Since the 1980s, vein surgery has been undergoing a revolution due to the invention of a technique called 'duplex ultrasound scanning'. This non-invasive ultrasound test can look inside the veins and show which way the blood is flowing. As blood only flows one way in normal veins due to the valves, but refluxes back down the veins in abnormal veins which have lost their valves, this test (when performed by a properly trained specialist) can identify the exact cause of the venous problem.
In recent times, starting in 1998, treatments radically changed with the introduction of endovenous surgery. The new treatments are called "endovenous" as the treatment is introduced into the vein, and treats the vein from within.
Treatment for the main (truncal) veins
Almost all venous conditions of the leg, whether varicose veins or due to 'hidden varicose veins' (venous reflux or incompetence) are caused by the failure of valves in the main truncal superficial veins of the leg. These veins; the Great Saphenous Vein (GSV), Small Saphenous Vein (SSV), and Anterior Accessory Saphenous Vein (AASV), are optimally treated by catheter based endovenous techniques under local anaesthetic:
Some specialists use Ultrasound Guided Foam Sclerotherapy (UGFS) for the main truncal veins but it only has very limited success in the medium to long term in most of these cases.
Treatment of Incompetent Perforating Veins (IPV)
The role of superficial veins of the legs is to take blood upwards and inwards into the deep venous system where it can be pumped back to the heart using the venous leg pump. Although a lot of the blood goes through the large junctions between superficial veins and deep veins, there are a lot of smaller communicating veins that perforate through the muscle and hence are called perforators. When the valves do not work in these veins and blood is pumped the wrong way out of them they are called Incompetent Perforating Veins (IPV), and can cause inflammation under the skin, varicose veins, or thread veins. Treatment of Incompetent Perforating Veins (IPV) used to be tying them through large incisions until 1985 when a technique called Subfascial Endoscopic Perforating vein Surgery (SEPS) was described by Hauer. This keyhole technique was the best way to treat IPVs until 2000 when Mark Whiteley and Judy Holdstock invented TRansLuminal Occlusion of Perforators (TRLOP) which is an ultrasound guided pinhole technique.
Treatment of pelvic vein reflux
Over the last decade, it has become clear that a great many women suffer from the consequences of pelvic vein reflux (i.e. varicose veins of the pelvis). This may cause symptoms that all together are called pelvic congestion syndrome, or may be seen on the surface as varicose veins in the vagina, vulva, and upper thighs. When treating varicose veins of the legs, it is often necessary to treat pelvic veins before treating the bulging varices or thread veins in the lower legs. Failure to do so leads to an extremely high chance of these veins returning soon after attempted treatment.
Treatment for bulging varicose veins (varices)
Once the underlying cause of the venous reflux has been treated, any visible bulging varicose veins need to be treated or else stagnant blood in them can cause phlebitis (red inflamed lumps leaving brown staining). The easiest and one of the most effective ways to remove these is 'phlebectomy' - literally the removal of the vein:
Treatment of thread veins of the legs
Research has shown that the majority of people with thread veins of the legs have an underlying cause - venous reflux or 'hidden varicose veins'. Once the underlying cause of the thread veins (venous reflux) has been checked for and treated, thread veins of the legs can then be addressed. Several techniques have been used, and although thread veins on the face can be successfully treated by lasers, IPL, or electrolysis, the optimal way of treating thread veins of the legs is by microsclerotherapy.