Treatment options for Varicose Veins: Endovenous Laser Therapy (EVLT)

EVLT has become the modern gold standard method of treating the main veins that lead to the development of varicose veins. It has completely replaced the old-fashioned and less effective surgical procedures like vein stripping. Unlike surgical stripping it is quick and easy to perform under local anaesthetic and does not require admission to hospital or general anaesthesia.

Endovenous laser therapy (EVLT) is

Quick: Procedures generally last between 30 and 45 minutes.
Convenient: Prolonged hospital admissions are not required and normal activity can commence right away.
Effective: Treatment success rates exceed 95% with almost immediate symptom relief.
Invisible: Surgical incisions were not required.

EVLT Treatment Sessions

All EVLT treatments are performed as a walk-in walkout day case procedure. Using ultrasound guidance, a small cannula is placed in the target vein and a thin laser fibre is slid up the inside of the vein. The vein is numbed with a few local anaesthetic injections and the laser gently heats the wall destroying the vein. Any visible varicose veins are treated with foam injections, and this is usually performed at the same time. Normal activity can be resumed immediately after treatment. Patients are advised to wear compression stockings for 1 to 2 weeks and to keep mobile during that period.

What veins can be treated with EVLT?

Laser energy is used to heat the walls of the veins getting treated and so EVLT cannot be used in varicose veins close to the skin. Also, veins need to be straight to allow the laser fibre to slide along the inside. So, EVLT is used to deal with the main veins deeper in the leg that are causing the visible varicose veins to appear. Treating these main veins is normally enough to improve symptoms and protect against complications for the vast majority of patients. However, to ensure a good cosmetic outcome, varicose can also be injected with foam sclerotherapy. For the vast majority of patients a combination of EVLT and foam sclerotherapy is used to deliver the optimum final result.

What veins cannot be treated with EVLT?

Veins that lie close to the skin or veins that are tortuous are not suitable for EVLT. In this case foam sclerotherapy is used to treat both the superficial visible veins and the main trunks that have led to their development. No one should be getting treated with an outdated surgical stripping procedure in the modern era.

Is EVLT better than Radiofrequency Ablation?

The short answer is no. However, EVLT is the preferred option of serious veins practitioners across the globe. Radiofrequency Ablation (RFA) is simpler and tends to be preferred by low volume units or practitioners. A simple analogy is with photography; modern camera phones take excellent pictures but almost all professional photographers use the more complex SLR cameras. EVLT is like the more complex cameras offering a selection of laser fibers and adjustable settings that allow experienced practitioners to fine tune the final treatment being delivered. If your specialist is unable to perform EVLT it is likely that they are not able to offer a complete range of treatment options or deliver the most up-to-date therapies for varicose veins that are available.

How can I make an appointment?

You can make and inquiry through the website, send an email to [email protected] or book in directly at one of the clinics. New consultation slots are available every week.

Varicose Veins

Around 75% of the adult population in the UK and Ireland will suffer from venous disease in their lifetime. Varicose Veins account for the largest group of those patients. These are bulging rope-like cords of veins that can occur anywhere on the legs, front or back, from the groin to the ankle. They tend to cause a lot more symptoms than spider veins or thread veins. This is because they allow blood to fall backwards towards the ankles increasing the pressure in tissues of the lower parts of the leg.

What causes varicose veins?

number of risk factors will allow veins to develop more rapidly in people who are prone to develop problems. These include-

  • Pregnancies
  • Prolonged standing
  • Lifestyle
  • Smoking
  • Body weight

The most important risk is family history and unfortunately some people are just very good at developing varicose veins. The majority of patients inherit a tendency to form varicose veins from one or both of their parents.

What problems do varicose veins cause?

Varicose veins often cause symptoms in the affected leg. This commonly include

  • Aching/heaviness
  • Itching
  • Numbness/tingling
  • Cramps/Night cramps/restless legs

A number of signs may be evident that tend to signify that the vein disease is at rick of progressing

  • Spider veins, especially around the ankles
  • Ankle swelling that is worse on the leg with more varicose veins
  • Skin discoloration, especially around the ankles
  • Bleeding veins and ulcers are fortunately much less common

If you suffer from any of these symptoms or signs and have visible veins, a consultation is highly recommended.

What treatment options are available?

The good news is that no one should be undergoing surgery in the modern age of varicose vein treatment. Two main keyhole methods are used to treat both the veins and the underlying problem that has lead to their development.

Endovenous Laser Therapy (or EVLT)

This often the best method to treat varicose veins. The procedure is performed on an outpatient basis. There is no need for hospital stays or general anaesthetics and a full return to normal activity is possible later that day. The procedure is performed under local anaesthetic on a walk-in walk-out basis and takes around 45 minutes in the Day Procedure Unit.

Ultrasound Guided Foam Sclerotherapy

This method is used to treat all the veins that can’t be managed with EVLT. Ultrasound is used to identify and access all the hidden veins that are causing problems. A special foam is injected to kill off the veins. This is then absorbed by the body in a matter of minutes so that nothing is left behind. These procedures are performed in an outpatient appointment which lasts around 30 minutes. Normal activity can resume immediately.

I have had surgery before, can I still get treatment?

Yes. Both EVLT and Ultrasound Guided Foam Sclerotherapy are ideal to manage both the recurrent veins and the hidden veins that have caused them to come back.

Will I need surgery if my varicose veins are really bad?

No. No-one should be having surgery in the modern era. Keyhole procedures are vastly more effective and avoid the need for what would be a more complex operation.

What are the alternatives to invasive procedures for varicose veins?

Good quality, well fitting compression stockings will control the symptoms of varicose veins and reduce the rate that veins progress. The will also reduce the risk of developing more serious complications of veins such as blood clots or skin damage. Unfortunately, compression stockings are not easy to wear on a year round basis and addressing the underlying venous disease is very beneficial.

What are the risks of not having treatment?

Varicose veins slowly get worse if they are left untreated. Existing veins become larger, bulge more and new varicose veins appear elsewhere. Symptoms also become more troublesome as veins get larger. The good news is that only 5% of sufferers are likely to go on to develop the more troublesome complications of varicose veins.

How can I arrange an appointment?

You can make and inquiry through the website, send an email to [email protected] or book in directly at one of the clinics. New consultation slots are available every week.

2023 Round Up

2023 proved to be a very successful year for my practice and I owe a huge debt of gratitude to all the wonderful patients who were a part of that journey.

Academic meetings

I was honoured to be invited to speak at the British Association of Sclerotherapists first in-person academic meeting since the cancellations that followed the 2020 Covid outbreak. My subject was “How to Investigate Venous Ulceration” and my presentation detailed how to properly assess the superficial and deep venous systems with Duplex Ultrasound and then use that information to direct treatment decisions. The presentation was so well received that afterwards I was asked to speak at the Royal Society of Medicine’s Venous Forum meeting a couple of months later. I was delighted to speak on “Endovenous Laser Ablation, Foam Sclerotherapy or a combination of both: How I decide which treatment to use” in front of a very distinguished audience of vascular surgeons. Once again, before that meeting had ended, I was approached by members of the Vascular Society of Great Britain and Ireland and was asked to join the faculty at a training day in the autumn. Here I delivered a talk on how to do Venous Duplex Ultrasound the right way and lead a hands-on training station in Ultrasound assessment of varicose veins.


Visitors to the site will see that I have been invited to join the Top Doctors network. This is a select service that offers diary management, collection of feedback and a platform for academic material to a select few clinicians who meet their high standards. Their prestigious Certificate of Excellence was awarded late in 2023.

The National Press

All this attention did not go unnoticed and I have been asked to provide a series of editorials on Varicose Veins and Venous Disease for The Daily Telegraph and The Independent. The first of those articles have been published already with more to follow in 2024. For those who missed it the full text is below.

Varicose veins and venous disease – Published in the Daily Telegraph on 6th and 13th January 2024

Around three quarters of all people in the United Kingdom will be affected by venous disease in their lifetime. The most common presentation is with thread veins or varicose veins, sometimes just on one leg and sometimes on both. For a large number of sufferers there is often little in the way of symptoms. However, thread veins and varicose veins are very common source of cosmetic concern.

For others, varicose veins can cause a wide range of symptoms. Aching, throbbing and heaviness in the lower legs are very common. Itchiness in the skin overlying veins is usually a sign that veins are becoming more severe. Leg swelling, night cramps and restless legs can be due to varicose veins. Skin damage and ultimately ulceration can occur in the most severe cases.

All varicose veins can now be treated with simple non-surgical procedures. Laser ablation is often the best treatment for varicose veins. It is quick and easy to perform and does not require a general anaesthetic. Sclerotherapy injections are often performed as part of this treatment. Foam Sclerotherapy can also be performed as an alternative treatment for patients who are not suitable for EVLT. These procedures are carried out on an outpatient basis using local anaesthetic and usually take less than 45 minutes.

Spider Veins or Thread Veins

Spider veins
 are tiny dilated blood vessels that appear close to the surface of the skin. They often resemble a web or a spider’s legs, hence the name. These veins are most commonly found on the legs, although they can also occur on the face and other parts of the body. Although they are largely harmless in themselves, they are unsightly and often cause significant cosmetic concerns for the majority of sufferers.

What causes spider veins?

The formation of spider veins is a normal part of the healing process, so anything that can cause stress in the skin can trigger the formation of new areas. Common triggers are minor injuries, exposure to heat or cold and surgical incisions on the legs. Prolonged standing and concurrent varicose veins tend to aggravate the development of spider veins. Genetic and hormonal factors are very important which explains why some patients are more prone to making new spider veins than others.

What can you do about spider veins?

If you’re concerned about the development of spider veins or already have them, it’s essential to consult with a vascular specialist. The most effective treatment option is microsclerotherapy, but it is important to rule out problems with bigger veins before commencing treatment. Creams and lotions have absolutely no effect on spider veins. Treatments with cosmetic laser such as IPL are often either ineffective or result in inferior outcomes to microsclerotherapy.

How does microsclerotherapy work?

A liquid is carefully injected into the veins which strips away their non-stick lining. Injected veins will then take on a darker appearance for a few weeks due to the old blood that can collect inside the lumen. After that, most of the treated veins will fade away as the body absorbs that old blood. Spider veins are a perfectly natural part of the body’s healing mechanism and a small proportion of successfully injected veins will always recover. For that reason, it will usually take two or three treatment sessions to obtain a desirable result.

I’ve had treatment in the past but it didn’t work, what can I do?

It is important to attend a clinician who has a large experience of treating spider veins. The most common cause for failed treatment is underlying veins that have been missed at the last attempt. The first step in assessing why a previous treatment has been unsuccessful if to undertake a detailed ultrasound assessment. This often identifies small veins (and sometimes not so small veins) that have helped keep the spider veins from responding to to the first treatment with microsclerotherapy.

What does microsclerotherapy involve?

A treatment session is a straightforward outpatient visit that lasts around 30 minutes. Very small needles are used to carefully inject spider veins and there is usually little or no discomfort. Compression stockings are worn for 3 days after treatment to speed up the healing process. A second microsclerotherapy session is often desirable around 6 to 8 weeks later.

A video of microsclerotherapy being performed can be found here.

ASPIRE Venous Training Day at the Vascular Society of Great Britain and Ireland Annual Meeting

The Conference Centre, Dublin, 21st November 2023

In recognition of his expertise in the assessment and treatment of varicose veins, Mr Lewis was honoured to be invited to join the faculty at the training day at the Vascular Society of Great Britain and Ireland. He joined a faculty of colleagues from across the UK and Ireland all of whom are recognised as experts in the management of all aspects of venous disease.

Demand for places was high amongst senior surgical trainees and a total of 36 were able to attend the day.

Mr Lewis led the session on the use of Ultrasound scans to assess varicose veins. Other speakers discussed how to plan a procedure to ensure a successful outcome, how best to manage varicose veins and pitfalls that may arise in practice.

A number of practical stations proved very successful and included how to do ultrasound scans and ultrasound guided procedures and how to do foam sclerotherapy and thermal ablation for varicose veins.

The feedback from the faculty, attendees and supporting organisations was excellent and plans are in place to host a similar training days through out 2024.