AMBULATORY PHLEBECTOMY (AP) and VEIN LIGATION

Ambulatory Phlebectomy (AP) is a surgical procedure allowing outpatient removal of visible veins. Essentially, almost all sizes of veins can be treated with this method.

Originally described by Cornelius Selsus (56 BC – 30 AD)!

Method: local anaesthetic is injected into the skin and a 1-2 mm incision is made. A specially designed Phlebectomy hook is utilised to grasp the vein, which is then extracted through the small incision. Part or whole of the varicose vein is extracted. Sometimes the vein will be ligated (tied off) with suture material and the vein left in place. Sometimes several of these small incisions need to be made. Bleeding is minimal and can be controlled by local pressure.

Complementary methods of venous treatment, including foam injection sclerotherapy and endovenous laser ablation sclerotherapy may be performed at the same time if necessary. The incisions are either left open or are closed by using steri-strips (small “band-aids”). Both legs may be treated in the one session but this depends on various factors, including patient’s wishes, and the extent and type of venous disease present. If follow-up therapy is needed, this would usually be performed two to four weeks later.

What should you do after phlebectomy / vein ligation?

You may be asked to go for a 20-30 minute walk immediately after treatment. If extensive Phlebectomy has been performed then you may be asked to return home and rest, and start your 20-30 minute walks the next day. You may be asked to keep the leg elevated as much as possible for the first 24 hours and walk for 20-30 minutes each day for one week. Maintain normal daytime activities and avoid standing still for long periods. Avoid strenuous physical activity such as aerobics for 2-3 days after treatment since this increases the risk of blood flow returning into the treated veins.

You are required to avoid any flights of longer than 2-4 hours duration for 4 weeks and any flights of greater than 4 hours duration for 6 weeks after treatment. If travel is unavoidable, then anticoagulants should be administered prior to the flight.

Stockings are worn continuously for 4 days and nights. They are then worn continuously for 3 days but removed at night. It is routine practice to perform an ultrasound scan 1 -2 weeks after treatment to ensure that the treated vein has been treated 100% successfully and to exclude the very small risk of DVT. If follow-up therapy is necessary to treat residual veins, this is performed about 2-4 weeks later.

What can you expect following phlebectomy / vein ligation?

The following features are expected. They are not a cause for concern although they should be reported at review:

• Mild pain or discomfort may persist for several days. Usually there is minimal discomfort but soreness can occur behind the knee from the bandage or stocking rubbing on the skin.
• Any discolouration and tender lumps are usually experienced early on. Red raised areas over treated veins are due to “trapped blood” and usually disappear within four to six weeks. At the 2 week review these areas may be pricked to release this trapped blood. Although it does not occur in every patient, this is so common it is considered a normal event that occurs as part of treatment. It is a sign that treatment has been successful. 

What are the possible complications from phlebectomy / vein ligation?

Complications can occur even with perfect technique.

• Post operative bleeding from puncture site (common but minor)
• Haematoma i.e. bruising
• Deep vein thrombosis (DVT) 
  A blood clot can form and extend into the deep veins. The risk is less than 1:2,000 compared to the background risk of about 1:9,000. This potentially serious complication is very uncommon if the protocol of compression and regular daily walking is followed.
  Although DVT post procedure is most uncommon, we at Specialist Vein Care perform Duplex scans routinely on all patients post Sclerotherapy/Endovenous Laser Ablation therapy to exclude this complication.
• Wound infection
• Lymphatic Disruption Lymphocele (Small lymphatic collections), Lymphorrhea (seeping of lymph through puncture site), lymphoedema
• Pigmentation
  Brown marks may appear near or along a treated vein and are due to haemosiderin, a form of iron from the blood. Most disappear within 3-12 months but in about 5% of patients, this can persist past 12 months. This is of cosmetic importance only and persistent pigmentation may respond to laser treatment.
• Nerve injury
  The adjacent sensory nerves can suffer damage, causing numbness (0.05% of cases). Damage to motor nerves is rare.
• Matting
  This is the development of a fine network of veins which produces a small bluish blush on the skin surface. This occurs most commonly on the inside of the knee in women. Approximately one third resolve spontaneously (this can take up to 6-9 months), one third can be treated by sclerotherapy, and about one third may be permanent. The cause is unknown and is of cosmetic importance only.
• Hypertrophic scars
• Blistering from bandages