The Small Saphenous Vein (SSV) is a truncal vein and as such takes a relatively large amount of blood through it. Compared to other superficial veins of the leg, the wall is quite thick. It is also quite straight. These factors are important when considering the best treatments for this vein.
1 – Thrombophlebitis of the Small Saphenous Vein (SSV) is firstly treated by anti-inflammatory medication, painkillers and support stockings until the symptoms resolve over a few days. If the inflammation is particularly bad, occasionally the blood clot can be drained surgically. However this is rarely required. Once the thrombophlebitis has settled, it is important to treat the Small Saphenous Vein before another bout of thrombophlebitis occurs. Thrombophlebitis almost always occurs in incompetent Small Saphenous Veins and, if they are not treated adequately, the thrombophlebitis will just keep recurring. Therefore the longer term treatment of Small Saphenous Vein thrombophlebitis is the same as for Small Saphenous Vein incompetence or reflux.
2 – Treatment of an incompetent Small Saphenous Vein (SSV) is aimed at stopping the blood refluxing (or ‘flowing back’) down the vein and causing varicose veins or damage to the superficial tissues.
In the past, the vein was tied surgically, or stripped away. Surgeons used to think that this was enough to permanently stop blood refluxing down the Small Saphenous Vein.
Unfortunately if the vein is only tied, blood does not flow through it and so it clots. Therefore superficial thrombophlebitis in the vein below the tie occurs. In addition, the surgical tie usually ends up breaking down in the fullness of time and the thrombophlebitis resolves – allowing the original problem to return. This makes the old operation of simple tying the vein useless.
There was a fashion to strip the Small Saphenous Vein away after the top was tied in an attempt to stop the blood from clotting and thrombophlebitis occurring. Unfortunately many surgeons still do this. To many this would seem to be a logical thing to do. Unfortunately however, the vein is part of the connective tissue and so when stripped away, the surrounding tissue tries to repair the damage and therefore wants to grow back again. Over time, a large proportion of veins that are stripped away grow back again. When the vein grows back, it does not have any valves in it and so once again, the reflux returns and so the operation is essentially useless in these patients.
Sclerotherapy – Liquid Sclerotherapy
Over many decades, sclerotherapy has been used to try to close the Small Saphenous Vein. Sclerotherapy is the injection of a liquid that destroys the cells in the vein wall. The idea is that if the vein wall can be destroyed, and the leg is compressed with a bandage stocking, the dead vein will “stick together” and be “eaten away” as a scar. Unfortunately blood is also a living tissue and if sclerotherapy liquid is injected into a large vein, such as the Small Saphenous Vein, it tends to destroy the blood cells within the blood as well as the cells in the inner lining of the Small Saphenous Vein, resulting in a clot or thrombus within the vein.
Those who advocate sclerotherapy call this “sclerothrombus” as if by giving it this name it makes it an acceptable result. However “sclerothrombus” and “thrombus” are just the same thing – they are clots within the vein and therefore both cause thrombophlebitis. This means that the vein gets tender and inflamed and, if the thrombus breaks down, iron can be released into the surrounding tissue. This release of toxic iron from the blood causes brown stains to appear on the overlying skin. Of course the other result of the thrombus breaking down is that the vein reopens again, causing recurrence of the reflux and failure of the Sclerotherapy.
Liquid sclerotherapy in the treatment of Small Saphenous Vein incompetence or reflux is not an optimal treatment. It is inexpensive and does not need much equipment and therefore is popular in some areas. However post-treatment discomfort from thrombophlebitis, the higher risk of brown stains and the high risk of the vein reopening again in the medium to long term makes it a very substandard treatment in today’s world.
Since the mid-1980s, foam sclerotherapy has become available. Initially described in 1935, foam sclerotherapy was reinvented in 1985 and has become incredibly popular throughout the world. The same liquid sclerosant that is used in most practices for liquid sclerotherapy, is mixed with gas to make foam, with a consistency very similar to shaving foam. When this is injected into veins (preferably under ultrasound control to ensure that it has actually gone into the target vein and to check where it is going) it physically pushes the blood out of the vein, making sure that the risk of sclerothrombus is kept to a minimum. Once the blood has been pushed out of the section of the vein to be treated, the sclerosant can then act on the vein wall killing the vein wall cells, and attempting to destroy it.
Of course it is not a good idea to inject gas, particularly air, into veins. Therefore the best vein clinics do not use air to make their foam sclerotherapy, but use mixtures of carbon dioxide and oxygen which are much safer when injected into the venous system.
Once the foam is in the vein, the bubbles within it will pop within a minute or two allowing the blood is to come back into the vein, which now has a layer of dead cells on the inner aspect of the wall. Once the living blood touches this dead inner lining of the vein wall, it will clot, causing a thrombus. To stop this from happening, as soon as the foam has been injected into the veins, a compression bandage is placed on the leg, squashing the vein flat and preventing blood from re-entering the vein. This compression bandage needs to be kept on for 14 days and nights which is the time it takes for tissue to start scarring. This scarring will hold the walls of the vein together and stop blood flowing back into it. It is at this stage, 14 days and nights after injection, that the vein wall is most likely to stay closed leading to successful treatment.
Foam sclerotherapy is very successful in small veins with thin walls. The bigger the vein and the thicker the wall, the less the foam sclerotherapy penetrates into the wall and the less successful treatment is in the medium to long term.
As the Small Saphenous Vein is a truncal vein with a thick wall, foam sclerotherapy is not the optimal treatment for this vein. Although some veins may well be small enough to be completely destroyed permanently by foam sclerotherapy, it is much more likely that a Small Saphenous Vein will be temporarily closed due to sclerothrombus after foam sclerotherapy and then in the medium to long term, will reopen with a recurrence of venous reflux.
Radiofrequency Ablation (RFA) is a technique where a radiofrequency ablation catheter is passed into the Small Saphenous Vein under ultrasound guidance, usually under local anaesthetic and through a small pinhole incision. More local anaesthetic is then injected around the vein itself, both to keep the area numb, and also to stop any heat being transmitted from the vein being treated to surrounding tissues. The radiofrequency current is switched on, and under ultrasound guidance, the radiofrequency ablation catheter is pulled back down the vein at a set rate. The radiofrequency catheter destroys sections of the vein by heating them with a radiofrequency current.
If the right technique is used with the right power settings, the vein is completely destroyed. The radiofrequency current produces heat that destroys the whole thickness of the vein wall. The vein first of all swells, closing the vein lumen and then over several weeks to months, turns into scar tissue which slowly gets removed by the body using inflammation. Failure is almost always due to poor technique. In expert hands when used correctly, radiofrequency ablation of the Small Saphenous Vein should give excellent results with no recurrence. This is one of the optimal techniques of treating the Small Saphenous Vein.
Endovenous laser ablation of the Small Saphenous Vein is a technique where a laser fibre is passed up inside the vein under ultrasound control through a small local anaesthetic pinhole, made lower down the leg. As with radiofrequency ablation, ultrasound is used to make sure that the laser fibre is in the correct position within the vein. Local anaesthetic is injected around the vein, using ultrasound to make sure it is in exactly the right place to stop heat being transmitted from the vein being treated to the surrounding tissues.
Once the laser is switched on, the laser fibre is pulled down the vein at a set rate, depending upon the wavelength and power of the laser. There are several different systems that are used and so protocols vary considerably.
However, provided the right power and right technique used, the vein wall should be completely destroyed by the heat generated by the laser and the vein should be completely closed. As with radiofrequency ablation, the heat kills the cells of the vein wall which causes them to swell, closing the lumen of the vein and stopping blood flowing through it immediately. Over several months the body removes the dead vein by a process of inflammation, leaving only a very small internal scar.
Endovenous laser ablation is one of the optimal techniques for treating the Small Saphenous Vein.
Other endovenous techniques to close the Small Saphenous Vein:
Since the advent of the new endovenous techniques in 1998, vein surgery has become very exciting and over the last few years there have been considerable number of new treatments.
Of those showing some promise, but at the time of writing this, still having many questions to answer, are:
ClariVein – a non-thermal mechanical sclerotherapy device which is introduced into the vein under ultrasound control (like a radiofrequency ablation or endovenous laser ablation catheter), which is similarly positioned correctly inside the vein by the ultrasound image. However it does not need any local anaesthetic injected around the vein itself, as it does not use heat and so there is no damage to the surrounding tissues. Instead of heat, a small wire protruding from the end of the device rotates at very high speeds, supposedly damaging the inside of the vein wall whilst sclerotherapy liquid is injected at the same time.
It is hoped that the combination of the mechanical damage to the inside part of the wall, enabling the liquid sclerotherapy to penetrate deeper, will allow the vein wall to be completely destroyed without heat and therefore without the need for local anaesthetic around the vein.
However, at the time of writing this there is no difference between the treatment recommended for thin-walled or thick-walled veins, suggesting that the thick-walled veins are probably going to be inadequately treated and therefore may open in the medium to long-term. Also, there is also a maximum dosage of sclerotherapy liquid that can be used in one treatment, meaning that patients that have several veins that need treatment will be forced to attend on different days, increasing their costs and their number of visits.
This is a very promising technique if these problems can be overcome.
Steam vein sclerosis – in this process, a catheter is passed up inside the vein under ultrasound control. Steam is then squirted through the catheter and into the vein. As both radiofrequency and endovenous laser have both shown that heat is a very potent and successful techniques for killing veins, there is clearly a possibility that this will work.
However the questions that will need to be answered by those using steam vein sclerosis, will be which protocols are required for which veins to get optimal treatment and whether local anaesthetic will be needed to be injected around the target vein. Also, it will be necessary to show how the steam is controlled to ensure that damage does not occur away from the target vein.
Glue Sclerotherapy – a very new technique has been emerging on the Internet which, at the time of writing this article, has got very little clinical data to support it. It appears that using this system, a catheter is passed up inside the target vein under ultrasound control, and when in position, glue is injected inside the vein. The leg is then bandaged tightly, making sure the vein wall is glued tightly together.
Although this appears very attractive, it does not follow the principles of destroying the whole of the vein wall and so it will be very interesting to see whether the body is able to re-cannulate a vein lumen around this glue in the medium to long term.
This website was last updated on 03/10/17.