Varicose Veins

How Are Varicose Veins Treated?

Treatment for varicose veins depends on the type of veins to be treated and the root cause of the problem.

Patients seek treatment either for purely cosmetic reasons, or because of uncomfortable symptoms such as aching and heaviness in the legs, or because in the late phase of the condition, they are getting skin damage at the ankle which can degenerate into a venous ulcer.

The first essential step in deciding on vein treatment is a good duplex ultrasound scan. This is a scan that looks under the skin surface and locates the precise leaking valve in the veins that is causing the varicose veins you can see on the skin.

Treatments for varicose veins include:

• Compression stockings

• Injection therapy

• Surgery

• Laser therapy

• Closure technique

• Treatment of ulcers

Compression Stockings

Your physician may recommend that you wear compression stockings-also called support hose-to reduce symptoms. These are elasticized stockings worn from the toes to the knee or sometimes to the top of the leg.

Compression stockings are ‘graduated’. That means the pressure of the stocking is higher at the ankle than at the knee. This gradient helps to push blood in the veins up the leg in the correct direction and prevents it ‘pooling’ in the lower part of the leg, which is what happens in varicose veins. Good quality compression stockings do help to reduce swelling, tiredness, and aching in the legs, but elastic hose will not cure varicose veins. A lot of patients also find them uncomfortable to wear long term.

Injection Therapy

For very small veins or for the fine ‘spider veins’ seen on the surface of the skin, a type of injection therapy, called sclerotherapy, may be used to close off damaged veins without the need for surgical removal. Sclerotherapy is usually performed in a doctor’s office and works like this:

• Using a fine needle, the doctor gently injects an irritating chemical (the sclerosing agent) into the varicose vein.

• To minimize discomfort, the doctor may mix a local anesthetic with the sclerosing agent.

• The sclerosing agent creates scar tissue inside the vein, which blocks off the flow of blood to that vein, shutting it down permanently.

Need To Know:

After the procedure:

• There may be some discomfort and redness of the skin at the injection sites.

• Your doctor will apply a compression bandage to the area. You will need to wear this bandage for a few days and a compression stocking for a few weeks after treatment.

• Walking is an important follow-up activity.

• Most people are able to return to work and daily chores within 24 hours, if not immediately.

Possible Complications of Sclerotherapy

Sclerotherapy is mostly successful, but not always. Individual varicose veins may occur again and require treatment. Other complications include:

• Blood may leak from the treated veins into the surrounding tissue, which produces brownish discoloration on the skin around the treated veins. This discoloration will eventually fade in four to six months, although sometimes it takes as long as a year. In rare cases, the discoloration is permanent.

• In rare cases, a small, depressed scar may appear after treatment, or a blood clot may develop in a treated vein.

• The procedure may leave a fine network of smaller varicose veins at the site where the larger vein was treated.

• Some of the chemical solutions used in for sclerotherapy contain high concentrations of salt, which can temporarily raise blood pressure.

• Solutions have caused allergic reactions in some people, but these are rare. The risk is about 1 in 10,000 cases.

• An ulcer at the site of the injection may occur in a very small number of individuals who undergo sclerotherapy.

Foam Sclerotherapy

Foam sclerotherapy is a variant of the injection technique described above and is used to treat larger varicose veins. The chemical solution is mixed with air or carbon dioxide to make‘foam’ before injection into the vein. The foam can be mixed up by the treating physician, or there are ready made products such as Varisolve.

Sclerotherapy works by damaging the inside lining of the vein. The sclerotherapy chemical is usually deactivated by contact with the proteins in the blood. Foam sclerotherapy is more effective than liquid sclerotherapy because the foam pushes the blood out of the vein and the contact time between the chemical and the vein wall is prolonged.

Foam sclerotherapy can work quite well, but the main problems are post procedure phlebitis (inflammation of a large vein) which can be sore, staining of the skin and recurrence. About 30% of patients treated with foam sclerotherapy will get a recurrence after 2 years

Surgery

Surgical treatment of varicose veins may be required to alleviate pain and to put a halt to recurrent bouts of phlebitis.

Surgery is especially beneficial when the large veins of the legs are involved. Surgery may also be chosen for cosmetic reasons.

Surgery can be divided into two main types – ‘open surgery’ such as a high tie and strip procedure and minimally invasive vein surgery techniques.

The main differences between the two options are:

Open surgery

• Requires a general or spinal anesthetic
• Requires a surgical incision in the top of the leg
• The damaged vein in the leg is physically stripped out
• May require a overnight stay in hospital
• Takes approximately 4 to 6 weeks for full recovery
• Has a recurrence rate of up to 30 % at 5 years

Minimally invasive surgery

• Usually performed under local anaesthetic (like going to the dentist)
• Does not require a major incision
• The damaged vein in the leg is sealed from within, usually by a heat based system such as a laser or radiofrequency probe.
• Recovery takes 1 to 2 weeks
• Recurrence rates are variable but estimated at 10 % at 5 years

Open surgical Vein Stripping

Varicose veins can be removed by an operation known as vein stripping. Vein stripping is the only option for removing the saphenous veins (the largest surface veins in the legs) that serve as the major channels for blood among the superficial veins in the leg.

A person undergoing this procedure may receive either general anesthesia (to be asleep for the procedure) or an epidural (a local anesthetic injection into the back that numbs the lower half of the body).

• The surgeon makes two small incisions-one in the groin and the other near the ankle or knee.

• The surgeon then ligates (ties off) the saphenous vein and its branches at the groin incision.

• The surgeon then passes a flexible wire through the vein from the ankle incision. A number of small incisions in the skin are sometimes needed along the vein to guide the wire along the length of the entire vein.

• When the wire reaches the groin incision, the surgeon pulls the wire out, bringing the entire vein with it (“strips the vein out”).

Recovery

Many patients are able to leave the hospital on the same day as the surgery–or at the most, the day following surgery.

It usually takes two to six weeks to recover from the operation. During that time, your physician may ask you to:

• Keep the leg or legs bandaged for several weeks following surgery.

• Take several short walks, starting with five minutes each time, and slowly increasing the time and distance covered each day.

• Lie down frequently and keep your leg elevated above your heart.

The bandages and any stitches used will be removed by the end of the first week, during a follow-up visit to the surgeon’s office.

Most people are able to return to work within one to two weeks of the operation.

Possible Complications of Vein Stripping

The principal complications following vein stripping include:

• Occasionally, the procedure can damage superficial nerves along the stripped vein, causing a patchy area of numbness in the leg. The nerves usually recover, however, and sensation returns.

• In some instances, it can result in such complications as infection, which will require antibiotic treatment, and bleeding, which can be treated usually by firm pressure.

• There is a recurrence rate of approximately 30% at 5 years after vein stripping.

Nice To Know:

Minimally invasive vein treatments

Endovenous laser ablation and VeNUS closure

Over the last 10 years there has been a move away from open surgical techniques in the treatment of varicose veins towards minimally invasive operations such as EVLT and VeNUS closure.

Several different types of laser are now used to treat leaking varicose veins under local anaesthetic. The vein treated is the same vein that is stripped out of the leg in the open surgery operation described above. With minimally invasive treatment a fine laser fiber is inserted into the vein through a pin hole nick in the skin, at or around the knee joint. Under ultrasound control the surgeon passes the fiber up the leg to the groin without making any further incisions. The vein is then surrounded by local anesthetic and saline solution by injections into the leg. This protects the other parts of the leg from the heat generated by the laser.

The laser is turned on and the fibre is slowly withdrawn down the vein. The heat of the laser burns the inside of the vein, causing it to seal and not have any blood flow within it. Over the course of a few months the vein usually shrinks away and is destroyed. The technique works well in 98 % of cases.

A bandage is then applied to the leg and the patient can walk right away. Painkiller tablets are needed for a few days after surgery, but most patients get back to normal activities within a week.

VeNUS closure is a very similar technique which uses a radiofrequency probe rather than a laser fibre to generate the heat required to close the vein. The fibre is inserted into the vein also under ultrasound control and local anaesthetic.

EVLT and VeNUS closure can be performed in a doctor’s office rather than in a formal operating theatre. For these reasons, minimally invasive treatments are now very popular for the treatment of varicose veins with both patients and surgeons alike.

After EVLT or VeNUS closure there may be a few residual veins on the calf. These can be removed by ambulatory phlebectomy or sclerotherapy to imporve the cosmetic appearance of the leg.

In ambulatory phlebectomy, a surgeon makes a series of tiny puncture holes along the vein and then takes out small segments of the vein under local anaesthetic.

The tiny incisions require no stitches. Most people experience very little pain after the operation and are able to walk immediately following surgery.

Treatment of Venous Ulcers

A venous ulcer is an open sore on the leg, usually around the ankle area. A venous ulcer is a complication of longstanding varicose veins. High pressure in a leaking vein over a long period of time will damage the skin in the lower part of the leg. Before the skin ulcerates, there are a characteristic series of changes. Initially the skin becomes dry and itchy – this is called ‘venous eczema’. The skin then develops a dark pigmentation and becomes hard and leathery. Eventually the skin can break down into an ulcer. Because the development of a venous ulcer takes a long time, they are more common in elderly people.

Venous ulcers are very hard to treat. They cause significant pain, discomfort and disability. The mainstay of treatment of an ulcer is compression bandaging of the leg in tandem with surgery on any leaking veins identified by ultrasound scanning.

With good compression bandaging, 90% of venous ulcers will heal up within 3 months. Surgery to the leaking veins may speed this up and reduce the risk of the ulcer recurring. Venous ulcers are very labour intensive and costly and require diligent regular nursing input.

Larger venous ulcers may require plastic surgery is required to cover the ulcers with skin grafts in order to achieve healing.

The best treatment for a venous ulcer is not to get one in the first place – in other words by prompt treatment of varicose veins before the condition degenerates into serious skin damage and ulceration.