Author - Duncan Black
What are Varicose Veins?
Varicose veins are commonly found in our population,
in both men and women. They are twists and swellings
of the veins close to the skin in the legs. By far the
commonest cause is genetic and they do run in families.
Blood normally circulates continuously through the body
helped by valves in the veins. When these valves do
not work effectively they leak and the back flow and
pressure of the blood in these veins causes the swelling,
resulting in what we call varicose veins.
Varicosities may be of cosmetic concern, but frequently
they can be the cause of bothersome symptoms such as
a feeling of fullness in the leg, ankle swelling, itchiness
(venous eczema) and discomfort in the calf in bed at
night. Clots can form in the varicosities causing pain
and tenderness – the medical term for this is
thrombophlebitis. Rarely the clot may extend into the
deep venous system leading to deep vein thrombosis (DVT)
and even pulmonary embolism (“economy class syndrome”).
Long-term complications of varicose veins include discoloration
and hardening of the skin of the lower leg and around
the ankle (the “gaiter” area). The medical
term for this condition is lipo-dermato-sclerosis, or
LDS for short. In the long run this can result in nasty
chronic ulcers of the lower leg which can be very difficult
to treat.
What can be done about varicose veins?
The symptoms varicose veins cause can be managed by
the wearing of special support stockings and elevating
the legs wherever possible. However, they can be uncomfortable
in warm weather and they have to be replaced every four
to six months as they lose their elasticity –
over the years the cost can be considerable.
Surgery is usually simple, relatively pain-free and
the recovery time short, and most people prefer this
solution. However, before one can reliably decide on
a surgical course of action one needs to know which
are the “leaky veins” (the ones where the
valves are not working properly). This is most reliably
done by Duplex Ultrasound scanning and is invaluable
to the surgeon in planning the correct operation. Some
surgeons even use the Duplex Ultrasound in theatre to
ensure that the leaky veins have indeed been successfully
removed at the end of the operation.
What types of surgical treatment are available?
TRADITIONAL SURGERY: The leaky vein is usually
the long saphenous vein (LSV) which drains into an even
larger vein in the groin. It, the LSV, is exposed in
the groin through a small cut and is tied off. The portion
of it in the thigh is then stripped out. The visible
varicosities are then individually “phlebectomised”,
in other words, pulled out through tiny incisions about
2 – 3 mm long – these tiny incisions heal
with no visible scar after a few months.
Sometimes it is the short saphenous vein (SSV) which
is the leaky one. This drains into a deeper vein behind
the knee, and it is here that it has to be tied off.
The groin incision and the one behind the knee are
small and closed carefully with special buried stitches
which take about five months to dissolve. They serve
to hold the wound tightly together until the body has
formed its own strong scar tissue – this prevents
the unsightly scar stretching that can occur as scars
age.
MINIMALLY INVASIVE methods such as VNUS (radiofrequency)
closure and Laser where there is no groin cut and the
leaky LSV is burnt to closure using a catheter introduced
via a needle at the level of the knee. Excellent results
can be obtained by these methods, but they are quite
a bit more expensive than traditional surgery. However,
it has to be said that, in experienced hands, traditional
surgery still has a very respectable place in the management
of varicose veins. My preference of the two minimally
invasive methods is VNUS closure and it is this method
I offer my patients if they prefer it to traditional
surgery.
Foam Sclerotherapy of the LSV and SSV. Foam
sclerotherapy of the major truncal veins (Long Saphenous
Vein and Short Saphenous Vein) is performed without
anaesthetic and is much in the news, but still in the
evaluation phase and many respected vascular surgeons
have very real concerns regarding its safety. For this
reason, I presently do not offer this procedure to my
patients. Another disadvantage of Foam Sclerotherapy
is that the patient has to return for repeated treatments
as only so much foam can be given at one sitting.
Will my veins come back after the operation?
The judicious use of Duplex Ultrasound has been shown
to significantly reduce the incidence of recurrence
and careful surgery will lower the incidence even more.
However, one cannot guarantee that new veins will not
form. And sometimes they do, but only at the rate of
about one to two percent per year. And if new ones do
form, you will no doubt be alerted to them and have
them treated early.
In summary, recurrence of varicose veins is a problem,
but in experienced hands and with the appropriate use
of modern technologies such as Duplex Ultrasound scans,
can be kept to a respectable minimum. And even if they
do recur, this is easily managed.
Thread Veins
Thread veins frequently have an underlying leaky major
vein (e.g. LSV or SSV) as their cause, in which case
the vein has to be treated surgically first. Sometimes
the thread veins are “primary” (i.e. no
underlying leaky vein), in which case a good result
with micro-injection sclerotherapy can usually be obtained.
Micro-injection sclerotherapy consists of the injection
of an irritant solution through a very thin needle into
the thread veins. This causes inflammation of the thread
vein and its eventual obliteration after a few weeks.
Micro-injection sclerotherapy should not be confused
with foam sclerotherapy – it is not associated
with the dangers of the latter.
This information was written by Mr. Duncan Black,
Consultant Vascular Surgeon, London Bridge Hosptial. NHS
Hospital: St Mary’s, Paddington.
Click here for more information on Vascular Surgery consultants at London Bridge Hospital
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