What is it about?

In March 1999, Mark Whiteley performed the first endovenous ("keyhole") surgery for varicose veins in the UK. Other surgeons started taking out the procedure in the early 2000's. Now endovenous laser and endovenous radiofrequency ablation has become the standard way of treating varicose veins and indeed, since 2013) are the NICE recommended first-line treatments. However, there are still some surgeons who cling to the old stripping techniques despite Whiteley Clinic research showing that such techniques have increased pain, bruising and a high risk of growing new varicose veins back again ("neovascularisation" and "strip-tract revascularisation"). This study was performed to audit the long-term results of the new endovenous treatments for varicose veins. Patients treated on average 15 years before the date of the study were invited to come back for a scan. 88% of patients had veins that were either totally closed, or almost totally closed with insignificant sections reopening. 12% of patients had a minor reopening of the top of the vein, leading into a new varicose vein. No patients had veins that are completely reopened again. 44% of patients had some new varicose veins forming over the 15 years. Almost all of these were found to be coming from different areas and not from the area that had been treated. This is the genetic deterioration of patients who have the familial propensity to develop varicose veins. This rate of recurrence is significantly lower than techniques that allow the same veins to come back again after treatment. 100% of patients said that they were pleased that they had undergone the endovenous surgery for varicose veins. 98% said they would recommend the treatment - and 2% said they might do. No one said they would not recommend it.

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Why is it important?

This study is one of the first to report the long-term outcomes from endovenous ("keyhole") surgery for varicose veins. In the early days of this technique, in the early 2000's, many surgeons and insurance companies were highly sceptical that this technique would work. This paper shows that when the technique is performed properly, not only is it going to close the target vein in the short term but because it completely destroys the vein then the results last into the long term. The first of these techniques to come into the UK was radiofrequency ablation (VNUS Closure) and so these are the results that have been presented. However, all of the techniques that use heat to close the vein such as endovenous laser, steam and potentially microwave, will be able to get the same results provided they can generate the same heat in the vein. Therefore this paper proves the principal that you can permanently close the target vein with heat if the right technique is used and the right amount of heat given to each section of vein. Unlike stripping of the vein, there was no regrowth due to damage of the vein, a process called "neovascularisation" or "strip-tract revascularisation". It must also be noted that patients who develop varicose veins are still prone to getting more in the future due to their genetics. However, if the mis-functioning veins are permanently treated, then the risk of recurrence is the lowest that is possible as the only risk remaining after treatment is the risk of opening new veins. This is the same risk as the general population developing varicose veins in the first place. Using techniques that do not have the same success rate of closing the target vein will give even higher risks of recurrence after treatment and therefore should be avoided.


There are some very important perspectives that are not mentioned in the paper itself, but I have subsequently written about in a chapter of a textbook. The first is that these excellent results were produced from treatment performed between 1999 and 2001, when we had old equipment and techniques compared to what is available today. - The ultrasound had a very small screen, had very low resolution and was very poor compared to the modern day ultrasound machines. - We used the first generation of radiofrequency catheters (VNUS Closure) which were far inferior to the endovenous lasers and radiofrequency catheters produced today. - In addition, we used general anaesthetic and rubber bandage used to bind the leg rather than the new tumescence under local anaesthetic. Despite these difficulties, the results that we have shown over 15 years are at least as good and in most cases even better than those reported even in the short term in more modern series. This shows that despite the endovenous techniques having the ability to completely destroy the target vein in the long term, results depend on the surgeon and their team using the equipment correctly. Unfortunately, even with the most modern equipment and modern ultrasound, many doctors fail to get results anywhere near as good as this even in the short term. This can only be due to poor technique and lack of experience. It is essential that patients do not think that to technique gives a certain result, but patients ask doctors if they audit their own results, and ask to see what their own individual results. A further technical point for those interested in how varicose veins come back again is also noted. In the past, many doctors have said that when the veins are removed in the groin, pressure can open up new veins causing recurrence. This study showed that after 15 years there was no evidence of any such veins. If the, and the correct technique used, there is no reopening of little veins in the groin due to pressure in the venous system.

Professor Mark S Whiteley
The Whiteley Clinic

Read the Original

This page is a summary of: Fifteen Year Results of Radiofrequency Ablation, Using VNUS Closure, for the Abolition of Truncal Venous Reflux in Patients with Varicose Veins, European Journal of Vascular and Endovascular Surgery, July 2017, Elsevier,
DOI: 10.1016/j.ejvs.2017.06.001.
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