The media are full of news about new therapies. Terms offered are sometimes puzzling – stripping, minimal surgery, laser, radiowave, VNUS closure, steam, adhesive, CHIVA and others.
Foam obliteration is another often offered method. But be careful: Results may be good in an individual case, but calamitous if all patients be solely treated by this method. Hardening, brown coloring and pain are frequent results.
Our credo is to accord every patient an individual, bespoke therapy on the basis of an exact color-ultrasound examination of the veins involved.
Laser combined with minisurgical treatment facilitates efficient and cosmetically appealing results to be received fast and painless – that is how we lie in the trend of the Centers of Excellence.
Which method suits me best?
As mentioned earlier we distinguish several forms of varices. In the planning of an examination, stress is on determining whether the venous valves are still closing properly. If the venous valve in the groin (inguinal valve) does not close, blood flows back from the groin to the vena saphena magna. That condition is called trunk varicosity.
The stripping operation has for over 100 years been the classical therapy. Today in most cases that can be replaced by a laser operation! But precondition is an exact clarification by means of a color-duplex examination: Not every patient is apt for vein-laser treatment, whereby on the other hand not each patient should have veins stripped.
If the inguinal venous valves close and varices be only palpable in the upper and lower leg regions, the condition is called varicosis of lateral saphenous branches. This is a case for minimal surgery. Partial foam obliteration may also be applied.
Betwixt and between are numerous hybrid forms of varicosity, advising various therapy combinations.
Vein laser (Endolaser)
A small cut into the knee or lower leg area allows the insertion of a laser probe into the long vein of the upper leg (vena saphena magna) or lower leg (vena saphena parva). The laser energy emitted from the tip of the probe causes dissolution of the vein.The method can be performed under local anesthesia and replaces the stripping operation of former days, which used an inguinal cut. Recovery takes place much prompter and patients can earlier return to their every-day activities.
Minimal surgery/ Microsurgery (ambulatory phlebectomy)
Minimal cuts of 0.3 – 4 mm each allow for the abscising of the dilated superficial veins using the “hooklet method“. The method substitutes the previously usual cuts in the skin of up to 2 cm length each and may in many cases be performed under local anesthesia (operation technique acc. to Varady). Afterwards a compression stocking has to be worn for 1-3 weeks. Minimal surgery is outstandingly suitable to be performed in combination with the vein laser (Endolaser).
Prof. h. c. Flor is vice president of the international forum for the minimal surgery of varicose veins and has, with great dedication, been performing this method since the nineties.
Transluminated miniphlebectomy acc. to Flor
Treatment of lateral branches/perforating veins
Principle: A light rod is applied under the vein web and the varices abscised subsequently using the hooklet method. Highly gentle intervention in cases of extended varicosis of lateral saphenous branches, severe damages of skin and tissue hardening (dermatoliposclerosis) and of lymphatic oedema. The technique is excellently suitable to be performed in combination with the vein laser (Endolaser).
The method, developed by Dr. Flor, was in 2002 awarded a Gold Award by the American Congress of Phlebology (ACP).
Duplex-controlled foam obliteration
Principle: Sclerosing agent is frothed up and brought into the vein, in most cases under ultrasound control. The method suites the treatment of varices remaining after prior operative intervention. A compression stocking should then be worn for 2-7 days.
The method is nowadays often discretely offered. Systemic side effects may include brown coloring of the skin, hardening and pain. We make very restrictive use of the method, doing so only in selected cases.
Treatment of spider veins
Classical technique for the treatment of smaller and smallest changes.
Principle: A sclerosing agent is brought into the vein, which eventually causes resorption of the veins/spider burst.
Treatment of frail spider veins
Principle: Laser energy is applied from outside over the skin into the vein, whereby the skin is cooled simultaneously. Method of choice in the treatment of finest, extensive spider veins.
Novel intervention: Adhesive is brought into the diseased trunk vein, which is sealed thereby and absorbed into the body. The method is routinely practiced at some centers worldwide, yet no long-term findings are available.
Crossectomy/ High Ligation
A small cut in the groin or into the hollow of the knee allows for the surgical interception of the veins discharging there. Although this represents a classical technique, complications such as bleeding, lymphatic or nerve damage cannot be ruled out. We prefer instead the intervention by laser, without cutting.
The intervention is carried out under narcosis or spinal anesthesia. The dilated trunk vein is completely abscised using a probe. In most cases patients can leave the clinic after one to three days.
Modern stripping techniques such as invert PIN stripping are somewhat more gentle than the traditional stripping method, but may nonetheless lead to extended effusion of blood (hematomas) as well as nerve damage.
“Keyhole surgery“ (endoscopic) in cases of low-leg ulceration (ulcus cruris)
Ulceration in the low leg (ulcus cruris) is mostly caused by malfunctioning perforating veins. These veins must be ligated, yet by avoiding cutting into the already marred skin. A camera is applied to the perforating vein in order to ligate it with a clip. The method is very complex and has within the last years been replaced by laser.
Principle: A light rod is applied under the vein web and subsequently the varices are “milled“ out in sight. The method may cause severe tissue damages and is not alluded to anymore during international congresses.