April 2015
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A Little Less Vein – Diagnosis and Effective Treatment of Leg Varicose Veins

Varicose veins are one of the most common problems seen by vascular specialists. It affects up to 4 in 10 women and many sufferers have had varicose veins for many years. Varicose veins manifest as unsightly bluish lumps (varicosities) and develop mainly over the calf areas but can also be seen in the inner thigh regions and over the dorsal surface of the foot. Aside from cosmesis, patients frequently complain of increasingly severe aching and pain in the calf, and this is made worse by prolonged standing. Other presentations include leg swelling, development of skin itchiness and scaling (eczema) over the inner calf or foot regions as well as skin darkening, pigmentation and thickening. In severe cases, an ulcer may form over the inner ankle/ calf region that takes a long time to heal. Precipitating risk factors for varicose veins include female gender, older age, a positive family history, pregnancy, occupations that require prolonged standing and a past history of blood clot in the lower limb deep veins (deep vein thrombosis). Underlying the development of varicose veins is the failure of the valves inside the superficial leg veins (the great saphenous in the inner thigh and short saphenous veins at the back of the calf) to function, resulting in inability to drain blood back to the heart. (venous reflux) Blood thus pools in the dependent parts of the leg, causing all the reported symptoms.

Recognizing the problem

Diagnosis of varicose veins can be made on clinical examination. This should then be confirmed by a specialized ultrasound scan of the veins to determine which vein segments are involved. Once that is done, a range of effective treatments can be offered. Such therapy should not only deal with the visible varicosities but more importantly, the refluxing saphenous vein segments.

Non-surgical therapy: compression stockings

Compression stockings work by physically forcing blood flow upwards in the diseased vein segments, thus preventing blood from pooling in the legs. However, the stockings are only effective if worn continuously and loose their benefit once removed. Moreover, many patients find the stockings too tight and uncomfortable in warm, humid climates like Singapore. Consequently, stockings are used frequently by patients who have declined or are unfit for surgery.

Open Surgery

This is the time-honoured method and involves removing the diseased vein segment entirely via open incisions in the groin or back of the knee, followed by small cuts to remove the visible varicosities. By completely removing the diseased vein segment, it is believed that recurrence rates are low. Moreover, for patient comfort and safety, this procedure is done under general anaesthesia. However, post-operative thigh pain and bruising are frequent complaints of patients who have undergone this procedure. Other side effects include persistent long-term pain and numbness. As such, the downtime for open surgery is significant with most patients taking up to 2 weeks for complete recovery and return to their pre-surgery lifestyle.

Minimally invasive vein surgery: RadioFrequency Ablation (RFA) , Clarivein Mechanochemical Endovenous Ablation (MOCA)

This form of surgery has evolved over the last decade due to new technologies. Under ultrasound guidance, a small puncture wound is made into the disease vein segment and small probes are introduced into the vein. These probes may be based on heat (radiofrequency) or chemical (MOCA) systems but both work on the principle of causing damage to the vein from the inside, causing it to close off. The vein is not physically removed. Patients undergoing RFA or Clarivein have minimal scarring and these procedures have often been dubbed as “scarless vein surgery”. Studies have also shown that when compared with open surgery, patients who undergo RFA have minimal pain and thigh bruising, have minimal downtime and resume their lifestyle earlier. Patients treated with RFA return to their daily activities much faster at an average of 2 days.

Mechanico-Chemico Ablation (MOCA) using Clarivein is another minimally invasive method of treating varicose veins. Unlike RFA, Clarivein is a device that is not heat-based and uses a high-speed rotating head and scleorosant chemicals to close-off the saphenous vein. As such, Clarivein can be done under local anaesthesia with very fast recovery. Overall, vein disease recurrence rates after RFA and Clarivein are very low comparable to those who have undergone open surgery and remains very low. Both these procedures can be done as day surgery procedures under mild sedation and local anaesthesia. Patients can walk home 1-2 hours after the surgery is completed and should return to their daily activities within 1-2 day. This makes it suitable for patients who would like vein surgery with minimal scars and fast recovery times.

Minimally invasive vein treatment: Injection sclerotherapy (vein scarring & closure)

This treatment involves injecting chemicals (either as liquid or as foam) into the diseased veins to cause it to scar and clot (thrombose). The injections are usually given using very fine needles and only a limited amount of chemicals can be used in each session of injections. As such, this method is more suitable for treating small varicosities and superficial skin spider/reticular vein patches and may require more than one session. When done well, results can be very impressive. However, there are some side effects of injection sclerotherapy. These include post-injection skin pigmentation, skin breakdown and ulcer formation. We now use newer formulations of sclerotherapy chemicals that come in a foam mixture. The foam mixture ensures a better closure of the spider/reticular veins with lower risk of pigmentation.

Given the wide range of treatment options available, varicose veins should be a condition that affected patients should not endure with. Treatment using the latest minimally invasive methods such as RFA, Clarivein and scleorotherapy now means an early return to an active lifestyle free from pain and unsightly varicosities. Patients should feel free to consult a vascular specialist for effective treatment!