Endovenous Laser Treatment for Large Varicose Veins in Chester

Large varicose veins can be particularly noticeable, but their size is only one part of the clinical picture. Prominent veins across the thigh, calf or behind the knee may be connected to an underlying superficial vein in which the valves are no longer controlling blood flow effectively. This is known as venous reflux.

For suitable patients, endovenous laser treatment for varicose veins, also known as EVLT or EVLA, can be used to close the faulty vein responsible for the problem. The treatment is performed from inside the vein using a fine laser fibre and usually requires only local anaesthetic.

Vein size does not automatically rule out laser treatment. Current European vascular guidance specifically addresses very large saphenous veins and supports consideration of endovenous thermal ablation in appropriately selected patients.

At Vein Solutions in Chester, we decide whether to use laser treatment based on a clinical examination and duplex ultrasound, not the veins’ appearance alone.

Large Varicose Veins

A large varicose vein is usually a dilated superficial vein that has become enlarged, tortuous or raised above the surface of the skin. Some develop into prominent rope-like veins running down the leg, while others form clusters around the calf, thigh or knee.

There is no single diameter that defines every visible varicose vein as large. More important is the relationship between the visible vein and the deeper superficial venous system.

One of the common sources is the great saphenous vein, which runs from the foot up the inner aspect of the leg towards the groin. The small saphenous vein, running predominantly along the back of the calf, can also develop reflux.

When valves in one of these veins become incompetent, blood can flow backwards when a person is standing. This increases pressure in connected veins and can contribute to increasingly prominent varicosities.

Patients interested in the wider process behind this condition can find further information on varicose veins and venous insufficiency.

Size Is Not The Only Consideration

It is easy to assume that a very large vein requires a more invasive treatment than a smaller one. Modern venous treatment does not work on that principle.

A large vein visible on the skin may be a tributary receiving abnormal blood flow from an incompetent saphenous vein. Treating only the visible bulging vein without identifying the source of reflux can therefore leave the underlying problem untreated.

Conversely, a large saphenous trunk may itself be suitable for endovenous laser treatment.

Vein diameter, anatomy, reflux pattern, previous treatment, proximity to nerves and the condition of the deep venous system all influence treatment planning.

This is the reason an assessment is required before recommending EVLT.

Ultrasound Assessment

A venous duplex ultrasound scan provides information that cannot be obtained simply by looking at the leg.

The scan combines conventional ultrasound imaging with Doppler assessment of blood flow. It allows the vascular specialist to examine the superficial and deep veins, identify reflux and map the veins involved.

NICE recommends duplex ultrasound to confirm varicose veins, determine the extent of truncal reflux and plan treatment for people with suspected primary or recurrent varicose veins.

For a patient with large varicose veins, the scan can establish whether the visible veins are associated with reflux in the great saphenous vein, small saphenous vein or another part of the superficial venous system.

This distinction directly influences the treatment plan.

Venous Reflux and Large Veins

Healthy leg veins contain valves that help blood flow upward toward the heart. Muscle contraction in the calf also helps propel blood through the veins.

If the valves become incompetent, some blood falls backwards between muscle contractions. This is venous reflux.

Persistent reflux raises pressure within the superficial veins. Over time, affected veins may widen and become more tortuous. Tributaries connected to them can then become the large varicose veins visible beneath the skin.

Symptoms are not necessarily proportional to vein size. A person with very prominent veins may have relatively few symptoms, while somebody with less dramatic veins can experience considerable aching, swelling or heaviness.

Symptoms associated with venous insufficiency can include aching, throbbing, itching, cramping and a feeling of heaviness or fatigue in the legs. NICE also recognises that chronic venous insufficiency can progress to inflammatory skin changes and ulceration in some patients.

Symptoms Associated With Large Varicose Veins

Large varicose veins may initially be regarded as a cosmetic concern. For some patients, however, they come with symptoms that become more noticeable after prolonged standing.

These can include aching or tenderness, heavy legs, ankle swelling, itching and localised discomfort around prominent veins.

Some veins become particularly firm or painful following superficial thrombophlebitis. Others are associated with skin pigmentation, venous eczema or changes to the tissues around the ankle.

A vein that suddenly becomes painful, red and hard requires assessment. Bleeding from a varicose vein also needs medical attention. NICE recommends immediate referral to a vascular service for bleeding varicose veins.

Patients experiencing persistent discomfort may also find the information on varicose vein pain useful in recognising symptoms associated with venous disease.

EVLT For Large Veins

EVLT treats the incompetent vein from within rather than removing it through a conventional surgical incision.

A fine laser fibre is introduced into the affected vein under ultrasound guidance. Laser energy produces controlled thermal injury to the vein wall, causing it to close. Blood then continues through functioning veins within the leg.

The closed vein is no longer required for normal circulation. Over time, it gradually becomes fibrotic and is broken down by the body.

NICE describes endovenous laser treatment as a minimally invasive alternative to surgical stripping of the long saphenous vein.

The procedure differs from using a laser on the skin’s surface. The energy is delivered inside the vein at the treatment site.

Very Large Saphenous Veins

Vein diameter deserves particular attention because older approaches sometimes favoured surgery for very large saphenous veins.

More recent evidence has changed this view.

The 2022 European Society for Vascular Surgery clinical practice guidelines discuss very large saphenous trunks separately. The guideline notes that definitions vary between studies, with reported thresholds ranging from more than 8 mm to more than 15 mm.

For an incompetent great saphenous vein with a truncal diameter greater than 12 mm, the ESVS states that endovenous thermal ablation should be considered.

This is particularly relevant to patients concerned that their veins are “too big” for laser treatment.

Large diameter alone does not determine suitability. Ultrasound findings and individual anatomy remain central to the decision.

NICE Guidance For Laser Treatment

UK guidance also places thermal ablation firmly within the treatment pathway for varicose veins.

For patients with confirmed varicose veins and truncal reflux, NICE recommends offering endothermal ablation. EVLT is one form of endothermal ablation.

If endothermal treatment is unsuitable, NICE recommends ultrasound-guided foam sclerotherapy. Surgery is considered if foam treatment is also unsuitable. NICE also advises treating incompetent varicose tributaries at the same time as the underlying reflux.

This treatment sequence is significant because it reflects the shift away from routine vein stripping towards minimally invasive treatment where clinically appropriate.

Further information is available in the Vein Solutions overview of NICE varicose vein diagnosis and management guidance.

The EVLT Procedure

Treatment begins with ultrasound identification of the vein. Local anaesthetic is used around the access point before the vein is entered with a needle.

A fine guidewire and catheter allow the laser fibre to be positioned inside the vein. Ultrasound is used throughout this stage to confirm its position.

Tumescent local anaesthetic is then placed around the treatment vein. This has several purposes. It provides anaesthesia, compresses the vein around the laser fibre and helps separate the vein from surrounding tissues.

The laser is activated as the fibre is withdrawn through the vein at a controlled rate. The heat acts on the vein wall, closing the incompetent section.

NICE describes EVLT as being carried out under ultrasound guidance and local anaesthesia, with a catheter and laser fibre positioned within the affected saphenous vein.

The procedure does not require the large groin incision traditionally associated with vein stripping.

Treating The Visible Varicose Veins

Closing the refluxing saphenous vein addresses the underlying source of abnormal flow, but a patient with very large surface varicosities may also require treatment of the visible veins.

This is an important distinction.

EVLT is principally used to treat the incompetent truncal vein. The bulging tributaries visible beneath the skin can then shrink after the source of reflux has been treated, but some remain.

Additional treatment can be performed during the same treatment episode or separately, depending on the patient’s anatomy and treatment plan.

Phlebectomy involves removing superficial varicose tributaries through very small skin openings under local anaesthetic. Foam treatment is another option for suitable residual veins.

NICE specifically states that where incompetent varicose tributaries are to be treated, treatment at the same time can be considered.

Foam Sclerotherapy

Some large or tortuous veins are not suitable for passage of a laser fibre. Foam sclerotherapy for varicose veins can therefore form part of a treatment plan, either as an alternative to thermal treatment in selected veins or as treatment for remaining tributaries.

A sclerosant is mixed into a foam and injected into the target vein under ultrasound guidance. Contact with the vein lining initiates a process that closes the treated vessel.

Choose between laser treatment, foam, and other procedures based on venous anatomy rather than applying one technique to every visible vein.

EVLT and Other Treatments

Vein Solutions offers several varicose vein treatment options. This allows us to select treatment based on the patient’s ultrasound findings and individual circumstances.

Endovenous thermal treatments include laser and radio frequency ablation. Both use thermal energy to close an incompetent vein, but they deliver that energy differently.

Non-thermal techniques are also available for appropriate patients, including cyanoacrylate closure and mechanochemical treatment.

Therefore, you do not need to assume that the largest visible vein dictates treatment. The aim is to identify the source of venous reflux and select the procedure, or combination of procedures, suited to that pattern.

EVLT and Traditional Surgery

Conventional varicose vein surgery historically involved tying off the affected saphenous vein and stripping a length of it from the leg.

Surgery remains appropriate in selected circumstances, but endovenous treatment has substantially changed the management of superficial venous reflux.

EVLT works through a small access point and is normally performed under local anaesthetic. This reduces the need for surgical incisions and allows outpatient treatment.

The shift towards endothermal ablation is reflected in current NICE recommendations, which place it ahead of foam sclerotherapy and surgery for confirmed truncal reflux where thermal treatment is suitable.

Comfort During Treatment

Local anaesthetic is used during EVLT, so a general anaesthetic is not normally required.

Patients may feel the injections used to administer the local anaesthetic and some pressure during parts of the procedure. The treated leg can feel tight, bruised or tender afterwards.

The amount of discomfort varies. Very large veins do not necessarily mean that treatment will be significantly more painful, as anaesthetic is placed around the vein being treated.

NICE’s EVLT guidance identifies pain, bruising, tightness and phlebitis among reported effects following treatment.

Recovery After EVLT

One advantage of endovenous laser treatment is that walking can usually begin shortly after the procedure.

Patients are encouraged to remain mobile rather than spending the recovery period in bed. Regular walking supports normal venous circulation.

Some bruising, tenderness and a pulling or tight sensation along the course of the treated vein can occur as the vein closes and begins to fibrose. These effects generally settle as healing progresses.

Return to work depends partly on the type of work involved. Someone with a desk role may be able to resume work relatively quickly, while a physically demanding occupation may require more time.

You may need to restrict strenuous exercise and heavy lifting temporarily, depending on the instructions provided after treatment.

More detailed information is available on EVLA laser treatment aftercare.

Compression After Treatment

Compression stockings may be recommended for a short period following EVLT, depending on the treatment performed and the individual patient.

It is worth distinguishing short-term compression following an intervention from compression stockings used as the main treatment for varicose veins.

NICE states that compression hosiery should not normally be offered as treatment for varicose veins where interventional treatment is suitable. If compression bandaging or hosiery is offered following interventional treatment, NICE recommends that it should not be used for more than seven days.

Your vascular specialist will provide instructions relevant to the procedure you have undergone.

Risks and Complications

EVLT has a good safety record, but no invasive procedure is completely free from risk.

Temporary bruising and tenderness are relatively common. Some patients develop inflammation in a superficial vein, often called phlebitis. Temporary altered sensation can occur where treatment is performed close to superficial nerves.

Less common complications include infection, skin injury and deep vein thrombosis. Thermal injury to nearby structures is uncommon when treatment is correctly planned and performed under ultrasound guidance.

Any sudden increase in leg swelling, severe pain, chest pain or breathlessness after treatment requires urgent medical assessment.

Discuss individual risks during consultation because previous thrombosis, medication, medical history, and venous anatomy can alter a patient’s risk profile.

Results After Treatment

EVLT aims to close the refluxing vein rather than make every surface vein disappear immediately.

Symptoms caused by venous reflux may improve as abnormal pressure in the superficial venous system decreases. Visible veins can gradually become less prominent, although large tributaries may require further treatment.

The closed truncal vein is progressively replaced by fibrous tissue and is no longer part of the active superficial circulation.

NICE’s specific guidance on endovenous laser treatment reports high saphenous vein closure rates in the clinical evidence considered.

Results vary between patients because venous disease can continue to develop elsewhere in the superficial venous system.

Recurrence After EVLT

Successful closure of a treated vein does not mean that a patient can never develop another varicose vein.

Varicose veins reflect underlying venous disease. New areas of valve incompetence can develop over the years, and previously small tributaries may enlarge.

Recurrent veins can also arise through different anatomical pathways from the vein originally treated.

This is different from saying that EVLT has failed. A successfully ablated vein may remain closed while new reflux develops elsewhere.

The causes are discussed in more detail in varicose veins reappearing after treatment.

Large Veins Behind The Knee

Prominent veins behind or around the knee require careful assessment because several superficial veins can pass through this area and the source of reflux is not always apparent from their position.

Some may be connected to the great saphenous system, while others are associated with the small saphenous vein or tributaries.

The anatomy around the knee also makes accurate ultrasound mapping particularly useful before treatment.

Patients with veins concentrated in this area can find further information on varicose veins behind the knee in Chester.

Delaying Treatment

Not every large varicose vein requires immediate intervention. Treatment depends on symptoms, clinical findings and the patient’s circumstances.

However, some situations require closer assessment. Increasing pain, persistent swelling, skin pigmentation, venous eczema, superficial thrombophlebitis, bleeding or ulceration can indicate progression of venous disease.

NICE recommends referral to a vascular service for symptomatic primary or recurrent varicose veins, lower limb skin changes caused by chronic venous insufficiency, superficial vein thrombosis with suspected venous incompetence and current or healed venous leg ulcers. Bleeding varicose veins require immediate referral.

Large veins that have changed or become increasingly uncomfortable should therefore not be judged on appearance alone.

Consultation In Chester

A varicose vein consultation in Chester provides the opportunity to determine whether large veins are suitable for EVLT and whether other treatments will also be required.

The assessment considers symptoms, previous vein treatment, medical history and the distribution of the visible veins.

Duplex ultrasound then provides the anatomical information required to identify reflux and plan treatment.

This means two patients with similarly large veins may receive different recommendations because their underlying venous disease patterns differ.

Endovenous Laser Treatment at Vein Solutions in Chester

At Vein Solutions, patients with large varicose veins are assessed by a vascular specialist before treatment is recommended.

The clinic provides minimally invasive vein treatment in Chester, including EVLT, radio frequency ablation, foam sclerotherapy and other options for patients whose anatomy makes another approach more appropriate.

Large varicose veins are not automatically too advanced for minimally invasive treatment. Modern endovenous techniques allow many sizeable refluxing veins to be treated without conventional vein stripping, and European vascular guidance supports thermal ablation even for very large incompetent great saphenous veins in suitable patients.

The starting point is a clinical assessment and ultrasound scan. By identifying the vein responsible for reflux, treatment can address the underlying problem rather than concentrating solely on the most prominent veins visible at the surface.

Patients considering laser treatment for varicose veins can contact Vein Solutions to arrange an assessment in Chester.

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