Treatment of Varicose Veins (a discussion)
VARICOSE VEINS Exist in many different forms and distributions. Trunk veins in the skin in two major areas, the long or great saphenous attached at the groin and the short or lesser saphenous which attaches usually at the back of the knee to the Popliteal Vein but in many cases (found with Duplex examination) goes high in the thigh to attach deeply but often goes postero-medially to attach to the long saphenous.
At the groin alternative pathways through very large anterior or medial thigh vein connections can occur.With or without long saphenous abnormality. These can develop after heat (Laser or RF( RadioFrequency)) ablation or low ligation surgery as the origins are not controlled.
Large clusters of Collateral Veins can develop independent of Trunk problems.
More peripheral extensions going progressively superficial are reticular veins, venectasia, thread veins and capillary clusters. defined by their size and position. All are primarily a cosmetic problem and can be managed within the limits of the treatment by sclerotherapy or microsclerotherapy. Laser surface treatment can be used as an adjunct but has the risk of depigmentation in the legs with white treatment areas, as much a cosmetic problem.
Foam sclerotherapy has increased the size and areas of veins that can be managed especially with Ultrasound guidance, but has a significant recurrence rate when used in the trunk veins compared to Surgery. The introduction of RF ablation and the new high frequency Laser heat fusion of the trunk veins is allowing us to consider better functional treatment than that of sclerotherapy for the large straight trunk veins as an alternative to surgery.
Surgical avulsions and sclerotherapy can be added to resolve more peripheral veins when they persist or if acute resolution is required.
The problem of the large incompetent perforators likely the cause of major distal varicose veins have become a new problem to us as we understand more about the condition of Popliteal Vein Compression Syndrome.
When the Popliteal Vein is occluded for prolonged periods with the knee extended there has to be a way out and what we see is that the deep calf decompresses by forming incompetence in the perforator connections. If these are occluded or treated without managing Popliteal Occlusion there is bound to be a high rate of Recurrent problems which is the current standard in the distal leg. Many services will not treat perforators because of the long term failure of treatment. This does not have to remain the standard of the future.