Varicose Veins: How to Manage and Treat

Management strategies for varicose veins depend on the patient’s choice, severity of the condition and fitness of the patient. Non-surgical options include:

1. Compression stockings

For those unsure about surgery, a trial with compression stockings is usually the first line of treatment. These prescription tight-fitting below-the-knee, above-the-knee or pantyhose stockings create a gentle pressure on the legs which prevents blood from pooling in the veins.

The CEAP (Clinical, Etiological, Anatomical, and Pathophysiological) classification for compression stockings include:

• (20-30mmHg) for C2- C4 disease of the CEAP classification
• (30-40mmHg) compression therapy with garment for C6 ulcer disease

2. Daily leg elevations

Raise legs above heart level for 15 to 30 minutes, 3 to 4 times daily, to improve circulation.

3. Increasing physical activity

Regular exercise like walking, cycling, or swimming strengthens calf muscles and boosts blood flow.

4. Avoiding prolonged standing or sitting

Change positions every 30 to 60 minutes to prevent blood from pooling.

5. Weight management

Shedding excess weight can help to lower pressure on leg veins.

6. Skin care

Moisturise skin to prevent itching or irritation.

When considering surgery, anatomy and general medical status are key.

as there are no incisions, no need for general anaesthesia, shorter downtime and greater likelihood of being performed as a day procedure.

1. Open surgery (ligation and stripping)

An early procedure, ligation and stripping involves general or half-body anaesthesia. The faulty veins are removed and blood flow directed through functioning veins.

The procedure requires incisions to be made at the groin, inner thigh and calf. Patients typically are given up to two weeks of leave for recovery, during which they are encouraged to walk.

2. Endovenous therapy

Endovenous therapy uses energy devices such as laser, radiofrequency ablation, microwave ablation and chemical ablation or sealant such as Veneseal or ClariVein.

It (endovenous therapy) is the standard for varicose veins treatment today as it does not require incisions, use of general anaesthesia, and have a shorter downtime and a greater likelihood of being performed as a day procedure.

Venaseal, Radiofrequency ablation and ClariVein

• VenaSeal is a minimally invasive, non-thermal procedure which works by deliverying a specially formulated medical adhesive (glue) to seal the diseased vein. A catheter is inserted to the diseased vein under ultrasound guidance through a small skin puncture to directly deliver the adhesive into the affected vein.
• Radiofrequency ablation (Venefit) helps close off saphenous veins – veins found near the surface of the skin in the leg – which are engorged or congested with blood. These engorged superficial veins are the source of varicose veins.
• This treatment method uses a long catheter that is inserted through a small 1 mm skin incision into the vein under ultrasound guidance. A mixture of saline and local anaesthetic solution is injected around the saphenous vein to compress it against the catheter. Heat transfer is then used to close off the vein thus preventing backflow, and curing the problem.
• In ClariVein ablation, a 0.5 mm skin incision is made and with ultrasound guidance, a rotating catheter is inserted into the saphenous vein. After an injection of liquid sclerosant, the saphenous vein is closed off. Since this procedure does not use heat or laser technology, there is no need to inject fluid around the vein during treatment.

“These two endovenous modalities of treatment have been used on varicose vein patients with good results. They have a high cure rate and leave minimal scarring. Additionally, they take less time and produce less pain and discomfort than earlier procedures – a patient can usually return to normal physical activity within a few hours after treatment,” Prof Chong said.

“Also, the recurrence rate of varicose veins after Venefit radiofrequency treatment is less than 5 per cent after two years. For ClariVein, the recurrence rate is less than 5 per cent after one year.”

“The most significant risk (for radiofrequency ablation and ClariVein treatments) is that of a blood clot forming in the veins. This can break off and travel to the lung veins, causing deep venous thrombosis (DVT) and pulmonary embolism. Fortunately, this risk is very small and it is further minimised as we (SGH) use ultrasound guidance to help us visualise the veins during the procedures,” he added.

3. Injection of foamed sclerosants

Another popular alternative is the injection of foamed sclerosants – liquid chemicals in bubble form – into the inner thigh to harden the vein.

This minimally invasive aesthetic procedure is more suitable for treating small, superficial “spider veins” (telangiectasias) and reticular veins (small blue veins).

Patients that undergo either endo-venous therapy or sclerosant injection just need to take a few painkillers and wear graduated compression stockings for 30 days to aid recovery.

As a precaution, Prof Chong advises patients to avoid long periods of standing and to practice leg elevation whenever possible to avoid a recurrence of varicose veins.

There are no food or activity limitations, which makes it convenient for patients from all walks of life, especially those with busy schedules that do not allow for much downtime.

Ref: F26