I have often been told by patients that they need surgery to fix their varicose veins. This statement is usually made after the patient has seen either a general practitioner or vascular surgeon. The statement may have been true 20 years ago but has not been correct for the past 20 years since Ultrasound Guided Sclerotherapy (UGS) was first used. UGS is used to treat the underlying incompetent vein that is responsible for the varicose veins that are seen on the surface. More recently, Endovenous Laser Ablation (EVLA) has been used an alternative to UGS to treat the underlying incompetent veins. EVLA is used for the more severe situations and UGS for the less severe cases. These two procedures have now essentially replaced surgery in America and are progressively replacing surgery in the rest of the world.

The reason for these two non–surgical approaches replacing surgery is simple: they have less complications at the time of the procedure and a lower rate of recurrence of varicose veins in subsequent years. Many doctors who have been trained in the traditional surgical technique of vein “stripping” have been slow to adopt these new techniques because of the costs of equipment (ultrasound and laser machines) as well as the time and financial cost of training to be able to perform these new techniques. I believe that to deny patients access to these procedures is bordering on incompetence.

This is a question that I am often asked to which I reply.... “If the quality of treatment is high the treatment frequency will be low”.

Specifically for surface veins, if the reticular veins (the blue / green veins that lead into spider veins) are treated prior to treating the spider veins then not only is the treatment more effective but it lasts a lot longer. For example, a 40 year old lady would usually get between 5 – 10 years between treatments if treated correctly. This time between treatments extends as people get older. The treated veins do not come back but there will be new veins grow over time for the same reason that the original veins grew – genetics!

If the reticular veins are not treated first then not only do patients often get a poor result but they require frequent treatment (every 6 -12 months) because the treated spider veins will just keep reappearing. There is also a higher incidence of the complication of “matting” if the reticular veins are not treated.

Why don’t all doctors treat veins this way? Sadly because the training of some doctors is less than optimal or their real interest lies elsewhere. For deeper veins treated with either Ultrasound Guided Sclerotherapy or Endovenous Laser Ablation, the results are invariably long term and often permanent with any recurrence usually minor in nature and easily treated. These successful results will only occur if the treating doctor is very well trained and experienced.

Why you shouldn’t have surgery for your varicose veins: why vein “stripping” = vein “pruning”

Many years ago vein “stripping” was only one option for the treatment of varicose veins. This operation consisted of a cut in the groin and one at the ankle with the underlying vein being pulled out. There were then many other cuts made to remove the varicose veins that were connected to the underlying vein that had been removed. Unfortunately these varicose veins did not also come out when the main vein was removed. The downside of this procedure was that because it was an operation there were many risks including the risks of general anaesthetic and the risk of infection with hospital bugs that can be extremely difficult to get rid of. There was also the long recovery time (often 4 weeks for those involved in manual labour and usually at least 2 weeks for those with more sedentary jobs).

As if that wasn’t enough, a large percentage of people then noticed over time that new varicose veins appeared where the old ones were removed from. With the advent of Ultrasound the source of these new varicose veins could be determined and was often found to be growing from the stump of the old veins that had been removed, particularly in the groin. This information was contrary to what patients had been told for a long time that recurrence was due to bad luck, bad genetics or the blood had to find somewhere to go. These explanations have been proved false and it is simply a case of vein “stripping” being the same as vein “pruning”. This effect is particularly marked in younger people because a “young tree” will sprout these new veins much quicker than an “old oak”.

Questions or comments about vein treatments

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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

Are you concerned about your treatment or have any additional questions about this article? Leave a question below.

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.