How varicose veins and spider veins are treated today

By far the most common treatments in phlebology involve varicose veins, followed by the cosmetic issue of spider veins. The biggest changes in recent years concern varicose veins. Here, so-called endovenous vein therapy (catheter technique under local anaesthesia) has displaced up to 85% (USA) of traditional vein surgery in recent years, and it can be assumed that this trend will continue. Endovenous techniques are already less burdensome and lower-risk than conventional surgery. They are also potentially more precise, more effective and more sustainable—although at present only a few highly specialised practitioners are able to implement this.

Only a few examiners can answer the important question of where to draw the line between “diseased” and “overloaded” veins, because examinations are normally performed with the patient more or less standing still. The result does not reveal everyday circumstances (what happens during prolonged sitting or standing?). Only a very small number of examiners who have received training in the partially vein-preserving CHIVA method will verify an intended therapy by pressing on vein segments with a finger and then using ultrasound to observe what changes in blood flow occur in the leg. It is clear that one should try to preserve “overloaded” veins.

Endovenous vein therapy uses thermal, chemical and adhesive systems: thermo-occlusive systems (ClosureFast/VeneFit®, F-Care®, Celon®, axial and radial lasers, 810–1470 nm, SteamVeinSclerosis®) are at a very similar performance level, but no system combines all advantages. While the 1470 nm ELVeS system with double-radial emission has the greatest physical potential for vein constriction and is therefore preferable, the simple 810 nm system is the only non-adhesive modality with which a robust, immediate closure of truncal veins can be achieved with precision of around 1 mm.

With no system does vein shrinkage occur “immediately”, as manufacturers like to illustrate. In reality, regression takes months and is often symptomatic in the first 4 weeks, especially with large vein diameters.

Potential relief can be provided by eccentric compressions (“home made” or, for example, the Venartis Silicone Pad for superficial vein courses), or, for non-superficial veins in the future, by using a hyaluronic acid solution with a half-life of around 4 weeks (study) instead of the usual tumescent anaesthesia.

The range of sclerotherapy techniques has been revitalised by ClariVein® (mechanical vein irritation by a rotating wire plus chemical sclerotherapy), as well as by less widely used sclerotherapy catheters with one or two occlusion balloons, and recently by the PhleboCath® system, which combines easily gliding PTFE catheters with a viscous sclerosing foam. The latter system appears to be about as effective as ClosureFast, but also allows concomitant treatment of side branches and connecting veins—requiring far less time and without anaesthesia or additional punctures.

Adhesive systems attempt to close diseased veins using adhesives and to keep the lumen small immediately. VenaSeal® was approved as the first modality, but only for truncal veins < 12 mm and without any discernible clinical advantage, at four times the cost compared with ClosureFast®. The adhesive is aggressive, resin-like, and breaks down only very slowly over many years. A still experimental modality is ScleroGlue®, which combines spot adhesions with foam sclerotherapy. It could become useful once rapidly resorbable adhesives are available.

Large superficial varicose veins are predominantly removed surgically or treated with foam sclerotherapy. The question of which is better has had to be answered anew since 2013, because new modalities such as the Venartis® Silicon Gel Pad and especially the new Venartis film reliably prevent possible disadvantages of foam sclerotherapy (inflammation, hardening, discoloration), so that both approaches lead to a cosmetically acceptable, symptom-free result. We prefer foam sclerotherapy combined with Venartis, as this is the gentler option.

Foam sclerotherapy deserves a separate note. Hardly any method seems so simple—just “quickly inject varicose veins away”. Anyone who does that will cause 1–4% thromboses (German study 2014). Foam sclerotherapy is probably the most difficult technique when perfection is required—i.e., when the effect is to be strictly limited to a specific segment and without side effects. The examiner must master the instruments with one hand while simultaneously performing ultrasound imaging with the other, in such a way that the entire spread of the foam is always in view. The standardised sclerosing foam VariThena®, newly approved in the USA, appears to offer no clinical advantages.

In addition to “vein-destroying” strategies, there have so far been only a few vein-preserving alternatives. Surgical extraluminal valvuloplasty is very interesting, but the operative insertion of a vein sleeve to reduce the diameter requires a significant procedure. Since 2013, it has been possible to model overstretched valve zones with hyaluronic acid gel so that they once again ensure healthy flow. It is the first method that offers complete vein preservation and long-term prospects of healing without surgery.

Venous thromboses could be diagnosed and treated more often at a reversible stage through better patient information, greater medical attention and intensified sonographic diagnostics. Vein occlusions can be resolved even after months by local lysis and often even after years by venous stenting.

Skin damage and “open legs” (ulcers) are gradually becoming less common. As a rule, these late stages should now be preventable through early treatment of venous insufficiency.

Finally, the problem of spider veins. Medical attention is low here, even though more than half of cases originate from deeper venous defects. If these are neglected, all treatments quickly lead to recurrence. The best results are achieved when relevant venous reflux is regulated first and spider veins are then treated in order of size with graduated techniques (foam, liquid sclerotherapy, laser).

For physicians and medical professionals, the original can be found at www.venartis.org/diskussionen