Chronic venous disease of the lower limbs, the condition responsible for so-called “varicose veins”, is one of the most frequent disorders in our population, affecting up to 56% of men and 60% of women (Epidemiology of chronic venous disease. Phlebology. 2008;23(3):103-11).
Up to 2% of the population reaches the most severe stages of the disease, thus suffering from chronic skin ulceration associated with venous hypertension (Ma H. The real cost of treating venous ulcers in a contemporary vascular practice. J Vasc Surg Venous Lymphat Disord. 2014 Oct;2(4):355-61).
For the clinical and diagnostic description, for the explanation regarding the saphenous vein, and for aesthetic treatments, click on the relevant word to be taken to the associated web page.
This section will address the difference between technique and strategy in the treatment of varicose veins.
In an era of continuous technological evolution, many minimally invasive treatment options are indeed available.
In particular, in addition to traditional surgery aimed at removing the entire saphenous vein and the venous branches connected to it (“stripping” procedure), it is now possible to treat the affected leg by means of endovascular procedures under ultrasound guidance.
These consist of introducing an instrument (a fibre, a catheter or a needle) into the diseased vessel and then eliminating that vessel by delivering thermal energy and/or occlusive substances. Among the thermal techniques, in particular, are laser, radiofrequency, microwave and steam.
All these approaches require the infiltration of an anaesthetic around the treated vein, since the high temperatures could cause pain during treatment.
Among the non-thermal ablation techniques, vein closure with glue is now included. In this case there is no need to use anaesthesia around the treated vein, since no thermal energy is delivered. The entire treated vein is glued shut, thus preventing blood from passing through it.
Another ablative therapeutic option, known as mechanochemical ablation (MOCA), consists of introducing a hooked catheter into the vessel. These hooks create micro-trauma of the inner wall of the vein. This trauma is intended to allow better penetration of a sclerosing agent injected at the same time and designed to eliminate the vein.
Finally, the same sclerosing agent can be used directly in liquid or “foam” form in order to eliminate the vessel without prior scarification of its inner wall.
The “foam” form is more potent than the corresponding liquid thanks to the ability of the foam itself to physically displace the blood, thus acting directly on the venous wall without dilution. Moreover, it is visible on ultrasound and therefore allows more precise localisation of the target area of the treatment.
BUT ALL THESE TECHNIQUES, more or less modern, are precisely techniques based on the SAME STRATEGY OF ELIMINATING the diseased vessel and, not by chance, the result in terms of VENOUS DISEASE RECURRENCE remains THE SAME.
All these techniques may indeed be more or less invasive, with or without anaesthesia, but they are still based on the DESTRUCTION of the diseased vessel. Conversely, as described on the page dedicated to the saphenous vein (link), it is possible to REPAIR the venous circulation by acting precisely and in a minimally invasive way at the points where the valves inside the vein are no longer able to ensure the correct direction of flow.
Following a detailed ultrasound examination (link), the type of pathological flow present is studied, together with the best site at which to redirect the blood so that it can return towards the heart and lungs instead of draining towards the surface and the most distal part of the leg.
This strategic approach has been shown to HALVE THE RISK OF DISEASE RECURRENCE compared with the approach of removing the diseased vessel (CHIVA method for the treatment of varicose veins. Cochrane Data- base of Systematic Reviews 2012, Issue 2. Art. No.: CD009648. DOI: 10.1002/14651858.CD00964). For a detailed explanation, see the relevant link.
Depending on which valves are malfunctioning, it will be possible to apply DIFFERENT TECHNIQUES, always MINIMALLY INVASIVE, under local anaesthesia or even without anaesthesia, aimed at closing the “leak points” of the venous system, thereby reducing the overload within the previously dilated vessel, restoring it to a normal calibre and thus eliminating venous reflux, WITHOUT REMOVING ANY VEIN (CHIVA: instructions for users. Phlebology Journal 2014).
If there is incompetence of the major valves, it will be possible to perform a minimally invasive surgical procedure under local anaesthesia, with no need for external sutures thanks to the precision of the procedure guided by ultrasound examination (Mini-invasive high-tie by clip apposition versus crossectomy by ligature: Long-term outcomes and review of the available therapeutic options. Phlebology. 2017 May;32(4):249-255; Femoral vein valve incompetence as a risk factor for junctional recurrence. Phlebology. 2018;33(3):206-212; ).
Where the incompetent valves are instead located in the superficial system, it will be possible to use the most modern endovascular technologies (laser, radiofrequency, glue, MOCA, ultrasound-guided endovascular foam treatment, microwave). Rather than using these techniques to remove the entire vessel, they should be used to treat specific points precisely identified along the venous circulation (Segmental Saphenous Ablation for Chronic Venous Disease Management. J Vasc Surg VL 2019;7(2):307-308).
It has been shown that a strategy based on repair rather than demolition leads to better results, provided it is carried out by specialists with considerable specific expertise, both in ultrasound and in practice. The guidelines themselves therefore recommend a reparative rather than a demolitive approach, but only in centres with sufficient experience (The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J. Vasc Surg 2011;53(5 Suppl):2S-48S).