Phlebologists (vein specialists) refer to the main superficial veins of the leg the Great Saphenous Vein (GSV) and Small Saphenous Veins (SSV) as Truncal veins as they drain the main “trunk “of the leg.
Varicose veins are swollen, twisted, blue veins that are close to the surface of the skin. Unsightly and uncomfortable, varicose leg veins can promote discomfort, itchy and discoloured skin. They are the result of venous reflux and if untreated can lead to venous ulceration, bleeding and thrombosis.
The branch vessels draining to the GSV and SSV are often referred to as tributary veins and it is usually these veins that dilate and protrude leading to the visible varicose veins.
Ultrasound provides an essential “road map” for the treating doctor to understand the exact nature of your vein dysfunction and plan the most appropriate treatment. Often what is seen on the surface is figuratively speaking the “tip of the iceberg”.
We have seen many patients have unsatisfactory outcomes when treated elsewhere without an ultrasound. Surface sclerotherapy performed without first eliminating venous reflux and “feeder vessels” for example may lead to new vessel growth and a dramatic worsening in cosmetic appearances.
Phlebectomy performed without elimination of underlying reflux (only detectable on ultrasound) similarly will often lead to new vessel proliferation and rapid recurrence of varicose veins.
Whilst a number of clinics offer vascular ultrasound, few have staff skilled in the performance of the highly specialised venous incompetence studies required to adequately understand the nature of your vein dysfunction and the most appropriate treatment.
It is best to have ultrasound performed at a specialised centre that is accustomed to the assessing patients before, during and after endovenous vein treatments. If we are to treat your veins, we cannot rely on assessments done elsewhere and will require our own detailed ultrasound scan prior your treatment.
In addition to modern high frequency ultrasound, the Vein Clinic is one of the few clinics in Australia to use specialised equipment (venapulse ™) to improve the accuracy of our venous incompetency studies.
In the last 15yrs a major revolution in the understanding of venous disease has occurred. Much of this new understanding has been driven by the greater use of high frequency ultrasound by properly trained ultrasound practitioners.
The introduction of endovenous laser ablation (EVLA) for treating truncal incompetence has been a major paradigm shift and has shifted thinking and research towards safer and better tolerated ways of treatment. The dark old days of surgical vein stripping are thankfully coming to an end.
UGS tends to be less than half the cost of ELVA and for that reason has gained popularity as a “catch all” treatment.
At the vein clinic we believe the optimal treatment that gives you the greatest chance of success with the least discomfort is always preferable.
We do not agree with a “one size fits all” approach to UGS and believe that in many instances UGS is not “best practice” for the treatment of primary truncal incompetence. The appropriate choice will be highly dependent on the exact anatomy and size of the veins involved. If we believe UGS is suitable for treating your ,veins, we will offer this option to you. It is only by undertaking a through clinical evaluation and ultrasound scan that we can appropriately advise you of the treatment options best for your individual circumstances.
Studies have shown that the success of UGS declines rapidly with increasing vein size. Once veins are > 6mm in size, recanalization (re-opening) rates increase dramatically and the chance of long term success decreases. The chances of post treatment complications such as thrombophlebitis and pigmentation also increases dramatically.
If appropriate laser energy is delivered to the wall of the vein with EVLA the chance of success is essentially 100%. This chance of success is virtually independent of vein size. The complications following EVLA are also usually minimal if properly performed.
Vein stripping is an older procedure for treating varicose veins that we would generally not recommend unless you are unsuitable for alternative treatments.
A incision is made in the groin and another cut farther down the leg, either in the calf or ankle. The surgeon will then divide the main superficial vein (GSV) from the femoral vein and “tie it off”. A flexible wire is then inserted into the vein through your groin and out the other cut end of the vein. The wire is then tied to the vein and pulled out through the lower cut, which pulls the vein out with it. In the process the side branches of the main vein are “avulsed” leading to bleeding and quite often extensive bruising. There is also risk of nerve and lymphatic damage during removal of the vein. In addition the side branches remain and have viable cells which may “re-grow” the vein leading to a high recurrence rate (up to 50% at 5yrs).
Vein stripping requires a general anaesthetic, overnight hospital stay, long recovery time, (2-3 weeks off work) and can cause pain, bruising and other problems, such as increased risk of DVT.
International experts and organisations around the globe agree that this type of surgery is no longer regarded as “best practice” for the treatment of varicose veins and associated truncal reflux.
Organisations such as the Australian and American Colleges of Phlebology, American Venous Forum, International Union of Phlebology and (NICE) now recommend more modern techniques such as laser and radiofrequency ablation.
“For people with confirmed varicose veins and truncal reflux offer endothermal ablation, if endothermal ablation is unsuitable , offer ultrasound guided foam sclerotherapy”.
In very tortuous veins that may not be accessible to a laser fibre, UGS can be considered however surgery may be a better option in such cases if the vein is very large or very superficial.
Ambulatory phlebectomy is a surgical method that involves making a small nick in the skin directly over an abnormal bulging vein and then placing a small hook through the wound to snare the vein. The vein is then pulled up and out through the skin like a piece of spaghetti. Traction is applied to continue removing the vein until such time as it “breaks’ and then the whole process is repeated. This is sometimes referred to as “nick and pick” surgery.
The short answer is NO.
Ambulatory phlebectomy is best used to “tidy up” surface bulges once the underlying truncal reflux has been dealt with either by EVLA or UGS. Simply performing ambulatory phlebectomy does nothing to address the underlying cause of the varicose veins (i.e. truncal reflux) and is akin to pruning the dead leaves off a tree that has disease roots.
Healthy veins have a one way vale, during walking the calf muscle act as a pump, contracting veins and forcing blood back to the heart. The valves function to prevent backflow of blood from the heart to the legs.
Varicose veins develop when the delicate valves in veins fail and no longer prevent back-flow of blood from the heart. When blood flows downhill in the veins this is referred to as venous “reflux”, also known as “insufficiency”, “incompetency” or “dysfunction”
This results in veins enlarging and becoming varicose. Side branches may also enlarge and lead to visible twisted, swollen veins close to the surface.
Genetic Risk of varicose veins if :
(Cornu-Thenard, A., et al. Importance of the familial factor in varicose disease, J Dermatol Surg Oncol. 1994. 20:318)
Although some studies have estimated that 20% of men and 40% of women will develop venous disease in their lifetime, this data has been refuted and it may simply be that men do not report the signs or symptoms of venous disease to their doctors until it is severe, as advanced chronic venous disease is more common in men.
The incidence of varicose veins increases with age. The risk of varicose veins, spider veins chronic venous insufficiency and ulcers all increase with age. A 70yr old is estimated to have twice the risk of varicose veins compared to a 40 yr old.
(Adhikari A, Criqui MH, Wooll V, Denenberg JO, Fronek A, Langer RD, et al. The epidemiology of chronic venous diseases, Phlebology 2000. 15: 2-18.)
There are other risk factors for varicose veins, but these are not as well-supported by the scientific evidence. (Bergan, JJ, Risk Factors, Manifestations, and Clinical Examination of the Patient with Primary Venous Insufficiency, The Vein Book, 120.)
Varicose veins may ache, itchy and cause skin irritation. Swelling of the feet and ankles may become evident towards the end of the days and symptoms are usually worse in hot weather.
A significant number of patient suffering from restless leg syndrome have venous insufficiency and the symptoms are frequently cured with treating the underlying venous disease.
Stagnant blood in varicose veins may lead to clotting (thrombosis).
Patient with varicosities are said to have a three times risk of deep venous thrombosis compared to the general population.
Varicose veins have a tendency to bleed if subjected to trauma.
The answer to this is a resounding NO.
EVLA is best done under local anaesthetic for reasons of safety.
Under general anaesthesia the patient is unable to give feedback as to effectiveness of the tumescent anaesthesia. It is important that the patient is conscious so that they can advise if any pain or discomfort is occurring during laser activation. This could indicate inadequate tumescent anaesthesia which greatly increases the risk of thermal nerve damage.
Secondly, general anaesthetics are associated with complications ranging from minor and common (sore throat, nausea etc.) to rare but serious i.e. deep venous thrombosis, anaphylaxis and death, (1/50,000 to 1/100,000).
The simple answer for nearly all people is no !
In almost all cases abnormal veins can be removed in a much gentler and safer way using endovenous ablation techniques. These techniques for varicose vein removal and treatment are much less invasive and associated with virtually no down time and much faster recover.
These techniques have been around in Australia since 2002 but still many doctors are unaware of them.
Latest methods of vein removal include the use of thermal energy (Endovenous laser or radiofrequency ablation) and non-thermal means (Clarivein TM, Venaseal TM and foam sclerotherapy).
In rare instances you may be more suitable for surgical removal, if this is the case we will tell you so and not offer a treatment that will not work well for you.
Well the simple answer is that surgeons/doctors are only able to offer you the treatments they are trained in and feel confident to do safely. Surgeons have been trained in surgery and this is there strength and main skill set, hence why they offer surgery.
Dr. Matar the founder of “The Vein Clinic” has been extensively trained in and is very experienced in ultrasound and ultrasound-guided interventions which is the primary skill set of the Radiologist rather than surgeon. The new endovenous techniques for treating varicose veins require high level skill with diagnostic and procedural ultrasound, something that takes years to acquire.
Traditional vein surgery for varicose veins which consists of “stripping”, may well result in less out of pocket expense than laser vein surgery which is often referred to as endovenous laser ablation (EVLA). This is because health fund rebates currently only apply to traditional surgery and not laser vein surgery.
Cost savings by having traditional vein surgery however may well be short sighted when one considers the time and income lost by several weeks off work , the inconvenience and added health risk of hospital admission, general anaesthetic and prolonged recovery.
When you weigh this all up, for most people the sensible decision is to spend a little on your health and have the best available treatment rather than an out-dated and inferior treatment. Whilst some initial savings may occur with surgery, in the long run this approach usually end up being more expensive not to mention uncomfortable and inconvenient.
If you are having microsclerotherapy often three treatments will be required at monthly intervals and then avoidance of sun exposure for 1 month is recommended. This means your treatment needs to start at least 4 mths prior to your holiday if you will be exposing your legs to the sun.
If your flight is longer than 4hrs, it is generally recommended you complete your treatment at least 4 weeks prior to travel. In certain circumstances such as unexpected work travel , we can prescribe a blood thinning agent (Clexane) to be taken prior to travel to reduce your risk of venous thrombosis.
If your concerns are purely cosmetic and relate to spider veins you can see Dr Hoffman who specialised in spider vein treatments without a referral.
If you have varicose veins or symptoms, we recommend you see Dr. Matar, and as a specialist a referral from another doctor is required to comply with Medicare regulations.
In order to maximise the Medicare benefits available to you for the comprehensive ultrasound assessment and subsequent treatment and follow up scans, we recommend you have your GP fill in our dedicated venous services referral forms.
If you have trouble getting into see your own GP or do not have a GP, there are several GP clinic within a few hundred metres of our clinic that can assist in this regard.
The costs will depend on the methods required to treat/remove your abnormal veins, the number of abnormal veins to be treated, the number of treatments required, the time and complexity of each treatment; the amount of consumables needed and will naturally vary significantly from person to person.
Once you have had a thorough ultrasound and clinical examination to identify the extent and nature of your vein problem, we will be in a position to provide a quote for treatment.
Due to the high overheads in running the vein clinic which is a state of the art assessment and treatment centre for venous disease, it is not financially viable for us to “bulk-bill” treatments as the medicare rebates nowhere meet the cost of providing these services.
If you have an appropriate referral from a medical doctor for a consultation and scan, we are happy to provide second opinions. If you have had an ultrasound assessment elsewhere we will generally repeat this at a greatly reduced fee to facilitate you getting a comprehensive assessment in order to allow you to make the best treatment decision for you.