Which veins are suitable for ambulatory phlebectomies?
Very simply, the bulging veins that can be seen through the skin when you are standing are suitable for phlebectomy. However we need to consider the cause of these before launching into such treatment.
As many of the other College of Phlebology websites will point out, the varicose veins that can be seen on the surface are not actually the major problem. In the majority of cases, the lumpy veins are being caused by an underlying problem with the deep or truncal veins which have lost their valves. Therefore a simple phlebectomy, or series of phlebectomies, is rarely enough to treat varicose veins and in the majority of cases, phlebectomies are only performed as part of another procedure which aims to treat the underlying problem.
In the past, patients would have had tying and stripping of a major vein such as the great saphenous vein (GSV) to treat the underlying venous reflux, followed by phlebectomies (or sometimes called “multiple avulsions”) to remove the surface veins, to complete the procedure.
As you will see in other College of Phlebology websites, in modern vein clinics run by doctors who remain current with the latest research and developments in vein treatments, tying and stripping of veins has now been completely replaced by local anaesthetic endovenous treatments such as endovenous laser ablation (EVLA), radiofrequency ablation (RFA), transluminal occlusion of perforators (TRLOP) and, in small veins, ultrasound guided foam sclerotherapy (UGFS).
At the end of the 1990s and early 2000’s, when the new endovenous techniques were being developed, it became clear that they could be used under local anaesthetic as they are nowadays. However, those of us who were used to performing vein procedures under general anaesthetic were very concerned that the physical removal of the veins during phlebectomies would not be suitable to a local anaesthetic approach.
Early on in the development of endovenous techniques, some doctors and companies suggested leaving the lumpy varicose veins and letting them “shrivel away”. However it was found that although the endovenous techniques can successfully treat the deeper underlying veins, the lumpy varicose veins near the surface did not usually disappear, despite adequate treatment of the underlying cause.
More worryingly, if these lumpy varicose veins are large and the treatment of the underlying vein reduces or stops the flow of blood through these veins, they clot causing phlebitis (superficial thrombophlebitis). This means that unsightly lumpy veins become hardened, red, painful or tender due to lumps of clotted blood within the inflamed vein. Not only is this very uncomfortable for the patient but can often go on to leave brown stains on the skin.
Therefore it became clear that these lumpy varicose veins could not be left untreated but instead would need to be treated as part of the endovenous treatment of the venous reflux within the legs.
Some doctors have tried to treat these veins using other techniques. Some have opted for simple procedures such as trying to get rid of the veins by sclerotherapy injections. Others have made it more complex by using mechanical aids to try and remove the veins. These will be discussed below but, in summary, there is nothing that has been shown to be more effective than phlebectomies in treating large surface varicose veins, once the underlying cause has been adequately treated.
Once it was identified that phlebectomies were necessary, the early specialists in endovenous surgery soon developed techniques for performing phlebectomies under local anaesthetic allowing patients to walk-in, have the surgery and walk-out very shortly afterwards, wearing only a bandage for compression. This resulted in the term “ambulatory phlebectomies”.