Varicose veins are extremely common and range in severity from minor cosmetic veins to venous ulcers. A number of treatments are available and it is possible to treat all levels of severity.
The bewildering choice of treatments available reflect the complex range of conditions that are grouped together as ‘varicose veins’. Treatments vary from injection sclerotherapy, light therapy, laser therapy, foam therapy, VNUS (and other minimally invasive treatments) to conventional open surgery.
Your surgeon should be fully conversant with the full range of conditions and modern treatments that are available. Each patient needs an individual treatment plan to address his or her particular problem.
http://www.warwickshiresurgicalpartners.co.uk/WSPdefault.aspx
Normal Veins
Blood travels from the heart to the extremities via the arteries. The blood returns to the heart via the veins. In a lying position the blood returns easily to the heart. In a standing or sitting position blood has to travel up hill to get back to the heart. In a normal leg there are a series of one-way valves which aid the flow back to the heart. Moving the calf squeezes the calf veins and aids the return of the blood the heart. This is called the calf pump.
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| Normal veins |
Abnormal veins |
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Abnormal Veins
However, if the valves are faulty, when the patient is standing, blood can either flow to the heart or to the feet when the patient is standing.
Long-standing distention of the veins can result in varicose veins.
Symptoms
- Aches and pains (usually towards the end of the day), which are often worse in hot weather.
- Itching, possible flaking skin or eczema.
- Swelling
- Heavy dragging legs
These symptoms are often worse in women during their menstrual periods
General advice for people with veins
There are a number of simple, generally sensible, steps that you can take that will ease your symptoms or prevent them from getting worse.
1. Take regular exercise
2. Attain a healthy weight
3. Eat a healthy balanced diet, including plenty of fibre to prevent constipation
4. Try to avoid long periods of sitting or standing, particularly at work or whilst travelling
5. When resting, sit with your feet up
6. Avoid very tight clothing
Signs
Varicose veins range from minor cosmetic blemishes through thread or spider veins to prominent, bulging, unsightly dark blue veins
Skin changes can occur – pigmentation (haemosiderin deposition), skin thickening (lipodermosclerosis) and even ulceration
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| Varicose Veins |
Substantial Varicose Veins |
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Vulval Varicosity |
Diagnosis and Special Investigations
Most veins are a result of faulty valves and are amenable to treatment. However, it is vital to accurately determine the site of the faulty valves so that the leaks can be corrected. Failure to deal with the major leak greatly increases the risk of a recurrence. Commonly the major leak is in the groin (sapheno-femoral) or behind the knee (sapheno-popliteal). Occasionally veins can arise from ‘perforators’ in the upper or lower leg or more rarely, in women, from varicose veins in the vulval area. All can be treated, and treatment will tend to improve both the symptoms and appearance.
The majority of first time veins can easily be assessed by clinical examination and a hand held ultrasound machine (doppler). Recurrent veins, complex veins or those arising behind the knee, are best assessed by a simple non-invasive ultrasound technique called Duplex imaging.
All patients with varicose veins will be assessed in clinic on their first visit with a portable Duplex machine. I use a SonoSite MicroMaxx which I find is a robust and portable machine having used it in the mountains.
http://www.healthimaging.com/content/view/5452/176/
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Below knee support stocking |
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Treatment Options
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| Leave alone |
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Most veins can be left alone but will tend to deteriorate with time |
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| Support hosiery |
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Support hosiery will usually control the symptoms of the veins (aching discomfort towards the end of the day). A good fit is essential if the stockings are to be comfortable and well tolerated. |
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| Compression bandaging |
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4-layer compression bandaging is a highly effective way of treating venous ulcers. Once the ulcer has been healed, adequate support hosiery (or venous surgery) is required.
The vast majority of venous ulcers can be treated in a Community Ulcer Clinic. |
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| Non-operative interventions |
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A number of treatments have been developed to treat minor veins, thread veins or spider veins including injection sclerotherapy, light or laser treatments.
The basic principle of each treatment is similar, in that the aim of the treatment is to cause the blood flow through the small vein to cease. |
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| Surgery |
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The aim of surgery is to improve both the symptoms and the appearance of the leg(s) by dealing with the major leaks and the more minor tributaries.
Surgery is often performed as a day case either under general, regional or local anaesthesia. Some bruising is inevitable and can occasionally be quite marked. In a small number of patients there can be some numbness around the wounds or ankle which usually resolves, but occasionally persists, but should clear rapidly, and return to normal activities is quick. Long haul air travel should be avoided for approximately 6 weeks.
Small scars are inevitable but they are kept to an absolute minimum. In a standard ‘high tie strip and avulsions’, the groin scar, which is within the bikini line, is normally 2.5-4cms long. The exit wound at the knee is approximately 1-1.5cms long. Other scars at the site of the avulsions are very small and sited over the veins. ‘Pin stripping’ reduces scars to a minimum and is possible in most patients.
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Thread / Cosmetic Veins
Thread veins are extremely common. They are usually symptomless, but not always. Thread veins are often unattractive to the sufferer. A number of treatments which significantly improve their appearance are available such as micro injection sclerotherapy, laser or light therapy.
Surgery
Using modern operative techniques it possible to offer safe conventional surgery through cosmetic incisions. See photos
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| Pin Strip |
Vein Hook |
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| Vein Avulsion |
Post Op |
Foam sclerotherapy and EVLT (endovenous laser treatment)
Over the last couple of years a number of minimally invasive treatments for varicose veins have been developed. Both foam and EVLT can be performed in a treatment room under local anaesthesia (a bit like going to the dentist) rather having to be performed in an operating theatre under a general anaesthetic. This has advantages in terms of both ease of treatment and cost over conventional open surgical treatment. The return to work/sport is much faster.
Long term results remain to be determined, but the newer techniques appear to be almost as effective as open surgery but far less invasive. The techniques involve identifying the main veins using ultrasound, and placing a plastic tube (cannula) under local anaesthesia into the vein.
Using continuous ultrasound guidance it is possible to seal the major veins using either glue (foam sclerotherapy) or a laser probe (EVLT). The glue is an emulsion of a well proven sclerosant (has been in use for more than twenty years) and air. The emulsion shows up well on ultrasound enabling the operator to see exactly which veins have been treated.
The whole procedure takes 30-45 minutes and the patient is able to walk out the treatment room, returning to normal activities. Firm bandaging and TED (thromboembolic deterrent) stockings are worn for the first week, and TED stockings alone for the next week.
Complex Venous Surgery
Occasionally complex venous reconstructions are necessary. The picture below was taken during a kidney transplant. The renal vein on the donated kidney was too short and it was necessary to reconstruct an extra length of vein using the recipient’s own long saphenous (leg) vein. A metal mandrill is used as a template.
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Venous Ulcers
Venous ulcers are the result of years of venous hypertension. This can be caused by problems in either the deep veins (previous DVT), the superficial veins or a combination of both. It is important to establish the correct diagnosis at an early stage, since there are a number of other conditions that can mimic the condition. An assessment of the arterial supply to the legs and the venous drainage from the legs is vital. Other factors such as diabetes, peripheral neuropathies, infection, trauma, cancer (squamous), and other rarer causes need to be considered.
Adequate compression will heal the majority of venous ulcers. This can be applied in the form of 4-layer compression bandages. Once the ulcer is healed, compression hosiery (at least 20-25mmHg) should maintain healing.
Venous surgery may be appropriate in some cases.
'MOST VENOUS ULCERS CAN BE HEALED'
Warwickshire vein clinic
http://www.warwickshireveinclinic.co.uk/default.aspx
BUPA Foam sclerotherapy
http://hcd2.bupa.co.uk/fact_sheets/html/foam_sclerotherapy.html?print
BUPA Varicose veins
http://hcd2.bupa.co.uk/fact_sheets/html/Varicose_veins.html?print
BUPA Vein surgery
http://hcd2.bupa.co.uk/fact_sheets/html/Varicose_vein_surgery.html?print
NICE Foam sclerotherapy
http://www.nice.org.uk/nicemedia/pdf/IPG217Guidance.pdf
NICE EVLT
http://www.nice.org.uk/nicemedia/pdf/IPG052publicinfo.pdf
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