Minimally Invasive Vein Surgery
It can be confusing and overwhelming to differentiate between different options for vein treatment.
We keep up to date by reviewing the latest data on vein treatments from specialist medical journals, as well as information from regular international conferences and meetings. We use collective knowledge to stay at the forefront of innovation, meaning you get the most effective treatment possible.
MINIMALLY INVASIVE VEIN SURGERY
All of the minimally invasive techniques share the same aim: to fix your veins without putting you to sleep, keeping you in hospital, and without making any major cuts in your legs.
Treatment is done on a walk-in walk-out basis, and relies on the surgeon using an ultrasound probe to ‘see’ inside your leg without cutting your skin open.
The differences between the techniques mainly hinge on how the leaky vein is closed:
1. Heat-based techniques
These include Endovenous Laser ablation (EVLT) and Radiofrequency ablation (RF). These are the most common techniques used in New Zealand, the UK, and USA, and have been around now for well over 10 years. There is much good data on outcomes to support them both.
Both of these operations use heat energy to seal the leaky vein in your leg. The laser uses heat generated by an intense light source. Radiofrequency uses heat generated from electricity.
In good hands both operations work very well – initial success rates are 98% or higher. Experienced surgeons can fix up to 90% of leaky veins this way.
Exceptions for these types of treatment include:
- Very large veins
- Some types of recurrent veins (usually after pervious open surgery)
We also know that the risk of common complications such as recurrence of veins, injury to adjacent nerves, and the risk of Deep Vein Thrombosis is lower with EVLT or RF than with the traditional ‘high tie and strip’.
My opinion: As a vascular surgeon I was brought up treating veins surgically under general anaesthetic. I still do this operation in public, however I have moved over almost completely to minimally invasive treatment of veins in my private practice (There are occasional times that surgery is still the best option). I believe this is now the 'gold standard' when it comes to treating veins, and in my experience is also what the patients want.
2. Foam sclerotherapy
Foam sclerotherapy closes leaky veins using a chemical injected into the vein under ultrasound control. The chemical is usually mixed up with air to make a ‘foam’, making it more effective than using the chemical as a liquid. The foam can be mixed by the surgeon using a couple of syringes or it can be purchased as a ready made kit (the trade name for the commonest one is Varisolve).
The most common chemical used in New Zealand is called Fibrovein (the chemical name is sodium tetra-decyl – STD for short). Fibrovein is a detergent and it works by making a chemical burn on the vein, closing it off.
Foam sclerotherapy can work quite well, but there are a couple of disadvantages in larger veins. Recurrence rate is quite high (about 30% of patients get their veins back within 2 years of treatment), and some patients get a brown mark on the leg called ‘skin staining’ that can take several months to go away.
There have also been some safety concerns about injecting a lot of air bubbles into the vein circulation – there have been reports in the medical literature of patients having ‘mini strokes’ after foam sclerotherapy to large veins, although the latest research on this matter suggests such events are very rare and all affected patients recover quickly.
Foam sclerotherapy does not replace laser or thermal treatment of the main feeding vein (if it is possible to treat with laser.) Foam sclerotherapy is a very useful technique for tortuous recurrent veins that can’t be lasered. The technique is also good for treating residual veins alongside EVLT.
Clarivein uses a mechanical device in combination with liquid Fibrovein chemical to close larger veins. It has the advantage of being almost painless to perform as there is no heat generated, so the surgeon does not need to inject local anaesthetic around the vein during treatment. It seems not to make the same skin staining as foam sclerotherapy.
Data on Clarivein is still being assessed as it is quite new – it is not yet accepted as a treatment in its own right by New Zealand insurance companies
Published evidence would suggest that Clarivein works well on smaller veins. It does also work on larger diameter veins but tends to have a higher recurrence rate. Some experts in the UK who have been leaders in trialing Clarivein also determined that it does not work as well on larger legs, and on the short saphenous vein behind the back of the knee.
My opinion: Clarivein may be a useful technique for use on selected cases. It has the advantage of being almost completely painless for the patient. However I don’t think it works as well as lasering for the larger diameter vein, it is not yet recognised by insurance companies in New Zealand, and for that reason I still use laser as my most common method of treatment at the moment.
4. The Sapheon glue system
This is a very new technique, still undergoing trials. It is not being used in New Zealand at present.
The technique uses a cyanoacrylate surgical glue (like superglue) to stick the vein together. It is painless for the patient, but at the moment is very expensive. I am waiting to evaluate the clinical data as it is published.
My opinion: Wait and see
5. Traditional high tie and strip
This was the standard surgical method of vein surgery until the beginning of this century.
High tie and strip requires the patient to have general anaesthetic, and several incisions in the leg. It has a 30 % recurrence rate at 5 years after surgery. There is an increased incidence of injury to the saphenous nerve that runs next to the leaky vein in the thigh, and risk of wound infection between 2 and 5 % depending on the case. There is the risk of Deep Vein thrombosis of approximately one in 400 cases. Many patients take 6 weeks to recover from a high tie and strip.
This is still the most common operation offered to vein patients in the public system.
My opinion: Minimally invasive treatments have replaced traditional surgery as the 'gold standard'. This is particularly true for recurrent vein surgery.
6. Other methods:
There are some other methods of treating varicose veins such as Steam ablation and even some drugs. These techniques are not in widespread anywhere in the world at present, and I have no personal experience of using them.