Treatment of Varicose Veins with Venaseal

What is Venaseal? Venaseal is the trade name for endovenous ablation using glue. Venaseal is approved for use in both the United Kingdom and United States, where it has been used for several years with good results.

What types of veins are suitable for Venaseal? Venaseal is used to treat lumpy varicose veins in patients’ legs. It does NOT treat spider or thread veins (although treating varicose veins is a necessary first step to allow successful treatment of thread and spider veins). To use Venaseal (or other catheter-based techniques such as laser or radiofrequency), the main vein feeding the varicose veins must be straight rather than curly. About 80% of varicose veins patients have a straight feeding vein and are suitable for a catheter-based technique. If you had varicose veins treated before, it is less likely that you will have a straight feeding vein and be suitable.

How does it work? Previously, the faulty superficial veins would have been stripped. This forces the blood into deeper veins which are working properly, and the varicose veins settle down. Venaseal does not rely on removing the vein. Instead, the Venaseal system glues the two walls of the veins together so blood cannot flow through the vein. Over the next few weeks and months, it forms scar tissue. Blood can no longer pass through the vein and instead passes into deeper, properly functioning veins. The surface bumpy veins usually shrink and disappear. Sometimes, if the surface veins are very large, some foam sclerosant may be injected into them at the end of the Venaseal procedure.

What will happen during the treatment? You will be asked to sit on a surgical couch. The couch will be tilted so that your legs are lower than your heart. This fills up the veins, just like when you stand up. The main feeding vein in the thigh or at the back of the calf will be identified using ultrasound. A small local anaesthetic injection will be given at the point where the Venaseal catheter is to be passed into the vein. Under ultrasound control, a fine needle will puncture the feeder vein and a wire will be passed into it. A fine tube called a sheath will be passed over the wire and then the Venaseal catheter will be passed through the sheath. The tip of the catheter will be placed near the top of the vein and the position confirmed using ultrasound. Once the position has been confirmed, glue will be injected near the top of the vein at two spots. The vein will then be pressed closed for three minutes using ultrasound to allow the glue to set. The glue is then injected every 3 cms along the vein with pressure to close the vein at each location for 30 seconds. It takes about 10 minutes to treat a 40cm length of vein. Once the vein is treated, the catheter is removed, leaving only a 1 millimeter skin puncture which does not require any stitches. A tight compression stocking is applied straight away and worn continuously over the first seven days and nights. It is then worn during the day for the next seven days. The nursing staff will perform some routine checks and you will be allowed home.

What can I expect afterwards? Some patients report mild discomfort in the area of the treated vein over the first few days. Simple pain killers such as paracetamol (1 gram every 4 to 6 hours, not exceeding 4 grams in 24 hours) usually prove very effective. Some patients prefer a mild anti-inflammatory such as ibuprofen (400mgs every 8 hours) although you should not take this if you have a history of asthma or stomach ulcers. Both of these pain killers are available ‘over the counter’ without any need for a prescription. Stronger pain killers are only very rarely needed. You can resume normal activity immediately. Over the first two days, we ask that you exercise for 5 minutes in every hour during the day e.g. get up from a desk and make a cup of tea or walk around the office for a few minutes. Very heavy physical activity in the first few days e.g. distance running, contact sports should be avoided as the treated vein may become very inflamed, triggering phlebitis.

Why use Venaseal and not one of the other catheter techniques like laser? Venaseal has a number of advantages when compared to the other catheter-based procedures such as endovenous laser. It is performed in an ambulatory setting, taking about 45 minutes. It allows immediate resumption of most normal activity. There are no incisions. Unlike conventional surgery or laser, there is no risk of nerve damage. Venaseal requires only a single local anaesthetic injection per feeding vein treated whereas laser requires injections every 1cm along the 40cms of vein usually treated i.e. 30 to 40 injections in total.

What problems can occur? No interventional procedure is 100% safe and Venaseal is no exception. Serious complications are rare. Complications which may occur are:

  • Phlebitis along the line of the treated vein if it becomes very inflamed. This presents as red, hot tender line along the inside of the leg. It can be treated by anti-inflammatories or by antibiotics if there is concern that it may represent infection. Phlebitis affects about 1 patient in every 75.
  • Cellulitis (infection in the skin) could occur due to the 1 mm skin puncture. It would present as a red hot tender area around the puncture site. You may feel unwell and have high temperatures. It would require antibiotics. It is very uncommon, affecting about 1 patients in 200.
  • The procedure occasionally fails to seal the vein.
  • Bruising along the thigh affects about patient in 10 and may require some anti-inflammatories.
  • Brown skin staining may occur along the line of the treated vein in the weeks following the procedure. This usually settles with time, but this cannot be guaranteed. Brown staining develops in about one patient in 10.
  • Any treatment for varicose veins carries a risk of a deep vein thrombosis (clot in the leg) or a clot on the lung (pulmonary embolus). The risk of this is about 1 in 2000 patients. In severe cases, clots on the lung may be fatal. This is very rare after varicose veins.
  • Sometimes, not all the superficial bulging veins seal up and need to be treated by foam injections a few weeks later. The foam injections avoid the previous requirement for multiple small incisions to remove the bulging veins surgically.
  • Occasionally, sealing one faulty vein triggers problems in other veins in the treated leg, leading to rapid recurrence of veins i.e in less than 6 months. It may also trigger the appearance of thread or spider veins that were not there previously. This is very unpredictable. It occurs in about one patient in 200. If it happens, we usually recommend a pelvic MRI scan to look for pelvic varicose veins which could be the cause.

Can the veins come back? It is very important to realise that, regardless of the treatment type, varicose veins recur. The best available data show that 50% of patients have more veins in the treated leg 5 years after their procedure. There is no difference between the treatment types (surgery, laser etc) with respect to recurrence. You should also bear in mind that 5 years is the average length of time before veins recur – in some patients they recur faster and in some, more slowly. They can be treated again when they recur.

I have thread veins – will this procedure help? 90% of patients with thread veins have underlying varicose veins which should be treated before the thread veins. If the underlying varicose veins are ignored, the thread veins will recur rapidly after any treatment. It is important to understand, though, that treating the varicose veins alone will not improve the thread veins. You should not expect any improvement in thread veins after varicose vein treatment alone.

Prof S Walsh

February 2018