Is a foam sclerotherapy equally effective in the treatment of small and large varicose veins?
Irrespective of the fact that compression sclerotherapy is one of the universal methods in the treatment of varicose veins, it is not a method of choice in case of enlarged and sinuous vein removal. Generally, varicose veins of the main trunks, presenting high dilation, are treated with the use of methods of higher effectiveness such as: endovenous laser ablation (EVLA), ‘superglue’ treatment (Venaseal) or surgical methods. In such situations, sclerotherapy, especially using a needle, is considered to be a complementary method, i.e. second-line therapy. In case of varicose veins of medium and large caliber, long-term effect of the occlusion of the main venous trunks, using foam sclerotherapy, is maximally about 70-75%. If required, in the Clinic of Phlebology-NASMED to improve long-term effectiveness of sclerotherapy we also use intravascular methods and tumescent-enhanced anaesthesia (it is the so called ultrasound guided and tumescent enhanced compression sclerotherapy using intravascular catheter). More information is accessible in the section: ‘Compression sclerotherapy’ and ‘Hybrid treatment’.

What is the difference between foam sclerotherapy and microsclerotherapy?
The first method is used to occlude varicose veins of larger caliber (widened reticular veins and varicose veins of small and medium caliber). The use of sclerosing agent in the form of foam with added carbon dioxide or air allows for more effective and faster obliteration of occluded vessel. Liquid sclerosants are injected by physician into small reticular veins and spider veins. In the Clinic of Phlebology-NASMED for such procedures we use the thinnest needles available on the market.

Are there any contraindications for sclerotherapy in pregnancy and breastfeeding?
Sclerotherapy is contraindicated in pregnancy and at childbirth as the agents administered during such procedure have not been registered for use in these periods. Furthermore, it should not be forgotten that the body and venous system of pregnant women are subject to dynamic changes in this special time. Therefore, any intervention is not suggested. It is recommended for a woman to wear adjusted, prophylactic compression devices in this period.

During breastfeeding, sclerotherapy is acceptable. However, several criteria are to be met. Of importance is that woman should not breastfeed her child directly after the administration of obliterating agent (about 24h). In this time, newborns are given previously frozen milk, most optimally shortly before the procedure. Within the first 24 hours following the procedure, milk can be expressed without any constraints as not to lead to lactation disorders.

Are spider veins exclusively of aesthetic significance?
Telangiectasias, commonly referred to as spider veins, are frequently the first symptom of chronic venous insufficiency. If it is a severe condition depends on the situation in which they appeared, how do they look like, where they are located and what is the dynamics of their appearance.
It is of importance not to neglect such changes on limbs. If they appear, you should consult a phlebologist to have Doppler ultrasound of lower limb veins performed and to have their character examined.

What are the contraindications for compression therapy?
Compression therapy is absolutely contraindicated in persons with advanced arteriosclerosis of lower limbs. Therefore, in case of any clinical suspicions, it is of importance to examine patient’s limb veins using Doppler ultrasound of lower limb arteries.
We refrain from the use of compression devices in case of patients with advanced chronic failure and acute conditions such as all inflammatory lesions on limbs, including vein thrombosis. Furthermore, phlegmasia cerulea dolens (painful blue edema) – acute, massive, life-threatening form of deep venous thrombosis – is a condition which precludes the application of compression at the initial stage of treatment. There are also conditions which constitute relative contraindications for compression therapy, i.a. diabetic autonomic neuropathy, arthritis or severe allergy to a material the compression garment is made of.

What is a mechanism of tumescent-enhanced anaesthesia offered in the Clinic of Phlebology-NASMED?
It is a method of local anaesthesia, which is more frequently used i.a. in a set of procedures of superficial veins treatment (e.g. sclerotherapy, laser therapy or surgeries). It consists in administering large volumes of inert, highly-diluted anaesthetic agents. The use of tumescence increses the effectiveness of treatment and its safety. It also improves the patient’s psychological condition after undergoing thermal methods such as laser therapy or radio frequency ablation (RF).

Why do pregnancy-related varicose veins appear more frequently on the left limb?
It results from the anatomy of vessels of the pelvis. Left common iliac vein crosses the right common iliac artery posteriorly (it is pressed by it which considerably hinders the blood outflow and leads to a change in its lumen). It is also an evidence of 3-8 higher frequency of venous thrombosis at the left side (so called May-Thurner syndrome). In the Clinic of Phlebology-NASMED, we are engaged in the diagnostics and minimally invasive treatment of conditions resulting from the compression of pelvic veins. During pregnancy, we recommend lying on the left side as to unblock the blood outflow by the inferior vena cava, pressed by the enlarged pelvis. It alleviates the symptoms of palpitation in the mother and improves the blood flow of pelvis and placenta.

What are the advantages of the occlusion of limb varicose veins, using glue inserted intravascularly (VenaSeal method), compared to other techniques?
Undoubtedly, the main advantages of the use of VenaSeal, which are distinctive compared to other recent methods of limb varicose vein treatment,
are: high effectiveness of this method in elimination of large venous trunks (alternative for surgeries), lack of adverse reactions resulting from heating of tissues during the procedure (different from laser therapy or radio frequency ablation), painless character, no need for wearing compression stockings in post-procedure period, quick recovery to every day activities and very low risk of discolouration (a good method to be used in summer!).

Is it required to refrain from movement and physical activity following compression sclerotherapy?
Following sclerotherapy, physical activeness is unquestionably recommended. Shortly after this procedure, we encourage our patients to walk intensively to start ‘muscle pump’ of the calf and enhance the distribution of sclerosant (injected drug) within the area of occluded vessels. The following days a moderate physical activity, long walks and nordic walking are also advocated while following the removal of compression dressing a beneficial type of activity would be swimming. Strenuous physical activity, as weight-training-exercises, should be avoided. Patients should also refrain from activities leading to heating of the skin.

When an improvement of limb appearance should be expected following sclerotherapy?
Most frequently, venous insufficiency-associated symptoms such as pain, heaviness or cramps at night resolve shortly after the procedure. Aesthetic improvement is visible at a later time. Smaller veins and spider veins disappear within 2 weeks to 3-6 months. Larger subcutaneous vessels and varicose veins require more time, even to 6 months. Occasionally, a slight bruising may be present on the course of large venous trunks, however, it usually disappears. Our experience suggests that it lasts no longer than 8-12 months.

How should I prepare myself for Doppler ultrasound of lower limb veins?
Generally, Doppler ultrasound of lower limb veins does not require any specific preparations. In case of patients suffering from venous insufficiency (with enlarged reticular veins and spider veins, swollen major venous trunks or their branches and hard-to-heal ulceration in the area of lower part of shin), such examination is usually performed in a standing position. It allows for the most credible assessment of venous system. In more complex situations (e.g. postthrombotic syndrome, suspicions of thrombosis or presence of comorbidities), physicians frequently adopt a modified form of examination.
There are also situations, however, when examination of venous system of lower limbs needs to be extended by examination of veins of the pelvis and abdominal cavity. Abdominal ultrasound examinations require a special preparation and respiratory cooperation from the patient. For Doppler ultrasound of the venous capacity of small pelvis patients need to be prepared just as thorougly as for the abdominal ultrasound.

What are the procedures following the endovenous laser ablation of limb varicose veins (EVLA)?
Following the EVLA procedure (endovenous laser ablation), performed with the use of a new PainLess technology the patient can almost immediately return to normal life (in the Clinic of Phlebology-NASMED ELVeS system is used for endovenous laser therapy). Only strenuous physical activity should be avoided, especially carrying heavy objects. The majority of patients subject to the procedure with the use of ELVeS system do not experience pain. Only a small proportion of patients complain of a slight discomfort, which does not require administration of prescription drugs. Following procedure, for several days, a visible bruising may be present. For 7-21 days (detailed recommendation would be presented by physicians after the procedure), a properly adjusted compression stocking should be worn. It enhances a healing and fibrosis process in the insufficient vein subject to procedure. In the Clinic of Phlebology-NASMED the cost of compression stocking is added to the cost of laser procedure.

How should I prepare myself for varicose vein elimination? Is it required to perform any laboratory tests?
In the majority of cases, no specific preparation for foam sclerotherapy is required. In special situations physician would inform the patient on the need of performing appropriate tests. In case of minimally invasive endovenous procedures, where large varicose veins are occluded (laser therapy or ‘superglue’ treatment, using Venaseal), as well as prior to the procedures of classic surgery, it is always required to perform several laboratory tests and follow the below-listed recommendations.

A complete list of preoperative laboratory tests can be found below. If any of the following tests are not necessary, you would be informed on it during qualification to the procedure.
Below there is a list of tests which are routinely performed in our Clinic:
– blood typing and Rh factor testing (original document should be presented)
– complete blood count with differential
– prothrombin time (INR, aPTT)
– electrolytes (Na+, K+)
– creatinine concentration
– fasting glycaemia (glucose in blood)
–
 anti-HCV and HBsAg (or anti-HBs in previously vaccinated persons)
Collection of blood specimen and analysis of all required parameters from the aforesaid list, may be performed in the Clinic NASMED for PLN 150.
Furthermore, it ought to be remembered that:
– patients who routinely apply drugs reducing blood coagulability (such as: Acard, Aspirin, Warfin or Acenokumarol) always should consult their physicians on the advisability of dosage change or eventually drug discontinuation
– at the day of procedure, the patient should come to our Clinic 15-20 minutes earlier to read and fill in a consent form for the procedure
– males are advised to shave (or depilate) the hair in the area of access to the varicose vein
– clothing and shoes worn after the procedure should be comfortable as to ensure the comfort of moving with the compression stocking (generally it does not refer to ‘superglue’ treatment (Venaseal), following which a compression stocking is rarely worn)
– in case of endovenous procedures such as laser therapy, using ELVeS system, VenaSeal (‘superglue’ treatment ) or surgical removal of varicose veins, patient should come with an adult companion.

What is the risk of complications following the endovenous laser ablation (EVLA) using ELVeS Radial system?
Laser procedure, using ELVeS system (Endo Laser Vein System), is a minimally invasive procedure. It results from the manner in which it is performed and the construction of fiber (for this procedure, very narrow radial optical fibers are employed with annular emission of laser light) and the length of luminous waves emitted by modern laser systems (1470 nm). Therefore, a risk of damage of neighboring tissues as well as pain experienced during the procedure are of very low nature. The procedure is performed in outpatient settings under local anesthesia with administration of highly-diluted lignocaine, i.e. tumescent liquid injected around the occluded vein. It is done to additionally reduce the diameter of varicose vein and minimize the
pain experienced by the patient during the procedure.

When are the effects of the endovenous laser ablation of limb varicose veins (EVLA) visible?
Effects are visible shortly after the procedure. A varicose vein subject to laser ablation is permanently occluded. Damage of vessel resulting from the impact of circular laser fiber effectively irritates an inner wall of vein, leading to its fibrosis and finally its constriction and closure.
The process of varicose vein occlusion with laser of 1470 nm waves using radial fiber, contrary to the post-procedure effects of echosclerotherapy, is performed more quickly and more effectively. Thus, with the use of ELVeS system, varicose veins of larger diameter may be occluded during one session, leading to its total elimination (the percentage of opening the lumen of varicose veins a
fter foam echosclerotherapy during several year-observation amounts to even 25-30%)

Is there any additional procedure required following the endovenous laser ablation of varicose veins (ELVeS) or ‘superglue’ treatment (Venaseal)?
It should not be forgotten that after the endovenous occlusion of insufficient venous trunks, even those most effective (laser ablation, using ELVeS and ‘superglue’ treatment’, using VenaSeal), a part of enlarged veins on the shin may still remain. It depends on the base severity of changes and advancement of chronic venous disease.
Dependent on individual clinical situation and needs, the Clinic of Phlebology-NASMED offers to occlude enlarged veins, using foam sclerotherapy or surgery, by small skin incision (miniphlebectomy). Most frequently such procedure, if required, is performed up to 3 months following the main procedure. It is an element of hybrid approach. More information can be found in the section – Hybrid treatment. The whole therapeutic procedure is discussed precisely with a specialist during a procedure qualification visit.

Can venous insufficiency be a medical problem of childhood?
It was confirmed that the first symptoms and prodromes of venous diseases appear in the early school age. In case of children aged 10-12 years, isolated points of reflux may be identified, i.e. the areas where venous insufficiency progresses in the superficial veins. In humans, they are most frequently reported at the orifice of the great saphenous vein to the deep venous system.
In adolescents aged 14-16 years, the areas of potential appearance of varicose veins are more frequently reported in females with a positive family history. It corresponds to the frequency of detection of insufficient fragments of veins at this stage of life. In our practice, we more often detect venous insufficiency in persons aged less than 20 years. It results from a raised awareness of young patients and visiting the Clinic to perform Doppler ultrasound of lower limb veins.
What are the factors predisposing to the appearance of varicose veins on limbs?
– family history (genetics)
– female gender (females – 1/3, males – 1/5-1/6)
– the number of pregnancies in females (first pregnancy – up to 30% of females, second and successive pregnancies – about 55% and more)
– age (the frequency of varicose veins increases for persons aged 50 years and more)
Are the perineal (or vulvar) varicose veins exclusively of aesthetic significance?
Varicose vein in the area of perineum and vulva appear most frequently in women during pregnancy or after labour. Despite unfavorable aesthetic effect, occasionally they are the symptoms of more severe disease: venostasis in small pelvis. In such situation varicose veins are present on limbs in rarely reported localizations: medial and posterior or posterior surfaces of thighs.
A full diagnostics of this disease requires a precise medical history taking, assessment of symptoms reported by the patient, using a special clinical form and performance of additional imaging tests (Doppler ultrasound of the veins of lower limbs, small pelvis and abdominal cavity, transvaginal ultrasound, venography-CT or MRI). In the Clinic of Phlebology-NASMED, we adjust an adequate method of treatment following the complete diagnostics.

More information on venous insufficiency in pregnancy can be found in the section: VENOUS SYSTEM IN PREGNANCY.

What are the factors affecting the appearance of deep vein thrombosis?
A list of the basic factors predisposing to deep vein thrombosis includes:
– long-term immobilization
– a history of surgeries
– pregnancy and childbirth
– inherited abnormalities of blood coagulation (thrombophilia)
– neoplastic disease
– use of oral contraceptive pills (frequently combined with tobacco smoking)
– dehydration
– obesity
– limb varicose veins
Nowadays, the following forms of thrombosis are also to be remembered:
– ‘thrombosis of the first day of vacation’ (thrombosis of the popliteal vein)
– thrombosis resulting from strenuous physical activity (e.g. persons who exercise fitness every day)
– ‘thrombosis of travellers’ (long flights or bus travels)