Varicose Veins

Varicose veins are distended branches of the major veins in the leg. They become distended due to failure of the valve s in the main veins which allows blood to fall back down the leg (reflux).  Venous reflux is the major cause of most venous diseases and is almost always the cause of varicose veins.

Varicose veins develop in the superficial veins of the leg and mainly affect the great saphenous vein although it is not uncommon for the small saphenous vein to be involved.
As the vein dilates the wall stretches in both width and length so that the vein becomes tortuous.
As the situation gets worse the veins become so dilated that large sacs form at the bends and the vein takes on a snake–like twisted effect.
Areas of stagnation occur where the bends are so extreme that blood does not  flow around them fully.
Rather than a fast flowing ‘river’, the vein will sometimes thrombose, leading to inflammation of the vein called superficial thhrombophlebitis.
Venous ulcers will continue to recur unless the underlying varicose veins are treated. Some people suffer only cosmetically, but very often people will complain of aching legs, particularly at the end of the day.

Causes

The specific causes of vein problems are undetermined and will vary according to the individual.  Contributary factors may include –

• Hereditary: there is a known relationship between hereditary factors and the development of varicose veins in the general population
  
• Age: the development of varicose veins may occur at any age but will usually start between the ages of 18 and 35, with peaks between 50 and 60.
  
• Gender: females are assumed to be affected more than males but this is more likely to be due to the fact that  females seek medical treatment more readily than men. In fact research has shown that the incidence of varicose veins occurring in both men and women is similar.
  
• Pregnancy: circulating hormones can weaken the vein walls. An enlarged uterus can compress veins causing higher vein pressure and dilated veins. Varicose veins that form during pregnancy can spontaneously improve and often disappear within a few months of childbirth. Research has shown that women who have developed valve problems (which are directly related to varicose veins) prior to pregnancy go on to develop varicose veins during or after the pregnancy. So pregnancy in itself does not cause varicose veins in the majority of people and varicose veins would have developed in any event at some point in the future.
  The above is true for about 98% of pregnant women with associated varicose veins. The remaining 2% of women do get varicose veins because of pregnancy. These women suffer from  ‘ovarian’ or ‘pelvic’ vein reflux which can typically cause vulval varicose veins or varicose veins of the upper inner thigh.
  
• Lifestyle: standing and sitting for long periods; tight clothing; obesity; heat; sedentary lifestyle; excessive alcohol intake and smoking, high heeled shoes; ‘the pill’ and, number of pregnancies are all associated but not a cause of varicose veins.

Preve ntion Tips

• Exercise regularly: it is often recommended that 3–4 times a week of approximately 20 minutes of fairly strenuous exercise, such as walking or swimming, reduces pressure in the veins generally. It is of course good for overall health.Exercise improves your leg strength, circulation and vein strength.
• Move legs frequently: flexing ankles periodically will pump the blood out of the legs. When standing or sitting for long periods, flex the ankles 10 times and repeat every ten minutes and try taking a short stroll every 30 minutes.
• Support/compression stockings: these provide extra pressure from the outside to assist with venous blood flow back to the heart. They reduce reflux and pressure in the veins and should be considered for long haul air travel and prolonged travel in cramped spaces generally.
• Avoid excessive heat on legs: hot baths or Jacuzzis may lead to increased vein distension and more pooling of blood.
• Elevate the legs: where possible the objective is keep the legs above the level of the heart thus providing a natural gravitational force of blood to the heart. So where possible, when resting elevate your legs as much as possible.
• Healthy diet: Make sure you eat a healthy diet, with enough fibre, to avoid constipation which can contribute to varicose veins.
• Maintaining a healthy weight

Investigations

Proper diagnosis is essential in order to devise an appropriate and successful treatment. Colour Duplex Ultrasound is the most reliable way and is the best current method of identifying  the location and extent of venous problems. This is a minor procedure carried out by a vascular technologist and maps which veins are working correctly and those which are not. Without this, even the most skilled practitioner may treat the wrong vein. Some evidence suggests that about 30% of patients have received the wrong operation as a result, and therefore it is not surprising that varicose veins come back.

A clear gel is put on the skin and the ultrasound probe is then placed onto this. A vascular technologist performs the scan in the clinic and can see the veins and the blood flowing through them. It sometimes also shows the valves in action and the flow rate and patterns of blood also illustrates the condition of the valves.
The rates of success for leg vein treatment, and the vastly reduced risk of recurring vein problems, is a direct result of this testing method.

Venous Ulcers

Venous ulcers account for 90% of the ulcers seen in clinical practice, and it is estimated that 1% of the population will suffer from a venous ulcer at some point in their life. Many people that have venous ulcers

have associated varicose veins.
It is this association that worries most people who have varicose veins and perhaps presents a further motive not to ignore varicose veins in the long term.
An ulcer can occur due to the chronic rise in pressure as a result of too much blood falling back through the veins (reflux). Damage to the delicate venous capillaries that should drain into the larger veins can result in the leaking of blood and plasma into the surrounding tissue.
Chemicals and enzymes in the blood and plasma then cause inflammation, itching, swelling and soreness. Eventually, this can lead to a break down of the skin causing an ulcer.
Ulcers are unlikely to heal unless the underlying cause is treated, in this case, the venous reflux. Hence the importance in dealing with varicose veins earlier rather than later.

Varicose Vein Treatments

Radiofrequency Occlusion

Radiofrequency Occlusion is an alternative to surgical stripping of veins. It treats the vein by heating it, causing the vein to contract and then close. Once the diseased vein is closed, other healthy veins take over and empty blood from the legs. Normal blood flow is re-established quickly and symptoms should improve noticeably.

To perform the procedure, the surgeon uses an ultrasound machine to map the vein, before numbing the area with a local anaesthetic. A needle is then placed into the lower end of the diseased vein, through which a small sheath is inserted. A radiofrequency catheter is placed through the sheath and advanced to the upper end of the diseased vein. Local anaesthesia is then delivered to the entire vein. As the catheter is slowly withdrawn back, the vein is heated.It then collapses and seals shut.

Following the procedure the catheter is removed, a bandage is placed over the incision site and compression stockings are prescribed for a short time. Patients are encouraged to mobilise and long periods of standing and inactivity are to be avoided. This procedure is minimally invasive with little discomfort and most patients can walk out after treatment within an hour.

Possible side effects of this procedure are slight bruising, skin numbness, skin burns, blood clots and phlebitis. However side effects are uncommon and the procedure offers a safer and more effective treatment than traditional surgical methods. Radiofrequency ablation is far less painful than surgical stripping and EVLT treatment. Bruising and recovery times are also greatly reduced.

Following radiofrequency ablation small residual veins may be treated with phlebectomy or ultrasound guided sclerotherapy.

Endovenous Laser Treatment (EVLT )

The EVLT procedure is a minimally invasive laser procedure in treating varicose veins. The laser energy heats the blood in the veins causing them to seal shut so that blood cannot flow through it. This eliminates the bulging of the vein at the source. After the treatment the blood in the faulty veins will be diverted to the many normal veins in the leg.

As with radiofrequency, the surgeon uses an ultrasound machine to map the vein, before numbing the area with a local anaesthetic. A needle is then placed into the lower end of the diseased vein, through which a small sheath is inserted. A laser catheter is placed through the sheath and advanced to the upper end of the diseased vein. Local anaesthesia is then delivered to the entire vein. As the catheter is slowly withdrawn back, the blood in the vein is heated causing the vein to collapse and seal shut.

This type of procedure takes around 45 minutes with a local anaesthetic and is done as an out-patient procedure.

The procedure leaves no visible scarring, and there is some post-operative pain although not as much as surgery. Walking is recommended immediately.

There are always risks from the use of lasers, although as a standard precaution special goggles are worn to protect the eyes in the event of accidentally coming into contact with the laser beam. Side effects may include slight bruising, pain, skin burns, blood clots and phlebitis.

Sclerotherapy for varicose veins under ultrasound guidence

A special chemical called a sclerosant is injected under ultrasound guidence into a varicose vein.This causes damage and inflammation and leads to the closure of the vein. The sclerosant may cause localised feelings of burning or cramping for several minutes but generally the procedure is relatively painless.

After the injection pressure is applied to the veins to prevent blood returning when the patient stands up. A compression stocking is worn for several weeks after the procedure to aid this process.

Treatment will normally take up to 30 minutes but can take less time, depending on how many veins there are to be treated. The number of injections and treatment sessions required depends on the extent of the varicose vein condition.

Foam sclerosant is also used in many cases, which offers advantages over liquid sclerosant. Foam makes better contact with the inside of the vein wall and stays in the vein longer thus generating more effect from the active chemical.

Side effects albeit rare, in sclerotherapy include skin colour changes around the treated area which usually disappear after 6-12 months, but in rare cases may be permanent. Occasionally there may be itching, bruising, pain, and blistering around the treated area.Very rarely a patient may experience localised scarring or ulceration and blood clots or damage in the deep vein system. Matting may occur in the treated area. This is when a leash of smaller vessels appear in the treated area but often resolves.

Phlebectomy

Phlebectomy is a method of removing varicose veins on the surface of the legs. It is done under local anaesthetic. This procedure involves making tiny incisions through which the varicose veins are removed. The incisions are so small that stitches are not required. Veins can collapse considerably and are very flexible and even large veins can be removed through a very small incision. Patients can also usually walk immediately after the procedure. Compression bandages and stockings are worn for a period after treatment. Walking or cycling is very often recommended to reduce the risk of blood clotting, reduce pressure in the vein, and increase the flow of blood.

Side effects may include light bruising, discomfort and nerve damage but these are rarely permanent.

Open vein surgery-vein stripping

During this procedure problem veins are tied up and removed from the leg. This treatment requires general anaesthetic. An incision is made in the groin along with many more incisions lower down the leg. A hospital stay may be required and pain killers, support bandages and leg elevation is needed post surgery.

Side effects may include known problems associated with general anaesthesia, wound infection, permanent scarring, nerve tissue damage, deep vein thrombosis and significant leg pain.

Origin Medical does not use this traditional technique unless for specific medical reasons (extremely rare) a patient cannot benefit from endovenous procedures such as radiofrequency or endovenous laser.

Compression stockings

Compression stockings are a simple and inexpensive way to treat varicose veins. They are designed to reduce the blood pooling due to venous reflux. The stockings apply pressure, with the highest pressure starting at the bottom around the ankles and a gradual reduction in pressure as they go up the leg. This encourages blood not to back flow, and to maintain its natural direction back towards the heart. They can be procured in varying strength levels depending on the individual’s condition.

Although they do not eliminate varicose veins, they do help to alleviate symptoms caused by varicose veins, such as aching, heaviness, and swelling, as well as help to prevent worsening. Compression stockings can also be used to reduce the risk of blood clots in airplanes and long distance travelling generally.

Compression stockings are worn after vein treatments to keep pressure on the treated area. This prevents blood returning in to the treated area reducing side effects and improving long term results.

Why do varicose veins recur after treatment?

There are three main reasons why varicose veins recur (After treatment)

1. If treatment is performed without ultrasound then there is an element of imprecision in the location and diagnosis of incompetent veins, thus increasing considerably the risk of missing the problem or under treating it.
2. If the old ‘tie and strip’ type operation is done, a new vein may grow as the body recanulates the site where the old vein was. (Revascularisation 23% after one year but less than 1% if using endovenous laser). The radiofrequency technique also avoids this.
3. New varicose veins can form: veins that were normal on the day of treatment but which can develop problems later on. This occurs in about 2% of people.