Treating varicose veins with foam injections

• Varicose veins are veins under the skin of the legs which have become tortuous, widened, and bulging (varicose). Varicose veins are very common and do not cause medical problems in most people.
• Blood flows down the legs through the arteries and back up the legs through the veins. The main systems of deep veins, carry most of the blood back to the heart. The veins under the skin (superficial veins), are less important and can form varicose veins.
• All veins contain valves which should only allow the blood to flow one way. If the veins become widened and varicose, these valves no longer work properly. Blood can then flow backwards down the veins and lead to increased pressure when standing, walking, or sitting. Lying down or ‘putting your foot up’ relieves this head of pressure and usually makes the legs feel better.
• The symptoms and treatment depend on how badly the valves in the veins are working, although the trouble people get from their varicose veins is variable. Varicose veins often appear first in pregnancy, when hormones relax the walls of the veins and when the womb presses on the veins coming up from the legs.
• People who are overweight are more likely to get varicose veins and to find the symptoms troublesome. Bad varicose veins can run in families, but this is not always the case. Usually there is no special cause for varicose veins.
• Varicose veins should not be confused with more superficial spider and thread veins which lie within the skin not deep into it.

• Although varicose veins can get worse over the years, this often happens very slowly. Worrying that ‘they might get worse’ is not a good reason for treatment. Most varicose veins do not require medical attention.
• In a few people high pressure in the veins causes damage to the skin near the ankle, which can become brown in colour, sometimes with scarred white areas. Eczema (a red skin rash) can develop. If these changes are allowed to progress or the skin is injured, an ulcer may form. Skin changes are a good reason for going to see your GP and for referral to a specialist.
• Other problems which varicose veins occasionally cause are phlebitis and bleeding. Superficial venous thrombosis (sometimes called thrombophlebitis) means inflammation of the veins accompanied by thrombosis (clotting of blood) inside the veins which become hard and tender. 
  This is not the same as deep vein thrombosis (DVT) and is not usually dangerous. It does not mean that the varicose veins must be treated, though treatment is recommended for recurrent attacks.
• The risk of bleeding because of knocking varicose veins worries many people, but this is rare. It will stop with firm pressure on the area and the veins can then be treated to remove the risk of further bleeding.

• Many varicose veins do not have to be treated at all unless they are causing serious symptoms, such as recurrent phlebitis, bleeding, or ulcers.
• If simple measures have failed and the symptoms from your veins are significantly affecting your quality of life you should consider a surgical procedure. All procedures have their risks; deaths from blood clots passing to the lungs following vein surgery has been reported (see Deep Vein Thrombosis below).
• Aching, itching, and heaviness of the legs can often be relieved by support stockings or tights. Your GP can prescribe firmer and more effective ‘graduated compression stockings’ if ordinary ones are not helpful enough, these usually need only to be below the knee, rather than full length stockings.

• Varicose veins can be dealt with by injection treatment (sclerotherapy). An irritant substance is injected into the veins which causes local inflammation and seals off the vein.
• Larger varicose veins may be treating using radiofrequency ablation with or without foam sclerotherapy - this is a surgical intervention which uses radio waves. We rarely do open surgical stripping of the veins as newer techniques are as effective, less invasive, and have a shorter recovery time. The treatments we offer are “walk in walk out” procedures and you will not need to stay in hospital.

• Injections by foam sclerotherapy using ultrasound guidance is a newer technique that allows larger veins to be treated.
• Several needles may be required to complete one treatment. Some patients need more than one treatment session.
• The foam is made by mixing air with an irritant substance (we use a product called Fibrovein™). Your leg is then elevated and you are asked to move your foot up and down to keep the blood moving in the deep veins.
  The foam is injected and followed as it moves along inside the vein using the ultrasound. Pressure is applied for a few minutes over the vein and a firm compression stocking is fitted and worn for 2 weeks.
• Foam sclerotherapy is an alternative to a surgical procedure tying off the vein (‘high tie’) and removing the vein surgically (‘stripping’).
• Although foam works effectively, long term results are unknown. Recurrence of varicose veins should be considered and may require future treatment.

• Not all veins are suitable for foam sclerotherapy treatment. During assessment of the veins we use ultrasound to see if foam can be used to treat.
• Foam sclerotherapy works by destroying the lining of the vein. This causes the vein to shrivel up and your body absorbs the remaining tissue over time. You may notice some discomfort or discolouration of the skin.

• We aim to do any procedure within 18 weeks from the time you were referred by your GP. We do not like to keep people waiting for a long time but have to deal with patients based on medical priorities. Those with more serious symptoms such as skin changes or ulcers are prioritised.
• Delays are caused by heavy demands on staff and resources. There are particular problems dealing with varicose veins because large numbers of patients are referred. This means there is a limit on the number of operations which can be done, while also dealing with other conditions which are a serious threat to life or health.
• In Bristol and Weston-super-Mare GPs have clear guidelines from integrated care boards (ICBs) for assessment and referral for treatment. Funding for treatment is confirmed before referral.

Most foam procedures are done as a day case. 

The hospital requires you to sign a consent form - as for any operation. 

You will not need to starve for foam injections but avoid a large meal immediately before the procedure. It is important to drink plenty on the day of the procedure as being dehydrated will cause the veins in your leg to shrink. 

You do not need to shave before foam injections. 

Painkillers are not routinely prescribed though you may wish to take paracetamol. 

• Immediately following the procedure you will be able to get up and dressed. You will walk to the recovery area and have a drink.
  Before leaving you will be given discharge information and aftercare instructions. Staff will check your leg for any bleeding, which is usually not much.
• You will be given an advice leaflet following your procedure. A discharge summary will be send to your GP to inform them of your hospital day case stay.
• You will be put in a compression stocking after the procedure with a bandage over the top. We usually ask you to wear both the stocking and bandage for 48 hours - so you will not be able to shower during this time. Following this you should be able to remove the compression stocking and bandage to shower. After you shower put the compression provided back on. You should do this for 2 weeks, only removing the compression to shower and sleep.
• If struggle to get the stocking on and off you can leave it on for a week or two, but you will not be able to shower.

Why wear support stockings? 

Wearing a compression stocking is recommended to reduce the risk of DVT. They can also provide support for comfort and reduce swelling.

When can drive? 

You should avoid driving a car for 24 hours after the procedure.

When can I return to work and play sports?

You can return to most sports as soon as you feel able. Avoid swimming and horse riding for at least a week and until all wounds are dry. 

When can I fly? 

• You should avoid long haul flights for six weeks after the procedure due to the risk of DVT.
• The risk from short haul flights is lower but should be avoided for four weeks after the procedure.

• Serious complications are uncommon. Occasionally the vein may not be completely seal after foam injections. In these cases a further attempt or a standard surgical operation may be offered.
• A small number of patients may experience brief side effects during foam treatment including lower back pain, chest tightness, confusion, migraine, coughing, faintness, panic attack, or visual disturbance. Visual disturbance has been reported by up to 6 percent of patients (6 in 100 patients). There are no reports of long term visual problems following foam treatment.
• Foam injections cause local inflammation which can cause mild discomfort, hard lumps where the veins were and brown staining of the skin. Rarely it is necessary to have trapped blood released a few days following the procedure.
• You are advised to avoid sun exposure for at least 6 weeks following treatment to reduce skin discoloration over the treated veins.
• Very occasionally the injections cause an allergic reaction.
• After any vein treatments tributaries of the vein (smaller veins) may remain.
• Aches, twinges, and areas of tenderness may all be felt in the legs for the first few weeks after the procedure. These will all settle down and should not stop you from becoming fully active as soon as you are able.
• Infection is an occasional problem. It usually settles with antibiotic treatment.
• Nerves under the skin can be damaged by the treatment. This is uncommon, but will give an area of numbness on the leg, which settles or gets smaller over weeks or months. If a nerve lying alongside one of the main veins under the skin is damaged, then a larger area of numbness can be caused. If this happens then numbness will happen over the inner part of the lower leg and foot.
• If a main vein behind the knee needs to be dealt with, then there is a risk to the nerve which gives feeling from the skin on the outer part of the lower leg and foot.
• Deep vein thrombosis causes swelling of the leg and can result in a blood clot passing to the lungs. It is a possible complication after varicose vein treatment, but is particularly unlikely if you start moving your legs and walking frequently soon after the operation.
• If you are taking the contraceptive pill/or are taking HRT, your risk of thrombosis is increased and the surgeon will discuss with you the pros and cons of stopping the pill or continuing it and taking special action to reduce your risk of thrombosis. If you start taking the contraceptive pill while waiting for your procedure, let the hospital know.

Some people develop new varicose veins during the years after a varicose vein procedure. Rarely, varicose veins simply re-grow in the areas which have been dealt with or else they develop in a different system of veins which were normal at the time of the original operation. If veins develop again, they can usually be dealt with by further treatment should they be troublesome.