Source Vein Treatment


Endovenous bioadhesive closure (Venaseal)

This is the most recent innovation in the treatment of incompetent vein trunks resulting in varicose veins. It requires only one injection of local anaesthetic to effect closure of the entire length of a truncal vein (unlike endothermal ablation procedures). It rarely causes any discomfort, and is instantly effective, with several individuals telling me ‘the leg feels better already’ whilst walking out the department. Compression hosiery is not required after the procedure. I probably have the largest experience in this technique in the Central South.

The results obtained in the two cases illustrated below were achieved using bioadhesive closure of the greater saphenous trunks (source veins) alone. No additional treatments were required directly to the large visible varices. Thus, the entire effect in both treated legs was achieved through only a single puncture under local anaesthesia.

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Mechanochemical Ablation (MOCA)

This is a relatively novel technique consisting of a combination of mechanical painless abrasion and chemical irritation of the lining of a vein trunk from within to effect potent and lasting occlusion the vein. It is totally painless in the majority of cases, requiring only a single local anaesthetic injection at one site over the vein to achieve treatment. I have presented a series of 50 consecutive cases using this method to an international conference in 2017 which was very well received, citing occlusion rates of over 96%. Compression hosiery is recommended for two weeks after the procedure.

The veins below were quite complex recurrent veins which responded to MOCA of the small saphenous vein alone with no additional procedures.

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Endoluminal Thermal Ablation

Thermal ablation can be achieved using either LASER or radiofrequency (RFA). RFA is the oldest established endovenous truncal treatment, but it is still a highly valid technique. The heat generated during all endothermal treatment mandates the use plentiful local anaesthetic solution, and may result in a greater localised reaction to nearby structures after the treatment. I prefer to use this technique in deeper and wider main vein trunks and if both legs need to be treated at the same time. Compression hosiery needs to be worn after the procedure for two weeks.

Endothermal ablation is almost always performed with the addition of phlebectomiesof the varicose veins themselves, as local anaesthetic is required for both parts of the procedure. Thus in situations where there are fewer visible varicose veins, other techniques may be equally effective and more appropriate.

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Stylet Perforator Ablation

This is a localised thermal ablation technique performed under local anaesthesia in the specific situation where varicose veins arise from a tortuous perforating vein. These veins link the superficial veins and the deep veins, and are present at many sites. Sometimes they permit blood to flow outward to fill the superficial veins rather than inward to empty them, and thus can be the origin of visible varicose veins.

There are other methods to deal with localised incompetent perforators. Always under local anaesthesia, I have used LASER endoluminal ablation, ultrasound-guided foam sclerotherapy and open ligation depending on the specific circumstances.

Ultrasound-Guided Foam Sclerotherapy (USGF)

This is a well-established technique that may be applied to both truncal veins and varicose veins. It comprises the direct injection of a foam-like preparation (created using a sclerosant mixed with air) into the vein to be treated under ultrasound control. The foam spreads causing muscular spasm of the vein and permanent irritation of the lining of the vein resulting in its occlusion. Compression of the leg following the treatment is mandatory in boosting the effectiveness of the treatment. Some vein trunks are not appropriate for this technique, or if treated, then require adjunctive procedures such as repeated aspiration of clots formed as a by-product of the procedure, or repeated foam injection to ensure a result. Staining of the skin, which is usually temporary, may result.

This is the result of successful ablation using USGF sclerotherapy on severe recurrent varicose veins arising from a wide refluxing residual accessory saphenous trunk, which is not visible, but was the source of the visible veins. The varices themselves in the photograph responded to a small quantity of foam and compression alone.

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