The NHS is largely withdrawing from the treatment of problem veins until serious complications arise. Sufferers concerned about the aesthetic effect of symptoms on their legs are therefore turning to private practice. Over the last 15 years professionals using everything from heat to glue have risen to the challenge, writes varicose vein specialist Dr Haroun Gajraj
About half the adult population suffers with telangiectasia—unsightly thread veins on the legs—and approximately a third of all adults have visible varicose veins. The first description of surgery for the problem was over 2,000 years ago: a hook extraction by a Roman called Aulus Cornelius Celsus. Doctors in the 1800s identified saphenous veins, which let blood flow in the wrong direction, as the major cause vein disease and surgeons went on to ligate and strip out such veins with varying degrees of effectiveness. Treatment didn’t change significantly for 100 years.
In 1995 the phlebologist Juan Cabrera invented ultrasound-guided foam sclerotherapy. His first demonstration wowed the surgical audience—injecting an ultrasound-guided foam solution into veins, causing them to close and disappear.
Soon after, Lorenzo Tessari invented his own method. He produced foam using a three-way tap, two syringes, some sclerosant and air. Both methods hit the scene in the mid-90s and revolutionised what we did for veins.
A series of innovations followed. In 1999 endothermal ablation arrived: under local anaesthetic inserting fine needles and catheters into refluxing veins to ablate them using heat energy—in this instance from radio frequency.
Then endovenous laser treatment appeared, another way of heating the vein from inside and ablating it. In 2010 we had mechanicochemical ablation (MOCA) a combination of sclerotherapy and mechanical methods; and in 2011 cyanoacrylate arrived, using one tiny local anaesthetic injection to insert a catheter and superglue a vein shut. Both endothermal ablation using radio frequency and endovenous laser treatments have now have US Food and Drug Administration (FDA) approval, as has MOCA. Cyanoacrylate is awaiting FDA approval but is available in Europe. The National Institute for Health and Care Excellence (NICE), just a few months ago described surgery as the last resort. Endothermal first, foam sclerotherapy second, surgery last.
The treatment that Juan Cabrera invented is the only approach that can treat nearly any sized vein in the leg—from thread to articular, varicose and sephenous.
The results of this treatment are comparable to surgical stripping, it’s very safe, avoids general anaesthesia and it’s a walk in/walk out procedure.
When it was introduced there was concern about the possibility of stroke, but we now know that this is rare and most neurological symptoms are a form of migraine with aura.
Anaphylaxis is unlikely but a possibility and a practitioner should be prepared to resuscitate a patient, with adrenalin available as a minimum.
Endovenous thermal ablation
This works by heating the vein in a variety of ways—the French are particularly keen on steam—but laser and radio frequency are my methods of choice. Tumescent local anaesthetic has helped transform veins treatment from a surgical procedure to an office procedure. Not only can patients walk in and out, with rapid recovery, they’re better in terms of cosmesis and recurrence.
There is a list of minor complications for thermal ablation, but compared with surgical procedures, it’s extremely safe. The only important one is endothermal heat-induced thrombosis, but in general people walk out very quickly and DVT is not very common.
We’ve got so good at treating veins that the discomfort of the administration of tumescent local anaesthetic seems to be the main issue – people don’t like being jabbed with needles.
In treatments to glue the vein from the inside we introduce a catheter with a single local anaesthetic jab. Because we’re not using heat energy we can’t burn the skin or cause nerve injuries.
Published studies only involve a few hundred patients, but so far no significant or severe adverse effects have been reported. Perioperative pain is minimal, I get people who walk in and walk out.
In summary, leg vein treatments have gone from invasive treatments performed by the Romans, to treatments under general anaesthesia by surgeons, to the very latest treatments that don’t involve very much local anaesthetic or invasion at all.
Not only are they associated with better recovery, they allow clients to walk in and walk out, they’re better in terms of recurrence. The chance of the veins coming back is lower and the complication rate is significantly reduced.
Dr Haroun Gajraj is a vein specialist and former vascular surgeon, and is director and founder of The VeinCare Centre. W: theveincarecentre.co.uk