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.

In some patients an annoying consequences of Sclerotherapy is dark staining of the skin where the spider veins have been treated. Fortunately, severe cases are uncommon and invariably, even with severe cases, the pigmentation fades with time. The patients that are of greatest risk of developing pigmentation are those who are from Asia or those who have Asian parents. There are also patterns of veins that are more likely to result in pigmentation after treatment.

The reasons for this are not clear. It doesn’t make medical sense that people with darker skin are more prone to pigmentation because the pigmentation is due to Ferritin (which an iron breakdown product of blood) and not Melanin (which is elevated in people with darker skin). The time frame for the fading can be up to 2 years but fortunately with most patients is usually much less. There is nothing that can be done to speed up the process. There are however several techniques that can be used during the initial spider vein treatment that will minimise the risk of pigmentation in those who are at higher risk.

I have various hurdles that patients must “jump” over before I will treat their spider veins or varicose veins for cosmetic concerns. In a world of increasing concern about physical appearance, I need to be convinced that the cosmetic concerns are reasonable. By this I mean would an average person think it reasonable for the patient to be seeking treatment. I also use the “2 meter rule” whereby if I cannot see any veins standing 2 meters away then I will not treat. Also if a patient has had numerous previous treatments which have resulted in a poor result then I will be reluctant to treat. This situation is like getting lots of poor tradesmen to do a renovation and by the time a skilled tradesman comes along the structure is just too badly damaged to get an acceptable result no matter what the expertise of the tradesman. I also reluctant to treat patients younger than 21 years old because results are generally not as good as for “older” patients and the tolerance of young patients for the discomfort of treatment and side effects is less. Side effects, particularly matting, are more common in younger patients.

Spider veins are invariably treated with Sclerotherapy whereby a small amount of solution (the sclerosant) is injected into the abnormal veins to close them off. The body then dissolves these treated veins. Laser treatment of spider veins has produced inferior results to Sclerotherapy. As with all medical treatments the skill of the treating doctor is a critical component to achieving a successful result. The Australasian College of Phlebology has a register of doctors credentialed to perform certain procedures. Varicose veins are increasingly being treated less with surgery (“vein stripping”) and more with the “non-surgical” procedures of Ultrasound Guided Sclerotherapy (UGS) and Endovenous Laser Ablation (ELA). Some Phlebologists still perform adjunctive surgery (ambulatory phlebectomies) in association with one of the non-surgical techniques. Whether UGS or ELA is used depends on many factors with the most important being the size of the vein being treated. The larger the veins are more likely to be treated with ELA.

Compression stockings

These come in a variety of compression strengths ranging from support pantyhose to Class 3 medical compression stockings. In between are the compression stockings that are useful in the prevention of DVT’s when flying and the anti-embolism stockings that are often work in hospital. After Sclerotherapy it is usual for a Class 2 stocking to be worn from 3 days to 2 weeks depending on which vein was treated. As an adjunct to wearing stockings it is important to do as much walking as is possible.

Endovenous techniques (radiofrequency and laser)

In many countries Endovenous Laser Ablation (ELA) is replacing, or has replaced, the traditional surgical “stripping” of veins. The reasons for this are that ELA can be done as an office procedure (walk-in, walk-out) and has less risk than surgery. It also does not have the recovery time associated with surgery. The long term results of ELA are excellent. Importantly the recurrence rate of new varicose veins after surgery, which is often very concerning for patients, is avoided by performing ELA. The technique of ELA consists of placing a small laser fibre up the middle of the vein. This fibre is then very slowly withdrawn from and the laser energy from the tip of the fibre then heat seals as it is withdrawn. The laser is introduced via a 3-4 mm cut (done under local anaesthetic) and the procedure itself is also done under local anaesthetic. Normal walking is possible straight away as the local anaesthetic is not into the muscles but only placed around the vein being treated. The actual laser treatment is painless although some patients report a buzzing sensation.

If you have pain in your legs, fullness, tiredness or heaviness, aching, mild swelling at the ankle, you may have varicose veins. Self care such as avoiding excessive standing, wearing support stocking and raising your legs when resting can help.  However if you are unable to obtain relief from any self care, it is advisable to seek medical attention to obtain a diagnosis.

Diagnosis is simple and is normally carried out by ultrasound. 

There are many types of treatment options for varicose veins including sclerotherapy, ultra sound guided sclerotherpay and laser ablation.Contact us today for an appointment where we can review your treatment options.

There are several reasons as to why some patients get ulcers after sclerotherapy. It appears that using a solution that is too strong or injected with too much pressure is one of the common causes.

Sometimes ulcers are due to the solution being injected outside the vein. With the newer solutions this is not usually a problem but if hypertonic saline is used then injection outside a vein can often lead to deep ulcers.

Sometimes inexperienced doctors (even under ultrasound guidance) have injected solution into arteries instead of veins.

Overall the chance of getting ulcers with sclerotherapy is very low but further underlines the importance of having a very experienced doctor treat your veins.

One of the most challenging aspects of sclerotherapy treatment for veins is the appearance of brown lines along the veins that were treated. These lines (pigmentation) are due to the skin being stained by the iron pigment in blood that is released as the blood within the vein is broken down. It is particularly noticed in people with darker skin and I have seen it particularly with Asian patients and Southern European patients. It is also more likely if very large veins are being treated. Fortunately there are several things that can be done to minimise the chance of pigmentation and these are adequate treatment of the underlying vein, compression of large varicose veins after treatment to minimise the amount of blood trapped and evacuation by needle prick of any trapped blood if it looks to be excessive.

Patients often come to my clinic claiming sclerotherapy does not work for them. What they need to understand when they make that statement is that there is an enormous variation in the skills of the doctors performing sclerotherapy. In some cases the doctors have been (at most) to a weekend course and have had little or no ongoing education. This situation contrasts with those doctors who have gained the highest award possible - Fellowship of The Australasian College of Phlebology. Invariably when patients complain that sclerotherapy has not worked for them, they have not had treatment by an ACP accredited doctor.

The difference in treatment technique is that with the former group of doctors they invariably do not treat the reticular veins. In this case sclerotherapy will either not work or last only a short period of time. The reticular veins are the larger blue / green veins that feed into the spider veins (telangiectasia) and if they are not treated first it is like trying to block a tributary of a river without first blocking the river. The inevitable consequence of this approach is that the spider veins will only go temporarily (if they go at all) and often there is the almost immediate appearance of “bruising” in the area. This bruising is a collection of smaller veins that unfortunately does not improve with time. This is called “matting”. Another cause of why sclerotherapy may not work is if there is an underlying vein that does not work properly (incompetent) and the pressure from this vein is feeding into the surface veins. This situation is only identified by a Duplex ultrasound scan performed before treatment to thoroughly evaluate the condition of the deeper veins.

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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.

Questions or comments about vein treatments

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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.

Questions or comments about vein treatments

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