Painless treatment of varicose veins with ClariVein and sclerotherapy

Mr Stephen Blair has been invited to speak on the subject of “Painless treatment of varicose veins with ClariVein and sclerotherapy” at this year’s meeting of the British Association of Sclerotherapists. It is an honour to be invited.

Painless treatment has been the “Holy Grail” of varicose vein surgery for over 30 years. In 1986 Stephen Blair published a trial which showed that a new method of removing varicose veins was significantly less painful than stripping varicose veins. 35% did not even need one Paracetamol after having their veins removed by sequential avulsions and consequently, the time off work and quality of life etc were better. However 65% still needed pain killers.

Endovenous treatment was then introduced and Laser treatment (EVLT) was a significant improvement and this could be done without a general anaesthetic with obvious benefits. However this could never be called painless. This requires about 250ml of local anaesthetic to be injected into the leg to reduce the chances of the laser burning other tissues. This is called tumescent analgesia.  Injecting this amount of fluid is painful. If the laser burns through the vein wall a haematoma can develop which is very painful and takes weeks to go away. The skin overlying the vein can also be burnt. If the local anaesthetic doesn’t push nerves away from the vein, nerve damage can occur which is as high as 10% in veins of the calf. This still requires time off work for most people.

Radiofrequency ablation followed, which  did not perforate the vein so was less painful. However it still required injecting large amounts of local anaesthetic (tumescent analgesia) which is painful and while it is being reabsorbed the pain continues.

ClariVein is equally effective as all the above treatments in getting rid of the main vein. It does not require tumescent analgesia ( large volumes of local anaesthetic). This is a mechanical method not a burning method therefore there is no nerve damage, no burning of skin and no haematomas. There is genuinely no pain during the procedure. It feels like the vibration of an electric toothbrush as the wire spins round inside the vein which it ablates with a combination of its mechanical effect and the release of a sclerosant to destroy the lining of the vein.

Foam Sclerotherapy can be used in combination with this to treat side branches, and obvious varicose veins around the leg. In common with other endovenous treatments, trials have shown that if these are not treated at the same time, recurrences are more common. This is again pain free treatment.

Bandaging is important for the treatment of these side veins. Conventionally this involves an ankle to top of thigh bandage. However from personal experience there are real problems with bandages of this type. Therefore a new bandaging technique has been developed and tested which enables both compression of side veins and a return to full normal activity including driving immediately after the procedure. Painless treatment of varicose veins with ClariVein and sclerotherapy has arrived.

 

Side effects of cyanoacrylate glue in the treatment of varicose veins

 

Dr Tobias Hirsch, Halle, Germany

 

Dr Hirsch made a presentation to the Liepzig Interventional Course on the side effects of glue in the treatment of varicose veins, which has been published in Venous News March 2019

In 2011 the American Venous Forum recommended thermal ablation (Heat with either laser or radiofrequency) as standard treatment of varicose veins. However these methods require large volumes of local anaesthetic which is painful , can cause discolouration of the skin (hyperpigmentation) and nerve damage in up to 10%. Therefore newer methods have been looked for.

Cyanoacrylate glue has been shown not to be inferior to other treatments like Laser, RF or ClariVein in its ability to ablate the primary vein. It is simple to do but the manufacturers advise not to inject glue within 5cms of the junction with a deep vein as this could lead to a Deep Vein Thrombosis (DVT). However most recurrences come from the top  5cms which is untreated with glue therapy. This is obviously of concern.

With cyanoacrylate glue “we have to consider toxicity and allergenic risk especially as it takes along time for adhesive to be reabsorbed. All trials show an excellent occlusion rate, but all trials also show a phlebitis-like reaction in up to 20% of cases” Therefore patients may have pain for 1 to 2 weeks and experience generalised skin affections. Talking about side effects Hirsch said that “acrylates are known to cause allergic reactions such as contact eczema. The only way to treat contact eczema is to halt exposure” Obviously the glue injected into varicose veins cannot be removed. Other symptoms such as hives and itching can be treated with antihistamines.

In choosing what method is used to treat  varicose veins, the key issues are:-

a) Does it ablate the vein treated ? – in this respect most treatments are equivalent

b) What side effects are there ? – Pain and nerve damage for Laser and Radio-frequency, Painful phlebitis and skin rashes for cyanoacrylate glue, None for ClariVein

c) What is the recurrence rate? Being unable to treat the top 5cms safely with Glue is concerning. Recurrence for ClariVein/Laser/RF are equivalent