Aim of Treatment of Varicose Veins (VV)
The aim of treatment of varicose veins is not just for cosmetic reasons alone, as is generally believed, but to prevent the development of the CVD as described above and to reverse the process of CVD in established cases.
Treatment of Primary Varicose Veins (VV)
Though there are some drugs available for varicose veins, they would help only to provide relief of symptoms to some extent. The definitive treatment is surgery. There are two types of surgical management.
A. Open Surgical Procedures
This procedure is basically meant to close the Saphenous Veins (external veins) at their exit points into the deep vein (internal vein), to block the flow of blood from Deep Vein into the Superficial (external) Venous System. It is known as ‘Trendelenburg’s Operation’. This procedure is usually combined with either of the following procedures.
(1) Stripping of the external vein.
(2) Multiple excisions of the vein to produce blocking of the vein or interruption at different levels of its course.
B. Minimally Invasive Procedures
Currently, there are different techniques designed to avoid extensive cuttings and resultant ugly looking scars. These would help to avoid prolonged stay in the hospital as well. They are,
1. Endo-Venous Laser Ablation (EVLT)
A small incision is made in the leg under anesthesia, to introduce a thin intravenous laser probe. After introduction of the probe, the inner wall of the vein is burned off with the laser beam, as it is gradually pulled out of the vein. The burn subsequently helps to occlude the lumen of the vein.
2. Radio Frequency Ablation: (RFA)
In this technique also, a thin probe is used as in Laser Treatment. Instead of the Laser beam, the tip of the probe is heated with Radiofrequency and the inner wall of the vein is burned to produce occlusion of the vein by scarring. This is the latest addition to the vein ablation procedures.
3. Microfoam Sclerotherapy (MFST)
Sclerotherapy is the oldest technique and it is centuries old (17th Century). The principle remains to be same as in EVLT and RFA. Instead of using thermal burn, a chemical solution is used to produce chemical burn, on the inner lining of the vein wall. The solution is mixed with air and agitated to make micro foam, whereby, with a very small quantity of chemical the volume can be increased enormously. This helps to cover a large area of veins and adds to the safety of the drug.
The advantages of Sclerotherapy?
1. No anesthesia is required, hence no risk of anesthesia
2. Very safe when compared to any other techniques
3. It is usually done as a ‘day care procedure’
4. The procedure may take hardly 10 minutes
5. Admission to hospital is required only in advanced stages of the disease.
6. The least expensive of all the procedures
7. It is more effective than all the other techniques.
8. Can go back to normal activities earlier than all other techniques
9. Safe, even for the very aged patients and those having other organic system disorders.
Disadvantages
Allergic/Hypersensitivity reactions (extremely rare)
Recurrence of new Varices or recanalisation
Local reactions, tissue necrosis, itching
Extremely very rare chance of Deep Vein Thrombosis (DVT)
Any Side effects?
1. Side effects, if at all, are very mild. Some patients may complain of some heaviness of head and dryness of mouth
2. Some may complain of itching over the injection site.
3. After a few weeks there may be some swelling of the lower limbs, pain, bleb formation, redness, indurations and/or discoloration at the injection site.
4. In case of extravasation of the sclerosant, it can cause excruciating pain locally.
5. Local Hirsutism/ or hypertrichisias has been observed in a few patients.
The effect of sclerotherapy?
The word sclero means ‘hardening’. A chemical solution is infused into the vein, which selectively burns the innermost lining of the vein.The chemical burn thus produced, makes the wall inflammed and hence the veins become swollen. Over a period of weeks, the inflammed vein wall will stick together and heals by scarring (fibrosis) and the vein lumen is completely occluded. The vein, though it will shrink immediately after the procedure, it will become harder and harder for about a few months. A crepe bandage is applied immediately after the procedure to keep the vein wall stick together during the process of healing. The bandage is need not be used after 3-4 weeks of the procedure.
4. Ultra Sound Guided MFST:
It is a modified version of sclerotherapy. The vein is cannulated with the help of Ultrasound in order to locate the perforators and major junctions (Saphenofemoral and Saphenopopletial junctions) and the scleorosant which is mixed with air and strongly agitated by a special technique, is injected. Trunkal veins are also injected in the same way.
In what all types of veins Sclerotherapy can be done?
In all types of veins from the smallest to the biggest and in all stages of the disease It can be used. It can be applied in recurrent varicose veins after any other surgical procedures as well.
Where not to be done?
1.In established Deep Vein Thrombosis (DVT)
2. If the patient is allergic/hypersensitive to the drug.
3. In pregnancy
4. In lactating mothers
Can both the legs be treated in one sitting?
Usually not. It is preferable to do the next leg after three months, after the first leg is set alright. This is mainly due to the following reasons:-
1) To give better care for the leg, especially in advanced stages of the disease.
2) Any recanalisation, revascularisation or skipped veins can be detected and corrected during the procedure of the 2nd leg.
3) There is also dosage limit.
How many sittings required?
Almost 90% can be treated in one sitting. But in very extensive and very large veins, it may require multiple sittings due to dosage limitations. Recanalisation/revascularisation of veins will also require multiple sittings.
How to care the leg after the Sclerotherapy.
1. There can be some pain, swelling and hardness at the site of injections & along the line of veins.
2. The hardness will increase slowly and will continue to progress for some weeks or months.
3. In some patients there may be some paraesthesia / numbness over the foot… It will subside over a period of time.
4. In case there is severe pain or swelling or redness over the leg along with fever, you have to report to the hospital.
5. Following the procedure there may be chances of developing some swelling in the ankle & foot. Keep the leg elevated for a few days or weeks. It will subside by itself.
6. From the very next day for about a week, remove the bandage apply the cream supplied to you and reapply the bandage.
7. After one week of the procedure, you need not apply the bandage while sleeping at night.
8. The nonhealing ulcers may take several weeks or months for healing.
9. You have to keep the leg moving after the procedure. Total immobilisation may lead to complications.
10. You can continue with your daily activities one week after the procedure, but beware, you have to avoid swelling in the legs.
11. Very rarely there can occur blisters or ulceration at the injected site. Then show the Doctor.
12. Please be vigilant to appear for periodic check up to evaluate your status as instructed in the review schedule already explained and handed over to you.
What is the sclerosant used?
There are two drugs available. Polidocanol (POL) & SodiumTetradecyl Sulfate (STS). Polidocanol (POL) is the one preferred at our Center.
Conclusion
The most cost effective technique
A very safe promising technique
Can be used in all stages of the disease, in all sizes of veins, in all people irrespective of age and with any co-existing diseases.