Treatment

Treatments for the Great Saphenous Vein (GSV)

Treatments available for the Great Saphenous Vein (GSV) depend upon which of the two main conditions affecting it are being treated.
 

1 - Treatment of superficial thrombophlebitis of the Great Saphenous Vein (GSV):

The treatment of superficial thrombophlebitis is broken up into two aspects. The first is the immediate treatment, the second is the medium to long term treatment.
 
The immediate treatment of superficial thrombophlebitis is to reduce the pain and inflammation of the phlebitis, whilst giving some mechanical support to make sure that the blood flows up the other veins quickly, reducing the risk of further thrombosis in nearby veins. Therefore the ideal treatment is to take non-steroidal anti-inflammatory tablets such as aspirin, provided the patient is able to. Contraindications stopping the patient taking these drugs include any indigestion or previous stomach ulcer or heartburn, or asthma - which can be worsened by these drugs. In such cases, paracetamol can act as a painkiller but it does not reduce the inflammation. There are certain non-steroidal anti-inflammatory gels that can be rubbed onto the area which do help, particularly in terms of the massaging.
 
Properly fitted graduated pressure support stockings should be worn. These make sure that the blood continues to flow up the veins normally, reducing the risk of further thrombophlebitis in the same vein or thrombophlebitis occurring in nearby veins. Such stockings should be proper medical compression stockings and not just shop bought normal tights or stockings with just a little support.
 
It is important to note that the immediate treatment of superficial thrombophlebitis does not include antibiotics. Despite the area being hot, red, painful and swollen, it is due to blood clot and not infection. Antibiotics play no role in the treatment of superficial thrombophlebitis unless there has been a complication that has allowed infection into the area, which is very rare. 
 
Once the immediate treatment has been performed, the medium to long-term treatment can be planned. In almost every case of superficial thrombophlebitis of the Great Saphenous Vein (GSV), there is an underlying problem. Very rarely this may be a systemic disease or a clotting abnormality. Much more commonly it is due to venous reflux (venous incompetence) i.e. visible varicose veins or "hidden varicose veins".
 
A venous expert will check for the underlying problems and will also check for venous reflux (venous incompetence) using a specialist venous duplex ultrasound scan. This is usually performed to make the diagnosis of thrombophlebitis and then repeated 3 to 6 months later, to check the thrombus has resolved and to find the underlying venous reflux (venous incompetence).
 
Once the pattern of venous reflux (venous incompetence) has been identified, then the appropriate treatment for the incompetent Great Saphenous Vein (GSV) can be recommended. 
 

2 - Treatment of venous incompetence in the Great Saphenous Vein (GSV):

Tying or tying and stripping:

The traditional treatment of venous reflux (venous incompetence) of the Great Saphenous Vein (GSV) is by open surgery. Under general anaesthetic, a cut is made in the groin and the saphenofemoral junction (SFJ) is tied with a surgical ligation. In most instances, the Great Saphenous Vein (GSV) is then stripped away using a vein stripper.
 
In 2007, prize-winning research from The Whiteley Clinic in the UK, showed that in a large number of cases (if not the majority) this traumatic removal of the vein merely cause the body to try and re-grow the vein back again. Therefore not only does tying and stripping the vein entail unnecessary large scars, bruising from stripping and an unnecessary general anaesthetic, in the medium to long term it does not even work in a large number of patients. When veins regrow again, they never grow back with valves that work and therefore are always incompetent allowing venous reflux.
 
Tying the Great Saphenous Vein (GSV) alone or tying and stripping of the Great Saphenous Vein (GSV) is not recommended and is not an optimal treatment for an incompetent Great Saphenous Vein (GSV).
 

Radiofrequency Ablation (RFA):

In 1998, a device was introduced that could heat the vein and destroy it, using radiofrequency current. This heralded the advent of endovenous surgery - surgery or treatment to the veins from within the vein itself rather than the traditional surgery which is performed through incisions approaching the vein from the outside.
 
A radiofrequency ablation (RFA) device is a long thin catheter that can be passed up inside the vein through a needle hole. A needle (or more correctly a "cannula") can be introduced into the vein under local anaesthetic, using ultrasound to ensure exactly the correct placement of the device into the vein. The radiofrequency catheter can then be passed up the Great Saphenous Vein (GSV) to the Sapheno-Femoral Junction under ultrasound control, ensuring precise placement of the device. Local anaesthetic is then injected around the vein under ultrasound guidance.
 
When in position, the radiofrequency current is switched on and the vein wall is heated, killing the cells and permanently ablating (closing) the vein. The radiofrequency catheter is then pulled back down the vein, heating the wall as it is retrieved. If the correct treatment protocol is used, the vein wall is ablated, permanently closing the vein.
 
Radiofrequency ablation (RFA) is one of the optimal techniques for the treatment of an incompetent Great Saphenous Vein (GSV).
 

Endovenous laser ablation (EVLA or EVLT):

Shortly after radiofrequency ablation (RFA) was proven to work, endovenous laser ablation (EVLA or EVLT) was developed. As with radiofrequency ablation (RFA) the endovenous laser ablation (EVLA or EVLT) is performed via a laser fibre or catheter that is introduced into the Great Saphenous Vein (GSV) under ultrasound control.
 
Once again, under local anaesthetic only, a needle (or "cannula") can be inserted into the Great Saphenous Vein (GSV) under a local anaesthetic. Using ultrasound to guide it, the endovenous laser fibre or catheter can then be passed up the Great Saphenous Vein (GSV) to the Sapheno-Femoral Junction (SFJ). When in the correct position, local anaesthetic can be injected around the vein under ultrasound control to ensure it is in the correct place. The laser is then fired and the wall is heated, killing the cells in the vein wall and ablating the vein. The endovenous laser fibre or device is then pulled back at a set rate treating the whole of the vein segment. Provided the correct technique is used and the right power given, the whole Great Saphenous Vein (GSV) can be permanently closed and destroyed. 
 
Endovenous laser ablation (EVLA or EVLT) is one of the optimal techniques in the treatment of the incompetent Great Saphenous Vein (GSV).
 

Sclerotherapy - liquid sclerotherapy or ultrasound guided foam sclerotherapy (UGFS):

Sclerotherapy has been a popular way of treating veins in some countries for many years. Essentially it is the process of injecting a liquid into the target vein with a view to killing the cells in the vein wall.
 
If the vein wall is very thin, and if the vein is very narrow, then liquid sclerotherapy (if used correctly and in the right concentration) can push the blood out of the vein and kill the vein wall. The sclerosant itself (the substance is injected) will kill any tissue that it comes into contact with and hence it needs to be injected carefully by an expert to make sure it does not get out of the vein and under the skin. In addition, if the vein is too big and the sclerosant mixes with blood, it will kill the blood cells rather than the vein wall causing a clot called "sclerothrombus". Sclerothrombus is of course actually the same as thrombus, but it has been caused by sclerotherapy!
 
If a sclerothrombus is formed, the blood in the thrombus can breakdown causing brown stains of the skin. Therefore if sclerotherapy is performed correctly, the vein needs to be bound tightly for 14 days and nights, to allow the compress dead vein wall together and allow it to be reabsorbed by the body without blood coming back into it and forming sclerothrombus.
 
In 1985, an idea from the 1930s was rediscovered to increase the size of vein that can be treated successfully by sclerotherapy. This new process is called foam sclerotherapy. By mixing the sclerosant liquid with gas, foam can be made that can be injected into veins to push more of the blood out of the bigger veins. This then results in the sclerosant liquid being in contact with the vein wall, allowing it to have the required effect in killing the cells of the vein wall. Of course once the foam pops, blood can come back into the vein and, if it does so, it will cause sclerothrombus. Therefore when foam sclerotherapy is performed, it is essential to bind the leg very quickly after injection to keep the blood out of the treated veins until healing has occurred. This means that the bindings have to be kept in place for 14 days and nights.
 
It can be dangerous to inject air into veins and therefore, in the best vein clinics, the foam in foam sclerotherapy is made with a combination of oxygen and/or carbon dioxide mixed with the sclerosant rather than air.
 
Liquid sclerotherapy (or ‘microsclerotherapy’) is very useful for thread veins and very small veins up to about 1 mm diameter. Ultrasound guided foam sclerotherapy is very effective when used correctly in veins up to the diameter of 3 to 4 mm. In veins over 5 to 6 mm, it has very poor results particularly in the long-term.
 
The Great Saphenous Vein (GSV) when incompetent is usually well over 6 mm in diameter and therefore ultrasound guided foam sclerotherapy is not an optimal treatment for an incompetent Great Saphenous Vein (GSV).
 

Other newer endovenous treatments:

There are a large number of new treatments that are being invented and tried in the vein wall at the moment. At the time of writing these, none have got as much data as the techniques described above. However those of note include:
 
Clarivein - this is an endovenous catheter that is passed up the Great Saphenous Vein (GSV) under ultrasound control. A wire protrudes from the end and spins around, causing some element of damage to the vein wall. The treating surgeon or doctor injects a sclerotherapy liquid with the aim to get better penetration than by liquid sclerotherapy or foam sclerotherapy alone. 
 
The advantages of this system are that due to the lack of heat and therefore thermal spread from the treatment, it does not need local anaesthetic around the vein itself and therefore is quick and virtually painless. However the potential problems are that it depends on the surgeon or doctor injecting the right amount of sclerosant as the treatment progresses as there is a limit to the maximum dose of sclerosant used and therefore only one major vein can be treated per treatment session, increasing visits and costs if more than one vein need treatment. The technique has not been proven to be effective in large veins as well a small veins in the medium to long term. However Clarivein is an exciting prospect and with further research and if it gets proven efficacy, may have a role to play in the future.
 
Steam vein sclerosis - this endovenous technique involves the injection of steam into the Great Saphenous Vein (GSV) vein through a special catheter. As heat has already been shown to be successful in abating the Great Saphenous Vein (GSV) with other techniques (notably radiofrequency ablation and endovenous laser ablation), this should work provided the technique can be perfected. However it will be essential to make sure the steam is controlled to treat only the target veins themselves and the treatment protocol needs to be proven to make it an optimal treatment.
 
Glue sclerotherapy  – this is a very new treatment that involves the injection of glue into a vein through an endovenous catheter, and it is currently being researched and will be shortly available. At the time of writing this, there is little data as to the efficacy of this procedure. It is a very exciting technique in that it does not require local anaesthetic to be injected around the vein nor does it use heat, but early data does not seem to show that it kills the vein wall itself. Therefore to be effective in the long-term, it would need to show that it can prevent the vein from reopening in the long-term.
 
 
This website was last updated on 11/10/16.

 

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