Surgical treatment of venous insufficiency 

In a healthcare setting where all resources are available, patients with venous ulcers who do not respond to regular treatment with compression and adequate dressings should be referred to vascular specialists. Here the patient will be examined for dilated insufficient veins, which directly communicate with the ulcer area.  These insufficient veins may be visible without aids ( i.e., varicose veins) or may lie deeper such as perforating veins that are only visible using, for example, ultrasound techniques. 

In some cases, a venous ulcer will not heal unless the insufficient veins are treated surgically. Also, treatment of insufficient veins may prevent the recurrence of the ulcer once it has healed. We will not detail the surgical alternatives here because most of our readers will not be involved in the surgical treatment of vein disorders.

 

Until about 2005, open surgery of insufficient veins was the standard treatment method in many western countries.  In many African regions, this may be the only option available. When carried out by an experienced surgeon, it is not a very invasive method, and the results can be excellent.  However, new and minimally invasive procedures were introduced for vein surgery with advances in the medical field.  

Shortly summarized - we usually attempt to solve most venous disorders by endovascular methods. These are mini-invasive procedures usually done in an outpatient setting or as day-care surgery in local anesthesia.  Some methods involve radio-frequency, laser, steam, foam, or glue to close insufficient veins. Smaller veins can be treated using ultrasound-guided injection methods with substances like polidocanol (aetoxysclerol). In some cases, open surgery is needed.​

While these types of surgical treatments are performed at some hospitals and private centers in Africa, they are not available to the majority of the patients there. If you work in a clinical setting where this type of surgery is not an option, you have to do the best out of the means you have available. Ensure that the patient really understands that compression treatment is the key to success and that they use it daily.

A method for treating superficial incompetent veins in areas of relatively limited resources is sclerotherapy. With this technique, substances like polidocanol are injected into the veins at various concentrations depending on the diameter of the veins. Ideally, this is done under ultrasound guidance, but where an ultrasound machine is unavailable, this can also be done under direct visual guidance with some training. The most effective method is to make a foam out of the sclerotizing agent by passing it back and forth between two syringes using a three-way connector. You will find many instructional videos på youtube or Vimeo if you search for sclerotherapy of varicose veins".  Below is a video that explains the basics of this technique. 

Video 1  Link to a video showing treatment of incompetent veins using sclerotherapy.  This is an effective procedure that can be learned with some training and which can also be performed in areas with limited resources. Click on the picture above to get to the film.

You may have a patient previously treated for varicose veins but has developed a venous ulcer nonetheless. Often the reason for recurrence is that the patient does not use compression.  Many patients are unaware that they need to continue using compression treatment even though they have surgically removed some varicose veins.  In other cases, the reason for an ulcer developing (or recurrence) may be a defect perforator vein that lies close to the ulcer.  Perforator veins connect the superficial veins to the deep veins, but when they do not work correctly, blood flows in the opposite direction- from the deep veins to the surface. This can cause ulcers.

We cannot visualize these perforator veins without technical aids- usually, an ultrasound machine is used. With only a little training, it is easy to find these veins. Previously a surgical method called SEPS            (subfascial endoscopic perforant surgery) was widespread. As the name implies, this was done endoscopically ( a thin video camera introduced under the skin). In the video below, this technique is demonstrated.

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Video 2  Link to a video showing the SEPS procedure.  The veins are ligated using metal clips.  Click on the picture above to get to the film - note that the video has no audio. Note: Because of age restrictions for sensitive content on youtube, you must verify your age on youtube to view the video. 

Today, a more modern method is the TRLOP ( transluminal occlusion of perforators)- pronounced "trollop." We use ultrasound-guided techniques to close the perforators using high temperatures delivered by radiofrequency or laser devices.  The video below shows how this procedure is performed. Again, this is a treatment you may find in Cairo or Cape Town, but this is not available to patients with venous insufficiency in most regions in Africa. 

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Video 3  Link to a video showing the TRLOP procedure. Click on the picture above to get to the video. Note: Because of age restrictions for sensitive content on youtube, you must verify your age on youtube to view the video. 

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Figure 1  Some examples of "before and after vein surgery" from Vein Centres South Africa, a private clinic.  If you click on the image above you get to their website and can read more about this type of surgery.  Image copyright: Dr. Johan Blignaut; Vein Centres South Africa.