Recurrent Varicose Veins

Modern treatments for Recurrent Varicose Veins

Since Mark Whiteley performed the first endovenous varicose vein surgery in the UK in March 1999, the treatment of recurrent varicose veins has been made much more logical (see: http://www.telegraph.co.uk/news/uknews/1374873/New-varicose-vein-surgery-speeds-recovery.html). Mark and his team realised the potential for the new techniques in recurrent varicose vein surgery, producing one of the first reports of this in 2002 (see: http://www.ncbi.nlm.nih.gov/pubmed/12384651).

Using these new endovenous techniques, it is possible to treat any vein that can be seen with a duplex ultrasound scan, under local anaesthetic using The Whiteley Protocol®.

Therefore, the treatments for recurrent varicose veins are the same set of treatment options as for primary varicose veins, namely:

• Endovenous laser ablation (EVLA or EVLT)


• Radiofrequency ablation (RFA)


• Ultrasound guided foam sclerotherapy (UGFS)


• Pelvic vein embolisation (PVE)


• TRansLuminal Occlusion of Perforators (TRLOP)


• Ambulatory phlebectomy


• Clarivein or mechanicochemical ablation (MOCA)


• Glue

Although the devices themselves may be the same, the way that they are used can be substantially different in recurrent varicose veins compared to normal varicose veins. This is because after scar tissue has formed, the veins may be distorted and much more difficult to treat.

Using The Whiteley Protocol®, we have never found any recurrent varicose veins that cannot be treated successfully. In the past, patients have often been told that their varicose veins are too difficult or complex to treat and so the patient must just get used to wearing support stockings. Using The Whiteley Protocol®, this is never the case.

Treatments for Recurrent Varicose Veins in the past

In the past, recurrent varicose veins were very difficult to treat.

Doctors used to use a general anaesthetic open surgical technique. Through incisions made in the groin or behind the knee, veins were tied and/or stripped. We now know that this is not a good way to treat veins and The Whiteley Clinic have not performed such archaic surgery since 1999. It is amazing that anyone still puts patients through this sort of procedure.

Additionally, doctors who tie and strip veins using open surgery still think that varicose veins come from either the great saphenous vein (GSV) or the small saphenous vein (SSV). This is why their incisions are either in the groin, to find the top of the great saphenous vein (GSV) or behind the knee for the top of the small saphenous vein (SSV).

However, back in 2001, research supervised by Mark Whiteley showed that varicose veins do not start from the top of the vein but rather with valves giving way lower down in the vein. With time, the problem ascends up the vein, with the top of the vein being affected last not first (see: http://phl.sagepub.com/content/17/1/29.abstract).

Therefore the old cutting and stripping operations are basically upside down.

In addition to this, further research from Mark Whiteley and The Whiteley Clinic showed that recurrent varicose veins were also associated with incompetent perforating veins (see: http://www.ncbi.nlm.nih.gov/pubmed/11352523) and pelvic varicose veins (see: http://www.jvsvenous.org/article/S2213-333X(12)00035-2/abstract) and research from elsewhere had already shown that other veins such as the anterior accessory saphenous vein (AASV) were also involved (see: http://www.ncbi.nlm.nih.gov/pubmed/14629879).

Therefore, as the open surgical technique causes scars and veins to grow back again, and is usually aimed at the wrong veins, it is not surprising that recurrent varicose veins are common. It is even less surprising that when open surgery for recurrent varicose veins is repeated, the results are even less successful.

Why Exactly Do Veins Come Back After Treatment?

When patients undergo varicose vein surgery, they expect that they have had the right operation using the right techniques and so their veins should be fixed.

However it is commonly considered that varicose veins always come back again. If this is true then there appears to be something wrong with varicose vein surgery or it might be that varicose veins are special and will always come back again regardless of treatment.

Research from The Whiteley Clinic has established not only why varicose veins come back again in some patients and after some treatments but also how to prevent this from happening.

Causes Of Recurrent Varicose Veins:

There are three main reasons as to why varicose veins come back again after treatment. These are:

• The wrong veins were treated


• The right veins were treated but with the wrong techniques


• New varicose veins formed due to more valves failing

We will go through each of these three causes in turn.

The wrong veins were treated

The varicose veins that are seen on the surface of the skin are the result of varicose vein problems, not the cause. To understand the cause of varicose veins, we need to know which underlying veins have lost their valves and are causing the varicose veins seen on the surface.

Most doctors and medical students are not particularly interested in varicose veins. Most medical schools still teach junior doctors that varicose veins only come because valves fail in either the great saphenous vein (GSV) or the small saphenous vein (SSV).

Duplex ultrasound scanning has been available since the mid 1980’s and this technology has allowed us to understand veins and varicose veins far better than we ever had before. This has also shown us that the old understanding was incorrect.

Rather than just two veins being the underlying cause, we now know that the anterior accessory saphenous vein (AASV), pelvic varicose veins, incompetent perforating veins and other abnormal veins can be responsible for varicose veins. In addition, it might not be just one of these veins but it may be any combination of them.

It is rare for any two patients with varicose veins to have the same pattern of disease. As such, in order to treat all the veins correctly, it is essential to have a thorough duplex ultrasound scan performed by a specialist trained to look for all these different veins. Such a scan will take at least 10 to 20 minutes per leg.

Most vein clinics perform quick scans, lasting only a couple of minutes and often performed by the doctor who treats the veins themselves so it is not surprising that many of the underlying causes of varicose veins are missed. In such clinics, doctors look for the major cause often based on the old understanding of varicose veins.

It has become clear that duplex ultrasound diagnosis of which veins are causing a problem has become of paramount importance in getting good varicose vein surgery. Quick scans performed either cheaply or even for free are a false economy. Saving money on a scan, which turns out to be inadequate, only leads to the wrong veins being treated and recurrent varicose veins.

The Right Veins Were Treated But With The Wrong Techniques

In most areas of surgery, when a surgeon removes part of the body, it is gone. We do not expect it to grow back again. Indeed many people would be very upset if, for example, a troublesome gallbladder grew back again after being removed surgically.

However that is because most things that are removed surgically are organs.

Veins are not organs. They are part of the connective tissue of the body and are programmed to grow back again after any trauma.

For instance, if you have surgery or trauma (such as a dog bite) to your arm, you expect everything to heal in time. You expect the skin to heal and for the veins to grow back again as part of this healing.

So when you have varicose veins removed, your body does not know that a surgeon wants them removed permanently. Your body only knows that there has been trauma and so will naturally try to grow the connective tissue, including the veins, back again.

Unfortunately when veins grow back again after trauma, they never have any valves in them. Therefore, when varicose veins are removed, the veins grow back again and there are no valves in them at all.

This is the reason why stripping does not work. We showed this in our research in 2007
(see: http://www.ncbi.nlm.nih.gov/pubmed/17410557)
and again in 2014 (see: http://www.ncbi.nlm.nih.gov/pubmed/24844250).

However, stripping isn’t the only problem technique still used in varicose vein surgery.

Although Mark Whiteley of The Whiteley Clinic performed the first endovenous thermal ablation in the UK in March 1999, and the National Institute of Health and Clinical Excellence (NICE) has now recommended this to be the best way to treat varicose veins (See: https://www.nice.org.uk/guidance/cg168/chapter/1-recommendations), it is still possible for this technique to fail.

Endovenous thermoablation (referred to by NICE as endothermal ablation), is not just one technique. This term encompasses a variety of techniques including radiofrequency ablation (bipolar, monopolar or segmental), endovenous laser ablation (with multiple wavelengths and fibre types being used) and more recently steam vein sclerosis and microwave.

With so many techniques and devices available, it is not surprising that there is a wide variety of costs. As with everything in life, branded techniques with a lot of research and development behind them that have been optimised both in their manufacture and usage tend to be more expensive. Those that are produced with a view to being cheap often have very little research behind them, if any. As with many things in life, quality comes with a price and medicine is not a great place to look for bargains – if medical care comes cheap then there is often a reason for it.

Although research from The Whiteley Clinic has shown that we can demonstrate excellent closure rates of veins that we have treated even in the long term (see: http://site2013.atlantacongress.org/userfiles/SITE2013/4/taylor.pdf ), there are many patients that we see from other clinics or hospitals who think they have had the same techniques, but when they are scanned, the veins are still there and incompetent. Therefore whether it be the device that was used was suboptimal or that the doctor performing the treatment did not use the optimal technique, the vein was not closed adequately.

In many such cases, patients think that the treatment has worked, only to find that the veins come back several months later. This is because inadequate treatment with endovenous thermal ablation causes thrombosis (or clots) which closes the vein temporarily only to reopen again in the future when the clot or thrombosis dissolves.

Furthermore, ultrasound guided foam sclerotherapy (which is the second line treatment recommended by the National Institute of Health and Clinical Excellence) has an even lower success rate in big veins and seems to only have reasonably good success rate in smaller veins.

Even when the right vein has been identified by duplex ultrasound scanning, the right technique has to be used in the right way to get the best results. This is the whole reason The Whiteley Protocol® was established – to make sure the best scan is performed and the best treatments are recommended based on the results of that scan.

New Varicose Veins Formed Due To More Valves Failing

The third and final reason for recurrent varicose veins, or the veins to come back again after treatment, is that veins that were previously working at the time of the treatment subsequently become varicose. This is called ‘de novo’ varicose veins or just ‘disease progression’.

The easiest way to describe this is as follows:

Imagine going into your local town today and stopping 100 adults at random. You then scan them using The Whiteley Protocol® and find that none of them have any varicose veins or hidden varicose veins. If you then check all of these people again in one year’s time, some of them will have now developed varicose veins.

That is the rate of disease progression or of de novo formation of varicose veins.

In people who have had varicose veins treated before, the risk of getting de novo varicose veins in other veins in their legs is approximately 3 to 4.5% a year. Therefore, perfect treatment should result in a recurrence rate of between 3.0 and 4.5% per year after treatment.

It is impossible to get below the de novo rate as this is the natural disease progression.

How Does The Whiteley Protocol® Reduce Recurrent Varicose Veins?

We know that recurrent varicose veins occur because of one of the following:

• The wrong veins were treated


• The right veins were treated but with the wrong techniques


• New varicose veins formed due to more valves failing

The Whiteley Protocol® is the result of research started by Mark Whiteley at the end of the 1990s to understand why veins recur (come back after surgery) and how best to try to prevent this.

As each cause of recurrent varicose veins has been identified, The Whiteley Protocol® has been developed to take this into account.

The Wrong Veins Were Treated

The Whiteley Protocol® starts off with ensuring that each patient with venous problems (such as recurrent varicose veins) gets a full duplex ultrasound scan performed by a The Whiteley Clinic trained vascular scientist.

Quick scans performed at other clinics tend to only check the major veins in the legs. Duplex ultrasound scans performed at the The Whiteley Clinic follow The Whiteley Protocol® and ensure that all of the veins in the legs are checked for problems.

This takes around 10 to 20 minutes per leg, using a high resolution modern duplex ultrasound scan machine operated by a highly trained vascular scientist trained in The Whiteley Protocol®. Therefore a proper venous duplex ultrasound scan costs money to perform.

Offering a duplex scan for free or offering it cheaply (which many vein clinics do) means that corners are being cut elsewhere. It might be that the scan is performed quickly, that a cheap scan machine is being used or the person doing the scan is not highly skilled. Whichever reason (or combination of reasons), it is highly unlikely that such a scan will be as thorough as a properly conducted duplex ultrasound scan performed at the The Whiteley Clinic.

By ensuring that every one of our vascular scientists has been fully trained in The Whiteley Protocol® and that they all scan using the same technique and routine, we can be certain that we rarely (if ever) miss an underlying vein that is causing the venous problem or varicose veins. This is particularly true as we developed the technique to scan paelvic veins using transvaginal duplex ultrasound scanning (see: http://www.ncbi.nlm.nih.gov/pubmed/25324278).

Our audited results support this in the only recurrences we see after treatment at the The Whiteley Clinic are ‘de novo’ veins or natural disease progression. It is exceptionally rare that we have ever seen anyone come back with recurrent varicose veins due to a vein that we have missed due to poor scanning and treatment.

The Right Veins Treated But With The Wrong Techniques

When Mark Whiteley performed the first endovenous thermal ablation in the UK in March 1999, it started a revolution of vein treatments.

The initial radiofrequency ablation treatment was quickly joined by endovenous laser and then ultrasound guided foam sclerotherapy.

Each of these basic mechanisms resulted in multiple companies producing different products within the same category.

Since 1999, the The Whiteley Clinic under the guidance of Prof Mark Whiteley, has performed clinical and laboratory-based research. In addition, audits are undertaken and both ensure that the treatments used at the The Whiteley Clinic are the best that are available.

By the early 2000’s, (before many people even thinking of treating varicose veins with these new endovenous techniques), Mark Whiteley and his team at the The Whiteley Clinic had already recognised that different veins needed different techniques. There could be no ‘one size fits all’ and so clinics only offering one technique, such as laser, would never get the best results for all of their patients.

Examples of the research studies can be seen as follows:

• Pelvic varicose veins could be successfully treated by puttiing embolisation coils into them under x-ray control
  (see: http://www.ncbi.nlm.nih.gov/pubmed/18756371)


• Incompetent perforator veins can be treated successfully with TRLOP – which was a technique invented by Mark Whiteley and Judy holdstock (see: http://www.ncbi.nlm.nih.gov/pubmed/19299275)


• A prize-winning laboratory experiment was performed using radiofrequency to find what the optimal treatment was. Research from the The Whiteley Clinic showed that the settings used by everyone else in the world using this radiofrequency device were probably inadequate – whereas the The Whiteley Clinic technique produced excellent results (see: http://www.ncbi.nlm.nih.gov/pubmed/25217038)


• Observations from The Whiteley Clinic as to how veins should be treated in a patient with Ehlers Danlos syndrome type IV (see: http://www.ncbi.nlm.nih.gov/pubmed/24714385)


• Experiments to find out how foam sclerotherapy changes in differrent enviromental conditions (see: http://www.jvsvenous.org/article/S2213-333X(14)00163-2/abstract)


• Invention of a new technique to make foam sclerotherapy – The Whiteley-Patel modification of the Tessari technique (see: http://www.ncbi.nlm.nih.gov/pubmed/25288590)

Using these results as well as many others from our audits, The Whiteley Protocol® recommends the right treatment technique for the right vein found on the duplex ultrasound scan.

New Varicose Veins Formed Due To More Valves Failing

The only factor in recurrent varicose veins that cannot be addressed by The Whiteley Protocol® is the continuation of the disease and more varicose veins forming due to more valves failing.

When patients are treated with The Whiteley Protocol®, all of the veins that are part of the varicose vein problem are treated with the correct sequence of techniques to get the best results.

The veins that have been treated are closed and the failure rates are virtually zero using The Whiteley Protocol®.

However, for each year following treatment somewhere between 3 and 4.5% of patients will develop new varicose veins because more valves have failed in previously normal veins. This is the ‘de novo’ rate of formation of new varicose veins – or more commonly called disease progression rate.

At the The Whiteley Clinic, we have performed several audits all of which show that recurrence rates after treatment with The Whiteley Protocol® are fairly constant at 3.3%. This is exactly within the “de novo” rate due to the formation of new varicose veins by disease progression. This both shows that we have successfully overcome the other two and more major causes of recurrent varicose veins by using The Whiteley Protocol® – and also that if other clinics or hospitals try really hard they may be able to equal these results but they will not be able to improve on them.

References

The Saphenofemoral Valve – A Gatekeeper Turned Into Rearguard Fassiadis N, Holdstock JM, Whiteley MS Phlebology 2002;17:29-31 (http://phl.sagepub.com/content/17/1/29.abstract)

Incompetent perforating veins are associated with recurrent varicose veins. Rutherford EE, Kianifard B, Cook SJ, Holdstock JM, Whiteley MS. Eur J Vasc Endovasc Surg. 2001 May;21(5):458-60. (http://www.ncbi.nlm.nih.gov/pubmed/11352523)

Pelvic Venous Reflux is a Major Contributory Cause of Recurrent Varicose Veins in more than a Quarter of Women Whiteley AM, Taylor DC, Whiteley MS. JVS Venous and Lymphatic Disorders. 2013 Jan;1(1):100-101. DOI: http://dx.doi.org/10.1016/j.jvsv.2012.10.007
(http://www.jvsvenous.org/article/S2213-333X(12)00035-2/abstract)

The lateral accessory saphenous vein – a common cause of recurrent varicose veins. Garner JP, Heppell PS, Leopold PW. Ann R Coll Surg Engl. 2003 Nov;85(6):389-92. (http://www.ncbi.nlm.nih.gov/pubmed/14629879)

New Varicose Vein Surgery Speeds Recovery The Telegraph 19 Nov 2000 (http://www.telegraph.co.uk/news/uknews/1374873/New-varicose-vein-surgery-speeds-recovery.html)

A novel approach to the treatment of recurrent varicose veins. Fassiadis N, Kianifard B, Holdstock JM, Whiteley MS. Int Angiol. 2002 Sep;21(3):275-6. (http://www.ncbi.nlm.nih.gov/pubmed/12384651)

Strip-track revascularization after stripping of the great saphenous vein.
Munasinghe A, Smith C, Kianifard B, Price BA, Holdstock JM, Whiteley MS.
Br J Surg. 2007 Jul;94(7):840-3.
(http://www.ncbi.nlm.nih.gov/pubmed/17410557)

Strip-tract revascularization as a source of recurrent venous reflux following high saphenous tie and stripping: results at 5-8 years after surgery.
Ostler AE, Holdstock JM, Harrison CC, Price BA, Whiteley MS.
Phlebology. 2014 May 20. pii: 0268355514535927. [Epub ahead of print]
(http://www.ncbi.nlm.nih.gov/pubmed/24844250)

NICE Clinical Guidance 168 – Varicose veins in the legs: The diagnosis and management of varicose veins
July 2013
(https://www.nice.org.uk/guidance/cg168)