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Last week, I attended the British Association of Sclerotherapists annual conference in Basingstoke.
This meeting reviews the latest developments in venous disease and leg vein treatment.
Seven main areas of controversy were reviewed and in this video, I will discuss them with
you.
The first controversy was Should Ultrasound Guided Foam Sclerotherapy be first choice
in the treatment of varicose veins? As I have stated in previous blogs, surgery
such as stripping under general anaesthetic is no longer appropriate for varicose veins.
The National Institute for Health and Care Excellence has recognised this and has indicated
that surgery is now third choice for varicose varicose veins. NICE has in fact recommended
that endothermal ablation is first choice and that Ultrasound Guided Foam Sclerotherapy
is second choice. Many at the BAS meeting in Basingstoke felt this is an unfair assessment..
At the meeting Dr Patrizia Pavei a phlebologist from Italy discussed the indications for Foam
Sclerotherapy. In her opinion, sclerotherapy is first choice for an impressive list of
situations including recurrent varicose veins, small saphenous reflux, non-saphenous veins,
perforator veins, residual veins and great saphenous veins less than 8 mm in diameter.
Although endothermal ablation is suitable for saphenous veins that are relatively straight,
ie they are not tortuous it is clear that sclerotherapy is far more versatile. Nearly
any vein in the leg can be treated and in this respect, many specialists believe that
Ultrasound Guided Foam Sclerotherapy be should be at least joint first choice in the treatment
of varicose veins.
The second area of controversy is How should Ultrasound Guided Foam Sclerotherapy be performed?
Dr Philip Coleridge Smith provided a live demonstration of varicose vein treatment at
the meeting. He emphasised the need to treat saphenous reflux, all the tributaries and
all the varicose veins all together usually in one treatment session. He showed how he
places multiple cannulas before administering the sclerosant. His aim is to obliterate all
reflux and visible veins and as part of his protocol, he sees patients 2 weeks later,
he aspirates any retained thrombus or coagulum and he retreats any veins that are persistent
or refluxing. Once he has eradicated all the reflux and varicose veins, he sees patients
six months after treatment and any signs of reflux or persistent varicose veins are once
again retreated. His protocol gives excellent results that are very comparable to endothermal
treatments.
The third area of controversy is Do all patients with leg telangiectasias –thread veins – need
a duplex ultrasound scan? Doctor Pavei addressed this issue. She provided a lot of evidence
and in her opinion, duplex ultrasound is mandatory prior to treating leg thread veins. She pointed
out that at least 25% of patients with leg telangiectasias have saphenous vein reflux.
Not all specialists at the meeting agreed. Many use duplex ultrasound selectively and
they would request a scan in some patients after a careful clinical assessment and perhaps
a hand held Doppler examination. It was acknowledged however that the trend is for more and more
specialists to regard a full colour duplex scan as an essential assessment prior to leg
thread vein treatment.
The fourth area of controversy is When should compression stockings be advised after sclerotherapy?
Dr Martyn King tackled this difficult subject with a thorough review of the medical literature
and he led a lively debate on the subject. My own impression is that wearing compression
certainly offers benefit to patients after Ultrasound Guided Foam Sclerotherapy and perhaps
it offers less benefit to patients after sclerotherapy for thread veins. At The VeinCare Centre we
advise compression after sclerotherapy but we suggest that if the compression is uncomfortable
or causing problems that it is immediately discontinued. It was acknowledged at the meeting
that many specialists do not prescribe compression stocking after thread vein injections.
Controversy number 5 Do all patients with phlebitis need a duplex scan. Dr Rangarajan
a consultant haematologist from Basingstoke gave a thorough review of deep vein thrombosis
and phlebitis. From her presentation it was clear to me that patients with phlebitis do
have clots in the superficial veins and that they are also in a hypercoagulable state – that
is they have sticky blood. As many as 25% of patient with phlebitis have a co-existing
deep vein thrombosis and many of the rest are at high risk of developing one. It is
my opinion having listened to Dr Rangarajan that everyone with phlebitis should have a
duplex ultrasound scan.
The sixth area of controversy was Can complications of sclerotherapy be avoided? Dr Philip Coleridge
Smith gave a wonderfully illustrated review of complications associated with sclerotherapy
many based on his role as a medical expert in cases of complaint and litigation. Based
on his presentation it appears that the majority of serious complication of sclerotherapy can
be avoided by careful technique, slow injection of small volumes of sclerosant and by using
the correct dose and strength of sclerosant.
Controversy number 7 was What is the best treatment for leg thread veins? This proved
to be the least controversial area. Live demonstrations of leg thread vein treatment by Claire Judge
and Julie Halford as well as discussions led by Dr Pavei, Dr Stephen Tristram, Dr Martyn
King and Philip Coleridge Smith confirmed that Microsclerotherapy carefully performed
after a thorough assessment (which in my opinion should include a duplex ultrasound scan) certainly
gives the best results.
Well I hope you have found this video interesting. Do please remember to subscribe and that way
you will be the first to see my next video on leg health and venous disease. My name
is Dr Haroun Gajraj, thank you for watching.