Therapies

We already know from before the common era of presentations of varicose altered limbs and therapeutic measures such as puncturing the varicose veins for relief, burning with a glowing iron, and surgical trials of therapy. The treatment today aims at the normalization of hemodynamics and at the improvement of symptoms as well as the avoidance of complications. Primary varicose veins are well accessible for curative therapies. In the meantime, there are a lot of technologies and concepts. We would like to give you a short overview with the following information. Please do not hesitate to contact us via our contact form under contacts if you need further information.

The treatment today aims at deactivating the affected vein with least adverse events. In addition, the tendency goes toward ambulatory varicose vein surgeries due to the pressure on costs from in-stationary services for years. For this reason, it is possible to distinguish the treatment between minimal invasive and invasive treatment. In the following, we will go into detail in regard to the individual technologies.

Surgery

The classic option to treat varicose veins is surgery. During the procedure, the generally called “stripping” of the affected larger branched varicose veins (perforating veins) as well as the truncus veins are treated. In case of a stripping, a flexible special probe is inserted into the pathologically dilated vein up to its end and, there, it is diverted. The varicose vein is then cut above and below and foxed on the probe taking away (stripping) the varicose altered vein under the skin. The stripping surgery is possible under general or local anesthesia; it can be performed ambulatory or stationary. The main factor here is the severity of the findings as well as the mental state of the patient. After the surgery, a compression with elastic stockings is recommended for 3 to 6 weeks, and, in order to avoid thrombosis, an anticoagulation therapy with heparin is also recommended.

There are also other surgical procedures such as invaginate mini stripping (PIN stripping). Here, the vein is pulled out through itself. A probe with a mini head is inserted into the truncus veins and removed through these veins. “Here, the vein is pulled out through itself.” In contrast to the classic stripping procedure, the cuts are significantly smaller. In most cases, the stitch incision heals without any scars. This is also a standard procedure. The disadvantage of this procedure is that it is not completely possible to remove the veins in case of closures. Another surgical procedure is the crossectomy. It is usually combined with the stripping of varicose veins. The expression crosse originates from the French and means “crosier”, “crook” or “bishop’s crook”. Crosse means the arched part of the V. saphena magna (or parva) next to the body, i.e. the segment of the superficial varicose vein branching into the deep vein. The classic varicose vein surgery starts with the crossectomy. The crossectomy includes the section of the superficial varicose vein (V. saphena) at its branch in the deep venous system, whereas the “hole” to the deep vein is tied up (ligature). In the area of the crosse, several smaller vein branches branch into the vena saphena, and for this reason this anatomic area is also called “venous star”.

The surgical section of the V. saphena from the deep vein including the ligature of all side branches branching in this area is called crossectomy. In case of the surgery with the affected V. saphena magna, the crossectomy is performed via an incision at the crista. In case of the surgery with the affected V. saphena parva, the crossectomy is performed via an incision at the popliteal region. Following the crossectomy, varicose vein stripping is usually performed. This is also a procedure that is very often applied.

Sclerosing (varicosclerozation)

This varicosclerozation procedure is often performed to treat retiform collections of varicose veins. In this case, a sclerosing agent (e.g. preparations with unsaturated fatty acids, preparations containing polidocanol (please also refer to further information below), highly concentrated sodium solutions (NaCl) or high percentage glucose solutions) is injected into the vein. This therapy provokes an artificial inflammation of the inner wall of the vessel within the vein and that leads to a conglutination and, therefore, to the occlusion of the veins. Well sclerosed veins are permanently occluded and there is no more blood flow. This results in better conditions in the leg as the venous blood that must be transported toward the heart does not form any more blood pools in the defect vein. Immediately after the sclerosing the incisions are conglutinated and elastic stockings are pulled over the treated leg. Larger varicose veins may be occluded by means of sclerosing foam. In this case, the sclerosing agent is mixed up with air to produce fine-bubble foam. This foam has a larger surface as liquid and is, therefore, more effective. By the use of always smaller catheters under ultrasound supervision, the range of implementation options has enormously grown over the past years. Furthermore, the procedure with sclerosing foam is relatively painless; it is fast and can be performed ambulatory.

Polydocanole:

Mono prepartions: Aethoxysklerol (D, A, CH), Anaesthesulf (D), Asclera (USA), Recessan (D, A), Sclerovein (CH)

Combination preparations: Acoin (D), Antidry calm (CH), Assan rem (CH), Balmed Hermal Plus (A, CH), Balneum Hermal Plus (D), Brand- und Wundgel (D), Dentalgin (A), Dentinox (D, A), Eludril (CH), Lindosan (A), Linola Fett-N Ölbad (D), Optiderm (D, A), Pruri-med (CH), Prurimix (A), Solcoseryl (D, A, CH), Sportusal Emgel/ Spray sine heparino (CH), Venucrem (CH), Vonum (A)

Endovascular surgeries

The endovascular laser therapy or endoluminal laser therapy (ELT) and the radio wave therapy (RWT) are relatively new minimal invasive treatment procedures for varicose veins. It is a very conserving surgical vein procedure with many benefits for the patient.

Radio wave therapy

The radio wave surgery of the veins has already been performed since the beginning of 2000 and offers many benefits for the patient. Comparable to the laser, the vein is not pulled out but occluded by the thermal destruction of the intima and wall of the vein. The surrounding tissue is protected by means of a special procedure (tumescence) through the injection of normally 300-500 mL sodium solution around the vein. This procedure securely prevents the thermal damage of the skin and other organs. In principle, all anesthesia procedures are possible (even a local anesthesia); as normally all side branches are also removed during the surgery, it is usually performed under local or general anesthesia. If the side branches are not touched, they must be removed during another surgery. The surgery can be performed for both legs – even in case of extreme varicose veins – without an increased risk at the same time due to the extensively reduced loss of blood. Apart from the much cheaper postoperative course (less hematomas, faster fitness to work, less scars) even patients with an increased risk for anesthesia and surgery benefit from this surgical procedure.

Endovascular laser therapy (ELT)

In case of endovascular laser therapy, a laser light conductor is directly inserted into the small or large truncus vein. The laser energy induced via the light conductor results in the occlusion of the damaged vein section. The insertion of the laser catheter is always performed ambulatory comparable to the RWT via a small venipuncture site under ultrasound supervision, whereas practically no scars and only minimal hematomas may arise. The patient benefits from very good cosmetic results, a short recovery phase, and only slight postsurgical pain. A repeated intervention is normally not required. Immediately after the surgery, the patient is able to stand up and move. The patient is also able to perform normal activities again on the first day after the laser therapy. Strenuous physical activities are not allowed and sports are not allowed for two weeks.

The absorption of the laser energy is performed within the intracellular fluid of the wall of the vein as well within the water portion of the blood. This irreversibly thermal damage induced by laser energy results in a complete occlusion of the treated vein. At the beginning, a laser with a low wavelength of 810, 940, and 980 nm has been used. In recent years, systems with a wavelength of 1,470 nm analog to the optimum absorption spectrum of water (main component of human blood) have been established. The probes used at the beginning only had a limited axial radiation angle. Radially radiating probes (360°) have been offered since 2008. The radially radiating probe results in a clearly increased field of action, and, therefore, extremely less energy is required. A reduction of the required energy results in not so high temperatures in the area around the probe.

Rare procedures:

Kyro-technique (icing)

A catheter is inserted into the truncus vein. The probe is pulled out after deep-freezing with the attached vein. This procedure is rarely used today.

General difficulties

The treatment of varicose veins leads to a relief from the symptoms. However, it is also possible that after 5 to 7 years varicose veins develop again. As a chronic disease with a genetic cause there is no possibility today to actively perform a therapy against the development of varicose veins – but it is possible to reduce the symptoms by diverse measures eliminating the varicose veins.

Therapies in case of further chronic venous diseases:

Deep leg vein thrombosis

Only a fast diagnosis and therapy of the thrombosis effectively prevent the development of pulmonary embolisms. In case of symptomatic patients, it is possible to induce an anticoagulation based on a positive compression sonograph. In case of negative findings, a final diagnosis via duplex sonography or phlebography should be envisaged immediately.

Hemorrhoids

Hemorrhoidalia are ointments and creams to treat hemorrhoids, but they can also reduce the symptoms. However, it is not possible to heal or stop the progression of the disease. It is possible to slow the progression of the disease some with a basis therapy. Healing is only possible with a surgical procedure. In the early stage of the disease, the interventions can be performed ambulatory or in a minimally invasive way. In case of hemorrhoids at a later stage, healing is only possible with surgery and a stationary stay. This may be prevented by an early therapy. In many cases, the affected people only go to the doctor if pain and inconvenience outweigh the sense of shame.

There is no universal way of treatment. Normally, ambulatory interventions are sufficient for hemorrhoids of stage 1 and 2. For hemorrhoids of stage 3 only surgery is the possible option. Sclerosing of hemorrhoids, also called obliteration of hemorrhoids is a therapy option for symptomatic hemorrhoids of the first or second stage. Sclerosing of hemorrhoids is a minimal invasive intervention that is normally performed ambulatory. No anesthesia is required here. The tissue to be sclerosed is largely insensitive to pain. Sclerosing is the option for the treatment of hemorrhoids of the first stage. Two sclerosing procedures have been established.

Sclerosing according to Blond and Hoff

Intrahemorrhoidal sclerosing was first described by Kasper Blond and Herbert Hoff in 1936. The treating physician injects with a syringe the sclerosing agent through a proctoscope into the tela submucosa (submucous). A blue-glassy coloration of the mucous membrane displays the correct injection visually through the proctoscope. The injection into the tela submucosa is painless as the tissue above the linea dentata has no free nerve terminals and is, therefore, less sensitive than below the linea dentata. Sclerosing is repeated in three to five sessions over approx. four to six weeks. The inflammatory reaction provoked within the hemorrhoidal padding leads to a scarring of the tissue and that reduces the arterial blood flow. Furthermore, the loose mucous membrane is fixed. In the meantime, sclerosing agents with a clearly smaller allergen potential such as polidocanol or zinc chloride solutions are used. This procedure is normally suitable for hemorrhoids of stage 1 and 2. In Germany, sclersing according to Blond and Hoff is the most common method to sclerose hemorrhoids.

Sclerosing according to Blanchard

Charles Elton Blanchard described suprahemorrhoidal sclerosing in 1928. This kind of sclerosing uses phenol, mostly as 5% solution in almond or peanut oil, as a sclerosing agent that is injected in the area of the arteries supplying the hemorrhoidal paddings in a paraventricular way. Here, a postinflammatory reaction provokes the fixing of the hemorrhoidal knot above the linea dentata, too. The application of phenol poses a legal problem in Germany for human use. Therefore, it is the sole responsibility of the physician (freedom of therapy). This method is in particular used in the Anglo-American area in case of symptomatic hemorrhoidal diseases of stage 1 to 3.

From an international point of view, sclerosing according to Blanchard is the most used sclerosing procedures in case of hemorrhoids.

The treatment can also be performed by the general practitioner, surgeons, dermatologists, gynecologists, urologists, or proctologists. Proctologists are specialized on the treatment of rectum diseases. For this reason, a proctologist is normally very used to the diagnosis – and in particular the differential diagnosis – and the treatment of hemorrhoids. The statutory health insurance normally covers the expenses for the treatment.

Lipedema

The medicinal induced liposuction is a procedure to remove excessive, pathological body fat that is not subject to weight reduction. The fat removed during this surgery is lost and will not build up again at the treated sites. Unfortunately, the lipedema is not healed as it is not curable. For this reason, special attention should still be paid to nutrition and physical activity as it is very important.

It is possible to perform the liposuction with different techniques. But in fact, there are only two techniques that are approved methods in regard of the liposuction of the lipedema, i.e. the WAL and the TLA technique. Today it is known that these procedures are very protective to the tissue and DO NOT damage the tissue. At the moment, there are not that many plastic surgeons who are proficient in these techniques, so be careful. However, we are not allowed to give further information.

Technologies of liposuction:

WAL technique:
Water beam assisted liposuction (water jet liposuction)

The water jet liposuction (WAL) is a very new method on the plastic-surgical market to suck fat. It is a very protective and fast method. It is based on the liposuction in the field of tumescence local anesthesia. The surgeon uses a very fine water beam during the WAL procedure. With this water beam it is possible to loosen the fatty tissue from the remaining tissue in a very protective way. This intervention requires approx. 70 percent less tumescence solution. The less intensive tumescence solution extremely limits the bloating of the body and facilitates the evaluation of the modeling for the surgeon. The duration of the surgery is shorter as no long application time must be taken into account. The surgeon can terminate the work after approx. one to one and a half hour.

The pressure of the water beam is perfectly adapted to the different connecting tissue structures so that the surgeon is able to selectively loosen the fatty depots. In addition, there is a second channel at the cannula. This is for the suction of water and of the extracted fat. The advantage is that fat cells and also a large amount of local anesthetic agent and tumescence solution can be extracted. This clearly reduces the medication and sodium solution load for the patient.

The benefit of this surgical procedure is that the surgeon is already able during the surgery to evaluate the result. He/she is able to balance out the dells and bumps. The patient is conscious during the procedure unless the patient opts for a twilight sleep or general anesthesia. But this is normally not necessary due to the local anesthesia. Furthermore, it is also possible to inspect the result during the surgery.

TLA technique:
Tumescence local anesthesia

The liposuction under tumescence local anesthesia is one of the most often performed surgical techniques in Germany. A syringe with tumescence fluid is injected in the patient before the intervention. This fluid results in the swelling of the fat and then, the suction is easier. The skin seems to be swollen after that. The tumescence fluid that was injected into the patient before also contains the local anesthetic. Dispersion is very good in combination with tumescence fluid and that leads to the non-sensitivity at the site of fat suction for the patient. The body organism is protected by doing without a general anesthesia. Furthermore, the surgeon can ask the patient to stand up during the treatment.

This is good for the removal of the remaining fatty depots that are not visible in a lying position. In total, a fat volume of up to four liters can be sucked during one session. This surgical procedure is protective for the surrounding tissue, nerves and larger blood vessels. Infections or so-called seroma are very rare after the liposuction. Seroma is a small cavity where lympha are collected. It is very simple to suck it out.

The suction is performed by means of very fine cannulas. With a slight swinging of the hand it is possible to slightly rock and suck the fat. It is also possible to treat sensitive parts such as the knee or ankle with this procedure.