused by genetic predisposition (this is also a reason for high varicose veins heredity) in combination with outer causes increasing venous blood pressure in lower limbs. These causes can be pregnancy, obesity, repeated hydrostatic overload of lower limb venous system (work in standing position without movement). The second group is secondary varicose veins, which are cause be some different disease (e.g. venous thrombosis), genetic disorder (e.g. angiodysplasia or vein valves malfunction) or as a consequence of trauma (acquired AV fistula, vein trauma etc.), Primary varicose vein are vastly outnumbering the secondary.

On both pictures we can see the lowest stage of varicose veins, so called venectasia.

(archive of 2nd Department of Surgery)

Reticular form of varicose veins is formed by dilatation of venous branches not involving (or minimally involving) the mail superficial vein trunks (GSV and SSV)

(archive of 2nd Department of Surgery)

On the other had truncal varicose veins are located initially on GSV and SSV and consequently spreading to their branches.

(archive of 2nd Department of Surgery)

There are three basic pillars for precise varicose vein diagnostic process - patients medical history, focusing on the presence of varicose veins in relatives and on possible outer causes such is a pregnancy, standing work or trauma. Second main pillar is physical examination, performed by checking standing patient for varicose veins signs such as visible vein dilatations, perimalleolar swelling and skin changes (brown skin color caused by hemostasis, skin ulcers and pre-ulcers). The last basic pillar is duplex ultrasound examination of venous system, which can precisely report a presence of pathological reflux on venous valves (e.g. sapheno-femoral junction), presence of dilatations even on hidden subcutaneous parts of the vein and presence of insufficient perforating veins. At the same time ultrasound can check the patency of deep venous system. If the right diagnose is set and mail origin of the problem is found (e.g. sapheno-femoral junction insufficiency) we can propose an ideal approach to varicose veins treatment. Goal of this treatment is resection of insufficient valves, perforating veins and dilated parts of venous system (usually whole GSV or SSV) but following the less possible invasive approach and respect to aesthetic point of view – here is no place for saying “great surgeon makes great cuts”.

This simple schema describes whole diagnostic and therapeutic process.

Source: Phlebolymphology: Treatment of Chronic Venous Disease

Rigorous ultrasound examination is essential for precise diagnosis and problem source identification. This examination should be performed by experienced sonographer, angiologist at the best. Experienced and skilled angiologist will provide you with detailed visualization of superficial venous system with marking of all insufficient parts and perforating veins.

Zdroj: Angiology ambulance of Dr. Štěpánek, Brno Zahradníkova

The first and the easies way of varicose veins treatment is conservative approach. This treatment consists of exercising and feasible movement activity and contrary avoiding a static burden. To further support this treatment we can add some venotonics into patients medication, these are particularly applicable in the warm summer months, when patients suffer the most from the varicose veins symptom. Such a medication is e.g. Detralex. The most effective part of conservative therapy is compressive stockings. This simple, but not always well accepted, therapy accelerates proximal venous flow, rises extravasal osmotic pressure lowering filtration and swelling and improves lymph flow as well. Problem of conservative treatment is that patients cooperation is required. Patients often refuse compressive therapy and changing their life style with weight reduction is even bigger problem. The second problem o conservative treatment is that is solves only consequences of the disease not its cause (e.g. sapheno-femoral junction insufficiency).

The least invasive type of treatment is so called sclerotherapy. Sclerotherapy is purely ambulatory procedure performed under local anesthesia by puncturing the varicose veins and application of sclerotizing agent (e.g. aethoxysclerol). This application can be done both by direct visualization in case of bigger veins or under ultrasound control or visualization using light source. After the sclerotizing agent is applied the vein endothelium is damaged leading to its fibrotization. Sclerotherapy can by used separately or as a supplement method after surgical or endovenous treatment of venous trunks.

(archive of 2nd Department of Surgery)

Classic varicose vein treatment and still golden standard is a surgical approach. Surgical treatment can be divided into three stages by their invasive level. The less invasive is ambulatory phlebectomy, the most invasive is classic stripping, in between are endovenous methods.

(archive of 2nd Department of Surgery)

Indication for surgical treatment is presence of symptomatic (subjective complaint, swelling, skin changes) primary varicose veins and insufficiency of GSV and SSV, primary insufficiency of perforating veins with clinical symptoms, varicose veins recurrence after both surgical and endovenous treatment, presence of venous ulcer and all causes of secondary varicose veins.

Choosing a right approach to the treatment in particular patient is a complex process and we must take more aspects into consideration. On one side there is a surgeon having his recommendation based on his preference and his actual outcomes and experience with each treatment method. Meaning that if the surgeon is not experienced in endovenous treatment he would rather offer classic surgical treatment if form of the stripping. On the other side there is a patient, at this time patients usually have some idea about the treatment options from their internet research, however this idea is often far off the reality. This is the reason why the surgeon has to inform the patient about a possible treatment options, their advantages and disadvantages including a significant financial difference. This is usually a strong reason why patients choose classic surgical approach.

Trend in last two decades is a gradual shift in the varicose vein treatment from classic surgery under general anesthesia with hospitalization (even one day stay) to endovenous treatment performed in ambulation setting under local anesthesia.

Ambulatory phlebectomy is the least invasive form of surgical treatment of varicose veins using a small incisions and a hook to remove the dilated parts of the reticular veins.

(archive of 2nd Department of Surgery)

Advantages of this method are low invasive approach, ambulatory setting, no need for sick leave and preservation of main venous trunks (if not affected by disease as well) for possible further use e.g. as a graft during bypass surgery. Disadvantage is that only a small uncomplicated reticular veins without the main trunk affection can be treated by this method and also a long time required for this method.

Golden standard in varicose vein treatment is classic stripping, which has a hundred years history all around the world. The principle of this method is insertion of stiff wire into insufficient GSV or SSV and pulling the wire with a sharp cap on its end cuts the vein out of the body.

(archive of 2nd Department of Surgery)

We can see whole GSV removed from the body by stripping. Stripping is done in range from ankle to groin, where all other branches and sapheno-femoral junction are ligated, this method is called crossectomy.

(archive of 2nd Department of Surgery)

As mentioned above the main advantage of this method is a huge set of experience and long-term outcomes from the patients gathered during the last century. This is still a dominant method at majority of the surgical centers. I tis also possible to remove just an insufficient part of the vein if it is not affected in all parts using so called limited stripping. Disadvantage of this method is logically its rather invasive approach and need of general anesthesia (or epidural), relatively high number of recurrence (mostly if the crossectomy is not done exactly) and longer reconvalescence period.

As well as any other surgical method has the surgical treatment of varicose veins certain portion of complications. The most common complications are injury of concomitant nerves (n.saphenus and n.suralis), skin injury (usually older patients with worse skin quality) and hematomas which are rather a logical consequence of vein removal than complication. To prevent bigger hematomas a bandage is applied immediately after the surgery. Less frequent but more severe complication is injury of deep venous system or artery. The most feared complication is pulmonary embolism, this is the reason why the low molecular weight heparin is applied in post-operative period for ten days. Surgical site infection is not common but in presence of bigger hematomas it can lead to huge abscess formation along the canal formed after the vein removal.

There are many kinds of endovenous treatment including mechanical, steam and chemical methods, however the two most frequent methods are endovenous laser and radiofrequency ablation.

RFA

EVLT

(from the manufacturer's catalog)

Endovenous laser is used for varicose veins treatment for almost 20 years, its principle is use of intensive laser beam of various wave length, which is delivered from the generator via optic-fiber inserted in the vein and on the tip of this fiber laser generates heat causing localized blood boiling and burning of the inner part of the vein. This damage leads to consequent obliteration and fibrotization of the vein. The procedure is done under ultrasound control and can be performed in ambulance under local anesthesia.

The principle of this method is described on the picture.

(EVLT Los Angeles - Varix Vein)

The precise ultrasound examination of superficial venous system is a key for successful laser treatment, it can be used to plan the course of the procedure. Tumescent anesthesia is a kind of local anesthesia using a pressurized solution of anesthetic drug to inject a tissue surrounding the vein. This has two effect – numbness of the area and pressing the vein wall on the catheter inside. During this method there is no crossectomy needed, so there is no need for groin incision. Since only main venous trunks can be treated by laser fiber there is usually a phlebectomy added during the procedure or sclerotherapy during a consequent ambulatory visit. The main advantage of this method is its low invasive approach allowing ambulatory setting and immediate patients leave after the procedure. Post-procedural bandage is required as well as after classic stripping.

The principle of radiofrequency ablation is similar to laser – heat generating inside the vein, only difference is the source of heat, in this case it is a radiofrequency current. Procedure performance is the same, but the catheter is producing heat in longer part (not only on the tip) and so the catheter movement is sequential not continual.

(Endovenous Radiofrequency Ablation (EVRFA) | The Oregon Clinic)

As mentioned repeatedly the main advantage of endovenous methods compared to classic surgery is the mini-invasive approach, they are done by one puncture with no need for surgical preparation, in ambulance and under local anesthesia. The biggest motivation for patient to choose these methods is the promise of shorter reconvalescence and quick return to work. Disadvantage is need for ultrasound experience which is needed during the procedure to control the catheter movement and position and also a need for consequent procedures in form of phlebectomy or sclerotherapy. Nonnegligible disadvantage is also the price of these procedures, which can be between 25 and 35 thousands CZK for one leg and it is not covered by insurance.

Overall the experience with endovenous methods is positive, the procedure is well tolerated and postoperative pain is small. Treatment effect, meaning solving the insufficiency in superficial venous system is also very good, although the long-term data are not available in such a power compared to classic surgery.