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Varicose Veins - Philip Bull md, Consultant Surgeon

Dr Bull's Vein Clinic

What you want to know about varicose veins

Varicose veins are very common ailment. They affect around 60% of the population at some time in their lives. They are swollen veins (usually on the legs) that look lumpy and bluish through the skin.

How does blood flow from your legs?

Blood is pumped from your heart to your legs through arteries. Once it has supplied oxygen and nutrients to the legs, blood returns to your heart through your veins. To do this from your legs, blood in your veins must flow upwards, against gravity.

The muscles in your legs help this flow. Each time your calf and thigh muscles contract when you are walking, veins deep inside your leg are squeezed. One-way valves inside your veins help prevent the blood from flowing backwards.

Illustration of the leg veins

What causes varicose veins?

The reason varicose veins develop is not fully understood. One of the basic problems is damage to the valves. This means that blood can’t travel up the veins as easily, and is more likely to pool.

It is possible that people inherit a tendency for weak valves. Alternatively, the vein walls may become weak, which causes bulging of the vein and so damage to the valves.

There is a greater risk of getting varicose veins during pregnancy, and if you are very overweight because this increases the pressure in your abdomen and so in your veins. Many other factors have been blamed for varicose veins, such as standing for long periods, crossing your legs while sitting, smoking and poor diet. However, there isn’t strong scientific evidence to support these theories.

Symptoms

The symptoms from varicose veins don’t necessarily match their size, and sometimes there are no symptoms at all apart from the veins being unsightly. Mild symptoms can include:

  • aching or discomfort in your legs
  • itching of the skin of your legs
  • swelling of your ankles

More severe symptoms are usually associated with the complications of varicose veins. These can include the following.

Thrombophlebitis – veins close to the surface of the skin can become painful and reddened due to inflammation or blockage of the vein. This is different to the more dangerous blockage of the deeper veins, known as deep vein thrombosis (DVT).

Bleeding – varicose veins near to the surface can bleed if the leg is cut or bumped. This bleeding might become a medical emergency if it can’t be stopped. If a varicose vein in your leg is bleeding, you need to lie down, raise your leg and apply pressure directly to the bleeding area. Then seek medical help.

Chronic venous insufficiency – the poor flow of blood in the veins ca interfere with the way the skin exchanges oxygen, nutrients and waste products with the blood. When this happens over a long period of time, it is called venous insufficiency, which can cause a number of problems including the following:

  • varicose eczema – brown or purple discolouration of the skin that can become permanent
  • venous ulcers – a minor wound, usually around the shin or ankle, can fail to heal – this causes an ulcer

Having varicose veins does not mean that you will definitely get complications or chronic venous insufficiency. And although they won’t usually get better without treatment, varicose veins only get worse slowly.

Diagnosis

Varicose veins are easily visible. To work out the position and extent of valve weakness, there are a number of tests a doctor might do.

  • A Doppler test is a technique that uses sound waves (ultrasound) to give information about the direction of blood flow in a vein and whether valves are working properly.
  • Colour duplex ultrasound imaging is used to look for any abnormalities in the vein structure.
  • The Trendelenburg test involves lying down and lifting one leg up in the air. The doctor uses a hand or a tourniquet to temporarily block off the blood flow in your veins. When you stand up again, the doctor can watch your varicose veins refilling with blood; this gives an indication of which part of the leg veins have faulty valves.

Treatments

Compression stockings

These may relieve the swelling and aching of your legs but do not prevent more varicose veins from developing. They need to be worn during the day and are taken off at night. Graduated compression stockings are tightest at the ankle and get gradually looser further up the leg. These help the blood to flow up towards the heart.

Compression stockings are available in various sizes and pressures and it is very important that they fit you properly. They are made to fit your calf diameter, not foot size. Your GP or pharmacist can provide advice.

Some people find compression stockings difficult to put on. There are tools available to help, or you could ask for help from a partner or friend. Stockings can be uncomfortable, especially in hot weather. But there is no point in wearing them rolled down.

Injection sclerotherapy

Small varicose veins can be injected with a chemical that damages the vein walls. As a result, scar tissue forms which closes off the affected vein. Other stronger veins take over and the treated vein, which is no longer filled with blood, becomes less visible.

For larger veins, a foam is sometimes injected instead of a liquid (this is called foam sclerotherapy), using ultrasound to guide the injection. Foam sclerotherapy is a new technique, and in a small number of people it can cause complications including blood clots in other leg veins, temporary vision problems, headaches and fainting. Your doctor will give you more information and advise whether foam sclerotherapy is a suitable treatment for you.

For best results, you should wear a compression bandage for between three and six weeks after injection sclerotherapy.

Injection sclerotherapy can be an alternative to surgery, but varicose veins may come back and nearby veins may become varicose. Often, several injections are needed. One possible side-effect of this treatment is skin discolouration. Your doctor will give you more information.

Varicose vein surgery

This involves removing the affected superficial veins. There are many variations of operation, depending on which veins need treatment. The most common is called ligation and stripping.

New approaches: the Endolaser

The clinic has been performing Endolaser Treatment for truncal varicose and perforating veins since 2002. The procedure introduces a fine laser probe inside the vein which heats and  vaporises the varicose vein.

Prevention

Anyone can develop varicose veins, so it may not always be possible to prevent them. Although there are no scientifically proven ways to prevent varicose veins, the following suggestions may be useful:

  • avoid standing still for long periods of time
  • take regular exercise, such as walking
  • maintain a healthy weight
  • wear properly fitted compression stockings to prevent further deterioration of existing varicose veins

FAQ - About Varicose Veins

The heart pumps blood to supply oxygen and nutrients to all parts of the body. Arteries carry blood from the heart towards the body parts, while veins carry blood from the body parts back to the heart. As the blood is pumped back to the heart, veins act as one-way valves to prevent the blood from flowing backwards. If the one-way valve becomes weak, some of the blood can leak back into the vein, collect there, and then become congested or clogged. This congestion will cause the vein to abnormally enlarge. These enlarged veins can be either varicose veins or spider veins. Varicose veins are very swollen and raised above the surface of the skin. They are dark purple or blue in colour, and can look like cords or very twisted and bulging. They are found most often on the backs of the calves or on the inside of the leg, anywhere from the groin to the ankle. During pregnancy, varicose veins called haemorrhoids can form in the vagina or around the anus.

Spider veins are similar to varicose veins, but they are smaller, are often red or blue in colour, and are closer to the surface of the skin than varicose veins. They can look like a tree branch or spider web with their short jagged lines. Spider veins can be found on both the legs and the face. They can cover either a very small or very large area of skin.

As many as 60% of all women and men suffer from some form of vein disorder, but women are more affected — up to 50% overall. It also is estimated that 41% of all women will suffer from abnormal leg veins by the time they are in the 50s.

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No one knows the exact cause of spider and varicose veins, but there are several factors that cause a person to be more likely to develop them. Heredity, or being born with weak vein valves, is the greatest factor. Hormones also play a role. The hormonal changes that occur during puberty, pregnancy, and menopause, as well as taking oestrogen, progesterone, and birth control pills can cause a woman to develop varicose veins or spider veins. During pregnancy, besides the increases in hormone levels, there also is a great increase in the volume of blood in the body that can cause veins to enlarge. The enlarged uterus also puts more pressure on the veins. (Within 3 months after delivery, varicose veins usually improve. However, more abnormal veins are likely to develop and remain after additional pregnancies.) Other factors that weaken vein valves and that may cause varicose or spider veins include aging, obesity, leg injury, and prolonged standing, such as for long hours on the job. Spider veins on the cheeks or nose of a fair-skinned person may occur from sun exposure.

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Medical treatment usually is not required for varicose or spider veins. However, varicose veins can become quite uncomfortable as well as look unattractive. Varicose veins usually enlarge and worsen over time. They can cause the legs and feet to swell. Although severe leg pain is not common, leg muscles may feel fatigued or heavy, or throb and cramp at night. The skin on the legs and around the ankles also can itch or burn.

In some cases, varicose veins and spider veins can cause more serious problems, and medical treatment will provide benefits. If the veins become severe, they can cause a condition called venous insufficiency, a severe clogging of the blood in the veins that prevents it from returning to the heart. This condition can cause problems like a deep-vein thrombosis (blood clot), or a severe bleeding infection. These usually are caused by injury to the varicose vein. A blood clot can be very dangerous because of the possibility of it travelling from the leg veins to the lungs, where it may block the heart and lungs from functioning. Lastly, because the skin tissue around the varicose vein may not receive enough nourishment, sores or skin ulcers may develop.

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There are several easy things you can do to help prevent varicose and spider veins and to relieve discomfort from the ones you have:

  • Protect your skin from the sun by wearing sunscreen to limit spider veins on the face.
  • Exercise regularly to improve your leg strength, circulation, and vein strength. Focus on exercises that work your legs, such as walking or running.
  • Control your weight to avoid placing too much pressure on your legs.
  • Do not cross your legs for too long when sitting, change often position. Try to elevate your legs when resting.
  • Do not stand for long periods of time. If you have to stand for long periods of time, shift your weight from one leg to the other every few minutes. If you have to sit for long periods of time, stand up and move around or take a short walk approximately every 30 minutes.
  • Wear elastic support stockings, but avoid clothing that is too tight or that will constrict your waist, groin, or legs.

Make sure to include high-fibre foods in your diet since constipation can contribute to varicose veins. High fibre foods include fresh fruits and vegetables and whole grains, like bran. Control your salt-intake. Salt, or sodium

Because the blood in the varicose veins does not move these). along well enough, it doesn’t carry away the waste products from the legs. Over a period of time, this can cause a number of problems, including.

  • Aching, heaviness, and cramping of the legs, which are made worse by standing for long periods of time.
  • Skin rash, thin skin, and poor wound healing. Sometimes an ulcer will form just above the inner part of the ankle.

Many persons are bothered by their unsightly appearance.

No. Indeed, walking is beneficial. When you walk, the muscles in your legs contract, squeezing the veins, thus helping to force the blood to move forward on its way back to the heart. If walking causes discomfort, you should see your physician to determine why walking is causing your discomfort (i.e. to exclude any other causes besides varicose veins). Walking is also an excellent form of exercise to help promote good cardiovascular health.

You should wear the support hose every day, all day. Because support hose lose their elasticity over time, a new pair should be purchased every three to four months. Following each sclerotherapy session: Immediately after each session, compression stocking must be worn. The stockings should be worn 24 hours a day for 3 days. Wear your compression stockings for an additional 2-3 weeks following treatment, putting them on in the morning and removing at night. Fading should continue over the next 2-6 weeks.
Walk at least 1 hour a day. Avoid standing for long periods of time.
Avoid strenuous activity, high impact aerobics, or weight lifting for 3-4 days after treatment.
Avoid hot baths for 2 weeks. Take cool showers to help keep veins closed.

The best things you can do to ease your pain is to wear support hose, avoid periods of prolonged standing, and elevate your legs at the end of the day.

After all, the reason I want to get rid of my varicose veins is because they are ugly. Why should I replace them with ugly scars?

A: Newer methods of minimal inasive venous procedure leave no scar at all. New and improved techniques in surgery leave almost no scars at all. The scars will fade over time. Discolouration can be covered with special cosmetic preparations (camouflage creams) until they fade completely.

Varicose veins are progressive, that is they will degenerate with time which means that symptoms worsen more or less depending on precautions you take. These measures consits mostly in exercises and compression tights.

Remember these important questions when deciding whether to see your doctor:

Has the varicose vein become swollen, red, or very tender or warm to the touch?

If yes, see your doctor.

If no, are there sores or a rash on the leg or near the ankle with the varicose vein, or are there circulation problems in your feet?

If yes, see your doctor.

If no, continue to follow the self-care tips above.

Besides a physical examination, your doctor can take x-rays or ultrasound pictures of the vein to assess the cause and severity of the problem. You may want to speak with a doctor who specializes in vein diseases (phlebology). You should discuss which treatment options are best for your condition and lifestyle. It is important to remember that not all cases of varicose veins are the same. Doctors may differ in the ways they treat you. Some available treatments or surgeries include:

Micro Foam Sclerotherapy

KTP-Laser

 

Of all available treatments, this one is most commonly used for both spider veins and varicose veins. It involves injecting a solution into the vein causing the lining of the vein walls to swell, stick together, and eventually seal shut. The flow of blood is stopped and the vein turns into scar tissue. In a few weeks, the vein should fade. Although the same vein may need to be injected with the solution more than once, sclerotherapy is very effective if done correctly. It is safe to say that per treatment 60 to 70% of the veins treated will respond.

Some side effects may only occur at the site of the injection, such as stinging or painful cramps; red raised patches of skin, small skin ulcers, and bruises. Spots, brown lines, or groups of fine red blood vessels could appear around the vein being treated. These usually disappear. The treated vein could become inflamed or develop lumps of coagulated or congested blood. These are not dangerous. Applying heat and taking aspirin or antibiotics can relieve inflammation. Lumps of coagulated blood can be drained. Cost of treatment can be high, Health insurance coverage varies. If the treatment is done for cosmetic reasons only, it may not be covered.

With foam it is possible to treat also large veins up to 9 mm. For larger veins endovenous procedures or surgery is the preferred method, followed by sclerotherapy a few months later.

. It is a sclerosant solution that has been transformed into foam by mixing it forcibly with with 2 to 4 parts of air. Under local anaesthetic, a needle is inserted into the main affected superficial vein and is monitored using ultrasound imaging. Foam is then injected and monitored. Once the foam has filled the entire main superficial vein, the top end of the vein is depressed to keep the foam in the superficial veins and the foot flexed to activate the calf muscles. The foam causes inflammation of the vein wall, obliteration of the vein’s lumen and vein occlusion. It is very effective for veins under 9 mm.

No, spider veins are the best indication for sclerotherapy.

There are a few specialists who are well trained in the management of sclerotherapy. Among them are dermatologists, vascular surgeons, plastic surgeons, and some so-called “phlebologists.” Surgery should ideally be performed by general or vascular surgeons. Beware of large-scale venous clinics and doctors advertising “nonsurgical treatment of varicose veins.”

There are several excellent elastic compression brands made for support and treatment of swelling of the legs and treatment of most (if not all) venous problems. Ask your doctor for the names of one or two of them. They may be custom made for children and other special needs.

The laser energy damages the vein walls, shrinking them and thus closing the faulty vein so that the blood can no longer flow through it.

No. There are many veins in the leg and after treatment the blood in the faulty veins will be diverted to normal veins in order to make its way back to the heart.

There are potential complications with any medical procedure however the only minimal complications experienced with the endovenous laser (EVLA) Procedure have been a small number of cases of transient paraesthesia (numbness) at the level of injection mostly around the ankle and under the knee . These resolve usually after a few  weeks or months.

No. You will be given a pair of special glasses to wear to protect your eyes, however this is just a precaution against accidental firing of laser energy outside the body.

Traditionally faulty Saphenous veins have been treated with surgical ligation and stripping. This involves at least two surgical incisions in order to tie off and pull out the faulty vein. It is usually performed under general anesthesia. EVLA  appears to have lower risk; shorter recovery period, lower costs and no scarring compared with surgery. One has to realise that treatment does not remove the tedency to develop varicose veins. Regular follow-up permits early touch-ups and less recurence after treatment.

Yes. The two common ones are ultrasound-guided sclerotherapy (injection therapy) and radio frequency electrosurgery. There are also methods including, glue, vapour, and rotating intruments.  Injection therapy for the Saphenous vein appears to have a high recurrence rate frequently requiring retreatment. However it is excellent for cosmetic treatment of any visible veins remaining after an endo-laser procedure. Radiofrequency electrosurgery is also very effective but seam more limited in the range of patients it can treat.

Our results have been extremely favourable with success rates as high as the conventional surgical approach, which is accepted as the ‘standard’ treatment. Endovenous laser will normally treat the cause of most vein reflux disease but additional/complimentary therapy like perforators ligation and injections to  parallel veins are necessary in many cases.

If the patch is a bruise and occurred immediately after the surgical procedure, it will go away. If, on the other hand, it is a patch of closely packed blood vessels in the skin, this will require treatment by injection techniques. The latter is called matting and is a rerouting of blood flow after removal of a vein.

You have described a bruising of the nerve that accompanies the long saphenous vein. This is a disturbing complication that may take many months to clear. For the most part, it will clear entirely. However, the occasional patient suffers continued numbness, which is not important medically but is annoying.

Some years ago, ligation of the saphenous vein was done in the groin. That would leave only a scar where the thigh joins the trunk and no scar at the ankle. A scar at the ankle usually indicates that the saphenous vein has been removed. After ligation, it is common to see recurrent varicose veins, and they recur in the same pattern as the veins were before surgery. It is best to have an ultrasound examination to show the doctor what has been done in the past. In this situation, the techniques of VNUS Closure® and endovenous laser work very well to treat the residual ligated saphenous vein. Surgery without those techniques can be done, but the groin re-exploration is a demanding surgical procedure and should be done only by experts.

Men tolerate very large varicose veins without any symptoms because they lack the hormone progesterone. Progesterone and symptoms seem to be linked and, of course, progesterone is found only in women. Very large varicose veins, when left untreated, have one chance in five of progressing to leg ulcer. In other words, these veins have an 80% chance of not becoming complicated.

You have had superficial phlebitis that is important to distinguish from deep vein thrombosis. The latter is a condition to be treated by anticoagulation. Superficial phlebitis in varicose veins regularly recurs, and the varicose veins should be removed surgically.

Ambulatory Phlebectomy – With this surgery, a special light source marks the location of the vein. Tiny incisions are made in the vein, and then with surgical hooks, the vein is pulled out of the leg. This surgery requires local or regional anesthesia. The vein usually is removed in one treatment. Side effects and complications are similar to those of ligation and stripping. The most common side effect is slight bruising. Compared to traditional surgery, ambulatory phlebectomy allows the removal of very large varicose veins while leaving only very small scars. Patients can return to normal activity the day after treatment.

Current treatments for varicose veins and spider veins have very high success rates. Although it is uncommon, these veins can return after treatment. One reason may be hidden areas in the body where there is a lot of pressure on the veins. This pressure may cause new spider veins. Doctors can diagnose this with ultrasound. Another cause may be new re-growth of vein branches. Doctors have found that tiny vein branches can grow through scar tissue to connect to both deep and superficial veins even after surgery.

 

Consultation

Every Thursday from 10 h to 13h