Varicose Vein Help and Advice
Provided By The Whitely Clinic
"The Pioneering Vein Clinic"www.thewhiteleyclinic.co.uk
Treatments for Veins and Varicose Veins:
If you have followed through the arguments through the "How Veins Work" section, you will now understand the basic problem underlying varicose veins and related problems (such as phlebitis, venous eczema, lipodermatosclerosis, venous bleeds, venous ulcers etc) is the no functioning of the valves in certain veins (see www.legulcers.co.uk for further understanding of how valve failure causes the tissue damage).
Therefore to fix the problem, we need to fix the valves and the effects of the blood refluxing (falling the wrong way) when the valves stop working.
Unfortunately, despite years of research, no-one has managed to identify a way to repair the valves effectively that lasts, or to make an artificial valve that works in the long term.
Thus if we can't fix the valves, we need to do the next best thing - stop the blood refluxing.
Firstly, we need to make sure that we only treat the veins which have faulty valves and leave any veins that are working properly alone. Therefore we use our duplex ultrasound to identify the pattern of disease.
This shows us which of the veins aren't working and what size and shape they are. By knowing these facts we can choose the optimal treatment options for each person.
The rest of this section is going to go through many of the new treatments that we have used or assessed at The Whiteley Clinic. There are several other methods that we have tried or that are available. However, I have only included those options that need special mention.
To aid understanding, I have included a set of diagrams starting with the basic anatomy and pathophysiology (what goes wrong) on this page, and then the other pages will follow on the series.
Finally there are many other Whiteley Clinic websites that look in more detail at certain of these conditions or techniques. Many will be linked from these pages - others can be found through our main site - www.TheWhiteleyClinic.co.uk.
Provided By The Whitely Clinic
"The Pioneering Vein Clinic"www.thewhiteleyclinic.co.uk
Stripping of Veins
Since the 1890's - well over 100 years - the standard treatment of veins was to tie the top of the Great Saphenous Vein, where it joined the deeper vein - called the femoral vein. The idea was that this would stop the blood from falling down the Great Saphenous Vein - thus stopping the reflux and so all of the complication that this caused.
This was started by a Doctor called Trendelenberg. He had checked the veins of dead people and had found that normal people had normal valves, but people who had suffered from varicose veins during life, showed defective valves when checked after death.
Unfortunately, as he couldn't see how the veins actually worked in life, he assumed that all of the valves gave way from the top - hence anything putting pressure on the top valve would help to cause varicose veins and vein problems. It was this theory that made generations of doctors and patients believe varicose veins were caused from:
- Being fat
- Pelvic tumours (stopping blood flow out of the leg)
- Constipation and straining
- Standing for long periods of time
all of which we now know are wrong.
His idea was that tying the top of the vein was like putting a top on a bottle - by stopping blood getting into the vein, it couldn't reflux down it.
However it soon became obvious that reflux could still occur after a successful tie, due to blood running into the incompetent vein from other veins - classically the "thigh perforator (see diagram above) although with duplex ultrasound, have found out that such a perforator is not necessary, as blood enters the vein from normal tributaries (branches feeding into the Great Saphenous Vein) in any case.
Research from The Whiteley Clinic from 2001 showed that the top valve is not the main problem in any case (see www.Pioneering-Veins-Surgery.co.uk). The valves fail from lower in the leg and work their way UP the leg - the reverse of what seems obvious. So many people with varicose veins actually have a normal valve at the Sapheno-Femoral Junction - meaning just a tie wouldn't do anything at all for them!!
So several decades ago surgeons decided that tying wasn't enough - and the vein would need to be stripped away.
Unfortunately although this seems like a good idea, the veins are part of the connective tissue of the body - which means that they heal. Unlike organs which are gone once removed, connective tissue grows back after it is damaged. If this wasn't the case, you wouldn't heal after cutting yourself.
So when the vein was stripped away, the bruising and trauma of the operation actually stimulates the ends of the vein and the branches to grow back again.
Prize winning research from The Whiteley Clinic was the first time this was proven*. We showed that 23% of people grow their veins back within 1 year of stripping - and our latest research shows 76% grow their veins back 5 years after stripping!!
Provided By The Whitely Clinic
"The Pioneering Vein Clinic"www.thewhiteleyclinic.co.uk
EVLA - EndoVenous Laser Ablation of Varicose Veins:
Endovenous laser ablation (EVLA) was invented following a discussion by 3 doctors at a venous meeting in 1998:
Dr Carlos Boné from Spain
Dr Luis Navarro from the USA
Dr Robert Min from the USA
(Endovenous laser: a new minimally invasive method of treatment for varicose veins--preliminary observations using an 810 nm diode laser. Navarro L, Min RJ, Boné CDermatol Surg. 2001 Feb;27(2):117-22 - click here to see abstract)
It had become clear that heating a vein with sufficient energy to destroy it, cause the vein to shrivel away and cause a permanent closure. Therefore the vein did not need to be removed - closing it gave the same result.
Both stopped the refluxing flow of blood back down the vein, therefore both stopped the damage that caused varicose veins and the complications of itching, thrombophlebitis, venous eczema, red and brown staining of the skin, bleeding and leg ulcers.
Initially EVLT® was the only technique that allowed laser to be introduced into the vein to destroy it. However many other companies have now produced different laser techniques to do the same job, using different wavelengths of laser, different introduction in techniques and even different ways the energy is fired out of the end of the laser fibre.
Therefore although some people still use the term EVLT® to mean laser treatment of varicose veins, in fact EVLT® is a registered trademark that only refers to one product. It is much more correct to use the term EVLA - endovenous laser ablation - when talking about a different techniques that are available.
Although there are different techniques of performing EVLA, the general principles are the same for all different techniques.
Using duplex ultrasound, a needle is passed into the vein under local anaesthetic. A wire is passed up the vein, once again under ultrasound control to make sure it is in exactly the right place.
A long sheath (like a very long biro refill) is then passed up over the wire - a technique called the "Seldinger technique".
When the vein is destroyed, the inside the vein can reach 700°C although the outside is usually much cooler than this. However to prevent any pain and to stop any heat burning any surrounding tissues, a very dilute solution of local anaesthetic and normal saline is injected around the vein. Ultrasound is used to make sure it is in exactly the right place. This is called tumescent anaesthesia.
The laser fibre can now be passed up inside the sheath. It was research from The Whiteley Clinic that showed that it was important to put the tumescence in before passing the fibre up, to make sure the fibre was not damaged by the anaesthetic needle. This research was one of the many prizes won by The Whiteley Clinic in the development of these techniques.
Once the ultrasound shows the laser fibre is in exactly the right place, the laser is fired and the sheath and fibre is pulled down at exactly the right speed, closing the vein at a precise energy level. Research is showing that 60 - 80 Joules per cm of vein will destroy the vein but will cause minimal pain and bruising.
Using EVLA in the veins identified as being suitable by Whiteley Clinic protocols, using The Whiteley Clinic techniques, allows us to permanently destroy appropriate veins using one pinhole incision for each vein.
Our research has shown that the best results come from treating not only the main vein, but in at least a third of people we need to treat at least one additional vein.
There are new EVLA procedures coming, and The Whiteley Clinic is involved in research with some and is trialling others to make sure that we keep offering patients the very best available treatments.
Unlike stripping, EVLA in our hands has not ever shown any re-growth of veins even after five years. You can contrast these results with the re-growth found after one year on the vein stripping part of this website.
EVLA in suitable patients really allows true walk-in walk-out varicose vein surgery, and when combined with other appropriate techniques gives us the excellent results that our patients require.
Provided By The Whitely Clinic
"The Pioneering Vein Clinic"www.thewhiteleyclinic.co.uk
VNUS Closure® and Closure® FAST™ ablation of Varicose Veins:
VNUS Closure® was the first of these new "keyhole surgery" techniques for varicose veins that came into the UK.
The first case performed as a "keyhole surgery" technique in the UK was by Mr Mark Whiteley and Judy Holdstock of The Whiteley Clinic, on the 12th of March 1999.
There had been other attempts at using heat to close veins ever since about the 1930s. However it was the VNUS Closure® technique and the modern ultrasound machines that allowed us to position the VNUS Closure® catheter precisely, that made this technique successful and to open the door to other keyhole surgical techniques.
The VNUS Closure® technique used radio frequency current which it passed through electrodes into the vein wall causing it to heat up to 85°C. The first cases in the UK were all performed under general anaesthetic and the procedure was very slow. Mr Mark Whiteley perfected the technique making sure that every vein he treated closed, giving his patients the best treatments he was able to do.
Other doctors in the United States and other countries using VNUS Closure® at the same time started using local anaesthetic, but had a failure rate of 5 to 40% at one year. Mr Mark Whiteley and Judy Holdstock used to run teaching courses to try and encourage surgeons to use their technique and replicate the excellent results they produced.
In addition, Mr Mark Whiteley and Judy Holdstock invented the TRLOP technique to close perforators using VNUS Closure® in 2000. Please see the page on SEPS/TRLOP for more information.
Although VNUS Closure® appeared before EVLA (laser treatment) many surgeons turned to EVLA as it was quicker and easier to use under a local anaesthetic.
Therefore the American VNUS company produced a new catheter called the Closure® FAST™ to speed up the treatment and to be used specifically under local anaesthetic (tumescence).
The first Closure® FAST™procedure in the UK was performed by Mr Mark Whiteley and Judy Holdstock on the 5th of March 2005.
The Closure® FAST™ has a 7 cm long end, which heats up to 120°C. This temperature permanently destroys the vein, as did the previous VNUS Closure® procedure, but much quicker.
At The Whiteley Clinic, we do use the Closure® FAST™ on appropriate patients. However, although this technique has been seen on the BBC News and several other television shows, as with most marketing they concentrated on the benefits and not the drawbacks.
For those patients with straight veins that reasonably large and with regular walls, the Closure® FAST™ is excellent, with almost no postoperative pain in our experience.
Unfortunately, the catheter itself is not particularly flexible and so it is not suitable for very small side branches which we at The Whiteley Clinic have shown that you have to treat if they are present. The catheter is also more expensive than the EVLA equivalent at the current time and also cannot be used in small segments of vein under 7 cm long which we commonly find in people with recurrent varicose veins.
We also do not like to use it in the small saphenous vein as this vein has some large nerves very close to it, and heating 7 cm at once stops us from identifying exactly where a nerve might be being heated. Finally, veins with clot or scars do not allow smooth passage of heat and therefore the excess energy of the EVLA is more appropriate for these veins.
As such, the Closure® FAST™ is an excellent procedure but only in selected patients. At The Whiteley Clinic we have developed protocols to identify exactly who will benefit most from which treatment.
Provided By The Whitely Clinic
"The Pioneering Vein Clinic"www.thewhiteleyclinic.co.uk
RFiTT®- Radiofrequency ablation of Varicose Veins:
Until recently, the only alternatives generally available to close the veins with heat (called thermoablation) were either laser (EVLA) all radio-frequency electricity (VNUS Closure® and Closure® FAST™).
In 2007 reports of a new radio frequency method for closing the veins very similar to the original VNUS Closure® started appearing. This technique is called RFiTT®.
As with the EVLA and VNUS techniques, RFiTT® is a catheter that is passed into the vein to be treated using a needle under local anaesthetic, and under ultrasound control to ensure it is in exactly the right place.
Just like VNUS Closure®, a radio frequency electric current passes between two electrodes at the end of the catheter, heating the vein wall and destroying it.
The RFiTT® device passes a great deal of energy very quickly into the vein wall, and the early results suggest that the procedure can therefore be performed very quickly.
However, there is a theoretical concern regarding whether sufficient energy is being passed into the vein wall to permanently destroy the vein as with EVLA, VNUS Closure® and Closure® FAST™. All of these techniques put about 60 to 80 J per centimetre into the vein and have shown complete closure and destructionof the vein at this level.
However RFiTT® only puts 20 J per centimetre into the vein - either meaning they have developed a much more efficient technique for destroying the same amount of tissue - or that the vein is not completely destroyed and might open again in the future. therefore although the preliminary results being reported appear good, we are awaiting proof that the vein is completely destroyed before offering this to our patients. We are currently talking to one of the companies involved with this product to see whether it is research we might become involved in at The Whiteley Clinic.
Regardless of its use in the Great Saphenous Vein, we have already developed its use in the TRLOP procedure, and will be reporting results later in 2009. The RFiTT® is now our preferred method of treating perforators using the TRLOP technique.
Provided By The Whitely Clinic
"The Pioneering Vein Clinic"www.thewhiteleyclinic.co.uk
SEPS (Sub-fascial Endoscopic Perforating Surgery), TRLOP (TRans-Luminal Occlusion of Perforators), RFS® (Radiofrequency - Radio Frequency Stylette) - for treatment of Incompetent Perforating Veins:
The role of the incompetent perforating vein in the varicose vein surgery is one of the more complex issues and many surgeons treating varicose veins do not understand either their role or their treatment.
Unfortunately, as many surgeons don't understand this, it is not surprising that some insurance companies also find it difficult to understand how essential it is to treat these veins.
Perforating veins should take blood from the superficial veins under the skin, in the through the muscle and into the deep veins to be pumped back to the heart. Normal people have about 150 of these perforating veins on each leg.
When these veins lose their valves, high-pressure blood from the deep veins can be squirted outwards into the surface veins, causing varicose veins, thread veins, venous eczema and itching as well as brown stains (haemosiderin) and possibly leg ulcers.
Some erroneous research suggested that these veins closed after standard varicose veins surgery and therefore could be safely ignored. This was shown to be wrong in prize-winning research from The Whiteley Clinic in 2004 - which was also the subject of an M.D. thesis sponsored by The Whiteley Clinic.
Mark Whiteley has also published research showing that 40% of patients with varicose veins have at least one incompetent perforator as do 63% of people with recurrent varicose veins. Not only this but those with recurrent varicose veins have more incompetent perforating veins per leg than those with primary varicose veins.
Therefore there is a very clear association between having incompetent perforating veins and getting your varicose veins back again after surgery.
This research is supported by many other surgeons who have shown similar trends in their own practices.
Some surgeons try to claim that incompetent perforating veins are just there to "allow blood back into the deep veins" from varicose veins higher up in the leg. However anyone with good enough duplex ultrasound will find a large number of patients with varicose veins and often skin damage who have incompetent perforating veins as the only cause - showing that incompetent perforating veins are a problem in their own right.
All in all, the evidence shows very clearly that if incompetent perforating veins are present in patients with varicose veins or venous problems, they should be treated as part of the correction of the vein pump.
Before 1985, these veins are treated by cutting open the leg under general anaesthetic and tying the veins off (such as the Cockett and Lynton procedures). This wasn't very successful and so in 1985, a German surgeon called Hauer invented SEPS (subfascial endoscopic perforating vein surgery).
SEPS involved inserting a endoscope (a surgical "telescope") between the muscle and the layer of fat under the veins, allowing the surgeon to see the incompetent perforating veins. These could then be clipped or burnt in an attempt to close them.
For many years this was revolutionary. However it did require a general anaesthetic, a 2 to 3 cm incision and caused considerable pain postoperatively.
In 2000, Mark Whiteley and Judy Holdstock invented a way of closing perforating veins using a needle hole only and the VNUS Closure® catheter. Using the ultrasound to find the incompetent perforating vein, Mark Whiteley and Judy Holdstock would pass a needle into it. They would then pass the VNUS Closure® catheter into the incompetent perforating vein, closing it permanently with heat at 85 degrees centigrade.
They called this technique TRLOP (TRansLuminal Occlusion of Perforators).
In 2004 VNUS manufactured the VNUS RFS® on the strength of their procedure, and using this we have been able to close incompetent perforating veins under local anaesthetic.
In 2008 we moved over to using the RFiTT® device for TRLOP technique which has given us an improvement in our results both in terms of closing the incompetent perforating veins and speed of procedure.
In 2004 Mr Mark Whiteley presented his TRLOP technique and four-year results in America. The following year, he went back to the same meeting in Miami to present a five-year results of TRLOP to find that one of the delegates from the previous year was presenting his one year results of "PAP". It transpires that the PAP - or perforator ablation procedure - is in fact the TRLOP technique. The "inventor" of the PAP technique claimed that it could be used with laser and therefore was different from TRLOP.
However as the TRLOP gaining access into a perforator using ultrasound and then passing a heating element into the perforator to close it, it can be seen that PAP is a copy of the TRLOP procedure with no material difference from it.
Provided By The Whitely Clinic
"The Pioneering Vein Clinic"www.thewhiteleyclinic.co.uk
Ultrasound guided foam sclerotherapy:
Sclerotherapy is a technique where a liquid is injected into a vein, to destroy it.
Sclerotherapy comes from Greek - "scleros" - to make hard and "therapea" - a service done to the sick.
When the vein is destroyed using sclerotherapy, the liquid kills the cells in the vein wall causing inflammation. When inflamed, the vein becomes hard to the touch. Over a period of several months the body eats away the dead vein, leaving only a tiny bit of scar tissue behind.
However, sclerotherapy only works in small veins and if there is no blood in the vein. If there is blood in the vein, the sclerotherapy liquid attacks the blood as well as the vein wall, causing it to clot. Clot inside the vein is called "thrombus" - or if caused by sclerotherapy, is called "sclerothrombus".
In order to get rid of the blood from inside the vein, the sclerotherapy liquid can be mixed with gas to form a foam. When mixed, the foam is like shaving foam. When injected into a vein, the foam pushes all of the blood out of the vein leaving the sclerotherapy liquid in the bubble wall to destroy the vein.
Although foam was originally made with air, the nitrogen in the air does not dissolve very well in the blood, and so can go up through the vein system, reaching the heart and, in some people, the brain.
This doesn't cause a problem in most people although a few people can get an alteration in their sight for up to 20 minutes.
At The Whiteley Clinic, we make foam sclerotherapy from a mixture of oxygen and carbon-dioxide. This allows the bubbles to dissolve quicker and so reduces the risk of any problems.
Ultrasound is used to direct the injection of foam sclerotherapy directly into the required vein.
As soon as it is in, the leg is bound, holding the vein shut and keeping the blood out of the dying vein, preventing sclerothrombus and the resulting painful lumps and brown stains.
It takes 14 days for the vein walls to scar together. For the whole of that time, the vein walls have to be held shut together preventing blood from getting back into the dying vein. Failure to do this means that the vein will fill with blood, which will clot and become sclerothrombus.
Provided By The Whitely Clinic
"The Pioneering Vein Clinic"www.thewhiteleyclinic.co.uk
Phlebectomies with tiny incisions and phlebectomy hooks:
Whenever blood stops flowing, even if still inside a vein or artery, it will clot.
When this happens inside a vein, the vein becomes very hard, red and tender - a condition called thrombophlebitis.
If we have treated the underlying cause of varicose veins successfully (ie:using EVLA, VNUS Closure® , Closure® FASTTM, RFiTT® or TRLOP) then the lumpy veins on the surface, called the varices, will clot and cause painful thrombophlebitis.
To prevent this from happening, the varices need to be treated.
If they are small enough, they can be treated with foam sclerotherapy (see previously).
If they are larger (which they usually are) then they need to be removed physically.
Removal of the vein is called "phlebectomy".
In medicine, "phleb" means vein and "ectomy" means removal.
A phlebectomy can be performed under local anaesthetic. The surgeon and draws around the vein when you're standing as when you lie down, they usually disappear.
Local anaesthetic is injected around the varices and tiny incisions are made (about 2 mm each) using a special blade called a Beaver blade.
A phlebectomy hook is then passed into the incision and each varicose vein is pulled out in turn.
Although this may sound barbaric, in fact it is an excellence technique with fantastic results - provided the underlying causes have been treated properly.
There have been attempts to produce an alternative to phlebectomy and most vein surgeons, ourselves included, would love to have an alternative.
Unfortunately no effective alternative has so far being developed that we have found to work in our hands.
Several years ago a technique called Trivex® was invented.
Trivex® used to different instruments passed into the leg.
The first was passed under the veins to illuminate them with a very bright light and to guide the second instrument, which "chewed" the veins with a rotating blade.
Although an excellent idea, and although some surgeons claimed good results, we were unable to get good results at The Whiteley Clinic using this technique.
In particular, as phlebectomies are only very superficial and only use tiny wounds, phlebectomy caused far less trauma to the surrounding tissue.
Therefore, four remaining varicosities, we still recommend phlebectomy at The Whiteley Clinic.
Provided By The Whitely Clinic
"The Pioneering Vein Clinic"www.thewhiteleyclinic.co.uk
Phlebectomies with tiny incisions and phlebectomy hooks:
Click here for Video of Microsclerotherapy
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