Varicose vein removal: EMWA, EVLA and new advances in treatment

Varicose veins are enlarged veins blue or dark purple in colour that usually appear on the legs and feet.

Here to provide an expert insight into the latest innovations in treatment for varicose veins, including ablation, sclerotherapy and phlebectomy treatments, is Mr Patrick Lintott, highly esteemed consultant vascular surgeon.

What is endovenous microwave ablation therapy (EMWA)?

EMWA is a minimally invasive venous ablation treatment for truncal reflex in superficial varicose veins.

In practice, it involves inserting a needle into the large vein in the body that feeds surface veins. A wire is passed up and a series of local anaesthetic injections are placed around it. The vein is then heated from the inside, so that it shrivels and closes. This is a modern equivalent to vein stripping, an old-fashioned method that involves making an incision near the groin and physically pulling the vein out.

The treatment is referred to as endovenous because it reaches inside of the vein. Once the wire is inside of the vein, radiofrequency ablation (EMWA) or laser ablation (EVLA) can then be used.

How is EMWA different from endovenous laser ablation (EVLA)?

There is little difference between EMWA and EVLA. The setup is exactly the same, using the same needle puncture and the same wire up the vein. The only difference here is that the wire is attached to a laser block box rather than a microwave block box.

With EVLA, laser-proof glasses need to be worn and the treatment needs to be performed in a laser-proof theatre. With EMWA, there is no need. From the patient’s point of view, actual treatment with EVLA takes 45 seconds to one minute to complete. With EMWA, treatment takes one to three minutes.

According to two paper comparisons head-to-head comparing EVLA and EMWA, both treatments are equivalent, resulting in extremely good 90 per cent closure rate to the vein.

In terms of post-operative complications, the only detail that the papers revealed is that EVLA is slightly more painful during the first five days after treatment, requiring three to four extra paracetamols intakes compared to EMWA.

Overall, both treatments work extremely well and are used in 90 per cent of varicose vein cases in the UK and the US. Although I tend to use EMWA the most, I’m happy to do both and I believe they can be seen as virtually equivalent.

What is involved in the procedure?

First of all, a patient needs to appropriately consent and understand in detail what is going to happen. The patient then lies flat on a theatre table.

During the procedure, a needle is inserted into a vein using ultrasound guidance. The inside of this needle is then wired up, and an EMWA or an EVLA catheter passed, up until the catheter is approximately 1cm away from the top of the leg where the varicose veins frequently stem from.

The next step is a series of local anaesthetic injections - between 10 to 15 - which take five minutes to administer. This is the most uncomfortable part of the operation. I personally add bicarbonate to buffer it so that it doesn’t sting, but without sedation, anaesthesia is the most uncomfortable part.

Once local anaesthesia is administered, the wire is plugged into a box – either an EMWA or an EVLA box – and another ultrasound is performed, to check that that the tip of the probe is in the correct position. A series of treatments are then carried out down the vein to close it off.

The procedure is then repeated, a process that takes between one to three minutes. After this, the ultrasound is also repeated, to ensure that the procedure has been successful.

What is the most effective treatment for varicose veins?

The most effective treatment depends on the patient’s varicose veins and any other underlying conditions that the patient may have (if there are any). Varicose vein treatment has to be tailored to the individual pathology in the patient’s anatomy.

To determine the most effective treatment, a specialist has to: make a good assessment; examine the patient’s medical history; look at the varicose veins and assess them properly; and order a duplex ultrasound to find out what the cause of the varicose veins is and why the patient has them.

There are two parts to varicose veins, and in order to understand how to treat them and how to achieve the best outcome from them, the parts need to be separated.

A varicose vein is an abnormally dilated superficial vein which stretches not only in its diameter, but also in its length. The vein becomes tortuous, as a result, and this is why varicose veins twist a little (because they’re getting longer in length as well as in diameter).

A superficial vein is a vein outside of the muscle. In the legs, deep veins are inside the muscle and superficial veins are outside the muscle. Despite this, there is a layer of subcutaneous tissue between muscle and skin, meaning that many varicose veins sit so deep under the skin that they’re not actually visible.

Hence, in terms of treating varicose veins, the veins that are visible on the surface are similar to the leaves on a tree, in which the root remains hidden. An ultrasound scan is required to find out where the varicose veins actually come from and where they have linked into the deep system.

Treatment for varicose veins can thus be split into two sections: the bit that is seen (the removal of varicose veins that are visible on the surface) and the bit that can't be seen (the removal of the veins that connect varicose surface veins to the deep veins, which need to be checked to make sure they're working properly).

Treatment for surface varicose veins

There are two ways of treating surface varicose veins:

1) Sclerotherapy, using an injection of sclerosant

Sclerotherapy can either be used neatly, diluting it, or turning it into foam, by squishing it with air between a few syringes until it frosts up to increase its surface area for the amount of chemical that’s being used.

Although it’s difficult to predict the exact direction of the foam, sclerotherapy is a relatively effective treatment for surface veins. It works by irritating the side walls of the vein, producing an inflammatory reaction in the body that causes the two walls of the vein to stick together. This prevents the vein from opening back again.

Patients are at risk of getting pigmentation afterwards if red blood cells get trapped within the foam, with the iron from the blood cells that’s being deposited in the skin. This is why sclerotherapy is associated with a 20 per cent pigmentation rate in the post-operative phases. Pigmentation can persist for a long time and even become permanent.

For this reason, sclerotherapy of large varicosities - whilst effective - often needs to be repeated to achieve a complete treatment and isn’t also the most cosmetic of approaches.

2) Avulsion or (ambulatory) phlebectomy

Avulsion is a technique for the removal of varicose veins that involves freezing the skin, making a nick in it, and pulling the vein out.

This might sound brutal, but avulsion procedures represent 80 per cent of all surface vein removals performed worldwide. It also produces the best cosmetic results, because only a small nick (1-2mm long) is involved which heals without a scar.

Avulsion, however, requires an operating theatre for the procedure and is also more uncomfortable than foam sclerotherapy.

Treatment for deep varicose veins

The veins that connect to the deep system are called “the truncal veins”. In general terms, the truncal veins are split into the great saphenous vein (GSV) and the short saphenous vein (SSV), one running up the inside of the leg and up to the groin with the other one running up the back of the calf up to in behind the knee.

If either of these two veins are affected (and usually one of them has to be, for a patient to have visible varicose veins) and left untreated (for example, by only treating the surface veins), this leads to the growth of new leaves in less than 18 months. If a patient had treatment for varicose veins but these returned within a couple of years, then this is usually what has happened: they received injections or avulsions for their varicose veins, but the underlying cause wasn’t untreated, leading to the return of the veins. Where the treatment for underlying truncal varicosity is successful, the recurrence rate drops greatly, down to around 10 per cent (it can’t be 0 per cent).

These veins have a genetic predisposition, with patients usually inheriting them from their parents. Genetics can’t be changed, but specialist treatment can help reduce a patient’s risk of developing varicose veins and also help remove already existing varicose veins.

In terms of treatment, EVLA or EMWA can be used to pass wires up to the veins and then heat them so that they shrivel up. This is the most common method, but there are many other alternatives, including traditional stripping in which the vein is pulled out (this is now performed in certain cases, only).

Foam sclerotherapy can be used for truncal veins as well, although a higher concentration and a higher volume of sclerosant is needed. The procedure also needs to be performed far away from the skin to avoid pigmentation – due to the location of the veins below the surface, there is a greater chance of the foam slipping into the deep system. For this reason, there’s a slightly higher deep vein thrombosis risk associated with foam sclerotherapy compared to other treatments. In head-to-head trials, its success rate also stands at 70 per cent, compared to EVLA or traditional stripping method (which have a 95 per cent success rate). Thus, having a repeat foam sclerotherapy treatment isn’t unusual. Nonetheless, many patients still achieve good results with foam sclerotherapy for truncal veins.

Finally, affected truncal veins can also be glued together with VenaSeal medical glue. This glue squashes the veins flat, thus holding the two walls of the vein together and causing the veins to disappear. This is an expensive treatment in which there’s also a risk of the glue dripping into the deep system, where it can cause severe health issues. However, with care, patients can achieve reasonable results for their varicose veins.

Besides this, there are many different alternatives to try, including a less-concentrated type of foam or even, a steam machine.

If you wish to discuss your options for varicose vein removal, or simply wish to know more about the latest innovations in treatment, do not hesitate to visit Mr Lintott’s Top Doctors profile today.