Duplex ultrasound scan
Duplex ultrasound scan is a non-invasive and pain free investigation. It is the gold standard investigation for venous diseases. It allows assessment the condition of both deep and superficial veins. It is often the only investigation required in majority of patients with varicose veins as it is able to provide adequate information to allow decision making on treatment. With colour duplex ultrasound imaging all veins and arteries can be visualized so that the direction of the blood flow can be demonstrated and measured. In patients with varicose veins, it will demonstrate incompetent valves and reversal of blood flowing toward the feet. A venous mapping and report is then produced to indicate all incompetent veins and where they arise from. This will assist surgeon to decide how to best manage your varicose veins.
Magnetic Resonance Venography (MRV)
Magnetic Resonance Venography (MRV) is Magnetic Resonance Imaging (MRI) of veins. It is a radiation-free scanning technique that uses radio waves and magnetic fields to produce detailed three-dimensional images of the body. It is a very sensitive test for deep and superficial venous disease in the lower legs and in the pelvis, where other imaging methods (eg duplex ultrasound scan) cannot reach. MRV is particularly useful for investigating nonvascular causes for leg pain and oedema. In addition, non-contrast imaging techniques are available with MRV, making MRV the preferred technique in patients with renal impairment or contrast allergy.
CT venography is also useful for evaluation and visualization of the anatomical structure of venous system varicose veins and venous malformations. CT venography has advantages of speed and spatial resolution in comparison with MRV. Many patients who are not candidates for MRV by virtue of pacemakers or other MRI incompatible devices, or claustrophobia, can be examined with CT venography. CT venography always requires the use of intravenous contrast and radiation exposure which are the main limitations of this technique.
What are the treatment options of varicose veins?
Endovenous thermal ablation
Endovenous Thermal Ablation is also known 'Laser Therapy' or ‘Radiofrequency Ablation. It is a new, minimally invasive procedure which has essential taken the place of traditional “vein stripping surgery’. The aim of this treatment is to destroy the vein from the inside using heat. A general anaesthetic or tumescent local anaesthetic is required. The procedure involves passing a laser fibre / radiofrequency probe, under ultrasound guidance, along the vein from the knee or calf towards the groin to treat large varicose veins in the thigh. Intense heat will be generated from laser fibre tip/ radiofrequency probe in the varicose vein, leading to closure of the targeted vein. The laser fibre /radiofrequency probe is withdrawn gradually to heat up and destroy the course of the targeted vein. This treatment closes off the varicose veins but leaves them in place to scar and eventually absorbed by the body. This procedure in therefore associated with much less bleeding, and bruising as compared with vein stripping surgery. Endovenous thermal ablation also results in less pain and a faster return to normal activities.
In our clinic, for endovenous thermal ablation treatment of vein, we only offer radiofrequency ablation (Venefit). Although both laser therapy and radiofrequency ablation are equally effective, there is increasing evidence to suggest that radiofrequency ablation is associated with less pain and bruising than laser therapy.
How long does the procedure take?
Endovenous thermal ablation typically takes 1hour or less for one leg. The procedure is often performed in association with microphlebectomy to remove the larger varicosities. This may require an additional 30 to 40 minutes.
What are the risks and potential complications of the procedure?
Your doctor will discuss the specific risks and potential benefits of the recommended procedure with you. This is generally a very safe procedure. However, as with any surgical procedure, there are risks. Complications after endovenous thermal ablation may include bruising along the site of ablation, pain along the site of ablation, the development of a blood clot in the veins in the treated leg, and irritation of the nerves that run along with the treated veins.
Endovenous Non-thermal Ablation
Mechanico-chemical sclerotherapy (Clarivein)- state of the art key-hole treatment for main feeding varicose veins in which the internal lining of the vein is destroyed by a rotating wire with concurrent injection of sclerosant via a single pin hole. This is a non-thermal technique without requirement of tumescent anaesthesia. There is no risk of thermal injury or nerve injury which is especially suitable for lesser saphenous vein and below knee greater saphenous vein reflux whereby there is potential risk of nerve injury heat. Ultrasound imaging is also used to map the veins before an operation. This enables the veins to be removed through the smallest possible incisions.
It can be performed under local anaesthetic as a daycase and is associated with lesser pain and bruising as compared to endovenous thermal ablation (laser therapy / radiofrequency therapy).
Short to medium term result of Clarivein treatment is excellent. The long term result however is yet to be confirmed.
ClariVein® infusion catheter is introduced percutaneously into the vein under ultrasound guidance. The catheter tip is positioned near the saphenofemoral junction. No tumescent anesthesia required.
The motorized handle rotates the catheter tip during pullback, creating vessel spasm to block forward flow and concentrate the targeted infusion of liquid sclerosant.
Besides closing the vein responsible for the varices, many times your doctor will recommend a procedure called a microphlebectomy. The visible veins protruding under your skin are actually branches from a deeper (superficial) vein. Even though the deeper vein, such as the GSV or SSV is removed or closed, these visible veins still remain. This is because the vein has been weakened beyond the point where it can contract to normal size. In this case, a phlebectomy offers the best cosmetic result for removing these veins. A phlebectomy is the removal of a vein through a very small incision under a local anesthetic. A small hook is passed through this incision to elevate and hook the vein. This may be done in conjunction with the primary procedure or done at a later date.
Ultrasound imaging is also used to map the veins before an operation. This enables the veins to be removed through the smallest possible incisions.
Ultrasound Guided Foam Sclerotherapy
Ultrasound-guided foam sclerotherapy is generally reserved for larger veins. Liquid sclerosant injected in to larger vein is likely to be diluted by the blood inside the vein thus reduces the effectiveness of sclerotherapy. Mixing liquid sclerosant and air to form a foam has been shown to be much more effective in treating these veins. When foam sclerosant is injected into a vein, the foam pushes all of the blood out of the vein. The foam allows better contact of sclerosant with the inside of the vein walls and stays in the vein longer to destroy the vein. The vein will then shrink into a fibrous cord and subsequently absorbed by the body. In our clinic, we use this technique mainly for patients with recurrent varicose veins and residual veins after vein stripping surgery or radiofrequency ablation/ endovenous laser ablation of varicose veins. Ultrasound is routine in this procedure to guide the injection to ensure accurate placement of needle.
Ultrasound guided foam sclerotherapy is performed as an outpatient procedure which allows the patient to carry on life as normal. There is little or no discomfort and only minimal bruising compared to other treatments, especially surgery.
Direct injection with liquid sclerosant of lower concentration into vein using very fine needle and magnifying glasses. This technique works well for spider veins. The lining of the vein is destroyed causing the walls to stick together. Blood stops flowing through the veins which are then absorbed by the body. Microsclerotherapy is performed as a clinic procedure. Normal activities can be resumed immediately. Several sessions may be required to eradicate all visible veins.
Surgery for Varicose Veins (Ligation and stripping)
Large varicose veins especially those with large diameter and tortuous may sometimes need to be surgically removed by ligation and stripping. Ligation and stripping is done under general or spinal anaesthesia. It can be performed as a day case or with overnight stay in hospital. It is used to remove the long or short saphenous veins in the legs. For removal of long saphenous vein, two incisions will be made, about 3-4cm long in your groin and the second one about 1cm in your leg. The vein will be divided and tied off (this is called ligation) through the cut in your groin to stop blood flowing through it. A thin flexible wire is then used to carefully pull (strip) out the varicose vein through the cut in your leg.
What are conservative treatment options of varicose veins?
The gold standard for conservative treatment of patients with varicose veins / chronic venous insufficiency are medical grade graduated compression stockings and compression bandaging (for patients with venous ulcers). They are able to improve symptoms as a result of deep, superficial or combined deep/superficial venous reflux. Compression stockings/ bandaging are specially designed to steadily squeeze your legs to improve your circulation. They are often tightest at the ankle and get gradually looser as they go further up your leg. This encourages your blood to flow upwards towards your heart. Reduction of hydrostatic pressure by decreased blood pooling in the leg will effectively minimize vein related symptoms. Compression stockings/bandaging have also been shown to improve calf muscle function. The effective pressure of compression at the ankle should be between 30 – 40 mmHg. However compliance is crucial as the effects of compression will only last as long as you wear them.
In our practice, we offer many options with compression stockings. This is an important factor influencing patient’s compliance. The stockings need to be properly measured and fitted for knee length, thigh length or pantyhose length as guided but doctor. Some patients may require custom made stockings if their leg size did not fit standard off the shelf stockings. We take great care in getting the right size of stockings with optimal compression pressure for our patients in order to achieve the maximum benefits of stocking. Wrongly measured and fitted stockings potentially can result in discomfort/ pain, skin ulceration or foot swelling. Our stockings also come in different colour, fabric and style, giving patients a wider choice and greater satisfaction.
Compression stockings may help to relieve the pain, discomfort and swelling in your legs that is caused by your varicose veins. However, it is not known whether the stockings help prevent your varicose veins getting worse, or prevent new varicose veins appearing.
Weight loss will lead to decrease in resistance of venous return to the heart and thus decrease venous pressure in the legs.
Elevating the legs above the heart will improve venous drainage from the legs. Reduction of venous pressure in the legs by reduction of blood pooling in the legs will help to improve symptoms fro venous reflux.
During exercise, the calf muscle pump will be activated, pushing blood in the deep veins towards the heart. Reduction of blood pooling in the legs will lead to decreased in venous pressure.
Non-steroidal anti-inflammatory medications and Horse Chestnut Seed Extract (Aesculus hippocastanum) have been shown in some studies to be effective in vein related symptom relief.