Having a procedure done can be a daunting process. To alleviate that stress and anticipation, the team at Palm Clinic have created a video to ease your woes. Featuring Dr Sam Dunn, as well as the ultrasound team, it provides great insight into the questions someone suffering from varicose vein issues may have.
We have taken all the gems of knowledge from that video and transferred it into this post for easy written reference.
I am one of the registered nurses at Palm Clinic and recently had a Laser treatment of my veins Endovenous Laser Ablation (EVLA). Here is my experience.
The first thing was my blood pressure was taken and I was asked if I had any allergies etc. and if I was on any medications. After the Doctor explained the procedure I signed the consent form.
I changed into a theatre gown, hat, shoes and g-string! (This was so my own undies would not get wet when they washed my legs down with skin prep).
Then it was through to the warm theatre – the theatre has to be warm to help the veins stay nice and big so they are easier to get into. When we are nervous or cold, our veins shrink.
As doctors we often perform procedures on our patients but do not know how it feels to be the recipient!
Having had relatively minor, symptom free varicose veins and spider veins for years, I was waiting until they became sufficiently troublesome to warrant treatment.
More recently, swelling and aching at the end of the day followed by restless legs waking me at night led to further investigation at Palm Clinic using ultrasound. This revealed venous incompetence (leaky valves) in thigh and calf veins.
All my leg veins were thoroughly checked and a diagram or venous map was drawn to detail veins needing treatment.
Veins are the blood vessels that take the blood from your feet and legs back to the heart, ready for another cycle around the body. This means the blood in your leg veins should flow upwards.
When your veins don’t work properly, they let blood flow backwards down the leg. This can cause you to have heavy, achy, tired or swollen legs, which feel worse when standing still. You get relief when you elevate your legs, as the bloods flows up the leg, back to the heart, under the influence of gravity.
If poorly functioning veins go untreated for too long, the skin on the legs can start to suffer. The first signs of this are itching or eczema of the skin, followed by brown pigmentation and eventually a leg ulcer.
People with longstanding varicose veins can develop lipodermatosclerosis. This is a fancy term for hardened woody skin of the lower legs.
Why do veins fail?
There are a few theories as to why your veins ‘fail’.
Palm Clinic is one of the most experienced Clinics for non surgical management of varicose veins in New Zealand. We have performed over 2800 cases of endovenous laser ablation (EVLA) which is regarded internationally as the most successful treatment for varicose veins.
Palm Clinic has treated over 2500 legs with varicose veins with laser. The UK is finally catching up with advice for all hospitals in England and Wales to use laser rather than surgery for varicose veins in new guidelines by NICE (National Institute for Health and Care Excellence).
These are the before and after treatment photographs of an active 36 year old man. He first noticed varicose veins aged 17, but they had become much worse in the previous five years. His symptoms were of aching and pain in both legs, but worse in his right leg and foot. There was swelling in both lower legs, ankles and feet.
Dr Karl A Ekbom proposed venous disease as a cause of restless leg syndrome (RLS) in 1944.
A study by CA Hayes et al from north Texas in 2008 examined the effect of endovenous laser ablation (EVLA) treatment in patients with concurrent restless leg syndrome and duplex ultrasound proven superficial venous insufficiency (SVI).
Thirty five patients with moderate to very severe RLS and duplex proven SVI completed an International RLS rating scale (IRLS) questionnaire and underwent standard ultrasound examination to objectively measure the baseline severity of their conditions. They were separated into two groups, operative and non operative. The operative cohort underwent EVLA of refluxing superficial axial veins and ultrasound guided sclerotherapy (UGS) of the remaining associated varicose veins with foamed sodium tetradecyl sulphate. All patients then completed a follow up IRLS questionnaire and the scores were compared.
The EVLA treated group decreased the mean IRLS score by 21.4 points from 26.9 to 5.5.
A total of 89% of patients enjoyed a decrease in their score of greater than or equal to 15 points. 84% of patients indicated their symptoms had largely or completely been alleviated.
Not all people with restless leg syndrome have varicose veins, and not all people with varicose veins have restless legs, however if you have both , treatment of the venous incompetence may significantly relieve symptoms.
The difference between stiockings bought over the counter and those bought at a specialist centre is the compression. Over the counter stockings will often not state what compression they provide or it will be less than 15mmHg. Specialist center stockings will provide a compression of 15-20mmHg for Class 1 stockings or 20-30mmHg for Class 2. The mmHg stands for millimetres of mercury and is the same pressure used to measure blood pressure. TED stockins (white) are often used in the hospital after surgery. These provide support but not as strong compression as a Class 1 or 2 stocking.
Class 1 Compression Hosiery are used for:
every day use to relieve symptoms of heavy tired legs
for support during pregnancy
after microsclerotherapy treatment for spider veins
for DVT prevention during flights if you don't have varicose veins
Class 2 Compression Hosiery are used for:
Chronic Venous Insufficiency
After a DVT
In the different classes of stockings a number of styles are available. These may be thigh or knee high and come with options of with or without toes. There is a colour choice of black or beige or skin colour. Some versions contain silver and are cooling with antibacterial properties.
For advice or fitting of the appropriate stocking for you visit Palm Clinic.
An ultrasound map will show if your leg veins are competent and working correctly or incompetent and allowing blood to flow the wrong way. Using grey scale ultrasound we can access the size, location and tortuosity of your veins.
We can also see how the valves are functioning and can localise tributaries and document these on a map for treatment.
Colour imaging is used to show flow direction of the veins. Using pulsed Doppler we will obtain a graphic display and audible signal denoting flow direction. We scan both the deep and superficial veins.
The superficial veins are the veins that become incompetent and varicosed. The deep veins are very important veins as they carry about 90% of the normal blood flow back to the heart and lungs. These deep veins are checked to ensure they are normal prior to treatment of the superficial varicose veins.
After your map you will know what treatment is best for your veins.
Laser Treatments for Varicose Veins
Varicose veins can occur in the teenage years. At Palm Clinic the youngest person who
has had Endovenous Laser Ablation (EVLA) is 15, the oldest 85 years old.
A fit, healthy 37 year old male first noticed his varicose veins aged 17, but they had
become much worse over the preceding five years. His symptoms were of pain, aching
and swelling of both lower legs at the end of the day. Examination revealed huge
varicosities in both left and right lower legs and shins extending into his feet. One of the
thigh veins had stretched and “blown out” to 24 mm (normal 4-5 mm).
He underwent Endovenous Laser Ablation and Ultrasound Guided in mid 2011 and
recently attended for a 12 month check. He is very delighted that all symptoms have
resolved and the varicosities have disappeared as can be seen in these photographs
Endovenous Laser AblationTreatment or EVLA is the latest non-surgical technique for treating varicose veins and has been available at Palm Clinic since 2004.
EVLA was first devised by Dr Min in the USA in 2001 and studies demonstrate very high closure rates in excess of 95% at 5 years.
This is a considerable improvement over surgery or sclerotherapy injections alone. EVLA is especially useful for large varicose veins but there is a requirement that the vein is straight. We can confirm this during your Ultrasound or duplex map.
The laser fibre is inserted inside the varicose vein through a small incision and is then passed up to the groin or behind the knee. Local anaesthetic is used to numb the vein. Once placement of the fibre has been confirmed by Ultrasound, the laser is turned on and slowly withdrawn by a mechanical device.
The Cooltouch laser used at Palm Clinic is a 1320nm Nd:Yag laser which targets water in the vein wall and heats it so that the lining of the vein is damaged. The vein is then sealed closed over time by the body as it naturally heals itself. The varicose vein shrinks away and the venous circulation is restored to normal.
Laser for Varicose Veins
Endovenous Laser Ablation (EVLA) is a popular minimally invasive treatment for varicose veins.
D. Carradice and colleagues (British Journal of Surgery vol 98; April 2011) performed a study comparing clinical effectiveness of surgery and EVLA. 280 patients were randomised into equal groups having either surgery or EVLA. All patients had primary, one sided, symptomatic varicose veins with isolated saphenofemoral junction incompetence.
Both groups had significant improvements in their Venous Clinical Severity Score, and pain scores.
Patients having conventional surgery had more pain and disability and took longer to return to work and normal activity (average 14 days) after their operation.
Patients who underwent EVLA had less pain and disability, returning to work and normal activity in an average of 4 days. Both surgery and EVLA were equally as effective methods of treatment.
Palm Clinic has performed well over 2000 EVLA cases since 2004. Nearly all patients who have veins which are sufficiently large and straight are amenable to EVLA. We find our patients are able to return to work either the same day or the next day.
Our experience is that patients are keen to avoid a general anaesthetic and like the minimally invasive technique which is a walk in/walk out procedure.
EVLA or EVLT for Varicose Veins
Endovenous laser ablation, also referred to as EVLA or EVLT is the most effective treatment for varicose veins. EVLA was pioneered by Dr Robert Min in the USA and is now the most widely used form of treatment for varicose veins in the USA, Australia and New Zealand.
A laser fibre is introduced into the saphenous vein through a very small needle hole in the skin. The fibre is then progressed to the junction of the abnormal varicose vein and the deep vein system. The saphenous vein is then surrounded by a special type of local anaesthetic called tumescent anesthesia which completely numbs the area around the vein and protects the surrounding tissue from the heat of the laser. The laser is then turned on and slowly withdrawn which instantly cauterises and seals the vein.
There is an initial inflammatory reaction to the cautery which leads to permanent closure of the vein in almost 100% of cases. The procedure is walk in walk out taking about 30-60 minutes for one or two legs. Because the laser cannot be used on the very tortous parts of the vein the EVLA treatment is often combined with UGS, an injection technique.
Prior to EVLT a comprehensive ultrasound map is performed so that all abnormal veins can be targeted by the treatment.
Below Knee Compression Hosiery
Good news for patients having varicose vein treatment at Palm Clinic. At a recent Australasian College of Phlebology Conference Professor Jean-Francois Uhl from France presented work in regards to compression therapy for chronic venous disorders and in particular after treatment of varicose veins.
There is no additional benefit in wearing compression hosiery to thigh level. Palm Clinic is now recommending below knee Class 2 compression hosiery following varicose vein treatment with Endovenous Laser Ablation (EVLA) and Ultrasound Guided Sclerotherapy (UGS).
We continue to stock full length hose with both open and closed toes for those who prefer them. There is no disadvantage clinically wearing the longer compression stockings but most people feel more comfortable in below knee stockings.
The main reason the stockings are worn after varicose vein treatment is to lower the small risk of deep vein thrombosis following treatment.