The Small Saphenous Vein 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 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 Vein 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 vein is aimed at stopping the blood refluxing 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 tie usually ends up breaking down and in the fullness of time, the thrombophlebitis resolves and the original problem returns making simple tying 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. To surgeons this seemed to be a logical thing to do. Unfortunately, the vein is part of the connective tissue and therefore wants to grow back again. Over time, a large proportion of veins that are stripped away grow back again. When the vein goes back, it does not have any valves in it and so once again, the reflux returns.
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 scar away. Unfortunately blood is also a living tissue and if sclerotherapy liquid is injected into a large vein at the Small Saphenous Vein, it tends to destroy the blood cells as well is the inner lining of the Small Saphenous Vein, resulting in a clot or thrombus.
Those who like sclerotherapy call this “sclerothrombus” as if by giving it this name it makes it an acceptable result. However a sclerothrombus and a thrombus are just the same – they are clots within the vein and therefore cause thrombophlebitis. This means that the vein gets tender and inflamed and, if the thrombus breaks down, iron can be released and brown stains can 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.
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 is used in most practices for liquid sclerotherapy is mixed with gas to make a foam very similar to shaving foam. When this is injected into veins, preferably under ultrasound control to check that it has actually gone into the vein and where it is going, it pushes the blood physically out of the vein making sure that the risk of scary thrombus is kept to a minimum. Once the blood has been pushed away, the sclerosant and then act on the vein wall killing the 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 units do not use air to make their foam sclerotherapy, but instead use mixtures of carbon dioxide and oxygen which are much safer in the venous system.
Once the foam is in the vein, it will pop within a minute or two allowing the blood is to come back into the vein and therefore to clot. 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 should be kept on for 14 days and nights which is the time it takes for tissue to start scarring. It is at this stage 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 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 the venous reflux.
Radiofrequency Ablation (RFA) is a technique where a catheter is passed into the small saphenous vein under ultrasound guidance usually under local anaesthetic through a small pinhole incision stop. Local anaesthetic is then injected around the vein itself both to keep the area numb and also to stop any being transmitted from the vein being treated to surrounding tissues. The radiofrequency is switched on and under ultrasound control, the Radiofrequency Ablation (RFA) catheter is pulled back down the vein at a set protocol. The radiofrequency catheter destroys sections of the vein by heating them with a radiofrequency current. As it is pulled down the vein, the whole of the wall is destroyed by this heating process.
If the right technique is used with the right power, the vein is completely destroyed. It destroys the whole thickness of the vein wall, and the vein first of all swells, and then over several weeks scar tissue will slowly get removed by the body. Failure is almost always due to poor technique. In expert hands and used correctly, Radiofrequency Ablation (RFA) of the Small Saphenous Vein should give excellent results with no recurrence. This is one of the optimal techniques are treating the small saphenous vein.
Endovenous Laser Ablation (EVLA) is a technique where a laser fibre is passed up inside the vein under ultrasound control through a small local anaesthetic pinhole lower down the leg.