Treatments

Non surgical treatments
Drugs
There are many molecules offering vascular protection available today. Many are made from plants.

MECHANISM OF ACTION
a) Venotonics are used to:

- repair changes in the vein walls
- increase the venous tone
- strengthen the capillary barrier
- decrease the capillary permeability
- improve the capillaro-venular flow
- protect the connective tissue surrounding the vessels
- reduce the flooding of surrounding tissues by proteins
- fight inflammation
- increase the lymphatic flow

b) Anti-oxidants such as vitamin C or vitamin E increase the capillary resistance.

PURPOSE
The advantage of venotonics is to:
- decrease pain and the feeling of heaviness in the legs
- decrease cramps
- stop the feeling of restlessness in the legs
- reduce oedemas and restore the elasticity of tissues by facilitating the absorption of fluids flooding the skin.

DRUG ADMINISTRATION
- orally as pills, packets or gelcaps
- locally as gels or creams

These drugs have not been proven to slow down the evolution of the venous insufficiency. They do not make existing varicose veins or thread veins disappear.

CONTRAINDICATION
In the vast majority of cases, these drugs have no contraindication. They can be used along with other treatments. They can also be prescribed to pregnant women.

It is better to offer these treatments during the warm season, and to keep elastic support treatment for the cold season when it is better accepted.
 
ELASTIC COMPRESSION
Principle:

The purpose of compression is to put pressure on the leg in order to reduce the enlargement of superficial veins, force the blood up towards the heart and prevent oedemas from stagnating in surrounding cutaneous and subcutaneous tissues.

A good compression management should :

- decrease the enlargment of superficial veins,
- prevent venous blood from stagnating by increasing its flow,
- reduce the oedema and inflammation of cutaneous and subcutaneous tissues,
- eliminate pain,
- shield the skin from external shocks.

Compression management should of course be perfectly adapted to the patient, with pressure spread over the whole leg, a little more around the ankle, a little less on the thigh.
Elastic compression hosiery is available as socks, stockings or panty hoses, and can be adapted to the length and shape of the leg, and also to the severity of circulatory problems:
"Support" hosiery is useful to relieve pain in people without any sign of varicose vein disease.
"Compression" hosiery comes in four different strengths graded from 1 to 4 according to the pressure exerted. The strength level is chosen on a case-by-case basis in relatively advanced venous insufficiencies.

Better accepted in autumn and winter than during the summer months, elastic compression is an excellent way to prevent venous diseases. Compression hosiery is more and more aesthetic, which makes it easier for patients to accept.
 
LASER
The laser uses an intense light beam whose wavelength power and duration trigger a sclerotic activity at the point of impact. It is effective in treating certain types of thread veins on the face, chest, abdomen or legs, but less so in varicose veins of large or medium calibre.

In the treatment of lower limb telangiectases, the efficiency of laser is closely tied to the depth and diameter of vessels to be treated; it can complement well sclerotherapy in the eradication of micro-vessels of less than 0.3mm in diameter.

An assessment of the venous system should be done before starting any treatment in order to pinpoint the feeding veins underlying the varicose veins; the former should be treated first in order to avoid short- or medium-term recurrences.

The laser is of particular interest in the treatment of varicose veins in people with resistance or contraindication to sclerotherapy (coagulation disorder, needle phobia, etc...)
 
THERMOCOAGULATION or ELECTROCOAGULATION
these techniques, can trigger a regression of telangectiases through a thermic lesion caused by a (high-frequency) electric current transmitted through a needle placed on the skin.
the method is especially very effective on the veins located on the face or on the body.

 
SCLEROTHERAPY (injections)
HISTORICAL BACKGROUND

1853 – Tested by three Lyons surgeons, the first sclerotherapy treatment of varicose veins used iron perchloride injected with a syringe invented a few years earlier. The first results were encouraging but there were too many complications because asepsis was still unknown and the product used was too powerful and dangerous. The method was abandoned for many years.

1890 – Tests were made with more diluted products and better asepsis. During a surgical congress in Lyons in 1894, a study of 164 sclerotic injections made without incident was presented. The action mechanism was starting to be better understood. It had to do with the irritating effect of iodine plus its antiseptic action on the walls of varicose veins. The term "injection sclerotherapy" was born. Sclerosing agents changed over time, but the iodine remained their prime component.

1920 – SICARD noticed the great efficacy of intravenous sodium injections.

1949 – TOURNAY insisted on the need for local concentration of the product in the vein although he had already proved that the injected product remained a long time at the injection site. Lab experiments then proliferated and showed that the density of the injected product was the most important diffusion factor, insuring contact with the wall of the vein to treat. Research therefore focussed on improving the quality of sclerosing agents which had to be harmless and as efficient as possible.

CURRENT SCLEROSING AGENTS

Sodium tetradecylsulfate
The most popular product in France currently. Easy to handle and very efficient. It is completely painless when injected and therefore easy to use in the treatment of large varicose veins.

Hydroxypolyetoxydodecan
Not quite as efficient as the previous one, it requires higher doses in the treatment of large varicose veins. It can be used for venules and telangectiases, which makes it a very useful product too.

Chrome glycerin
Limited to the treatment of telangiectases, its sclerotic power is weaker. It can therefore not be used in the treatment of advanced varicose veins. It is limited to the cosmetic treatment of insignificant venous insufficiencies.

Foam
Sodium tetradecylsulfate and hydroxypolyetoxydodecan are chemical agents which can be used in liquid or foam form. The foam version allows for a better contact of the product with the wall of the varicose vein, which makes it easier to treat some large calibre varicose veins which would have been treated surgically otherwise.


ACTION MODE OF SCLEROSING AGENTS

- They irritate and destroy the internal intima of the vein but not its more external intimae. A conjonctive organisation takes place afterwards until a final resorption is reached.
- It is important to know that only varicose veins respond to the treatment.
- Histological studies have confirmed the benignity of the process triggered by sclerosing agents.

PURPOSE

The purpose of sclerotherapy is to reduce the calibre and obtain the total fibrosis of the treated vein in order to make it vanish.

PRINCIPLE

In sclerotherapy, a sclerotic product is injected inside the varicose vein in order to provoke an irritation of the vein wall at the injection site. This irritation triggers an inflammatory reaction, a spasm and then an obliteration and transformation of the vein. Its gradual disappearance takes usually 2 to 3 weeks.

METHOD

The injection is made using extremely fine needles (<0.5 mm in diameter). The shot itself and the injection of the product are painless. In the case of superficial veins, the injection is given immediately after the varicose vein has been localized through simple palpation. In the case of deeper varicose veins, the varicose vein is localised and the needle positioned inside it with the help of ultrasound equipment.

As a general rule, the varicose veins located the closest to the groin or in the back of the knees should be sclerosed first in order to get rid of the reflux points responsible for the development of underlying varicose veins. These underlying varicose veins will be treated later with smaller doses if the reflux points upstream have been eliminated.

The patient is examined standing up but the injections are done lying down. After the varicose veins have been localized and the skin disinfected with alcohol, the needle is inserted quickly directly into the vein. The solution is then injected with its amount depending on the size of the varicose vein and the solution concentration: 1 to 2 cc are usually needed. These steps can be repeated at different points of the leg in the same vein or in collateral branches. A piece of cotton and band-aid are then put over the injection site and must be kept for a few hours.

The principle of microsclerotherapy of telangectisases is exactly the same as that of large varicose veins, except that the products and dosages used are different.

Several injections are made during one session. Sessions are scheduled 3 or 4 weeks apart. The treatment can take place in any season.

Given the fact that patients react differently to products, doses and concentrations are increased gradually in order to avoid painful local inflammatory reactions. The treatment is therefore customised according to a strategic plan determined in a way consistent with the initial clinical and ultrasound exams. if It is implemented by an experienced doctor, well trained in modern techniques, the results are excellent.

Used in France for more than a century, sclerotherapy has been popular ever the 60¹s. 2,000 doctors practice it in close collaboration with General Practitioner¹s and surgeons.
 
SPA THERAPY (Spring water treatment)
60 to 70% of patients treated in spa resorts, specialising in vascular diseases, have venous problems, 30 to 35% have a chronic arterial illness.

INDICATIONS
In the area of venous pathology, there are two specific indications for spa therapy:
- Recent phlebitis and sequels of previous phlebitis
If undergone within two or three months of an acute episode, spa therapy can reduce by 40% associated oedemas.
If undergone later, spa therapy reinforces the benefits of elastic support, physiotherapy and venotonic drugs.

- Chronic venous insufficiency, and its skin and functional complications. Especially indicated in case of pain and oedemas, spa therapy also improves skin quality.

Doctors agree that the earlier in the disease the patient is seen, the more spectacular the results of spa therapy are.

CONTRAINDICATIONS
- poor general health, since active participation by the patient is a must for a positive outcome of spa therapy
- local infectious complications such as eczema, infected ulcers, lymphangitis
- local evolving inflammations such as acute or sub-acute hypodermites

TECHNICAL MODALITIES
a) types of treatments
- Baths (in carbonated water or not): relaxation of patient and positive influence of water on skin infiltrates. Baths mobilise fluids in the lower extremities and improve skin oxygenation.
- Bubbling baths give a superficial massage with very positive microcirculatory effects
- Walking inside a pool amounts to walking with strong compression hosiery
- Moving around in a pool improves articular functioning especially in patients with rheumatic problems
- Underwater massages improve skin elasticity
- Local micro-showers

b) length of stay: regular spa therapies usually last three weeks

Although considered somewhat old-fashioned by the medical body, spa therapy has made a comeback recently. Treatments are cheap and indications are better understood. Many resorts now propose mixed treatments for both circulatory and rheumatic problems since both pathologies are often intertwined and dependent on one another.

Apart from their therapeutic role, spa treatments also play an important preventive and educational role which can be perfectly integrated in the handling of this life-long disease.
 

Surgical treatments
Surgery always requires local, epidural or general anaesthesia, and often a few days in the hospital. It is used mostly in cases of advanced varicose disease and/or cutaneous complications.
AMBULATORY PHLEBECTOMY
With the help of ultrasounds, the location of varicose veins is pencilled on the skin with permanent ink. The surgeon thus knows the exact location of the veins to be removed. A local anaesthetics is injected along the varicose veins marked for removal; through tiny incisions 1 to 3 mm wide, the varicose veins are then extracted using special mini-hooks.

The incisions do not require stitching; small local dressings are held by elastic bandages for eight days, and then by compression stockings for two weeks. The surgery can last one to three hours, depending on the importance of varicose veins. The patient can walk immediately after the operation.



 
STRIPPING
Classic or invaginated, stripping remains the surgical method of choice to remove the largest varicose veins and main points of reflux.

A cut is made in the groin or the back of the knee depending on whether the internal or external saphenous vein is involved. Another cut is made usually in the ankle or calf, the surgeon ties off and cuts the superficial vein near the crotch (i.e. near where it connects with the deep venous system), then by the ankle. After inserting a metal probe in the diseased vein, one end of the vein is attached to it and pulled from inside out like the finger of a glove (invagination method) as the probe is removed. This surgical method has many variations depending on the tools used.

Incisions do not exceed 2 or 3 cm in the groin or behind the knee, 1/2 cm at the ankle. General or epidural anaesthesia is required. Two or three days in the hospital are usually needed. The patient can walk one day after surgery but a compression bandage must be worn for three weeks.
 
CRYOSURGERY (cold surgery)
In this method, the varicose vein is frozen from the inside. It has both the inconvenience of surgery (hospitalisation, incisions, sometimes pain and nerve damage) and a very high relapse rate (30%). Cryosurgery is hardly ever used these days.
 
OTHER METHODS
Other methods have come up in recent years, hit the news and then fallen into oblivion just as fast as fads come and go, with unhappy patients or victims forced to resort to traditional surgery. There are hopes with the intra-vascular laser, its initial results are promising but it is too early to judge the quality or permanency of these results.

This does not mean that surgical protocols do not change over time and that techniques do not improve regularly. Hospital stays are shorter and shorter. Anti-clotting and anti-infectious treatments have all but eliminated the risk of serious complications. Surgical results are now excellent thanks to pre-surgery Doppler scanning which help guide the surgeon¹s hands.
 

Choosing a treatment
Stripping is recommended when there is an inversion of the blood flow in a very enlarged internal or external saphenous vein. Surgery is then the best option. If there is no inversion and blood flows normally from the feet to the heart, surgery is not indicated.

Ambulatory phlebectomy is a technique used primarily for tributaries of the internal or external saphenous veins, when the affected veins are large and flow backwards. It is done separately or as a complement to stripping, or when varicose veins relapse after surgery.

Sclerotherapy is indicated in the treatment of varicose veins without excessive enlargement or major reflux. It is also recommended as a complement to surgery for best results and to avoid relapses. Sclerotherapy is the treatment choice not only for cosmetic results but also to prevent further vein damage. Simple to do and virtually painless, sclerotherapy nevertheless requires a precise strategy. It must be done by a trained doctor familiar with duplex scanning, a prerequisite before starting treatment.

As a conclusion, these different treatment methods are not mutually exclusive but rather complementary on a case-by-case basis. The choice depends on the data coming from the clinical exam and duplex scanning, and on the awareness of all the possibilities offered by modern technology,