Varicose veins Information

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If you are suffering from varicose veins and require immediate help and advice, please contact my Private Secretary on 01753 743422.
For further information on Varicose veins, read the articles on the publications pages, covering Varicose Veins:-

• Symptoms and diagnosis

• Treatment.

There are a number of factors which lead to varicose veins:

• Heredity - This is the most important factor, so if your parents and grandparents have the problem you are at increased risk.

• Gender - Women have a higher incidence of varicose veins due in part to the female hormones affecting the vein walls.

• Pregnancy - This causes a risk in blood pressure and volume and also adds to the hormonal effect mentioned above.

• Age - As we ago so our tissues loose elasticity and this is true of vein walls causing the valve system to work less well.

There are additional factors which do not cause varicose veins, but will speed up their development and make them worse:

• Obesity - Increases in weight often go hand in hand with increased blood pressure which will add to vein problems.

• Prolonged Standing - The volume and pressure of blood in the lower limbs is affected by gravity, so the longer you stand the greater the effect.

• Physical Trauma - Sometimes trauma to the lower limbs can damage the underlying blood vessels and add to the problem of varicose veins.

How do Varicose Veins occur? The veins are the means by which blood is returned from the legs to the heart. Muscles in the foot, calf and thigh act as pumps to push blood from the foot to the heart and from the superficial veins (long saphenous and short saphenous veins) to the deep veins via perforator veins.  When muscles relax, blood is prevented from running back to the feet and from the deep to the superficial veins, by valves in the veins which close like gates, once blood tries to run in the wrong direction.

Varicose veins occur when these valves or gates no longer work properly, allowing blood to bank up in the veins.  The varicose veins you see in your legs are due to blood damming up in superficial veins and their branches.

Why these veins fail is not completely understood.  It may be due to a weakness in the valve itself or in the vein wall.

Types of varicose veins

1. Thread or Spider Veins These occur mainly in women, and are more common in the thigh.  There may be no other varicose veins.

2. Primary Varicose Veins These are the most common type and occur in the long and short saphenous veins and their branches.

3. Secondary Varicose Veins These act as bypass veins when the deep veins have been damaged or occluded.  They should not be removed.

4. Vulval Varices They occur in women as a complication of pregnancy or infection.

The symptoms associated with varicose veins fall into three categories:

If varicose veins are due to damage to the deep veins, then they may cause itching, brown discolouration round the ankle, swelling of the leg and large ulcers.  The latter may last for years and be very resistant to treatment.

1. Hand Held Doppler Examination: this is a small instrument used in the clinic by a vascular surgeon to listen to the direction of blood flow in the main superficial veins in the leg and so determine if the blood is running back in the leg (reflux).

2. Duplex Ultrasonography: this is the most common laboratory test for varicose veins.  It enables the veins and blood flow to be visualised as well as listened to.  With this test, back-flow (reflux) in the main superficial veins and their tributaries can be mapped out.  The junctions of the superficial veins with their deep veins can be localised (especially important behind the knee) and incompetent perforators can be located ( and marked before surgery).  The duplex ultrasound can also visualise whether there is reflux or obstruction of the deep veins.  This test is performed by putting an ultrasound probe in the skin over the vein.  It is completely painless.  No injections are required.

3. Venography: this involves placing a needle in a vein in the foot and injecting contrast media into the vein.  This is useful to see if there is evidence of old clots (deep vein thrombosis) in the deep veins.  It can also identify incompetent perforators.  This test has largely been superseded by duplex ultrasound.

4. Varicography: This involves injecting contrast directly into a varicose vein.  This requires a needle puncture of the vein.  It outlines (road maps) the varicose vein and where they connect with the deep veins.  I don't use it routinely but find it useful in patients who have recurrent varicose veins - usually from inadequate initial surgery.

Treatment

Non Operative treatment Patients with varicose veins usually request treatment for two reasons - cosmetic or because the varicose veins are causing problems.

1. Compression stockings: These can relieve symptoms, hide veins and slow down deterioration of skin changes.  They need to be worn every day - summer and winter.  Many people find this irksome.  Stockings need to be replaced every six months since they wear out. They need to be graduated - with the highest pressure at the ankle, dropping to 75% at the calf and 50% at the thigh.  Most people only need the below knee stockings which are easier to wear than full length ones. Indications: Varicose veins developing during pregnancy. - Patients who have varicose veins but don't want or are unfit for surgery. - Patients with secondary varicose veins.

2. Sclerotherapy:  This procedure involves injecting a sclerosant solution into varicose veins. This irritates the inside of the vein wall which is then compressed with a bandage which cause the wall to stick together and obliterate the lumen ( that part through which the blood flows) of the vein.  Sclerotherapy is easily done in the consulting room without anaesthetic. Bandages remain on for 10 days to 2 weeks and patients are encouraged to walk for about an hour a day until next seen at the clinic. Most vascular surgeons feel that patients with incompetence of the long and short saphenous veins and their major branches should have surgery since the recurrence rate is less. Indications: The sclerotherapy works well for patients with isolated varicose veins and thread veins.  It is less satisfactory for short veins above the knee than below the knee, since they are more difficult to compress. Complications of scelotherapy include - ulceration ( sclerosant injected outside the vein ), thrombophlebitis ( inflammation and thus pain  in the injected vein), skin pigmentation in the injected site ( this usually fades ), and deep vein thrombosis.

Operative Treatments:

1. Surgery: Most varicose vein surgery can be done as day surgery.  It can be done under general, regional or local anaesthetic. Following surgery I prefer to keep a compression bandage on for 24 hours.  This can be replaced by a stocking until the first clinic visit one week later, and then dispensed with.  Following surgery patients can walk, carry on with their social activities, go shopping etc.  Driving can be undertaken once there is no groin tenderness. Surgery is associated with very little pain or tenderness.  Most patients can commence work a week after surgery or less.  If the laser frequency ablation technique is used this can be as short as 36 hours. Technique: For patients with long saphenous vein incompetence the standard procedure involves a small groin incision.  The long saphenous vein is tied off and divided from the femoral vein ( together with surrounding branches ).  It is then stripped down to just below the knee (under the skin).  The varicose branches (which are premarked before surgery) are avulsed through a series of stab incisions about 2mm in length.  The lesser saphenous vein is similarly dealt with except that the incision is behind the knee where this vein drains into the popliteal vein.

2. Minimally invasive surgery: A new technique  - endovenous laser ablation is now available. This involves passing a laser catheter up the long saphenous vein. The laser catheter is then activated and slowly withdrawn down the vein. This heats up the inside of the vein wall causing it to stick together thus obliterating the inside of the vein. This procedure avoids a groin incision and largely eliminates the bruising in the thigh that occurs with the open procedure. Avulsions may still be necessary. This technique can be done under local anaesthetic as an outpatient procedure, and patients can go home directly afterwards. Patients can be back at work after 36 hours - See our pages about EVLTŪ

3. S.E.P.S (subfascial endoscopic perforator surgery).  This is also a minimally invasive technique of obliterating incompetent perforator veins through a 1.5- 2cm incision on the inside of the calf.  A thin hollow tube is passed down in the space between the muscle and its cover (fascia).  The perforator veins that traverse this space are clipped off.  This is often used in conjunction with standard surgery particularly in patients with venous ulcers where an incompetent perforator has been identified (on duplex ultrasound) at the location of the ulcer.

Thread veins.  These can occur on their own or in association with long or short saphenous vein incompetence.  In the latter case the main superficial vein incompetence should be dealt with surgically.  Then  the thread veins can  be injected.  This may involve several treatments.  Thread veins can also be treated with laser therapy but this may also involve many treatments and may also leave areas of skin pigmentation.

1. Damage to major arteries or veins.  This should not occur when the procedure is done by an experienced vascular surgeon.

2. Nerve damage. In long saphenous vein surgery the saphenous nerve may be damaged causing anaesthesia in the local part of the leg. In short saphenous vein surgery the common peroneal nerve may be damaged causing foot drop. These are uncommon when surgery is performed by a vascular surgeon. The incidence is 2%

3. Development of the thread veins can occur after venous surgery.

4. Deep vein thrombosis.  This is rare in healthy patients having uncomplicated varicose vein surgery. The incidence is less than 1%

5. Wound Infection. Incidence is 2-3%

6. Recurrence. This may be as high as 20%, but should be less if done by an experienced vascular surgeon.

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