What is a Varicose Vein?
Dilated, elongated, and tortuous veins are called varicose veins. They afflict about 20 per cent of the adult western population. About 50 to 55% of women and 40 to 45% of men suffer from some form of vein problem. They are reportedly five times more common in females. Primary varicose veins occur in the absence of a known cause and are often familial (a woman whose both parents are afflicted with varicose veins has an 80 per cent chance of developing the same). Varicose veins are more common in people whose profession involves prolonged standing. Secondary varicose veins usually follow DVT or pregnancy. Varicose veins occur due to reflux of blood in the vein. This is due to failure of vein valves.
Patients usually complain of unsightly varicose veins. A tired aching sensation in the legs, night cramps in the calf and 'restless legs' at night are occasional symptoms. Varicose veins may be due to superficial venous incompetence (SVI) or deep venous insufficiency (DVI). Valvular incompetence in deep veins may be due to congenital absence or weakness of valves (rare), degeneration of valve cusps, or due to damage to the valves because of DVT. Valves are frequently destroyed when recanalisation of a thrombosed vein takes place. In other instances, the vein may become narrow, scarred, and fibrosed following DVT, and is then unable to carry blood. Rarely, the deep vein may fail to recanalise, leading to chronic venous obstruction. Though they may be occasionally found in long-standing superficial venous incompetence, their presence should alert the examiner that DVI is likely.
Varicose veins may vary considerably in size. Interestingly, the symptoms are not proportional to the size of the varicosity. Generally, they can be classified into one of these three groups:
• Dermal flares (thread veins) are small varicosities up to 0.5 mm in diameter
• Reticular veins are larger, from ,1-3 mm, lying just under the skin
• Large varicose veins, usually from 5-15 mm, are seen in the calf, leg, or sometimes in the thigh.
Several clinical tests are described; these are useful in diagnosing simple varicose veins and deciding the level of valvular incompetence. Varicose veins on the medial side of the leg indicate incompetence of the long saphenous system (commonly at the saphenofemoral junction, while those on the posterior part of the calf and popliteal fossa signify incompetence of the short saphenous vein. Iliac vein obstruction presents as varicosities in the groin and along the anterior abdominal wall .
A thorough clinical examination is all that is required before surgery in a case of simple varicose veins involving the superficial system. Several investigative modalities are available; they are mostly required in cases of DVI and to localize perforator incompetence.
• Doppler Ultrasonography
• Duplex imaging
This is the most important noninvasive investigation for practically all venous disorders. It produces high quality pictures using a combination of B mode imaging and Doppler ultrasound . Anatomical, physiological, and functional details can thus be obtained. Venous lumen, flow, direction, and reflux of blood can be accurately visualized. The site of perforator incompetence can be located with great accuracy. It is also useful in mapping of the saphenous vein before 'in-situ bypass surgery in peripheral occlusive arterial disease. Duplex scan has practically replaced venography for the assessment of varicose veins, DVT, and chronic venous insufficiency.
Do I need treatment or a referral for varicose veins?
You may want to have treatment for one of the following reasons:
If complications develop - If leg swelling or skin changes develop over prominent veins, then treatment is usually advised to prevent a skin ulcer from developing. If a skin ulcer does occur then treatment of any varicose veins may help to cure it. If you have a varicose vein which has bled, then you should be referred urgently for treatment.
For symptoms of itching, swelling, night cramps or discomfort.
Cosmetic reasons. You may feel that the veins look unsightly. Treatment which is purely for cosmetic reasons is not usually available on private insurance companies.
If you have a combination of BOTH varicose veins which are problematic, AND 'arterial disease (poor circulation, or peripheral vascular disease) of the legs. Or if arterial disease is suspected. In this situation, you will need to have the leg circulation examined, before certain treatments such as compression stockings can be used (tests and treatments are explained below).
What are the symptoms?
• Many people have no symptoms at all from their varicose veins, except for the fact that they are noticeable, and their appearance can be embarrassing.
• Other than cosmetic embarrassment the commonest symptoms from varicose veins are aching, discomfort, and heaviness of the legs, which are usually worse at the end of the day. Sometimes the ankle can swell, too. These symptoms are not medically serious, but can be treated if they are sufficiently troublesome.
Although varicose veins can get worse over the years, this often happens very slowly.
• In a few people the high pressure in the veins causes damage to the skin near the ankle, which can become brown in color, sometimes with scarred white areas.
• Eczema (a red skin rash) can develop.
• If these skin changes are allowed to progress, or if the skin is injured, an ulcer may result. Skin changes are therefore a good reason for going to see your vascular surgeon.
Other problems which varicose veins can occasionally produce:
Phlebitis (sometimes called thrombophlebitis) means inflammation of the veins, and is often accompanied by some thrombosis (clotting of blood) inside the affected 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 necessarily have to be treated.
The risk of bleeding as a result of knocking varicose veins worries many people, but this is very rare. It will always stop with firm pressure and the veins can then be treated to remove the risk of further bleeding.
Deep Vein Thrombosis
Varicose veins are associated with DVT in some patients. It is not clear whether varicose veins themselves increase the risk of DVT, but certainly DVT leads to varicose veins and skin damage around the ankle.
If you feel that your varicose veins are presenting any of these symptoms, you should see your vascular surgeon.
What are the treatment options for varicose veins?
There are several different options, plus a number of new treatments.
Conventional (usual) treatments
Avoid prolonged standing or sitting still. Try to "put your feet up" frequently (sit or lie down and raise the feet above the level of your hips, for example, use extra pillows under your feet on a bed or footrest). This helps to reduce blood 'pooling' in the veins. Use moisturizing cream to protect the skin if it is dry, flaky or itchy. (Aqueous cream is suitable and inexpensive, or there are other types available - ask your pharmacist or doctor.)
Exercises for varicose veins prevention:
Office / Travel Exercises:
Support tights and compression stockings
These counter the extra pressure in the veins. They may help to ease symptoms such as ache, though there is little proof as to how well they work. Support tights and compression stockings may also help to prevent early complications from getting worse. To work properly, they need to be correctly fitted. They come in different strengths and sizes. Ideally, they should be put on first thing in the morning, before you get out of bed, and taken off when going to bed at night. Compression stockings are available on prescription or can be purchased.
Note: If you have arterial disease (poor circulation or peripheral vascular disease) in the legs, you will need a medical assessment of your circulation to decide if compression stockings are suitable.
Surgery (Stripping/ Ligation-Crossectomy)
Surgery is the mainstay in the treatment of varicose veins. Several options exist: saphenofemoral or saphenopopliteal ligation, either alone or more commonly, in combination with stripping of the vein, or multiple excision/avulsion of varicosities. Perforator ligation, either by conventional surgery or endoscopically, is required for perforator incompetence. Before ligating superficial veins, the surgeon should exclude deep venous obstruction. In the latter instance, superficial veins are often the only venous outflow channels; they may be dilated/varicosed because of increased flow. Their removal in such a setting can be disastrous. These operations are performed under general or spinal/epidural anesthesia. SF ligation alone can be done under local anesthesia. Simpler operations can be done as 'day care surgery', and the patient returns home in the evening.
NO off work is needed afterwards, in two days you may turn to work depending on your job.
Traditionally, excision of varicose segments has been done by multiple small incisions. The varicosity is picked up by a curved artery forceps, extracted outside the wound, ligated at both ends, and the skin closed without any suture (Cosmetic advantage). This often leaves less than an optimal cosmetic result. Lately, smaller incisions (1-2 mm in size) have been employed. The varicose segment is picked up by a specially designed hook ('hook phlebectomy') and removed. The skin incision need not be sutured; it is closed by adhesive strips. Excellent cosmetic results have been reported with this technique.
Subfascial endoscopic perforator Surgery (SEPS)
This technique has been devised to site the skin incision distant from skin changes and ulceration, and to achieve a more thorough perforator ligation.
The cosmetic and functional results are far superior to conventional perforator ligation surgery. SEPS is indicated in CEAP class 4, 5, and 6 where perforator incompetence has been demonstrated. Contraindications to SEPS include infected ulcers, concomitant occlusive arterial disease, poor risk patients, and morbidly obese patients.
In these patients we perform Laser Ablation with better cosmetic results and fewer complications.
Injection of a chemical solution (sclerosant) in a vein destroys its endothelial lining. For sclerotherapy to be effective, the solution has to be injected in an empty vein. The aim is to produce sclerosis (not thrombosis) of the vein, leaving it incapable of recanalisation. Ultimately, it becomes a fibrous cord. Sclerotherapy is indicated for small varicosities, residual varicosities (after surgery), and occasionally for the treatment of perforator incompetence. Dermal flares and reticular veins can be treated effectively by microsclerotherapy. Treating saphenofemoral or saphenopopliteal reflux by sclerotherapy has been described. Several courses are usually required at weekly intervals. Complications include skin pigmentation or even ulceration due to extravasation of the solution, superficial thrombophlebitis, allergic reactions, anaphylaxis (rare), and neoangiogenesis. Rarely DVT may result if the solution finds its way into the deep veins.
Especially spider web varicosities respond well to dermal laser with cosmetic results. Combining sclerotherapy and dermal laser is best for custom made treatment os superficial varicosities.
Newer techniques have also been developed to treat varicose veins. Their aim is to reduce the need for traditional 'stripping' of the veins, and to reduce bruising or other possible complications of surgery. The new treatments include:
Radiofrequency ablation and endovenous laser ablation
These methods involve passing a probe into one of the longer varicose veins, using ultrasound to guide the position. The laser or radiofrequency energy makes the vein heat up, which seals it. Same day you turn back to home.
This uses a chemical mixed with air to make foam. The foam is injected into the veins, pushing the blood away and making the veins go into spasm. Ultrasound is used to help guide the injection. After treatment, compression stockings are needed, and the veins will be hard and swollen for a while before they shrink down. More than one treatment may be needed.
All types of surgery or injection for varicose veins have a small risk of complications, for example, damage to nearby nerves or skin. Also, it is quite common to have side-effects such as pain and bruising for a while afterwards. There is also a chance that the varicose veins can recur (come back). Ask your surgeon about the pros and cons of different treatments in relation to your own particular veins.