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Our understanding of varicose veins and how best to treat patients with this problem has improved in the past decade. This is in part due to the use of duplex ultrasound, which is used to look at blood flow in the veins.
Normally, blood circulates from the heart to the legs via arteries and back to the heart via the veins. Duplex Doppler ultrasound uses ultrasound images or pictures to visualise the vein and at the same time determines the direction of the blood flow. Duplex Doppler ultrasound is carried out before treatment in all patients with varicose veins to identify reflux (blood flow in the wrong direction) that causes varicose veins to appear and to establish the pattern of the abnormality.
In the legs (and elsewhere in the body), veins contain one-way valves that allow blood to return from the legs against gravity. If the valves leak, blood pools in the leg veins, and the veins become enlarged and visible underneath the skin. After a physical examination and a duplex ultrasound, an individualised treatment plan is developed to occlude the varicose veins (cut off/prevent the flow of blood) and divert the blood flow to nearby healthy veins. This may include any or all of the following:
The above three processes are also known by the general term of endo-venous ablation (EVA).
Varicose vein ablation can help to treat patients with symptoms of chronic venous insufficiency. The procedure is often carried out due to cosmetic concerns.
The interventional radiologist (specialist doctor) who will carry out the procedure will normally discuss all of the following with you during the preprocedure consultation:
Before treating your varicose veins using EVA, all the possible complications associated with the treatment and the cost involved will be discussed with you as part of the informed consent procedure to allow you to plan and prepare for the procedure.
When you attend the clinic or hospital where the procedure is to be carried out, you should report all medications that you are taking, including herbal supplements, as well as any allergies you have, especially to local anaesthetic, or any reactions you may have had previously when undergoing sclerotherapy.
Before the procedure, you may be advised to stop taking blood thinning medication; that is, aspirin, non-steroidal anti-inflammatory medications (NSAIDs) or blood thinner, such as warfarin or Clexane, for a specified period of time.
You should wear comfortable, loose-fitting clothing, and you will be asked to remove all clothing and jewellery in the area to be treated.
Remember to bring compression stockings to wear immediately after the procedure. The type you require should be discussed when you make the appointment for the procedure. The type and size of stockings you need to bring will be discussed at the preprocedure consultation with the doctor who will carry out the procedure.
You should plan to walk for 30–40 minutes immediately after the procedure and daily thereafter for 14 days.
You will need to wear your compression stockings for the first 14 days – day and night for the first four days – and then during the day, but not at night, for the next 10 days.
You may experience some discomfort (general aching or tightness in the legs or soreness in the treated vein(s) after the procedure, for which you may take paracetamol.
The procedure is carried out on an outpatient basis using local anaesthetic injected around the veins.
Under ultrasound guidance and in a standing position, the varicose veins on the leg to be treated will be mapped.
The leg being treated will be shaved, cleaned, sterilized and covered with a surgical drape.
If laser ablation is used, you will be given protective eyewear.
The area where a laser fibre or RFA catheter (a thin plastic tube) will be inserted into the abnormal vein will be numbed with a local anaesthetic.
Under ultrasound guidance (using ultrasound images or pictures on a screen) the laser fibre or RFA catheter is inserted through a small cut in the skin into the vein and positioned within the abnormal vein.
Using ultrasound guidance, local anaesthetic is injected around the abnormal vein.
Laser or radiofrequency energy is applied as the fibre or catheter is slowly withdrawn and removed. The faulty vein has now been sealed and blood flow has been diverted to the nearby healthy veins.
The fibre or catheter is removed and pressure is applied to stop any bleeding. The tiny opening in the skin is covered with a small dressing.
The compression stocking is applied.
When sclerotherapy is used to ablate the veins, a very fine needle, smaller than a pin, is placed within the vein and a chemical substance is injected. When this is done, no local anaesthetic is used.
There will usually be some bruising, swelling with minimal pain and discomfort after the procedure. Because of the appearance of the bruising and inflammation that often occurs in the treated area, and the need to wear thick supportive stockings, you may want to consider having the procedure carried out in the cooler months of the year.
Patchy numbness in the area of the treated vein may last for a short time or may take 3–6 months to resolve.
Inflammatory changes around the vein called superficial phlebitis will show as reddening of the skin, and minor local pain and tenderness. The inflammatory changes may start 7–21 days after the procedure and may last for up to 10 days.
If you develop calf tenderness and swelling, this may indicate deep vein thrombosis (see signs and symptoms described under the heading ‘What are the risks of varicose vein ablation’). If this happens, you need to immediately contact the radiology department or practice where you had the procedure.
The procedure takes 45–60 minutes. If you need multiple veins treated in both legs, you may need a number of treatments on separate days over a period of 4–6 weeks. After every treatment, you will be wearing your compression stockings for 14 days and walking daily for 30–45 minutes.
EVA is generally complication-free and safe, leaving virtually no scars.
Injections into the skin can cause skin infection requiring antibiotic treatment and this is seen in less than 1 in 1000 people who have this procedure.
Some patients may experience significant bruising and tenderness due to the procedure and local anaesthetic placed around the vein, which is alleviated by the compression stockings.
Heat damage to nerves adjacent to the veins is seen in 1 in 150 patients and generally goes away in 3–6 months, but may also be permanent.
Thrombophlebitis (inflammation, not infection, of the vein) is not uncommon and is seen in 1 in 20 patients, causing pain and redness over the treated area. This generally responds well to ice packs and non-steroidal anti-inflammatory drugs (NSAIDs).
Deep vein thrombosis (DVT) is seen in 1 in 400 patients, with the risk of developing a DVT returning to normal in 2–4 weeks. Blood clots that form in the veins can travel to the lungs (pulmonary embolism), although this is an extremely rare occurrence that happens in less than half of the people who develop a DVT. Pulmonary embolism is a very serious, and occasionally fatal, complication requiring hospitalisation and many weeks of treatment with blood thinning medication. You can decrease the chance of DVT by:
The following symptoms should make you suspect the possibility of a DVT and if you notice them you should see your local doctor, the practice that carried out your venous ablation procedure or the local emergency department (if at night or a weekend) as soon as possible:
Signs and symptoms of deep vein thrombosis include:
It is true that many patients with varicose veins return months to years later with new varicose veins elsewhere. It is important to understand that the underlying weakness in the vein wall and dysfunctional valves in the veins will allow new varicose veins to appear with time. EVA has a successful closure rate of 85–94% from 6 months to 5 years.
No surgical incision is needed – only a small 2-mm cut in the skin that does not require stitching.
When compared with traditional vein stripping, EVA has fewer complications, is associated with much less pain during recovery and offers a less invasive alternative to standard surgery.
Most of the veins treated become invisible after the procedure, but may take up to 12 months to completely disappear. It is common to have persistent bruising, or yellowish-brown or blue discolouration of the skin around the treated vein for weeks to months after the procedure.
Most patients report relief of their symptoms (such as aching and swelling of the legs, and the appearance of the varicose veins) and are able to return to normal daily activities immediately, with little or no pain.
Varicose vein ablation is carried out by an interventional radiologist, phlebologist, dermatologist or vascular surgeon – all specialist doctors. Ultrasound used for guidance is carried out by a sonographer or other trained health professional.
Varicose vein ablation is carried out at a hospital radiology department or private radiology practice.
Endovenous laser ablation (EVLA) has a successful initial closure rate of 95–100%. The outcomes appear durable, with a persistent closure rate after 10 years of 85–97%.
Radiofrequency ablation with the ClosureFast catheter has a successful closure rate of 99.6% at 2 years.
Studies of quality-of-life are scarce, but significant improvements in disease-specific quality-of-life after EVA have been reported.
Endovenous techniques have largely replaced surgical vein stripping in many countries as the first-line treatment for varicose veins.
Animated YouTube videos:
Society of Interventional Radiology:
Merchant RF, Pichot O. Long-term outcomes of endovenous radiofrequency obliteration of saphenous reflux as a treatment for superficial venous insufficiency. JVS. 2005 May 1; 42(3): 1-9
Proebstle TM, Aim BJ, Guckeritz O, Wenzel C, Noppeney T, et al. Five-year results from the prospective European multicentre cohort study on radiofrequency segmental thermal ablation for incompetent great saphenous veins. BJS. 2014 Sept 19; 102: 212-218
Page last modified on 30/8/2018.
RANZCR® is not aware that any person intends to act or rely upon the opinions, advices or information contained in this publication or of the manner in which it might be possible to do so. It issues no invitation to any person to act or rely upon such opinions, advices or information or any of them and it accepts no responsibility for any of them.
RANZCR® intends by this statement to exclude liability for any such opinions, advices or information. The content of this publication is not intended as a substitute for medical advice. It is designed to support, not replace, the relationship that exists between a patient and his/her doctor. Some of the tests and procedures included in this publication may not be available at all radiology providers.
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