1. UK guidelines regarding The Diagnosis and Management of Varicose Veins of the Leg. The full guidelines can be found at the National Institute for Health and Care Excellence (NICE) website: guidance.nice.org.uk/cg168 (July 2013) Summary:

• Patients should be assessed by duplex ultrasound scanning to determine the extent of the problem and to plan treatment.
• Endovenous Laser Ablation EVLA (or RadioFrequency Ablation - RFA) should be offered when appropriate and if this is unsuitable, offer ultrasound-guided foam sclerotherapy.
• If ultrasound guided foam sclerotherapy is unsuitable (virtually no-one), offer surgery.
• Consider treating varicose veins visible externally at the same time.
• If interventional treatment is unsuitable, consider long-term compression stockings.

UK guidelines relating to patient referral for varicose vein treatment can be found at: Recommendations for the referral and treatment of patients with lower limb chronic venous insufficiency (including varicose veins)Phlebology 2011 26: 91

They state that treatment can:

• Significantly improve disease specific and generic health related quality of life
• Relieve a wide range of troublesome lower limb symptoms
• Delay and prevent the onset of complications of chronic venous insufficiency
• Represent a highly cost-effective use of NHS resources

European Guidelines were published in 2015 by the European Society for Vascular Surgery. The full guidelines can be found at Management of Chronic Venous Disease Eur J Vasc Endovasc Surg (2015) 49, 678-737.

They state that EVLA should be used in preference to ultrasound guided foam sclerotherapy and surgical stripping of varicose veins – similar to the NICE Guidelines above.

USA Guidelines for the management of varicose veins:

The first guidelines were published in the USA by two surgical groups (the American Venous Forum and the Society for Vascular Surgery) The full guidelines can be found at Guidelines for the management of varicose veins. P Gloviczki and M L Gloviczki. Phlebology 2012;27 Suppl 1:2–9.

They stated:

“The need for such guidelines has been evident since imaging techniques and minimally invasive technologies have progressed by leaps and bounds and radiofrequency ablation, laser and sclerotherapy have largely replaced classical open surgery of saphenous stripping…… The management of varicose veins has rapidly progressed in the last two decades and open surgical treatment using the classical high ligation and saphenous stripping is rarely performed today”.

These guidelines recommended that:

• Evaluation of patients with varicose veins should include duplex ultrasound scanning of the deep and superficial veins.
• Endovenous thermal ablation (endovenous laser/RF) should be used in preference to surgical stripping when available.
• Compression therapy should be used as the primary treatment to aid healing of venous ulceration.
• To decrease recurrence of venous ulcers, compression therapy should be supplemented with ablation of the incompetent superficial veins.
• Phlebectomy or sclerotherapy is recommended to treat varicose tributaries.
• Foam sclerotherapy (UGFS) is suggested as an option to treat the incompetent saphenous vein. UGSF for treatment of the incompetent saphenous vein is much more popular in Europe than in the USA and supporting evidence on both its efficacy and safety is steadily increasing.
• The committee recommended against selective treatment of perforating vein incompetence in patients with simple varicose veins.

The European guidelines for Sclerotherapy recommended sclerotherapy for all types of veins. The full guidelines can be found at: European guidelines for sclerotherapy in chronic venous disorders. E Rabe, FX Breu, A Cavezzi, P Coleridge Smith, A Frullini, JL Gillet, JJ Guex, C Hamel-Desnos, P Kern, B Partsch, AA Ramelet, L Tessari, F Pannier and for the Guideline Group
Phlebology published online 3 May 2013

Objectives of sclerotherapy are:

• Ablation of varicose veins
• Prevention and treatment of complications of chronic venous disorders (CVD)
• Improvement and/or relief of venous symptoms, improvement of quality of life
• Improvement of venous function
• Improvement of the aesthetic appearance

Recommendations:

They recommend sclerotherapy for all types of veins, in particular:

• Incompetent saphenous veins
• Tributary varicose veins
• Incompetent perforating veins
• Reticular varicose veins
• Telangiectasias (spider veins)
• Residual and recurrent varicose veins after previous interventions
• Varicose veins of pelvic origin
• Varicose veins in proximity of leg ulcers
• Venous malformations

Success Rates:

There are numerous reports of success rates for the various treatment options. The long-term success rates (greater than 5 years) for the various treatment options average out at approximately:

• EVLA / RF > 95%
• UGFS – 70 to 80%
• Surgery < 75%

A recent medical publication from the UK relating to surgical stripping showed 82% of legs had some evidence of recurrence in the region of previous surgery beyond 5 years.

Alexandra E Ostler, Judy M Holdstock, Charmaine C Harrison, Barrie A Price and Mark S Whiteley; Strip-tract revascularization as a source of recurrent venous reflux following high saphenous tie and stripping: results
at 5–8 years after surgery. Phlebology
2015, Vol. 30(8) 569–572

• Unlike surgery, UGFS is simple and readily repeated.
• In the unlikely event that success was not achieved with EVLA or RF, the vein is normally not suitable to be retreated the same way again. However, UGFS will complete the treatment well.
• Individual doctors may have better or poorer success rates than those quoted above. UGFS is a much simpler procedure than stripping with very good results when performed proficiently (see ‘Training in Phlebology” below). EVLA/RF consistently have the highest success rates - though be mindful that treating a relatively small vein (average diameter < 4mm) may be like cracking a peanut with a sledge hammer!
• For surface veins, sclerotherapy is considered the gold standard with the external lasering of surface veins through the skin coming a poor second. (Lasering through the skin is a totally different use of lasers compared to EVLA – which is from within the vein)
• Ultrasound guided foam sclerotherapy is the least expensive treatment, followed by EVLA/RF and surgery is generally the most expensive. The cost of the different treatments can vary widely from one doctor to another.

Combination Treatment is needed for Varicose Veins

There are a number of different procedures used to treat varicose veins. Mostly they need to be used in combination to get a thorough and lasting good long-term result. EVLA needs additional UGFS and sclerotherapy to surface veins (if required) to achieve a good clearance. UGFS needs superficial sclerotherapy to achieve a good cosmetic result, while surgery needs phlebectomy or ultrasound guided sclerotherapy plus sclerotherapy of surface veins to achieve a good cosmetic result and a good long-term outcome. If you are told you only need one of the above procedures or you have inadequate follow-up, it is likely you will achieve a suboptimal result.

Is having your varicose veins treated an urgent issue?

Generally, no. Doctors will inform you of potential complications of not treating varicose veins - that you could get clots in your legs, leg ulcers or your varicose veins may bleed, sometimes with the implication that if you don’t have them treated soon you could be in big trouble. Providing the skin of your lower legs is in good condition, there is generally little risk of imminent problems. Many patients have large varicose veins for many years without any problems. If you have skin ulceration, superficial vein thrombosis (clotting in veins) or bleeding, is it wise to act sooner rather than later. Treating varicose veins that are not symptomatic can help prevent complications in the long-term and when treated early, the less invasive, less expensive option of UGFS can work very, very well.

Is having your varicose veins treated an urgent issue?

Generally, no. Doctors will inform you of potential complications of not treating varicose veins - that you could get clots in your legs, leg ulcers or your varicose veins may bleed, sometimes with the implication that if you don’t have them treated soon you could be in big trouble. Providing the skin of your lower legs is in good condition, there is generally little risk of imminent problems. Many patients have large varicose veins for many years without any problems. If you have skin ulceration, superficial vein thrombosis (clotting in veins) or bleeding, is it wise to act sooner rather than later. Treating varicose veins that are not symptomatic can help prevent complications in the long-term and when treated early, the less invasive, less expensive option of UGFS can work very, very well.

Seeking another opinion

There is a significant body of evidence showing that varicose vein surgery promotes the development of new varicose veins. This information has been available since 2001 to 2005. As you can see from the above guidelines, surgery is no longer the recommended treatment; EVLA has been available for over 15 years in Australia and it is not new. To be told your veins are too bad for anything but surgery is completely untrue and you should question the credibility of that advice. Any doctor interested in venous disease will be well aware of UGFS, EVLA and RF and the ‘best practice’ guidelines. When you consult a specialist you should be able to expect that:

(i) You have been given an honest opinion and the information provided is up to date,

(ii) The information given is a fair representation of current treatments and methods

(iii) You should be told

• What to expect if you choose to do nothing
• What to expect if you opt for conservative treatment over more invasive treatment
• What the proposed treatment involves, its risks and complications
• The alternative treatment options
• An approximation of the expected cost

(iv) You should then have the capability of making an informed and appropriate decision once health issues, quality of life and financial considerations have been addressed. Signing a consent form implies all of the above have been given due consideration.

EVLA, RF, UGS and superficial sclerotherapy are not available in the public hospital system. Consequently doctors-in-training have no exposure to varicose vein treatments and no doctor, whether GP or specialist, has meaningful post-graduate training in venous disease - unless they have specifically pursued further training. Post-graduate training is voluntary in Australia and there is no compulsion for doctors to do it! ‘Fellow’ and ‘Certified Sclerotherapist’ are post-graduate qualifications from the Australasian College of Phlebology, whereas ‘Member’ of the college is not an academic achievement. ‘Phlebologist’ is a term the Australasian College of Phlebology reserves for its Fellows, however, some doctors who have done no post-graduate training will refer to themselves as a ‘phlebologist’.

EVLA

The total cost, from initial consult to completion of treatment is approximately $4100 to $6500 for EVLA depending on whether one or both legs can be treated in the same treatment session (rather than separate treatment sessions), and whether one or more veins are treated on the same leg. This includes the cost of consultations, duplex mapping and follow-up scans and any associated ultrasound guided foam sclerotherapy (UGFS) that is required for the large visible branch veins. The Medicare rebate (excluding Safety Net rebates which may increase your rebate) is approximately 25% of the cost.

UGFS

The cost of UGFS alone – when the underlying veins are not large enough to warrant EVLA - is approximately $2200 to $3300, depending on whether one or both legs need treating and how extensive the problem is. Again, this includes consultations, duplex scans and any tidy-up treatment that may be necessary. However, the cost of having spider veins injected is in addition to that of EVLA or UGS for patients who have both spider and varicose veins. The Medicare rebate (excluding Safety Net rebates which may increase your rebate) is approximately 25% of the cost.

Cosmetic Spider Veins

Spider veins (in the skin) and reticular veins (just under the skin) are generally cosmetic in nature. It is uncommon for them to cause medical problems in the long term whereas larger varicose veins certainly can. It can take several treatments per leg to get a good cosmetic result. Spider veins do not usually pose a health problem and Medicare does not rebate for cosmetic treatment. A Medicare rebate is available once veins being treated are over 2.5mm. On average it costs around $2000 to $2500 for most patients to achieve a reasonably good result.