Operations for Varicose Veins

Most major studies of varicose veins are concerned with treatments for venous ulcers. Randomised studies on the clinical and cost effectiveness of foam sclerotherapy, and of radiofrequency and laser ablation compared with conventional surgery, are needed to establish the proper place of these treatments in the management of varicose veins.

Data on long term outcomes (at least five years and preferably 10 years after treatment) are important because varicose veins may return gradually in the years after treatment. Information about large numbers of patients having foam sclerotherapy would be useful, with comprehensive data on adverse events to address concerns about the possible risk of stroke.

Conventional surgery usually means saphenofemoral ligation (not just a “high tie” but ligation of the long saphenous vein flush with the femoral vein) with stripping of the long saphenous vein and phlebectomies. Stripping is supported by evidence from randomised controlled trials. Precise technique varies, mostly with the aim of reducing postoperative bruising.

Patients with obese legs or big varicose veins may have considerable post-operative bruising, but many patients have little discomfort and recover quickly, requiring no further intervention and being completely rid of all their varicose veins. These are alternatives to stripping of the long saphenous vein.

If done without any other kind of treatment they may cause some varicose veins to disappear, but usually varicose veins need to be dealt with by phlebectomies or sclerotherapy. Radiofrequency and laser ablation each involve passing a probe up the long saphenous vein from knee level to the groin under ultrasound guidance and then ablating the vein in sections.

This avoids a groin incision and may lead to less bruising and quicker recovery. These benefits have been documented in small randomised studies for radiofrequency ablation and by large case series for both methods, but the scale of the advantages remains uncertain. Some surgeons use these techniques under local anaesthetic infiltration rather than general anaesthesia.

The precise place of laser and radiofrequency ablation remains uncertain. They require dedicated equipment and use of intraoperative duplex ultrasonography, and they take longer to do than conventional surgery in experienced hands. The amount of benefit for patients is variable: obvious varicose veins still need to be treated.

Phlebectomies of large veins are often the main cause of bruising and discomfort after the operation. Varying longer term results have been reported, but in general outcomes seem similar to those of surgery. It has been suggested that endovenous ablation techniques may lead to less neovascularisation in the groin than surgical dissection, so reducing this cause of recurrence of varicose veins.

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