VARICOSE VEINS

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Varicose veins have two major components.

The first are the obvious lumpy veins on the surface. These are the “varicose veins”.

The second are the underlying veins. These are the “truncal veins” and “incompetent perforator veins”.

The underlying veins are invisible from the surface. However, these underlying veins cause most of the problems. They cause swelling of the ankles, aching of the legs, red or brown stains around the ankles and eventually leg ulcers. Therefore it is essential to treat these underlying veins first followed by the lumpy veins on the surface.

In the past, doctors “stripped” away these underlying veins. However, stripping causes most of these veins to grow back again. When veins re-grow after stripping, they fail to grow new valves. Therefore the new veins are immediately varicose veins. We proved this and published the information in 2007 and 2014.

In 1999, Mark Whiteley introduced endovenous surgery into the UK. Over the last 20 years, he has shown that treating the underlying veins with the correct amount of heat energy can give a permanent cure. His methods destroy the deficient veins by ablation. This means that they cannot come back again, provided the surgeon uses the correct energy levels. This is the basis of The Whiteley Protocol.

Endovenous Laser Ablation (EVLA/EVLT) is a varicose vein treatment using laser energy under local anaesthesia, often termed EVLT. It replaces outdated stripping surgery. "Endovenous" means inside the veins, while "laser" refers to Light Amplification by Stimulated Emission of Radiation, and "ablation" signifies destruction. EVLA involves inserting a laser fibre into the problem vein and heating it to close it. The procedure, performed as a walk-in, walk-out technique, doesn't require general anaesthesia, reducing risks and costs. EVLA targets main venous trunks like the Great Saphenous Vein and Small Saphenous Vein, guided by ultrasound. Unlike traditional surgeries, EVLA doesn't treat surface varicosities directly. The safe and reproducible technique offers advantages in treating varicose veins' underlying causes, such as venous reflux. Variations exist, including different laser wavelengths, but all forms of Endovenous Laser aim to ablate veins from within, making them a part of EVLA.

Radiofrequency Ablation (RFA) of varicose veins, pioneered as one of the first minimally invasive endovenous treatments, involves using heat to close veins internally. This procedure, also known as endovenous thermablation, eliminates the need for traditional stripping surgeries. Initially introduced with devices like the VNUS® Closure®, RFA has seen advancements over time, including the development of techniques like RFiTT®. Similar to other endovenous methods, RFA utilises a catheter inserted into the targeted vein under local anesthesia and ultrasound guidance. The catheter delivers radiofrequency energy to heat and destroy the vein wall. While RFA offers quick procedure times, concerns have been raised about its efficacy compared to other methods like Endovenous Laser Ablation (EVLA). Research from The Whiteley Clinic suggests that higher energy levels are necessary for optimal results with RFA. While RFA remains an option, The Whiteley Clinic now favors EVLA and other advanced treatments for varicose veins, including TRLOP and ultrasound-guided foam sclerotherapy, based on their extensive experience and research findings.

Ultrasound-guided foam sclerotherapy is an advanced technique used to treat small varicose veins effectively. Sclerotherapy involves injecting a liquid into the vein to destroy it, causing inflammation and eventual closure. However, this method is only effective in small veins without blood flow; otherwise, it can cause clot formation known as sclerothrombus. To overcome this limitation, the sclerosant liquid is mixed with gas to create a foam, allowing the blood to be pushed out of the vein before injection. At The Whiteley Clinic, foam sclerotherapy is made using a mixture of oxygen and carbon dioxide to reduce the risk of complications. Ultrasound guidance ensures precise injection of the foam into the targeted vein. Once injected, the leg is bound to keep the vein closed and prevent blood from re-entering, promoting optimal vein closure without sclerothrombus formation. This procedure requires careful monitoring to ensure successful vein closure over approximately 21 days, minimising the risk of complications and achieving favorable outcomes in treating varicose veins.

Venaseal™, also known as the "superglue" treatment by Sapheon, offers a novel approach to closing the main vein responsible for varicose veins without the need for multiple needle holes. Unlike traditional methods like endovenous laser ablation or radiofrequency ablation, Venaseal™ requires only one needle hole per treated vein, eliminating the need for additional local anaesthetic injections around the vein. However, its recent introduction means it lacks a procedure code and is not covered by private medical insurance, making it accessible only to self-paying patients. While promising early findings suggest effectiveness, the long-term closure of treated veins remains uncertain compared to established techniques like endovenous laser ablation. Additionally, although Venaseal™ reduces the number of injections significantly, further injections may be necessary for additional procedures like phlebectomies. Despite its potential benefits, the current novelty of Venaseal™ results in a higher cost compared to conventional treatments, reflecting its recent introduction and ongoing research to establish its long-term efficacy. Patients considering Venaseal™ treatment should be aware of these factors and undergo a consultation and venous duplex ultrasonography to determine suitability and individualised pricing based on their specific needs.

Clarivein, also known as Mechanochemical Ablation (MOCA), represents a cutting-edge method for treating varicose veins developed by Dr. Michael Tal. Unlike traditional vein treatments such as vein stripping, which can lead to high recurrence rates, Clarivein stands out as a significant advancement in minimally invasive techniques since 1999. Unlike procedures like Radiofrequency Ablation and Endovenous Laser Ablation that require local anaesthesia, Clarivein is tumescence-free, as it doesn't use heat to destroy the vein. Instead, it employs mechanochemical ablation techniques, combining mechanical trauma and sclerotherapy. A catheter is inserted into the vein under ultrasound guidance, with a rotating wire tip causing mechanical damage to the vein wall. This damage facilitates the penetration of sclerotherapy solution, effectively destroying the vein. By creating small "tunnels" in the vein wall, the sclerosant flows in, causing permanent ablation. Clarivein offers several benefits, including reduced discomfort due to fewer local anesthetic injections, shorter treatment times, and enhanced safety, especially for veins near nerves and lower leg areas. However, it may not be suitable for all patients, particularly those with large veins, allergies to sclerosants, or multiple veins requiring treatment simultaneously. Moreover, its efficacy in treating incompetent perforating veins remains under evaluation. Prospective patients should consult with their Whiteley Clinic consultant to explore whether Clarivein is the right option for them.

Pelvic Vein Embolisation is a minimally invasive procedure used to treat conditions like pelvic congestion syndrome, vulval varicose veins, vaginal varicose veins, and leg varicose veins originating from the pelvis. Traditionally, older methods such as open or laparoscopic surgery were traumatic and yielded poor results. However, with Pelvic Vein Embolisation, a needle is inserted into the affected vein, and under X-ray guidance, a catheter is advanced into the vein. Once properly positioned, a metal coil or a special embolic material like Gelfoam is deployed into the vein to block blood flow. Although these embolisation techniques are not new and have been used safely for over 20 years in various areas of the body, including testicular and ovarian veins, the success of Pelvic Vein Embolisation lies in the developed techniques. By blocking refluxing blood in pelvic veins, this procedure causes varicose veins to shrink over time, alleviating symptoms like chronic pelvic pain and heaviness. While rare, some patients may require additional embolisation attempts for complete recovery. Overall, Pelvic Vein Embolisation offers a safe and effective solution for treating pelvic vein reflux and associated symptoms.

The Rafaelo Procedure offers a safe and effective solution for internal haemorrhoids by utilising Radiofrequency ablation technology to address the root cause of the condition. Unlike traditional treatments like haemorrhoidectomy, The Rafaelo Procedure is minimally invasive, performed under local anaesthetic, and boasts a walk-in, walk-out approach, allowing patients to resume their daily activities promptly. With over 2,000 successful treatments performed in the past three years, it has demonstrated outstanding results with minimal discomfort and post-operative care. By reducing blood flow to the haemorrhoid, the procedure induces shrinkage and eventual disappearance, often requiring only one 15-minute session. Patients experience immediate relief from symptoms, making it an attractive option for individuals seeking long-term solutions for internal haemorrhoids. The procedure is suitable for all grades of internal haemorrhoids and can even benefit patients with external haemorrhoids, offering hope to those struggling with this condition.

Phlebectomy, derived from "phleb" meaning vein and "ectomy" meaning removal, involves the extraction of visible bulging veins, known as varices, just beneath the skin's surface. Unlike stripping, a now outdated procedure that involved surgically tying off and removing deep-seated truncal veins, phlebectomy focuses solely on surface veins. Stripping, being more invasive, causes significant pain and often stimulates vein regrowth, rendering it less favorable. Phlebectomy effectively eliminates surface varicose veins but doesn't address the underlying cause, typically necessitating complementary treatments like endovenous laser or pelvic vein embolisation. An ambulatory phlebectomy, performed under local anesthesia, allows patients to undergo varicose vein treatment as a walk-in, walk-out procedure, eliminating the need for hospitalisation. During the procedure, the surgeon marks the veins while the patient is standing, administers local anesthesia to numb the area, and makes tiny incisions over the marked veins. Using precise tools, the surgeon removes the veins through these incisions, causing minimal discomfort or pain. The procedure concludes with the closure of the incisions using adhesive tapes, obviating the need for stitches and enabling a swift recovery.