In many ways, technological advancements can be seen as a response to overcome limitations in understanding vascular pathology. Traditionally, medical diagnosis was dependent upon a good history and clinical examination. At best, this would allow for an educated guess as to the underlying pathology. In the mid-80s, duplex ultrasound provided a real-time image of blood flow in the veins and arteries. This greatly improved the understanding of vascular disease and led to a much more precise method of diagnosis. Duplex ultrasound has now become standard in many vascular practices, and a variety of other diagnostic tools are being utilized adjunctively.
The past two decades have seen an exponential growth in technological development in the field of non-invasive vascular diagnostics. The wide acceptance and prevalence of duplex ultrasound has been the driving force behind this rapid growth in new technologies for vascular diagnosis.
Diagnosis of Varicose Veins
Ultrasound and Doppler ultrasound are the most widely used methods of investigating varicose veins and other venous problems. They are very safe, comfortable, and quick to perform and are the most effective means of diagnosing a patient’s condition. Due to the minimally invasive nature of the examination and the absence of any harmful effects, such as radiation, it can be repeated as often as required and is often used to monitor the progression or regression of a venous condition during and after specific treatment.
An ultrasound or Doppler examination can be performed in a variety of settings, such as a hospital outpatient department, community clinic, or a GP surgery. It generally takes between 15-30 minutes to perform and requires no special prior preparation. Both the patient and the doctor may find it useful if the patient wears loose-fitting clothing to the examination.
Doppler ultrasound involves a probe being passed over the leg. The probe emits sound waves that bounce off moving objects. These sound waves then reflect back to the probe and are detected. The reflected sound waves are then used to create an audio signal, which can be heard through a speaker. This audio signal is a series of ‘whooshing’ noises of varying pitch. The different pitch and characteristics of the ‘whooshing’ noises can give lots of information about the blood flow within a blood vessel and can help to locate and assess any abnormalities, such as a blood clot or faulty valve within the flow. Doppler ultrasound is also painless and avoids the use of harmful radiation.
Ultrasound imaging involves passing high-frequency sound waves (ultrasound) into the leg. The different tissues of the leg, such as skin, fat, muscle, and blood, all reflect the sound waves differently. This reflection creates a picture from which the blood flow within the veins and any blood clots can be seen. Ultrasound imaging is painless and avoids the use of x-rays or other potentially harmful forms of radiation.
ltrasound Imaging
Colour Duplex ultrasound (CDU) works by using the same principles as traditional ultrasound but combining software that gives the vessel a colour, usually red or blue. This technique can also give a continuous image of blood flow (see Doppler Ultrasound) as well as still images. These still images can be saved and are useful for future reference or for showing to a patient. Finally, intravascular ultrasound is newer, less used, and a more expensive form of ultrasound. It uses an ultrasound probe that is inserted into the vessel, very much like a venous catheter. The probe allows for images to give good visualization of the vein depths and surrounding structures. However, and despite using Doppler US, it still lacks the ability to map superficial veins and there is a risk of deep vein thrombosis from inserting the probe. Any form of ultrasound is safe and does not involve using ionizing radiation. This makes it safe to use in any patient, including pregnant women.
Ultrasound imaging is the most well known and the most widely used imaging modality for diagnosing varicose veins. Three types of ultrasound exist: traditional ultrasound, colour duplex ultrasound, and intravascular ultrasound. Traditional ultrasound gives a two-dimensional cross-sectional image of the vessel, vein, or artery that is being observed. Because it only gives a 2D image, it can be harder to detect which part of the vessel the ultrasound is cross-sectioning. This makes diagnosing the various different patterns and types of varicose veins harder to do. However, the technique is good for mapping superficial veins and better for mapping deeper veins. This is particularly good when diagnosing venous disease in post-thrombotic patients.
Doppler Ultrasound
The ability to identify abnormal blood flow in veins has made Doppler Ultrasound the current first line investigation in suspected chronic venous disease. It has largely replaced more invasive and less accurate investigations such as ascending phlebography and has more advantages than other techniques like MRV and CTV. The IIIDVV Guidelines recommend that the diagnosis of varicose veins should be made using simple non-invasive techniques and an accurate and detailed history and clinical examination. Treatment planning should be based upon accurate mapping of the superficial and deep venous system with identification sites of reflux or obstruction. Clinical class and etiological cause each have 3 levels of severity and treatment should be linked according to these alone. Anatomical distribution has 5 levels of severity and clinical class should be grouped into C1, C2, C3, C4, C5, C6 for classification to be accurate. Doppler ultrasound can provide all this information.
The aim of “Doppler Ultrasound” is to provide a simplified explanation of how the technique of Doppler Ultrasound works in diagnosing diseases. It demonstrates how blood flow can be identified in vessels using the change in frequency of ultrasound, and how this can be used to detect the presence and the site of any blood flow disturbances.
Venography
Venography is a method used to visualise the veins in the leg. A catheter is inserted into a vein at the ankle and a small amount of contrast is injected. The contrast highlights the vein on an x-ray film. The test is good for visualising the site and extent of a varicose vein, can help identify other problems with the leg veins and is still considered the best test to identify the site of a recurrent varicose vein, or where a vein is causing a leg ulcer. An MRI is an alternative method of imaging the deep veins, but is not so good at visualising the superficial veins to be able to compete with venography. Since venography does have some potential complications, and is invasive, it is not commonly used in the diagnosis of varicose veins. This is unlikely to change for a while yet, though the development of new methods of using the contrast with x-ray, e.g. digital subtraction venography, may make it less invasive and more reliable.
Treatment Options for Varicose Veins
Sclerotherapy is another method of non-surgical treatment for varicose vein. A sclerosing solution is injected into the veins, which will cause them to collapse and the blood to reroute through healthier veins. After the injection, some form of compression must be applied to the treated area, usually with stockings, and the patient must walk for a period of time. There are two forms of sclerotherapy: the more traditional method using hypertonic saline, and the newer method using foam sclerosing agents. The newer method is gaining popularity, as it is thought to be more effective with larger veins and may require fewer injections. This treatment method can improve symptoms, worsening of vein disease, and the appearance of varicose veins. It is estimated that patients will require about 10-20 needle sticks, and it may take weeks or months to see definitive improvement from this treatment. This is highly dependent on the size of the veins, the skill of the physician, and the specific solution used.
Compression stockings are one of the simplest and easiest treatment options for varicose veins. They come in many different sizes and pressures. It is important that they are properly sized and fitted by a professional. They act as a means to externally support the veins in order to prevent further disease progression or the occurrence of new disease. The pressure that the stockings provide also prevents swelling and alleviates the symptoms of vein disease. Improvement of symptoms can be seen within a few weeks of use, though they are a lifetime commitment if the goal is to control symptoms. If stockings are discontinued, symptoms will likely return. Despite their ease of use and good initial patient compliance, it is estimated that only 20-30% of patients will wear them as much as they should.
Compression Stockings
Stockings are an effective treatment to control symptoms and slow the progression of varicose veins. Some people who have minimal symptoms simply do not like the appearance of the veins and choose stockings as their only form of treatment. The only symptoms that stockings do not help are skin changes and ulcers in the extreme cases.
Graduated compression stockings are longer and tightest at the ankle. Over the knee styles are also available. You will need to be fitted for the stockings, and it is best to have more than one pair. It is important to put them on first thing in the morning when you do not have any swelling in your legs. They can be very difficult to put on, and it may take you some time to get used to the process. Gloves or rubber pads may help in the donning. Stockings will also need to be replaced every 3-6 months in order to continue being effective.
Compression stockings consistently have been shown to reduce some of the symptoms associated with varicose veins. They are available at your local pharmacy and at many medical supply stores. When properly fitted, they provide graduated pressure up the leg. This pressure, in turn, helps to move the blood in the superficial veins (closest to the skin) towards the deep veins (located in the muscle). This, in turn, helps to prevent blood from refluxing back into the superficial veins. Stockings are a good initial treatment to try before moving on to any other treatment. They are relatively cheap in comparison to the other treatments for varicose veins and are covered by many insurance providers. Stockings are also used in combination with any of the other forms of treatment for varicose veins.
Sclerotherapy
There are several things to keep in mind after this procedure is done. In most cases, further sessions could still be necessary to achieve the desired result. Because varicose veins have a high recurrence rate, it is possible that new veins could form over time or that the same vein could reopen. In the case that the vein does reopen, the procedure can be repeated. Patients should also be aware that hyperpigmentation and the development of ulcers is a possible side effect of treatment. In most cases, these conditions can be treated and are only a cosmetic annoyance. In general, sclerotherapy is considered a safe and effective treatment for varicose veins, especially when treating smaller veins.
Comparing with laser treatment, there are several advantages. The procedure is less costly, there is no heat involved which can cause discomfort to some patients, there are no needles on the skin, and there is no recovery period.
Sclerotherapy is a procedure that has been used in the treatment of varicose veins for over 150 years. It is the injection of a solution into the veins, which will cause the vein to close and blood flow to be re-routed through healthier veins. The solution used can be in the form of detergents, hyperosmolar, or hypertonic. Injection of the solution is guided by ultrasound and can be given to large isolated varicose veins or small varicose veins. The number of injections necessary to achieve closure of the vein will depend on the size and pressure within the vein. After the injections are given, the leg is bandaged and compression stockings need to be worn for 5-7 days. Walking is encouraged and strenuous aerobic activity should be avoided for several days. This treatment is usually reserved for either the cosmetic improvement of varicose and spider veins or for those whose conditions are too severe for surgical treatment. Success rates for closing the vein and improving the appearance of the leg generally range from 50-90% and can be expected in a few weeks to months.
Endovenous Laser Treatment
EVLT has been proven to be effective and is associated with early return to normal walking activities and less post-operative complications compared to vein stripping surgery. EVLT is popular as it leaves minimal scarring due to its small incisions and there is less pain after the procedure. Post-operatively, it is advisable to use compression stockings for 1-2 weeks and avoid heavy lifting and vigorous exercise for 2-4 weeks. EVLT is not suitable for all types of varicose veins and is less effective for veins that have a tortuous or coiled shape. EVLT is a relatively expensive procedure and is currently not subsidised by Medicare, which can impact on a person’s health care decision, however it is likely to be covered by private health insurance.
Endovenous laser treatment (EVLT) is a relatively new technique to treat varicose veins and is an attractive alternative to surgical stripping. This technique uses a slim, flexible tube known as a catheter and a diode laser light to apply heat to the affected vein. The light energy causes the vein to close and seal shut. The blood is then re-routed to other healthy veins in the leg and the symptoms of varicose veins can resolve. EVLT can be performed in the outpatient setting using local anaesthetic and patients usually recover quicker with less discomfort compared to surgical stripping.
Radiofrequency Ablation
The RFA procedure is usually performed under local anesthesia. It involves a single needle puncture which allows for at-site tumescent anesthesia, followed by the insertion of the VNUS Closure catheter into the GSV under ultrasound guidance. The position of the catheter tip is then confirmed before the administrator activates the RFA generator. This causes the catheter to heat at a controlled temperature, and the impedance of the surrounding tissue is monitored and displayed as a graph. This allows the operator to track the treatment progress; the RFA generator deactivates once the catheter has passed 7cm distal to the saphenofemoral junction.
Whilst the etiology of venous ulcers is likely to involve the deep venous system, RFA is considered the better treatment option for these as it is difficult to pass an EVLT or ELVes laser fiber through the LSV when it is nearly completely occluded without perforating into the deep system. In addition to this, RFA causes less perivenous nerve damage when compared to laser. This was demonstrated by a double-blind randomized controlled study which showed that patients who had RFA performed in their LSV were more likely to have ablation along the nerve, but the laser group were more likely to have altered sensation along the distribution of the saphenous nerve.
Radiofrequency ablation (RFA) has become increasingly popular and accepted as the treatment method of choice for VNUS Closure™. The decision to use catheter ablation techniques, such as VNUS Closure™, is usually recommended for those with venous ulcers and deep system incompetence. The reason for this is that RFA is more successful in the long saphenous vein (LSV) than laser, as described by a more recent review which showed a 93.5% closure rate for RFA in a 24-month period compared to 85.3% for endovenous laser.
Surgical Procedures
Today, if other treatments have failed or if the varicose veins are too severe, a surgical operation may be the best alternative. The surgical techniques have changed tremendously in the last 10 years. The most invasive surgical method, vein stripping, involves removal of long segments of the greater saphenous vein. Several small incisions are made along the path of the vein and a length of wire is passed through the vein to pull it out. Ligation, or tying off of the vein, is sometimes done in conjunction with vein stripping. Phlebectomy is an ambulatory procedure done using local anesthesia. This procedure involves the removal of smaller varicose veins. A surgeon will make several 1-2 mm incisions along the path of the leg and remove the vein using a small hook. Deep vein surgery is a last resort when other methods have failed. This is usually performed by a vascular surgeon for advanced cases such as venous leg ulcers. The surgeon will make an incision below the knee to the groin. Using bypass surgery, this detours the blood flow to healthy veins.
Advancements in Technology for Varicose Vein Diagnosis and Treatment
Injection methods – Sclerotherapy is a method that involves injecting a chemical irritant into the vein in order to occlude it. In the past, a hypertonic saline solution was used; however, this often caused an inflammatory reaction in the skin and did not always occlude the vein. More recently, Aethoxysklerol and Fibrovein have been used, which cause less of an inflammatory reaction and are more successful at occluding the vein. Pediatric catheter-directed sclerotherapy is a similar method that uses ultrasound to guide a needle into the vein followed by injection of the sclerosant. This is often used to treat veins in children, post-pregnancy veins, and malformation venous syndromes.
Minimally Invasive Procedures Carrying on from image-guided systems, several minimally invasive procedures have been developed. The majority of these procedures involve altering the vein in order to occlude it and change its hemodynamic status. These procedures tend to be more effective than compression therapy or medication, although it is dependent on which method is used to treat the vein.
Image-Guided Systems Image-guided systems allow for a non-invasive form of treatment to be performed on varicose veins. Previously, complex surgical operations were performed to ligate and strip the incompetent veins. Image-guided systems involved ultrasound or infrared technology that was used to visualize the vein beneath the skin. Using local anesthetic, a small needle is inserted into the vein, the tip of which is placed against the skin. A small nick is made in the skin allowing a catheter to be inserted into the vein. The needle is then removed and the catheter is advanced into the vein under ultrasound guidance. Once in the correct position, further local anesthetic can be administered alongside tumescent anesthesia around the vein. This technique uses either a laser or radiofrequency fiber in the catheter to heat the vein, thus occluding it. The catheter is slowly pulled out while the vein is heated and the whole process is repeated until the entire length of refluxing vein is treated. The advantages of this technique include minimal discomfort and early return to normal activity.
Image-Guided Systems
The National Institute for Health and Clinical Excellence (NICE) guidelines state that all patients being considered for treatment that affects the saphenous veins at the saphenofemoral junction or above should have a full duplex ultrasound scan as the primary investigation. This is a ‘quality statement’ indicating that there are clear benefits and no disadvantages to ultrasound scanning. With this in mind, ultrasound was the first imaging technology used in an image-guided treatment for varicose veins, the results of which have been detailed in section 4.2.
The traditional method of using hand-held Doppler to localize refluxing sites does not provide a visual aid and can lead to misdiagnosis and inappropriate treatment. Ultrasound has the ability to identify the source of varicose veins in 95% of cases, in comparison to 82% using clinical, non-imaging methods. Key findings can be shared with the patient to give them a better understanding of their condition. This enables patients to make decisions about their varicose vein treatment in a more informed way.
The use of image-guided systems has become more prevalent in the field of medicine with the increasing availability and quality of ultrasound. In essence, the use of imaging techniques in the form of ultrasound (typically) allows efficient visualization of the vascular system for accurate diagnosis. Furthermore, it can provide a ‘blueprint’ prior to treatment, highlighting aberrant anatomy, hence aiding the intervention.
Minimally Invasive Procedures
Injection of a Sclerosing Agent: Sclerotherapy This is a process that uses a highly concentrated saline solution or a specially made detergent to irritate the inner lining of the vein. Small discomfort may be felt and is usually alleviated with ibuprofen. The injection causes the vein to close; blood is rerouted through healthier veins and the problem vein is reabsorbed into the tissue. Over time, the appearance of the vein will usually fade. Compression hose is required for 3-7 days, up to 1 month. This procedure may need to be repeated for severe veins but typically has a 50-90% success rate. New, less invasive forms of sclerotherapy that use ultrasound and foam sclerosants are available. These are showing to be equally or more effective than older forms and require no need for anesthetic or days of compression post-treatment. Echosclerotherapy is an advanced form of ultrasound-guided foam sclerotherapy. This has proven to be a far more effective treatment for varicose veins and costs relatively the same as endothermal ablation methods.
Traditional surgery led to a hospital stay and recovery period from 2 weeks up to 6 weeks. This is no longer the case. With new advanced technology, there are many new procedures that can be done in the doctor’s office, allowing the patient to go home the same day. The average patient recovery period is 24-48 hours. In the past, most vein treatments involved painful procedures that left scars. New technology has brought forth treatments that are minimally invasive, with little to no pain and minimal scarring.
Virtual Reality in Treatment Planning
The traditional means of preoperative assessment involve a physical exam and duplex ultrasound, using visual and mental approximation to determine the location of the problematic veins. Often, the vein anatomy is traced with a skin marker during the examination, and a mental three-dimensional map is formulated using the two-dimensional ultrasonic images. Duplex ultrasound can sometimes give an unclear indication of the vein morphology, especially to the untrained eye. The scanning doctor requires much experience to correctly interpret the images. This process can be time-consuming and at times inconclusive. High-quality imaging, such as MRV or CT, is often impractical for vein assessment due to cost and the inability to see the veins under functional stress, the position in which varicose veins are most apparent.
Virtual reality (VR) is a computer-based technology that simulates a real or imaginary world through three-dimensional interactive environments. It creates an illusion in which the user believes they are present in the displayed environment. This technology has been found to be of great interest within the medical field, particularly in the area of treatment planning for invasive procedures. Varicose veins are the perfect model for VR assessment and treatment simulation. The treatment of varicose veins can be a tricky process; often, if done incorrectly, it can cause additional damage, making the condition worse for the patient. Because of the complexity of the involved anatomy, high variability between patients, and the nature of the treatment, it is often difficult to correctly assess the exact nature of the problem and decide on the best form of treatment.
