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1. Treatment Options Available in Australia
Surgical stripping from the groin involves tying off normal veins that drain the skin of the lower abdomen to the groin where blood flows to the deep veins and subsequently back to the heart. When these veins are tied off during a ‘stripping’ procedure, blood flow is redirected to the skin of the leg with gravity, and causes more varicose veins. Patients have been told for years that they will develop new varicose veins because ‘they are prone to developing varicose veins’, but the fact is that patients frequently develop more varicose veins because they have had varicose vein surgery and blood flow has been redirected. Clinically, the patients with the most complicated veins tend to be those who have had previous surgery and the more procedures the more complicated the recurrences. Generally most surgeons will do no more than two operations in the groin due to the risk of chronic lymphatic problems (permanently swollen leg).
Phlebectomy is a minor surgical procedure with veins being removed by numerous small nicks in the skin. The vein is captured using a hook and sections of vein are pulled out through the small incisions. This procedure is commonly done under local anaesthetic and is used in conjunction with surgical stripping or endovenous laser ablation. It is uncommon for this to be a stand-alone procedure.
Endovenous laser ablation (EVLA) of large varicose veins has been performed in Australia since 2002. The published data shows a 99% closure rate of large varicose veins from one procedure at one year and up to 98% closure at five year1. Success rates of this magnitude have been responsible for the recent enthusiasm for this procedure in Australia.
Radiofrequency ablation (RF ablation) uses different technology to laser but it is a very similar procedure with similar long-term success rates.
Clarivein is a new device that combines a rotating wire (to scour the inside of the vein wall) and foam sclerotherapy. The equipment is similar in cost to RF (both significantly more expensive that laser fibres) however there is only short-term evidence to date and no indication that the long term results are any better than EVLA or indeed foam sclerotherapy alone.
Ultrasound Guided Sclerotherapy (UGS) has been performed in Australia since 1998. It requires on-site ultrasound equipment, a significant understanding of ultrasound principles and extensive experience with sclerotherapy. Repeat treatments are not uncommon and patient follow-up with ultrasound is essential for 6 to 12 months afterwards to be sure the veins have disappeared.
Neither UGS nor EVLA destroy the normal venous drainage in the groin. Neither procedure has the high incidence of neovascularisation (new veins) occurring after the procedure. Both these procedures are office based and are walk-in walk-out procedures with no time lost from work. You can drive home immediately afterwards.
If you are told your veins are too big for injecting or lasering, if you are not informed about EVLA or UGS, or if you are told that surgery is the only option, sadly your advice is out of date and you should seek another opinion. Signing a consent form for a medical procedure implies you have been informed of the benefits, risks and complications of no treatment, the advised treatment and alternative treatments.
2. Another Perspective
Over recent years there have been a number of published studies in medical journals questioning the wisdom of the traditional ‘flush ligation and stripping’ of varicose veins. Varicose vein surgery has been the accepted yard-stick for many decades. This does not mean it has been a good or particularly successful treatment, simply that it was the only treatment available. It is a relatively more traumatic procedure, significantly higher in risk compared to UGS and EVLA, and it can have a high recurrence rate – up to 60% after 5 years2.
Patients are frequently told “Those veins are so large that surgery is the only way to treat them” or “Your veins are too big for injecting” implying that surgery will be more successful. This is not true. The best surgical technique frequently produces poor results2, 3 while poor surgical technique (or poor sclerotherapy technique) will always produce poor results; and there is evidence to show that it doesn’t really matter whether your surgery was performed by the senior vascular specialist or the junior hospital surgeon – the success rate is about the same2.
Patients are sometimes told that the varicose veins below the knee will be left “in case you need heart by-pass surgery”. If these veins are varicose veins, the cardio-thoracic surgeons do not use them. They are too big to be used as a replacement vessel for a coronary artery that is only a few millimeters in diameter. Stents and balloon procedures are frequently performed as a day procedure for many patients who previously required open-heart surgery. If heart surgery is required, an artery from the arm (the radial artery) is generally preferred rather than normal vein from the leg. Normal veins are left intact with UGS and EVLA.
The saphenous nerve travels next to the great saphenous vein in the calf and supplies sensation to the skin on the inner aspect of the calf. This nerve can be damaged during surgical stripping and was the most frequent reason for patients seeking legal compensation after surgery. From the early 1990s it became common practice to avoid stripping the great saphenous vein below the knee to avoid nerve damage. Alternatively, phlebectomies were performed so that the nerve could be separated away from the vein and the nerve is less likely to be damaged. When surgeons do not strip the varicose great saphenous vein below the knee, only part of the problem (the thigh segment) has been treated often leaving patients with ongoing problems.
Surgical stripping is a significantly more invasive procedure requiring hospital admission, general anaesthetic and days to weeks off work. It has been shown to promote the development of new varicose veins; it carries a higher risk profile and leaves scars – though significantly smaller now than in years past. Reports of infection following surgery are in the order of 7%. The risk of clinical deep vein thrombosis after surgery is approximately 2%4.
As surgical stripping was previously the only procedure available to control reflux from the groin combined with the fact that the veins are ‘removed’, many patients and doctors have the expectation that surgery is a superior procedure. Medical evidence shows otherwise. There have been a number of theories regarding the cause of varicose veins over the decades. It is now recognised that varicose veins occur as a result of dilatation of abnormal veins (rather than primarily being a valve problem) and this dilatation results in blood refluxing down the leg, instead of flowing back to the heart. Reflux can just occur in segments of vein, or it can involve the entire length; tributary veins can be involved without the main venous trunks being affected. Hence treatment has to be modified to suit the particular pattern of reflux in each individual patient.
With the non-surgical techniques available, we can treat virtually all varicose veins without surgery. The following information is provided for patients wishing to gain a better understanding of their treatment options. The information below regarding varicose vein surgery is taken from a respected surgical textbook on varicose vein surgery5. The incidence of complications will vary from surgeon to surgeon.
3. Background
Anaesthetics and antibiotics improved the safety of general surgery in the 1930s and surgical stripping of varicose veins has been the mainstay of treatment, by necessity, until more recent years. Surgical techniques have changed little in this time. There have been a number of surgical innovations developed with the intention of making operative treatment less traumatic, a day surgical procedure and less expensive. Unfortunately there is little evidence to show that these newer surgical techniques have improved the long-term success rate.
4. Surgical Stripping
This technique involves general anaesthesia, one or two days in hospital, a week or two off work and a painful leg for days to six weeks. The procedure involves cutting down onto the saphenous vein in the groin and a wire (stripper) is fed down the vein to just below the knee. The vein is tied onto the wire then the vein is stripped out by pulling on the wire at the groin incision. Inversion stripping and pin stripping are less traumatic modifications of the older technique.
There is significant evidence confirming that with surgical stripping the necessity to tie off normally functioning veins in the groin promotes the development of new varicose veins in the leg. Many patients are told they will develop more varicosities because they are prone to them. We now know you are far more likely to develop recurrences if you have surgery involving the groin.
5. Other Surgical Techniques
The following list will enable you to undertake further research into the various surgical options. Information regarding most of these procedures may be found by searching surgical websites.
• Subfascial Endoscopic Perforator Surgery (SEPS)
• Venocuff
• Pin stripping
• Trivex
• CHIVA
• VNUS
Of the above, SEPS and Trivex are obsolete. Venocuff involves groin surgery, usually addresses the terminal valve of the GSV alone and it is generally used in patients with early venous disease. CHIVA is mainly used in Europe and is a surgical approach that endeavours to achieve the outcome achieved by EVLA / UGS. VNUS is the RF procedure, similar to EVLA that uses radiofrequency rather than laser light to treat the varicose vein.
6. Complications of Varicose Vein Surgery
The complications are not listed in order of frequency or severity and the list is intended for the sole purpose of informing patients considering surgery of potentail complications. Further advice and information should be sought from the consultant surgeon.
• Chest infection after general anaesthetic
• Wound dehiscence wound falling apart
• Wound infection requires antibiotics
• Wound necrosis skin of wound edge dies
• Recurrence new veins and/or insufficient treatment
• Matting appearance of new fine spider veins
• Bruising often extensive, resolves in weeks
• Oedema swelling of the leg following the procedure
• Keloid scars heaped up, unsightly scar tissue
• Haematoma collection of blood in operation site
• Deep vein thrombosis clot in the leg - can travel to lungs
• Pulmonary embolism clot in the lungs - can be fatal
• Haemorrhage bleeding during or immediately after the procedure
• Deep vein damage surgically repaired - can cause DVT or blood loss
• Arterial damage surgically repaired - causes blood loss
• Nerve damage causes numbness and/or foot drop.
• Lymphatic damage can cause a permanently swollen leg
• Lymphocoele a lump that is a collection of lymph
As you can see, there is a lot to discuss before you agree to any procedure. Consenting to a treatment implies you have been told the possible outcomes of having no treatment, of the various treatment options, and of their potential risks and complications.
Dr David Jenkins
MB,BS FACP
© 2011 Sydney Inner West Vein Centre