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The Nursing Mirror - 02 September 1966

W. G. FEGAN, M.Ch., F.R.C.S.I.

I hesitate to attempt to popularize the injection technique which I have devised as a treatment for varicose veins, because of the high failure rate and the bad results obtained with it by people who fail to appreciate the great importance of a few simple, but essential, features of the method. It is also possible, even after understanding and executing the technique perfectly, to get a bad result if one does not explain skilfully and simply to the patient, his or her part in the procedure. The patient must be made to understand that the treatment by the doctor has only initiated a process in his veins, the outcome of which depends largely on the patient's co-operation.

It is true that the results of surgery on varicose veins, by good surgeons, are excellent. Unfortunately, most good surgeons are extremely busy, and vein cases simply accumulate to become a formidable waiting list. It is for this reason, among others, that this treatment is so valuable. When a patient enters hospital for an operation on his veins, he is away from his job and home for a week or so, he occupies a bed in a surgical ward for several days, is in an operating theatre for up to three hours, and runs all the risks of general anaesthesia. He may even die. All these disadvantages are avoided by injection treatment, which is performed as outpatient procedure with no risk. It takes up little time, and interferes with the patient's activities and work very little, if at all.

Varicose veins in pregnancy are particularly suitable for injection treatment, which gives great relief to the patient, while few surgeons will operate on such veins. The treatment of varicose veins in pregnancy is, in fact, very important, as early treatment prevents the veins from becoming worse as pregnancy progresses, and greatly reduces the risk of thrombophlebitis in the puerperium. Vulval varices, too, can be treated very satisfactorily by injection.

Varicose veins have been treated by injections of one sort or another for over 100, years, and it is important to appreciate the marked differences between the results of the old methods of injection and the new.

The results of the old technique was the formation of a large thrombus occupying a considerable length of superficial vein. When the pain and tenderness associated with this had subsided, the effect seemed satisfactory. Unfortunately, within a matter of months veins very often re-opened, the fibrosed thrombus forming a thickening along one side of the vein, while the rest of the wall became thin, sacculated and varicose. An even more unfortunate aspect was the fact that this process often spread, to involve normal veins, and, in particular, the perforating or communicating veins which normally carry blood from the superficial veins to the deep. The fibrosis and re-opening in these veins damaged previously normal valves, rendering them incompetent.

The seriousness of this effect is seen when it is realized that the case of varicosis of the superficial veins is incompetence of the valves in the perforating veins. One of the main forces returning blood from the lower limbs to the heart is the pumping effect of the muscles. When they contract, they compress the deep veins, and since these veins have valves, the blood is pumped towards the heart. The valves in the perforating veins normally prevent blood from flowing out into the superficial veins. However, if these valves are incompetent, each muscular contraction will pump blood under high pressure into the superficial veins, causing them to dilate and become varicose. The signs and symptoms of varicose veins are not due to the veins themselves, but to the fact that, with such leaks, the pumping action of the muscles becomes ineffective, and venous return is reduced, producing a state of chronic venous congestion in the limb.

The aim of the new method of injection treatment is to block the incompetent perforating veins, keeping the effect of the injection carefully localized in order to avoid damage to normal veins. With the leaks closed, the venous pumps are restored to efficiency, and the venous congestion disappears.

With the patient standing, the doctor carefully marks with a skin pencil all the superficial veins which can be seen or felt. The incompetent perforating veins can often be found on palpation, as there is usually an opening in the deep fascia through which they pass. Their presence is confirmed by lying the patient down, raising the leg to empty the veins, and then occluding the suspected perforating veins with the fingers. The patient then stands, while the pressure of the fingers is maintained, and the leg is watched to see if the filling of the veins has been controlled. It is usual to find that pressure on two or three sites will control the filling of a large complex of veins, and these are chosen for injection.

The patient sits on a couch with the legs straight in front. The skin is swabbed with antiseptic, and the needle is introduced into the vein at the chosen site. Twenty gauge disposable needles on 2 ml. all-glass syringes are used, as these make it easy to detect when the needle enters the vein. Once this has occurred, the syringe is steadied against the leg, the patient lies back and the leg is raised to empty the veins. The vein is occluded above and below the injection site by finger pressure, and ½ -1ml. of the sclerosant, sodium-tetradecyl, is injected.  A 3 in. cotton bandage is applied immediately, and the fingers isolating the injection site are not removed until just before a turn of bandage covers it.  A piece of sponge rubber, with bevelled edges, is placed over the site and bandaged into place.  After the desired number of injections has been given, the leg is bandaged from the roots of the toes up to above the highest injection. It is never necessary to give an injection higher than the mid-point of the thigh.

The bandaging technique is very important. It is wise to do it by feel rather than by sight, with one hand holding the bandage and the other assessing its tension. The bandage follows the contour of the leg, with reverse turns made whenever necessary, rather than a neat spiral.  This method does not produce a tidy pattern, but the bandages will remain in place for up to six weeks. It is absolutely imperative that the leg, following bandaging, should be subjected to even pressure, and that there should not be a tight zone immediately above a loose one, or the patient's leg will look like the Mr. Michelin advertisements on the return visit.

A full-length elastic stocking is then put on, and the patient instructed to wear it continuously, day and night, until the next visit. The stocking is important in preventing disturbance of the bandaging, and in maintaining compression following the disappearance of oedema. The patient is advised to walk at least three miles every day, and strongly warned against standing still. When not walking, the patient should sit, with the legs elevated if possible.

At the next visit, a fortnight later, the sites of injection are examined, and any further necessary injections are given, up to a maximum of five at one sitting. The bandages and stocking are re-applied. Compression is maintained for six weeks after the last injection, by which time the veins at the injection sires are hard, painless cords, and the rest of the veins have regained their normal size. With the efficiency of the venous pumps restored, the signs and symptoms disappear.

The compression is of great importance, because it is this which prevents re-opening of the injected vein. The sclerosant does not cause clotting of blood, but damages the intima of the vein. The damaged surfaces are kept in close apposition, with as little blood between as possible, by immediate and continued compression. Organization and fibrosis can then occur, plugging the vein with fibrous tissue. The tendency to re-open veins injected by this technique is small, and most of the recurrences appear in the first year, but overall results are as good as those produced by operative treatment.

In order to deal with the large numbers of patients (50 new ones each week) the treatment is given in a clinic specially designed for the purpose. The patients enter a waiting-room, in which they are weighed and measured, and given cards explaining the treatment and the importance of their co-operation. Samples of blood and urine are taken, and patients with diseases other than varicose veins are separated out. Each patient is then brought into the treatment room in which there are couches, with one doctor and one nurse to each couch. The history is taken, and recorded on a punched card. Patients who are more than 10 per cent. overweight are advised to reduce before treatment. The leg is examined, and the treatment is then given, the site of each injection being recorded on the card. Adequate numbers of pre-loaded syringes and 3 in. cotton bandages are kept beside each couch. Cotton bandages without elastic are used because they are stiff transversely, and do not exert excessive tension. Elastic bandages can be very dangerous if arteriosclerosis is present, and are not used. If an ulcer is present, a dry sterile dressing is applied, and the injections given in the usual way.

When all the injections have been given, the patient walks to the other end of the O.P.D. to get an elastic stocking put on, and then makes an appointment to return in a fortnight. The importance of walking, avoiding standing still, and of keeping the bandages and stocking on all the time, are continually emphasised.

Pregnant patients are treated in a similar clinic,, and injections are given up to the eight month of pregnancy. Injections for vulval varices are given after preparation of the vulva, and pressure is exerted by two sanitary pads and a tight pair of pants.

The treatment of varicose veins by injection produces results as good as the best surgery, provided that there is meticulous attention to detail at all stages of treatment. The co-operation of the patient is essential, and every effort must be made to ensure that it is given.

The treatment should be given only in large clinics specifically designed for the purpose, and where a large number of cases are seen.

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