The answer depends first on the size of the vein and second on issues of affordability. Generally, for veins that have a diameter greater than 5 or 6 mm’s, most Phlebologists believe that Laser is a better form of treatment. Sclerosant injection into veins of this size is challenging because the large amount of blood in these veins will dilute the sclerosant and make it difficult to get adequate concentrations of the sclerosant. This effect is not substantial for veins less than 4mm. Once veins are greater than 8mm the number of treatments that would be required generally make UGS an inefficient way of treating veins of this size.

ELA is however a more expensive procedure so the inconvenience of multiple visits may be preferable to the extra cost of ELA. Provided the veins are not over 8mm (which makes it extremely difficult to effectively close veins with UGS no matter how many treatments) after the initial occlusion is established the results are similar when patients are reviewed several years after treatment. However, the use of large quantities of sclerosant makes pigmentation more likely because of the large amount of blood that is trapped when very large veins are treated with UGS.

  

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Unfortunately there is not. The situation is perplexing because the procedure is a better alternative to surgery and is replacing surgery throughout the world. In fact, in the U.S.A., insurance companies no longer cover surgery because when the risk / cost / benefit analysis is done it is clear that conventional surgery just doesn’t stack up against the non-surgical alternatives of Ultrasound Guided Sclerotherapy (UGS) and ELA. Medicare have indicated that there will at some stage be an Item number for ELA, but have not yet provided one. I have no doubt that Australia will follow the American model and that convention surgery (vein “stripping”) will continue to be replaced by the less invasive and more effective non-surgical procedures of UGS and ELA.

UPDATE:   November 1, 2011 Medicare introduced on an Item number associated with ELA that will now give patients a rebate that covers some of the cost of the procedure.

If you have your legs treated by a well trained and experienced practitioner you can expect to not require further treatment for many years. The actual time will depend mainly on your genetic predisposition, your age, the number of pregnancies that you have after treatment and your occupation. To a less extent it will depend on your weight and whether you wear high heel shoes. For example a lady who is 40 years old with little in the way of family history, no more pregnancies and a job that involves sitting down, can reasonably expect 5-10 years between sclerotherapy treatments. Younger girls can expect to be closer to the 5 year timeframe and older ladies closer to the 10 year timeframe. This of course assumes that your legs are properly treated in the first place meaning all reticular veins are treated prior to any telangiectasia (spider veins) being treated.

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The function of leg veins is to facilitate the return of the blood (that has been bought in by arteries) back to the heart. Because the flow of blood in veins is against gravity there is a system of one-way valves in leg veins that allows blood to go up but not come back down. When the calf contracts with walking, the blood squirts up which opens up the valves. When the calf muscle relaxes this same blood is forced down the leg by gravity. In a normal vein any movement down the leg is enough to close the one-way valves. When these valves do no function properly (i.e. they are permanently open) then there is no restriction to blood going down the vein. This extra flow / pressure initially causes the vein to expand, because it is under more pressure, and eventually this pressure will find an “escape route” to the surface which we see as a varicose vein.

Varicose veins before and after treatment

In a world with constant advertising and editorials it is often hard to work out who really should be treating your legs. The easiest way to work out this dilemma is to look at who has qualifications that have been certified by an acknowledged training organisation. In Australia the most respected training organisation is The Australasian College of Phlebology (ACP). The ACP training programs have been adopted by the American College of Phlebology and are in the process of being adapted for use by The International Union of Phlebology. The ACP has a website where you can check the qualifications of your doctor. You should treat your legs as you would any other very important purchasing decision and do your research. The first treatment of your condition will influence your long term prognosis – if it is not done properly it is like a poorly done renovation – you will never be able to get the result you could have got if you had the right treatment in the first place.

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The traditional surgery for varicose of “stripping” has been around for a long time and for many doctors it has been the only vein procedure that they are familiar with. For many older style surgeons, it was what they were taught when going through Medicine and it is what they have always done for their patients. Whilst some patients have been happy with “stripping”, many more have found it to be a procedure associated with significant pain at the time of operation, sometimes anaesthetic problems or difficult to manage hospital infections and a recovery time that was longer than they anticipated.

These issues are however are not the most troubling aspect for many patients. What many patients are more concerned about is that they develop new varicose veins soon after their surgery. The origin of these veins was not clear until we started doing Duplex ultrasound examinations on these patients and often found that these new veins were growing from the stumps of the veins that had been previously removed. This process of “neovascularisation” is now widely accepted as the main cause of new varicose veins after surgery. It means that vein “stripping” should be renamed vein “pruning”. Despite this knowledge, unfortunately it is often hard to teach “old dogs new tricks” and some surgeons just persist doing what they have always done despite evidence of the problems associated with the procedure.

Questions or comments about vein treatments

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One of the most commonly asked questions is “Does it hurt?”

Obviously pain is a very subjective matter  but after asking many patients to rate each procedure on a pain scale of 1-10 (with 1 being hardly noticeable and 10 being pain that is so severe to be unbearable) all of the procedures are consistently rated 2-3 for almost all patients. This was irrespective of whether the procedure was Standard Sclerotherapy, Ultrasound Guided Sclerotherapy or Endovenous Laser Ablation.

What this means is that most patients felt the procedures were somewhat “annoying” or “irritating” but certainly easily manageable. In 16 years I have not anyone who was booked for treatment of both legs who did not return after treatment of the first leg. For people who have a particularly low pain threshold, I get them to use Penthrox which is an inhaled analgesic. Interestingly this is only ever required very occasionally.

If the varicose veins are large then invariably they are the result of a deeper problem. This deeper problem is a malfunction of very small one way valves within the deeper vein. These valves normally allow blood to go up the leg veins back to the heart but prevent blood flow down the leg. The malfunction of these valves is that they are permanently open and so cannot prevent flow back down the leg. This increased flow / pressure finds escape routes (= varicose veins) that appear on the surface of the leg. The implication of this mechanism is that treating the visible varicose vein will be inadequate unless the deeper vein is also treated. Otherwise there would be very early recurrence of the varicose vein. The ways of treating the deeper vein are by Ultrasound Guided Sclerotherapy or Endovenous Laser Ablation. The traditional method of “stripping” has been replaced by these non-surgical methods because these procedures have less risk, less (no) downtime and the long term results are better. If the varicose veins are small then they may just be surface veins with no underlying problem. In this case treatment with standard sclerotherapy will be adequate.

The short answer is no. In the past (and sadly still now) some surgeons claimed that if the veins were very big then surgery was the only treatment that worked. This is not true. When Ultrasound Guided Sclerotherapy was the only non-surgical treatment available, it could be said that it was an inefficient was of treating very large veins because multiple treatments would often be required to get the desired result. This has all changed with the advent of Endovenous Laser Ablation where the size of the vein is not a limiting factor because of the way the vein is treated.

For many patients surgery used to be the only answer for these type of veins but now there are a range of non surgical options that give a better result with no downtime. Explore our treatment options which include Standard Sclerotherapy, Ultra Sound Guided Sclerotherapy, and Endovenous Laser Ablation.