Varicose vein treatment options

A new treatment for varicose veins looks promising but there’s a danger unqualified operators could benefit at the expense of patients.
 
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01 .Vein pain

Varicose veins

In brief

  • Varicose veins can be painful, uncomfortable and lead to serious health consequences if left untreated.
  • Endovenous laser therapy offers a good success rate, provided it’s done by accredited practitioners.
  • If you have a tendency to varicose veins, you’re likely again no matter what treatment you have.

Varicose veins aren't merely a cosmetic problem. They can cause pain and discomfort on a daily basis, with some of the more persistent symptoms including swelling, throbbing and cramping of the legs. Serious complications can develop over time, such as phlebitis (vein inflammation), blood clots, dermatitis and painful vein ulcers that in extreme cases can lead to amputation.

While many treatments exist, the one currently attracting most attention is endovenous laser therapy – a less invasive alternative to surgery with good success rates reported in the hands of experienced and skilled practitioners. Its popularity is likely to increase if a proposed Medicare rebate for the treatment is approved.

CHOICE discovers what varicose veins are and who gets them, what treatment options are available, and management strategies to help reduce discomfort.

Please note: this information was current as of May 2009 but is still a useful guide today.


What are varicose veins?

There are two venous systems in our legs, deep veins and superficial veins, which are joined by perforator veins. Most varicosities are due to problems with the main superficial, or saphenous, veins, that collect blood from other surface veins.

One-way valves in veins direct the flow of blood back to the heart. In the legs – the most common location of varicose veins – these valves are particularly important because the blood is flowing against gravity. When one or more valves fail, blood can pool in the section, causing the bulgy, tortuous appearance of varicose veins. Weak vein walls exacerbate the problem.

When the blood flows backwards because of weak valves, it is known as reflux. Deeper veins, which lie within and between muscles, are not affected in the same way, because muscular contraction (when walking and so on) compresses the veins, creating a pumping action that returns blood to the heart and provides support. The veins near the surface, however, have little support.

Not all varicosities are caused by valve problems in the saphenous or perforating veins; any superficial leg vein can become varicose, although these veins are usually quite small and cause few symptoms. However, the severity of the symptoms isn’t always related to the appearance of the veins, and even large, obvious ones may cause little or no discomfort.

Varicose veins serve no useful purpose: alternative pathways have already been formed to bypass the abnormal varicose veins and return blood to the heart. Compressing, closing off or eliminating varicose veins improves circulation and relieves many of the symptoms.

Who gets varicose veins and why?

In Western nations it’s estimated about 40% of people suffer from varicose veins, and it appears to be hereditary. Susceptibility varies among cultures, although it’s not clear if this is genetic or lifestyle-related (poor diet and lack of physical activity may be partly responsible).

Women seem to get varicose veins more than men, most likely due to the hormone oestrogen. Taking oestrogen-based contraceptive pills or hormone replacement therapy also appears to increase risk. Women who have had children are more likely to get varicose veins in the future, as hormones in pregnancy relax vein walls, and the weight of the uterus puts more pressure on leg veins. Varicose veins that occur during pregnancy often go away within a few months of giving birth.

Poor diet, obesity, smoking and a sedentary lifestyle increase risk, as does standing still for long periods of time.

 
 

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As there’s no cure for varicose veins, there is also no guarantee one treatment will fix the problem for life. The earlier you treat varicose veins, the more successful the outcome.

Your first port of call should be your GP, who can refer you to a phlebologist, vascular specialist or other surgeon who practises phlebology. An ultrasound “map” of your blood vessels will provide an overview of how they’re functioning and where the problems lie, and what the future holds if you choose to do nothing.

Treatment may require several stages. For severe varicosities, the first stage is usually to treat the root of the problem: the saphenous veins. The reflux in these veins affects the tributary veins that run from them. Once the saphenous veins have been fixed, affected perforator and tributary veins can then be treated. Spider veins are almost always associated with deeper vein problems, so further investigation is needed to identify the cause (which should be treated first).

Most treatments are done in an office or clinic setting with local or no anaesthetic. Ligation and stripping takes place in hospital and may require general anaesthetic.

After any treatment, you must wear compression stockings all day and night for about two weeks to assist the process of sealing veins and preventing clots. Regular walking is an important part of healing, although you may have to avoid more strenuous exercise for a while. The physician will conduct an ultrasound examination soon after the treatment to ensure there are no clots.

Managing varicose veins without surgery

If your varicose veins aren't too severe, or you are trying to slow down their recurrance, the following strategies may help.

  • Regular exercise, a low-fat diet with plenty of fruit and vegetables, and keeping your weight at a healthy level can help prevent varicose veins becoming problematic.
  • Elevating your legs when possible can also provide relief, as can compression stockings, which are elastic stockings that use graduated pressure to squeeze your veins and stop blood from pooling or flowing backwards.
  • A large review of clinical trials of horse chestnut tablets containing escin found it reduced pain, itching and swelling, at least in the short term. It appears to be safe, although it may interact with some medicines (check with your doctor), and its long-term effectiveness hasn’t been established.
  • Some cosmetic creams claim to reduce the appearance of spider veins, but there’s no evidence they have anything more than a minor effect.

Procedures

Microsclerotherapy and ultrasound-guided sclerotherapy

An irritating liquid or foam is injected into the blood vessel, causing it to swell and stick together, aided by external pressure from compression stockings. The blood vessel is eventually absorbed by surrounding tissue and fades from view. This treatment is often used in conjunction with vascular ultrasound to guide the injections in larger and/or deeper veins.

Costs: This ultrasound-guided sclerotherapy costs about $800-$1000, with a $300 Medicare rebate; sclerotherapy for small veins and spider veins is more like $300-$500, with a $100 rebate.

Ambulatory phlebectomy

A tiny incision is made over the vein which, using a phlebectomy hook, is pulled out until it breaks or cannot be pulled any further. The process is repeated along the entire length of the vein to be extracted, and no stitches are necessary.

Costs: It costs about $900, with a $300 rebate.

Endovenous laser therapy

The vein is punctured near the knee or ankle, depending on which part of the vein is being treated, and a fine laser probe inserted. The laser is activated, causing the vein walls to fibrose and close off as it’s withdrawn. The procedure involves minimal discomfort and local anaesthetic is used to reduce pain.

Costs: A Medicare rebate of about $600 is in the pipeline, but for now you’re looking at costs of between $3000 and $4000 per treatment. See below for more about endovenous laser therapy.

Radiofrequency ablation

Similar in technique and outcome to endovenous laser therapy, radiofrequency ablation uses a catheter to heat the blood and destroy the vein.

Costs: Costs and risks are similar to endovenous laser therapy, but there’s no Medicare rebate available.

Surgery

An incision is made at the top of the leg over the vein, which is then cut and tied off (ligation). A thin wire is inserted down the length of the vein and the vein pulled out – stripping. Smaller incisions may be needed to separate connecting veins along the way.

Costs: It costs about $2000 plus hospital and anaesthetic costs. The Medicare rebate is about $500-1000, but check with your doctor for a better estimate.

Treatment risks

All types of treatment are likely to result in temporary bruising, aching, discolouration and inflammation. Deep vein thrombosis (DVT) and temporary numbness due to nerve damage are rare. For one treatment, sclerotherapy, additional but rare risks include pockets of blood trapped in veins (this is different from DVT), pigmentation along treated veins, allergic reaction to the solution and skin ulceration.

Costs and rebates

Medicare rebates apply to most procedures considered medically necessary, so your varicose vein treatment needs to be more than just a cosmetic concern, and veins should be 2.5mm or more in diameter and have reflux. The cost and rebate figures we’ve provided are only a guide for comparative purposes, and your doctor will be able to give you a more accurate guide to out-of-pocket expenses.

Private health insurers don’t cover most treatments because it doesn’t take place in a hospital, however they may cover part of the cost of post-operative compression stockings.

Endovenous laser therapy: Call for accreditation

At up to $4000 a pop or even more, this increasingly popular treatment isn’t cheap. And in the wrong hands, it may be ineffective or even unsafe. If you’re undergoing endovenous laser therapy, it’s important to know the person is an accredited laser operator trained in its operation.

The machines are readily available, so in theory anyone could buy and use one. Although they’re expensive to purchase, some companies overseas are giving away the machines for free, relying on recouping their largesse from the high cost of consumables, such as the laser probes themselves. According to Dr Kurosh Parsi, President of the Australasian College of Phlebology, this has led to sometimes disastrous results in the United States, such as probes breaking off in the blood vessels (because they were used too often) and long-term complications from inappropriate or incorrect use.

Endovenous laser therapy has been recommended for inclusion on the Medical Benefits Schedule, which means it would then attract a Medicare rebate, possibly before the end of the year. However, there is concern that many people put off by the idea of undergoing surgery who wouldn’t otherwise have sought treatment for varicose veins will come forward, not only increasing demand for services but also enticing practitioners who haven’t undertaken proper training to jump on board the taxpayer-funded gravy train.

The Australasian College of Phlebology has petitioned the government to limit Medicare rebates to patients who attend accredited practitioners; a position supported by the Australian and New Zealand Society of Vascular Surgeons. The society’s president, Dr Michael Grigg, points out that a thorough diagnostic assessment takes more than just knowledge of the technique, which is not difficult to learn, but also a good understanding of vascular medicine. “We have a saying in surgery: it takes about three months to learn how to do a procedure, but it takes three years to learn when to do it.”

CHOICE supports the call for accreditation, because this would encourage consumers to choose practitioners who have been fully trained to safely and effectively use the procedure.

More information

For more information about varicose veins and their treatment, see the website of the Australasian College of Phlebology or phone (02) 9386 1811. Fellows of the College accredited in performing endovenous laser therapy or radiofrequency ablation are listed, while Members of the College certified in sclerotherapy are listed as “Certified Sclerotherapists”.

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