Recently several new techniques for the treatment of varicose veins have been reported in the medical literature. The main aim of these is to avoid surgical removal of varicose veins. The idea is to avoid the need for general anaesthetic, incisions inn the legs and a hospital operating threatre. One of the most promising of these is Ultrasound Guided Foam Sclerotherapy.
The use of injections to cure varicose veins dates back more than 100 years. In 1942 Obach described a method of creating a foam or froth with the solution he injected. He claimed that this increased the efficacy of injection treatment. This method was used by a small number of surgeons but never found a great following.
In 1992 Juan Cabrera, a surgeon from Granada in Spain, found that he could greatly enhance the effect of injection treatment by making a foam of very small bubbles, which he called 'microfoam'. He used ultrasound imaging to guide his injections into the main surface veins and found that he no longer needed surgical methods to treat his patients.
Over the last 6 or 7 years, the use of foam injections has spread widely in France, Spain and Italy. It is now being enthusiastically taken up in several European countries. Experts in treating vein problems have used a number of different methods to create the foam that they inject but the result is the same: using a foam greatly increases the effect of the treatment without producing any additional side-effects.
The solutions that are injected are exactly the same as those which are already used to treat varicose veins. These are mixed with air to create a mousse or microfoam. It has been shown that this is perfectly safe to inject into the veins. The air is rapidly absorbed leaving the solution to treat the veins.
When a solution is injected into a vein it is immediately diluted by the blood. reducing its efficacy. Foam pushes the blood out of the way and completely fills the vein: the foam is not diluted by the blood. In fact, far less solution has to be injected to obtain the same effect.
Treatment is usually performed in a treatment room or ultrasound examination room, and not an operating theatre. The patients rests comfortable on a couch. In order to treat large varicose veins it is necessary to block the main vein feeding the varices. This could be done surgically, but with foam treatment all that is necessary is to put a needle into the main affected surface vein. This is the only part of the procedure which might cause discomfort and is usually performed with a small amount of local anaesthetic. The position of the needle is carefully monitored using ultrasound imaging to make sure it is in exactly the right place.
Next, the foam is injected whilst watching its progress using the ultrasound machine. Suprisingly, injecting the foam causes no discomfort, although the leg may ache slightly afterwards. Once the foam has filled all the main surface vein, the top end of the vein is pressed on to keep the foam in the surface veins.
The varicose veins in the leg are checked to see if foam has entered these from the main surface vein where the injection was given. A few further injections are usually given through a tiny needle in order to make sure that all the varicose veins have been completely injected. The whole treatment usually takes no more than 15 - 20 minutes.
Finally a firm bandage is applied to the leg. The aim of this is to keep the veins compressed so that they do not fill with blood when the patient stands up. The bandage is usually worn with a stocking for a week followed by the elastic compression stocking for a further week.
When the bandages are removed at the follow up appointment, it is usual to find that all the varicose veins have gone. They can sometimes be felt as small lumps beneath the skin. The leg may be a little bruised at this stage, although this is usually fairly minor. Lumps which can be felt at this stage slowly resolve over several weeks. If any varicose veins have not been completely treated in the first session, they are injected and bandaged to complete the removal of all veins. If varicose veins are present in both legs it is standard practise to treat them on seperate occasions about one week apart.
Most patients with small or moderate size varicose veins can be treated in this way. Those patients with very extensive large varicose veins are usually best treated surgically to obtain a more rapid result. Some patients with large veins lying close to the skin are better treated surgically since brown discoloration of the skin over the treated vein may occur. If there has been previous surgery to the veins of the leg, this does not cause any difficulty in using foam sclerotherapy. In fact, it is often far easier to treat recurrent varicose veins by foam injections than by more surgery. If varicose veins recur some years after the initial treatment, the nit is straightforward to use the same method of foam sclerotherapy again.
Several detailed clinical series have been published in the medical press. These suggest that 80 - 90% of saphenous veins (the main surface vein) are permanently occluded by this treatment when examined one to two years later using ultrasound imaging. This is similar to the success rate claimed for other new techniques such as VNUS Closure and Endovenous Laser Treatment. Surgery also has its failures and after 10 years, further varicose veins may have appeared in about 10% of patients. Clinical trials are currently in progress which directly compare surgery and foam sclerotherapy.
At present only a handful of surgeons in the UK are experienced in this treatment. It needs a specialist who is skilled at ultrasound imaging as well as injecting veins.
Unwanted side effects are rare. An allergic reaction to the sclerosant fluid occurs in about one person in 100,000. The injection can initiate a migraine attack and suffers are advised to take their prescribed medicine at least one hour beforehand. Occasionally the foam can cause a disturbance of vision or a dry cough. This always passes off after a few minutes.
Up to 40% of treatments may result in some staining of the skin overlying the veins. This is more common if the vein is close to the skin and a superior cosmetic result may be achieved by injecting only the main vein trunks leaving smaller veins to return to normal size once the back pressure has been alleviated. Any staining fades almost completely but may take up to a year to do so.
Stripping of the vein is avoided and there is little or no discomfort after treatment.
There is much less bruising than following surgery.
There is no need for general anaesthetic, incisions in the leg, admission to hospital or an operating theatre.
Re-treatment for further varices is simple.
Much less expensive than surgical treatment - less than half the cost of surgery.
No time needed off work, except for the treatment sessions. The treatment may produce mild discomfort in the leg which can last for 2-4 weeks.
It also produces mild bruising which may last for several weeks following treatment.
The final outcome may take a number of months to evolve following treatment, and this is longer than would be taken following surgery.