By: Norman Bauman for Veins1
For 100 years, doctors have been using surgery to treat varicose veins. Now they're using "less invasive" radiofrequency and laser heat treatments, and chemical sclerotherapy. Sclerotherapy is when a solution is injected into the vein, causing the vein to gradually disappear. Are they really less invasive? Do they work as well? These were some of the questions posed at the annual VEITHsymposium in New York City.
"The benefits that are claimed for the new technology is that they can be done in an office, they can be offered under local anesthetic," Alun H. Davies, M.A., D.M., F.R.C.S., a vascular surgeon from Imperial College, Charing Cross Hospital, London, U.K., told Veins1. "The downsides are if you have very extensive veins you may have to bring the patient back for numerous treatments, including other minor surgery or injections."
So are the new treatments better? The answer is: maybe. They avoid bruising, they avoid an incision in the groin, or sometimes any incision at all. But do they work as well? Do they get rid of the varicose veins? Do the veins come back?
The body's wonderful recuperative abilities often create problems for surgeons. When they remove varicose veins, the veins often grow back. This has been well-established for traditional surgery. According to a 2006 review article on varicose veins in the British Medical Journal, a few varicose veins reappear in many patients, and about a third have troublesome recurrence at 10 years. Radiofrequency and laser ablation have similar results, but they've only been followed for three years. Sclerotherapy has a similar result.
"Evidence-based medicine works from looking at the best evidence," explained Dr. Davies. "This is usually obtained from randomized controlled trials." The problem is, "in this area, there are very limited randomized controlled trials comparing the new technology of radiofrequency ablation, laser ablation and sclerotherapy with traditional surgery. The evidence to date is there is no difference with respect to the recurrence rate."
The British National Health Service compared the results of sclerotherapy, conventional surgery and no treatment in a randomized controlled trial of 1,009 patients over two years. The result: In the worst cases, conventional surgery is effective and cost-effective as well, even for the UK's thrifty health care system. For those cases, sclerotherapy wasn't as good. But sclerotherapy was slightly better for minor varicose veins, they said in a 2006 study.
"Costs are comparatively much more with the newer technology," said Dr. Davies. Doctors who prefer the newer technology say that you save money in the long run, because you can go back to work earlier instead of staying out on sick days (which sometimes convinces employers in the United States to pay for the new treatments in their health plans). "But this is unproven," said Dr. Davies, "and it is likely that surgery is better in the long term compared to laser and radiofrequency, looking at the initial success rates of ablating the veins."
Sometimes varicose veins are a cosmetic problem, but severe cases can cause itching, heaviness and pain, which makes it difficult to walk or stand for very long. Rarely, they become ulcerated. Patients have a "significantly impaired quality of life," said Dr. Davies. "We know that by a form of treatment you can significantly improve their quality of life," he said. "It's been well documented in the U.K."
Enlarged veins, damaged valves
Varicose veins are enlarged, twisted veins on the surface of the legs, caused by damaged valves. Some veins (the superficial veins) are right under the skin, and some veins (the deep veins) run up the middle of the leg muscles. When you walk, the muscles squeeze the deep veins, and pump the blood back up towards the heart. Along their length, veins have valves, made of leaflets, which help them pump.
The superficial veins under the skin often enlarge. When they do, the leaflets can't meet each other, so the valves don't work, and that interferes with the pump. Blood collects in the veins, raises the pressure, and the veins enlarge even more. That's varicose veins.
The inside and outside leg veins meet in the groin. From there, the blood from each set of veins is supposed to flow up to the heart. But if the valve at the groin doesn't work, the blood from the high-pressure inside veins overflows into the low-pressure surface veins, and flows back down toward the knee, instead of going up to the heart.
The 100-year-old surgery is to remove the surface veins. You don't need surface veins, especially if they don't work, because the deep veins carry 90 percent of the blood. The vein most commonly affected is the great saphenous vein, which starts at the front of the foot, moves up along the inside of the knee, and ends in the groin. The doctor makes an incision in the groin (usually under general anesthesia), cuts the great saphenous vein, passes a wire down the vein to the knee, makes an incision at the knee to get the wire, and pulls the vein out from the inside. Smaller branches of the great saphenous vein can be pulled out with a similar method. If you don't pull them out, veins are more likely to grow back. Many patients have minimal discomfort, but some have bruising. Most people require a few days off from work after the surgery.
Two newer techniques, radiofrequency and laser ablation, are done under general or local anesthesia. The doctor makes just one incision at the knee, passes a probe up the great saphenous vein, and slowly draws the probe back down, coagulating the vein as it goes. These procedures can be done under general or local anesthesia, and cause less bruising. Most people require fewer days off from work. But frequently the procedure has to be repeated.
Sclerotherapy doesn't require any incision at all. The doctor injects a caustic liquid into the vein. Sclerotherapy had problems with veins recurring, but a newer treatment injects the liquid as a foam, which works better. It is best used for smaller veins and veins below the knee, but is the most likely to require repeate treatment.
The low-tech solution of support stockings can actually provide good relief. Exercise "sounds sensible but is not supported by evidence," according to the British Medical Journal.
"The jury remains out," said Dr. Davies. It's likely that any of the treatments will have their advantages in a particular circumstance, he said. "I personally also offer patients laser ablation, but I discuss with each patient which option they would prefer," said Dr. Davies. "You have to talk with patients and give them the options of which treatment they would prefer."
You shouldn't be doing it, said Dr. Davies, because "the doctor wants to play with some new technology."