What is it about?

It has been shown that varicose veins are best treated with endovenous thermal ablation (EVTA), rather than foam sclerotherapy or stripping. EVTA means both endovenous laser and radiofrequency. This has been shown by the NICE Clinical Guidelines in the UK (NICE CG168), as well as in guidelines in Europe and America. However, many doctors still tell their patients that varicose veins are too large to be treated with these new endovenous techniques. In the past many doctors have used a maximum diameter of 10 mm or 15 mm. Bigger than this, they often recommend stripping! This research paper shows two things. Firstly, at Whiteley Clinics, about one in six patients that we treat have veins that are larger than 15mm diameter. Secondly, we have described a method of closing big veins using a "multi-pass" technique. We have shown that on ultrasound, we most veins contract concentrically as a circle around the laser. or radiofrequency catheter. This means that they can be treated using the usual endovenous technique as the heat energy will reach all parts of the vein wall. However, if a vein squashes flat rather than constricts concentrically as a circle, it looks like a "smile" on ultrasound. The laser device is stuck in one area of the "smile" and cannot reach all of the vein wall during treatment. We have named this the "smile sign". We have also shown that when a vein is so big in diameter that it shows the "smile sign", we are still able to close the vein using endovenous laser ablation (EVLA). We do this using a new multi-pass technique. This is described in full in the paper. We have reported results from almost 2000 veins that have been treated at Whiteley Clinics and shown that no patient with varicose veins ever needs to be turned down for endovenous surgery under local anaesthetic merely due to the size of their veins.

Featured Image

Why is it important?

This research is very important for patients as It is known that endovenous treatment of varicose veins has many advantages. These include reduced pain, local anaesthetic treatment allowing out-patient "walk-in, walk-out" surgery, early return to work and activities as well as the prevention recurrent varicose veins due to re-growth of the ends of the veins (called "neovascularisation"). However, many surgeons who are not venous experts but do some varicose veins use the fact that the vein is large to persuade patients to have other treatments such as stripping or foam sclerotherapy. This research shows that this is not correct and no patient should be advised this way. Provided doctors are able to diagnose the smile sign on ultrasound, and are able to use our multipass technique, all patients should be able to have the advantages of endovenous surgery under local anaesthetic regardless of the size of their veins. Nobody with varicose veins should be turned down for local anaesthetic endovenous surgery merely because their veins are "too big".


Having introduced endovenous surgery into the UK in 1999, and having performed the country's first endovenous procedure in March that year, I have been fascinated by all the different techniques that have been proposed for the treatment of varicose veins. Through the research department of Whiteley Clinics, we have now come to understand how these endovenous techniques work and what results in success and failure. By understanding this, our patients can get optimal treatment. It has been frustrating that some reports of good results following varicose vein treatment come from units where difficult patients are excluded. This does not give a "real-world view" of these techniques. In our practice, no patient with varicose veins is turned down for endovenous surgery. This paper represents one of the many advances we have made in endovenous surgery at the Whiteley Clinics and have put into the public domain so that others can follow our lead.

Professor Mark S Whiteley
The Whiteley Clinic

Read the Original

This page is a summary of: A description of the ‘smile sign’ and multi-pass technique for endovenous laser ablation of large diameter great saphenous veins, Phlebology The Journal of Venous Disease, September 2017, SAGE Publications,
DOI: 10.1177/0268355517734480.
You can read the full text:



The following have contributed to this page