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Why Exactly Do Veins Come Back After Treatment?

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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.


References:

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)