This is important as it affects a large portion of the population and has many implications for healthcare resources. Chronic venous disease can affect up to 56% of women and 33% of men in Western countries. Varicose veins are not merely a cosmetic issue with an estimated 3-6% of the population suffering from more advanced forms such as skin changes and ulceration. The pathophysiology of the disease is due to venous hypertension which was initially described by Wittens, 2007. This results from valvular incompetence in the superficial or deep venous system and the transmission of abnormally high pressure to the microcirculation. Increased venous pressure is an insidious process and often minimally noticed by the patient but is associated with symptoms such as aching and discomfort, and progression to visible varicosities and more advanced forms of disease. Left untreated, this can lead to more severe skin changes and ulceration. It is important to have a strong understanding of the nature of the disease as it greatly affects the clinical outcomes and measures of success for different treatment options.
There is an ongoing debate in medicine and within the specialty of phlebology regarding the management of varicose vein. The primary therapeutic modalities are conservative, consisting of elastic compression stockings and lifestyle adjustments, and interventional, using a wide variety of approaches ranging from traditional surgery to sclerotherapy. The expert opinion and research published in medical journals are often conflicting and no definitive algorithm is available. The purpose of this paper is to compare and contrast the different treatment modalities for varicose veins thereby providing a clear guide for management based on current available evidence posed by randomized controlled trials and meta-analysis. This paper will be organized in a progression from conservative to interventional therapy and at each step beginning with the least invasive therapy technique. We will also pay attention to the patient outcomes with respective therapies. Measures that perhaps decrease the progression of venous disease such as improvement in quality of life or reduction in size and or visible varicosities would be discussed. Finally, as the objective is to provide a clear treatment guide, we will conclude with an algorithm for management. This is intended to be a fluid document with changes over time given the evolving landscape of medical care.
Conservative Management of Varicose Veins
Lifestyle changes are often recommended for individuals with varicose veins as the most conservative approach to treatment. This includes losing weight, avoiding prolonged periods of standing or sitting, and elevating the legs to decrease ankle swelling. Compression stockings are widely used in the treatment of varicose veins. Elastic stockings squeeze the veins and prevent blood from flowing backwards. This will help prevent further damage to the vein walls and decrease the likelihood of more varicose veins developing. A prescription may not always be needed; however, it is recommended that patients with varicose veins use a higher strength of compression. This will be more beneficial than the over-the-counter stockings. There have been various studies that have supported the use of compression stockings as a treatment for varicose veins. One study showed significant improvement in the severity of leg pain and swelling in the legs. This indicates that compression therapy is an effective treatment for varicose veins.
Lifestyle Modifications
Lifestyle modifications play a significant role in the management of varicose veins. Obese individuals often have venous disease due to the increased pressure on the veins. Even a 10-pound weight loss can result in improvement of leg pain and swelling. Avoiding tight clothing, especially garments that are constricting around the waist, groin, or legs can help improve the circulation in your legs. This also includes avoiding high-heeled shoes as they don’t work the calf muscle enough to promote good blood flow. Leg elevation is also important to improve the blood flow from the legs back to the heart. It is important to try and elevate your legs for ten minutes every two hours and elevate your legs above the level of your heart for twenty minutes 3-4 times a day. Elevating your legs on a regular basis can prevent blood from pooling in the veins and causing further vein distention. This can also help decrease leg swelling that may occur after prolonged sitting or standing.
Compression Therapy
– High efficacy in healing of CVI and venous ulceration. Reduction of venous hypertension and ambulatory venous pressure. Improvement of venous emptying. Increase of calf muscle pump function. Reduction of venous distensibility and reversal of venous reflux at the saphenofemoral junction. Prevention and slowing of the progression of chronic venous insufficiency. – SOCKS: Stockings Or Compression for the treatment of Varicose Veins. In an NIH randomized trial, 434 patients with at least one 3-8mm varicose vein were randomized to either 15-20mm Hg compression stocking or Unna boot with high compression. The primary focus was to determine the quality of life and symptom relief between the two treatment groups. The researchers found symptom relief and overall quality of life to improve equally in the Unna boot and the compression stocking groups over the 6-week study period. This is in comparison to a Cochrane review article where the authors suggest that there was insufficient evidence to make firm conclusions about the relative effectiveness of different types of compression.
Exercise and Physical Activity
Exercise does not have to be vigorous to be effective, and in fact high impact activities may exacerbate symptoms due to the increased venous pressure and lower limb venous hypertension. In these cases, low impact activities such as walking and swimming are recommended. Walking is a good form of exercise because it uses the calf muscle and strengthens the calf muscle pump. Swimming is beneficial as it is non-weight bearing and the hydrostatic pressure of the water helps to improve circulation in the legs. Patients who perform regular exercise should be advised to wear support stockings, as exercise without compression can lead to further damage of the already incompetent veins.
Regular physical activity is beneficial in the management of varicose veins because it can reduce symptoms and improve quality of life. Varicose veins are a common chronic venous disorder that highly affects quality of life with symptoms ranging from mild to severe. They represent a common condition that carries significant morbidity and, in some patients, progresses to cause more severe chronic venous diseases. Exercise can increase muscle tone and improve circulation which is the key to prevention. Movement of the calf muscle pump is an essential part of the mechanism by which deep veins propel the blood back towards the heart. Filling of the deep calf veins during walking, followed by sustained increased pressure in the foot and calf while the muscle pump is activated, leads to emptying of the calf and thigh veins.
Interventional Management of Varicose Veins
There have been numerous randomized control trials (RCTs) comparing several different modalities of treatment of varicose veins. A recent Cochrane review, which compared endovenous therapy with open surgical management for varicose veins, included 11 RCTs with a total of 900 patients. This review found that there were no significant differences in the clinical success rate between endovenous treatment and surgery in the short term. However, more recurrences were noted in the endovenous group 12 to 18 months after treatment. Data is still lacking in the long-term outcomes of endovenous treatments compared to open surgery.
Using less invasive techniques to treat varicose veins has gained a great deal of attention in recent years with the development of new technologies. The NICE guidelines in the UK have recently advised that the treatment of varicose veins with endovenous procedures should be offered before surgical ligation and stripping. This is likely to be mirrored in other countries and reflects a major change in practice in this field. Patients are now demanding less invasive treatments with much quicker recovery times and reduced post-operative morbidity.
Endovenous Ablation
The most definitive method of treating saphenous varicose veins is to destroy or remove the entire greater saphenous vein. Multiple methods are available to achieve this, and the traditional “open” surgical procedures are being challenged by newer, less invasive methods. Endovenous laser treatment (EVLT) has been shown in a multitude of trials to be an effective method of treating the greater saphenous vein, with good occlusion rates and low rates of recurrence. The procedure is usually performed under local anaesthetic, and involves passing a laser fibre up the saphenous vein through a small skin incision at the knee, and then applying laser energy to the inside of the vein while slowly withdrawing the fibre. The laser energy heats the vein and causes it to close, and a thrombus then forms and organises to cause fibrosis and eventual absorption of the vein. A similar method is performed using a radiofrequency catheter to heat the vein, known as radiofrequency ablation, and multiple trials have demonstrated its efficacy compared to surgery, although there are few trials directly comparing RFA and EVLT. A more recent method is the use of medical superglue to close the vein, technically known as endovenous cyanoacrylate adhesive ablation. This method has demonstrated good initial results in a number of trials, although long term data is not yet available. All of these methods have the advantage of being minimally invasive and can usually be performed in an outpatient setting, with a rapid return to normal activity. They are associated with lower rates of complications compared to surgery, although there may be higher rates of minor complications such as paraesthesia or vein thrombosis. As these methods are relatively new, the long term rates of vein closure and recurrence of varicose veins are not yet known, and continued follow up and trials are required to assess their lasting efficacy.
Sclerotherapy
As a method of treating varicose veins, sclerotherapy has proven to be less effective than other treatments. In a review of 58 randomized trials comparing sclerotherapy with surgery or with conservative management, the authors concluded that “surgery or conservatively oriented treatments were associated with a better outcome in the management of varicose veins.” Sclerotherapy has also been associated with certain side effects that are not seen in other treatments. The development of telangiectatic matting and, more seriously, deep vein thrombosis are both complications associated with sclerotherapy that can make it an unsuitable treatment for some patients with varicose veins.
Sclerotherapy is the process of injecting an irritant solution into the target vein, damaging the endothelium and causing inflammation that leads to fibrosis and eventually vein closure. Sclerotherapy is used as a treatment for spider veins and smaller varicose veins. It is a simple procedure that can be performed in the doctor’s office in under an hour. Patients are able to walk immediately after the procedure, and recovery time is minimal. Local complications may include superficial deep vein thrombosis, and the incidence of pulmonary embolism is currently at one per 1000 procedures. Newer, foam-based sclerotherapy techniques are more effective than traditional fluid sclerotherapy, with a 10-20% increased rate of vein occlusion. Foamed sclerotherapy is now recommended in the treatment of varicose veins, and it has been suggested that sclerotherapy should be the first choice of treatment for patients with venous eczema and ulceration.
Surgical Options
Currently, there are two types of surgical procedures commonly used to manage varicose veins: ligation and stripping, and phlebectomy. Ligation is the surgical tying of a vein. It is a simple, local anaesthetic treatment that will stop any circulation in the veins being tied. This is due to the fact that veins have a large number of alternative pathways for blood to travel, therefore removing a vein will not greatly affect the circulation of blood around the body. By stopping circulation in these ‘problem’ veins, the result is an immediate lessening of the varicose veins and any associated symptoms. Although ligation will treat the varicose veins, it may lead to the development of minor skin discoloration. Stripping and/or high ligation is removing the vein through two small incisions, one near the groin and the other over the vein’s location. Between these two incisions, the vein is stripped or removed. This treatment is effective when treating large varicose veins that have developed from a leaking junction into a deeper vein. High ligation and stripping is performed while under local or regional anaesthetic and can also result in the development of minor skin discoloration. Phlebectomy is a minimally invasive surgical procedure used to remove varicose veins. Usually, it is performed on large surface veins. Unlike vein stripping, the entire vein is not removed from the body, only the section of vein between two incisions. This is, in effect, ‘fishing’ the vein out with a long, thin instrument. This procedure is minimally invasive and will leave a vein substantially less noticeable while also minimizing scarring and skin discoloration.
Minimally Invasive Procedures
Laser surgery uses light energy to heat and seal off the abnormal blood vessels, after which they slowly disappear over time. It is performed under local anesthesia and requires only a small incision, usually by the knee. The patient is then required to wear compression bandages on the leg for a period of time and is usually encouraged to do a lot of walking. There are two types of laser vein surgery – simple laser treatment and endovenous laser treatment (EVLT). Simple laser treatment is a less invasive procedure utilizing more modern laser technology. The penetration and absorption of the light energy are better targeted to the abnormal vessels and require no incision, resulting in less pain and bruising and a faster recovery time than sclerotherapy. EVLT is an endovenous technique, is more akin to the traditional surgical procedures, and is now being covered in the National Health Service due to recent NICE guidelines. It has been shown to be more beneficial than surgery and is becoming the optimal choice for minimally invasive treatment.
Minimally invasive procedures include ambulatory phlebotomy, laser surgery, and sclerotherapy. Ambulatory phlebotomy is a technique similar to the much older “vein stripping” surgery. It involves the removal of problem veins through a series of small punctures along the course of the vein. The punctures are so small that they do not require stitches, and the procedure can be performed under local anesthesia in the doctor’s office. Removing the veins that are causing the varicose veins to develop should alleviate symptoms, reduce the likelihood of the veins becoming worse, and may result in an improvement in the appearance of the leg. Ambulatory phlebotomy has the advantage over traditional “vein stripping” in that it causes very little bruising or discomfort and has an immediate recovery time. It is not, however, suitable for everyone as it requires an adequate replacement deep venous system. Also, removing veins in small pieces could theoretically lead to a higher incidence of deep vein thrombosis. Due to the high success rates and other various benefits, endovenous techniques are becoming more and more successful in comparison to ambulatory phlebotomy.
Conclusion
By conducting this evaluation with improved outcome measures, it hopes to establish a framework for practice and quality that will be easier to evaluate and guide. This may also help achieve an effective and efficient way of treating the most common form of lower limb chronic venous disease. This essay has looked at the options for a varicose vein patient in choosing conservative management versus interventional treatment. The findings have highlighted a profound bias in the NHS system towards the former. Understandably, an organization with finite resources may choose a cheaper option of similar effectiveness and much work to date has suggested that it is in this instance compared to most operations, albeit not vein ablation, procedures. Despite this, the current private sector poses an alternative opportunity for patients to allow them to bypass the waiting lists and choose to pay for an interventional method with great results on their quality of life. This does, however, create an inequality in service provision and the NHS, with this new quality framework, may be forced to re-examine its standard practice for varicose vein patients.
Conservative treatments are too often prescribed, and sufferers and health experts may place too much trust in the stronger evidence from randomized trials. This indicates that the superiority of an intervention can only be judged in the context of actual medical practice. In this respect, it can be difficult to assess the appropriate interventional approach as those affected by it may need to be ethically allocated no intervention. The authors believe it would be morally wrong, at the very least, to not offer and attempt the catheter off technique in C2C3 disorder. It offers the possibility of a higher immediate vein closure rate and it is believed that compliance will be higher as discomfort and bruising are significantly less than with the standard method. A comparison between the two techniques is justified and in order to determine appropriate practice, the varicose vein patient needs to be evaluated in terms of changes in disease-specific and general quality of life measures. Whether patients or GPs and Consultants involved in the care of varicose vein patients can believe or be swayed by these measures instead of traditional.