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Treatment for Varicose Veins

Varicose veins are distended tributaries or ‘branches’ of the major veins in the leg. They are normally seen as bulging veins on the legs that disappear on lying down.


The basic aim of treatment for varicose veins is to permanently remove the underlying cause of the varicose veins as well as the visible varicose veins. This not only gives the best possible result in the short term, but also the lowest possible chance of recurrence in the long term.

In order to do this, we need a co-ordinated system with the best possible understanding of what the problem is in the patient and then to tailor the treatment individually to that patient.

It is this approach that we have been following since 1999 that has made The Whiteley Clinic unique. The system that we use through the examination, investigation and then treatment of patients is called The Whiteley Protocol™. By using The Whiteley Protocol™ we can work out exactly what pattern of problem each individual patient has and make sure each patient gets the very best treatment tailored for themselves.

It is because we are able to tailor treatments to each individual patient, and not just assume that every patient has one of a very limited number of simple conditions, that we are unable to give exact prices for a treatment plan until we have performed the extended venous duplex ultrasound scan performed by our specialist technologists. Clinics that assume that varicose veins are still simple and only use quick screening scans (often performed by the doctor themselves), are usually unaware of the complexities of venous disease and hence do not need to tailor treatments to the individual patients. The medium to long-term results are highly unlikely to be equivalent.

All of the procedures performed under The Whiteley Protocol™ are performed under local anaesthetic as walk in, walk out surgery – often called ambulatory surgery. Unless there are any exceptional circumstances, you should be back to work and relatively normal activities the day following treatment.

Vein stripping, which is the traditional open surgery for varicose veins, has been shown to be inadequate in the majority of cases. Since 1999, we have not stripped a great saphenous vein outside of a research study or in the rare case where patients have requested this (in the early days of endovenous surgery). In the last 17,000 cases that we have treated, there has not been a single case where stripping was required. With the correct techniques, every vein can be treated with endovenous techniques with all of the advantages that these bestow.

A brief description of the techniques currently used at The Whiteley Clinic will now follow. Each is linked to a more in-depth page should you wish to explore any in particular.

Over the last decade, The Whiteley Clinic research has called for endovenous thermoablation to replace stripping. Indeed on 7 December 2010, Mark Whiteley was quoted in the Daily Mail calling for this change to be made national.

See Daily Mail Article »

In July 2013, the National Institute of Health and Clinic Excellence (NICE) issued guidelines (CG 168) that mirrored what The Whiteley Clinic had been preaching for a decade.

The optimal treatment for major truncal vein incompetence found on venous duplex ultrasound scanning is endovenous thermoablation (although NICE refers to this as endothermal ablation). The major techniques of endovenous thermoablation are endovenous laser ablation (EVLA) and radiofrequency ablation (RFA). Other techniques being looked at include steam (steam vein sclerosis) and microwave, but these are not currently adopted within The Whiteley Protocol™ as they do not appear to have any advantage over those techniques already used.


Endovenous laser ablation (EVLA)

It is very important to note that not all endovenous laser is the same.

Also, one should note that on the Internet and within some marketing literature, many doctors, clinics and hospitals offer endovenous laser ablation or similar words.

However there are a great many different products that fall under endovenous laser ablation (EVLA), with varying wavelengths, ways of producing laser, fibres and of course many different techniques of using the devices with doctors varying the methods on different energies and pullback speeds.

The Whiteley Clinic spends a huge amount of time and energy researching the different techniques and this is a unique feature of The Whiteley Clinic and The Whiteley Protocol™. Unlike more commercial practices that are influenced by cutting costs rather than performing their own research, The Whiteley Clinic produces huge amounts of research data that not only keeps the The Whiteley Protocol™ updated but also leads to presentations around the world and publications in peer-reviewed journals.

From our own research and also research gleaned from other institutions that perform their own original research, we have decided not to use the cheap bare-tipped fibres as there is reasonably good evidence that these are much more likely to perforate the vein leading to increased pain and bruising and potentially the risk of veins re-growing. We do not believe that the reduction in cost is worth these risks.

In addition we will not use unbranded fibres in which there is not a clear quality assurance pathway as these medical devices are inserted into our patients.

We will only use laser devices that we have personally tested and that have rigorous quality assurance throughout their manufacture. This does mean that our prices end up being slightly higher than other clinics, but we feel this is essential to bring the very best quality to our patients in what is a medical treatment.

EVLA works by passing the endovenous laser fibre or device up inside the vein under ultrasound control. Local anaesthetic is placed around the vein not only to numb the area, but also to make sure the vein contracts hard onto the laser fibre or device ensuring excellent contact. In addition, the volume of fluid makes sure that heat generated in the vein to destroy the wall does not pass out to nerves or surrounding tissue making the risk of skin burns virtually impossible under The Whiteley Protocol™.

For more information see Endovenous Laser Ablation Treatment »


Radiofrequency ablation (RFA) of varicose veins

As with endovenous laser ablation (EVLA), there are several different devices and products used for radiofrequency ablation of varicose veins.

Although Mark Whiteley used radiofrequency ablation for the first endovenous operation in the UK in March 1999, by 2005 The Whiteley Clinic had moved over to endovenous laser ablation for the majority of cases.

Although the principles of heating the vein from the inside with local anaesthetic solution surrounding vein are the same with the two techniques, radiofrequency ablation requires contact between the device and the vein wall whereas endovenous laser ablation does not.
This means that generally, radiofrequency ablation can only treat a more limited range of veins than endovenous laser ablation. In particular, endovenous laser has an advantage over radiofrequency ablation, particularly in patients with very severe venous disease – such as very large veins, ones with thrombus within them or calcium within the vein wall.

Therefore though radiofrequency ablation is a very useful technique in many patients, there are certain patients that can be treated with endovenous laser ablation better than with radiofrequency ablation.

On the converse side, radiofrequency ablation does not require laser protocols and laser protection within the operating theatre and so some clinics do find this attractive.

For more information see Radio Frequency Ablation Treatment »


TRansLuminal Occlusion of Perforators (TRLOP)

Whilst dealing with the main veins usually resolves the underlying cause of varicose veins, sometimes there are other small veins called perforating veins that appear minor, but if left untreated can be a major cause of recurrent varicose veins.

In the past these were treated with open surgery or keyhole surgery under general anaesthetic called Subfascial Endoscopic Perforator vein Surgery (SEPS). However in 2001 Mark Whiteley and Judy Holdstock invented a new technique that can be performed under ultrasound control with a pinhole access only. This is called TRansLuminal Occlusion of Perforators (TRLOP).

There are several different devices that can be used to perform TRLOP

For more information see TRLOP Treatment »


Foam Sclerotherapy – ultrasound guided foam sclerotherapy (UGFS)

Foam sclerotherapy or more correctly ‘ultrasound guided foam sclerotherapy’ has had a major effect on varicose vein treatments over the last decade or so.

Without doubt it has allowed us to treat certain veins that we were not able to treat any other way and it is an excellent adjunct to other treatments and sometimes is an adequate treatment by itself.

The Whiteley clinic has spent considerable time and effort researching foam sclerotherapy and sclerotherapy and has also kept abreast of other research performed elsewhere around the world. Indeed The Whiteley Clinic won a national research prize at the Royal Society of Medicine’s Venous Forum in April 2014 for some of the research work that we had been performing in the area of the production and understanding of foam sclerotherapy.

What has become clear to us is that foam sclerotherapy is an excellent treatment for certain vein problems such as small varicose veins, vein networks under leg ulcers and damaged skin, small veins growing back after stripping surgery (neovascular tissue) and complex veins that are difficult to get to such as varicose veins of the vulval or vagina. However in veins suitable for endovenous laser ablation, the results of ultrasound guided foam sclerotherapy are far inferior to ablation with laser.

As such ultrasound guided foam sclerotherapy is an essential part of many of our treatments and has helped us get the excellent results that we find. It is a significant part of the The Whiteley Protocol™ and used for many patients as part of their treatment plan. However, although some clinics and hospitals use it as a treatment by itself, we have found that it is rarely optimal to do so.

For more information see Foam Sclerotherapy Treatment »


MOCA (Clarivein)

Mechnochemical Ablation (MOCA – also known as Clarivein) is a new technique for closing the large truncal veins that would otherwise need endovenous laser ablation or radiofrequency ablation.

The advantage with MOCA is that it does not use heat and therefore does not need local anaesthetic injected around the vein wall. It works by having a rotating wire on the end of a catheter that is pulled slowly down the vein, damaging the vein wall and allowing sclerotherapy liquid to enter deep into the wall itself. This then causes inflammation and death of the vein, permanently closing it.

The Whiteley Clinic in conjunction with the University of Surrey has been performing some advanced scientific investigations into the effects of MOCA on the vein wall with very impressive results.

MOCA is available as part of The Whiteley Protocol™ for patients who wish to have this.


Glue (Venaseal) – glue treatment of varicose veins

One of the most innovative ways of treating varicose veins over the last few years has been the introduction of superglue. The first of these techniques was called Venaseal and The Whiteley Clinic was one of three centres in the UK to perform the original clinical study on this product.

As with MOCA, there is no heat required and as such there is no need to inject lots of local anaesthetic around the vein to be treated. This makes it a more comfortable treatment than endovenous laser ablation or radiofrequency.

It is still a new product, so although very useful for small and moderate sized veins, it is not proven as to whether it will handle large diseased veins. As with endovenous laser ablation or radiofrequency ablation, it also requires adjunct treatments such as phlebectomies in the majority of cases.

Finally it is considerably more expensive than endovenous laser ablation but hopefully with time this will reduce and will be more accessible to patients.

Venaseal glue is available as part of The Whiteley Protocol™ for patients who wish to have this.

For more information see Venaseal Glue Treatment »


Phlebectomies – Ambulatory phlebectomies

Despite all of the very clever ablation devices above, all of these mentioned so far close the underlying veins that cause the surface varicose veins.

Although small varicose veins on the surface can then be left to wither away or more usually injected with foam sclerotherapy to remove them, large capacious varicose veins on the surface will only fill with blood and cause phlebitis if left alone. Therefore, in patients with very large varicose veins under the surface of the skin, all of the techniques listed above are then completed with the removal of the venous sacs using a process called ambulatory phlebectomies.

Local anaesthetic is injected around the dilated veins and these are removed using a tiny blade and phlebectomies hook. This is not the same as stripping as it is only removing small sections of vein very close to the skin and the other end has already been closed using one of the ablation devices as above.

For more information see Phlebectomy Treatment »


Microsclerotherapy

Once varicose veins have been treated successfully, there are frequently thread veins or spider veins left on the surface.

Provided the underlying veins have been treated (so there is no underlying hidden varicose vein reflux), thread veins or spider veins can be treated usually with great success.

For more information see Microsclerotherapy Treatment »


Pelvic Vein Embolisation (PVE)

Pelvic vein embolisation has become a major treatment for leg varicose veins in women. Research from The Whiteley Clinic and published internationally has shown that 1 in 7 women with leg varicose veins (1 in 5 if they have had a baby by normal vaginal delivery) have a major contribution to their leg varicose veins from the pelvic varicose veins.

The optimal treatment for pelvic vein reflux (PVR) otherwise known as pelvic varicose veins is a treatment called pelvic vein embolisation (PVE).

This is performed under local anaesthetic at The Whiteley Clinic in Bond Street, London by very specialist interventional radiologists trained in The Whiteley Protocol™.

Under x-ray control, a very fine tube is passed into the pelvic vein that needs treatment. A combination of foam sclerotherapy and/or a surgical coil is passed into the vein to be destroyed.

The foam and coil combined with the vein wall instantly shrivel it away and close the vein permanently.

This is one of the areas of vein surgery that The Whiteley Clinic has been leading the world in and figures have shown excellent results in both the short, medium and long term.

For more information see Pelvic Vein Embolisation Treatment »