Vascular (Varicose Veins) Patient Advice in Essex, UK

Vascualr surgeon for varicose veins, renal and general surgical conditions and procedures

Patient Advice and Information

Classical Surgery for Varicose Veins
by Dr Panayiotopoulos, Consultant Vascular and General Surgeon Essex.

1. What are varicose veins?

Varicose veins are abnormally tortuous [dilated, swollen] veins which are visible just below the skin surface, especially on the erect position. Smaller veins in the skin itself are sometimes called “thread veins” or “spider veins” or “teleangiectasias”. These are more common in women and although they may be unsightly, they are not the same as varicose veins and treatment options for these are different.

Varicose veins:

· Insufficiency of a proximal faulty valve

· Dilatation of all tributaries

· Prominent bulging veins especially when standing

· Often bilateral development

· Familial predisposition in most cases

· On the picture they are marked just before surgery

· Intradermal veins

· Thread veins

· Teleangiectasias

Are not varicose veins

2. How do normal veins function?

Veins are the blood vessels that carry blood back to the heart [venous return]. In humans fluids flow according to a gradient of height, like a mountain stream, downwards, or according to a pressure gradient, as in water supply system, from points of higher pressure to points of lower pressure. This principle applies to the whole circulatory system. The calf muscles also help by acting as a pump to propel the blood upwards.

In the leg there are two systems of veins, the deep veins which run between the muscles, have a high pressure and convey 9/10^ths of the blood and the superficial veins, which represent an alternative route with low pressure, conveying only 1/10^th of the blood. The superficial veins start from the ankle and join the deep system at two sites, in the groin [long saphenous vein] and behind the knee [short saphenous vein].

Furthermore, the deep and superficial systems are interconnected through small veins, like the steps of a ladder, called “perforators”. All the leg veins have one way valves which allow blood to flow only from the surface inward and only towards the centre. The presence of valves and the action of the calf muscles [squeeze the veins] overcome gravity and facilitate flow towards the heart.

3. What causes varicose veins?

They are always due to a fault in the one way valves inside the veins. If the valve leaks, then blood will flow backwards [reflux, reverse flow] towards the area with low pressure, assisted by gravity on standing. This reverse flow increases pressure in the superficial veins, which, as blood stagnates, become swollen and varicose. In such a case, venous hypertension ensues, and the pressure does not fall during elevation or walking, as the muscle calf pump is not efficient.

Calf Muscle Pump

However, as valve incompetence [leakage] is always there, it may be caused by a variety of reasons:

a. Weak vein structure. These varicose veins often run in the family and as you get older they are more likely to occur.

b. Valve leakage at the junction between deep and superficial veins This is the commonest cause of varicosities [primary varicose veins, 90%].

Perforator incompetence

When the most proximal valve is not able to close, blood flows like a waterfall from the deep vein that has a far higher pressure into the superficial vein. As a result of this increased refluxing blood volume the main trunk dilates and its small branches become initially varicose, followed by the main trunk. In the lower leg the perforators are overloaded by the retrograde flow and are themselves secondarily dilated, resulting in a blow out. Blood now circulates to and fro and the pumping action of the muscles is lost as well.

c. The same mechanism may cause varicosities during pregnancy or weight gain that increases the pressure in the deep veins, resulting in proximal valve incompetence.

d. Faulty valves in the perforators. Blood then flows from the deep veins [with high pressure] to the small superficial veins in the calf causing them to swell. The extent of these varicosities may not be as much as those caused by proximal valve incompetence but the symptoms are more severe and more evident during exercise.

e. Post-thrombotic varices. In this condition, after thrombosis of the deep veins and destruction of their valves, the pressure increases dramatically, the perforators blow out and blood is forced back into the superficial vein network. The patient has usually suffered a previous episode of deep vein thrombosis [although deep valve destruction may occur spontaneously] with a painful, red, swollen leg. The resulting post thrombotic syndrome gradually causes leg oedema, pigmentation around the ankle and secondary varicosities. The risk of ulceration is significant and without appropriate compression therapy the complications become more evident and the symptoms more prominent.

4. What trouble do varicose veins cause?

Varicose veins are very common [10-15% of the population are affected] and usually give no symptoms, although they may look unsightly. However, aching in the leg is common, especially after a day of standing, and ankle swelling may occur. Often as well they may cause heaviness in the leg, jumpiness, fatigue and night cramps which are a manifestation of venous hypotonia.

Occasionally, severe varicose veins, usually associated with deep vein disease, can damage the skin of the leg above the ankle causing itchiness, pigmentation and discoloration [eczema]. Without treatment an ulcer may eventually occur. Here it should be reiterated that not every leg ulcer is venous.

Sometimes, one of the varicose veins may become red, hard and tender. This inflammation is called thrombophlebitis and usually settles within a week with conservative management.

Rarely, one of the varicose veins may burst and bleed profusely.

However, the risk of all these serious complications [skin changes/ulcer, thrombophlebitis, bleeding] is only 2-5% in a lifetime.

5. What tests are required?

In most cases a simple clinical examination with rubber bands plus a painless test with an ultrasound machine is all that is needed to enable your specialist to identify the cause of your varicosities. It is important to identify the reflux point, where blood flows backwards because of a faulty valve.

Occasionally, a more detailed ultrasound scan [colour flow duplex] or a special X-ray [venography & varicography] may be necessary before advice about treatment can be given. This is especially likely if your varicose veins have recurred following previous treatment or when there are multiple causes for your varicose veins [multiple reflux points] found during clinical examination.

Colour flow duplex

6. Do I need treatment?

Treatment for varicose veins is rarely essential since serious complications rarely occur [especially for primary varicose veins with proximal faulty valve] and disease progression is usually slow. In such a condition, usually the choice is yours.

However, it should be taken into account that the care for your legs should be life long and would require a controlled strategy in relation to compliance. The symptoms are likely to deteriorate as you get older, the varicose veins may progress and you may have to alter your life style slightly. Many patients have varicose veins for the whole of their adult life and never suffer any problem with them.

If your specialist thinks that you should have treatment you will be informed of this at your consultation.

7. What treatment is available?

a) Conservative

Avoidance of standing for long periods and prolonged sitting as the veins are particularly under stress in these conditions. If you have to, move your feet. Avoid crossing your legs as the veins are thus compressed.
Avoidance of all that may increase the abdominal pressure [i.e. constipation, lifting, prolonged driving and sitting, smoking].
Avoid tight clothing and high heels
Loss of weight
Elevation of the legs several times daily, for 5-10 minutes. The lower end of the bed may be also tilted up at night to increase venous return.
Regular walking and gentle exercise are recommended.
Beware of sports with sudden changes of movement, such as more than sensible jogging, jumping and those which carry a risk of direct trauma, like team sports.
Avoid high competitive sports which put a heavy strain on the veins.

b. Sclerotherapy [injections]

The indications for sclerotherapy depend on the site and size of varices, the presence of reflux points as well as the functional state of the main vein trunks.

Is also useful as adjuvant treatment after surgery.

It is more effective for small varicose veins and thread veins. However, the success rate is less than 50%.

A small amount of a special chemical [sclerosant] is injected into each vein [after emptying it from blood] and the leg is then bandaged firmly for 2-3 weeks. Sclerosants exert their effect upon the inner lining of the vein causing inflammation and thrombosis, obliterating the vein, at the end, by formed scar tissue. Multiple sclerotherapy sessions may have to be performed, each one following the previous after 2 weeks.

Complications occur rarely but these may include haematoma, superficial thrombophlebitis, contact allergies, local sensitivity with urticaria, pigmentation and skin necrosis.

Sclerotherapy is effective in thread veins, usually on outpatient basis.

c. Surgery.

More severe varicose veins may require surgery.

The vein in the thigh may also be removed [stripped] to reduce the risk of recurrent [returning] varicose veins. The visible varicose veins are then removed [avulsed, pulled out] through a series of small cuts, 2-3mm]. However, surgery is a compromise between the attempt to remove the diseased veins and the need for an acceptable cosmetic result [minimal scars].

The aim of surgery is to:

disconnect the superficial from the deep veins by tying off the reflux point [at the groin or behind the knee] caused by valve incompetence.

Thus, the increased venous pressure will not be transmitted to the superficial veins.

If the reflux is caused by incompetent perforators, then they should be identified and tied off. However, as it is more difficult to find them during the procedure, firstly, an ultrasound scan may be needed before surgery to localize it and secondly, the scar in the calf may be longer than the usual avulsion scars.

8. How about drug therapy?

Drug therapy [phlebotonic drugs, flavanoids, ritosides, ruscus alkaloids] is of little or no benefit and has not been shown to hold progression of the condition. The only benefit may be a minor oedema-protective effect by sealing of the capillaries, however, the gentle massage to apply the cream is probably the most important mechanism of action of the drug.

9. How good is treatment?

No treatment can remove all varicose veins, nor is there any such thing as invisible mend, as injections may cause skin staining and surgery some scarring.

Sclerotherapy is successful in less than 50% of the cases and in less than 30% if undertaken in cases with proximal reflux and main trunk varicosities. After sclerotherapy, long-term compression hosiery may be needed, plus awareness of adopting a life style that avoids risk factors and incorporates protective measures in everyday routine.

Surgery is successful in more than 90% of cases and in 95% if the reflux site is properly identified and tied off. Some residual varicose veins may remain after surgery, which can easily treated with sclerotherapy.

New varicose veins may appear [5-10%] even after satisfactory treatment. However, it may be years before they return, and they may be due to a new faulty valve, which was competent at the initial treatment time.

The symptoms of ache, heaviness, ankle swelling, fatigue and cramping usually disappear after successful treatment; however, if you have pain, an operation may not help this.

10. How about the alternative methods of surgery for varicose veins?

In the last decade, with the fashion of minimally invasive surgery, doctors tried to find ways to treat the veins in a different way. Three techniques were developed:

a. Foam [Varicofoam] sclerotherapy with ultrasound guidance.

It is similar to the classical injection treatment, but the sclerosant is mixed with air, containing babbles. This is done in order to avoid dilusion of the sclerosant and allow the chemical to come in contact with the wall of the vein. The needle is positioned under ultrasound guidance and the foam is injected. When blood is displaced after the injection, the top of the vein is compressed to stop blood rushing down from the deep vein. Foam sclerotherapy can also be used for varicose clusters, but is time consuming and may need multiple sessions.

b. EVLT [Endoveous laser treatment]

Uses laser technology [passing the laser instrument into the vein] to block the large main trunk of the incompetent vein that supplies the varicose veins in the leg. It cannot be used for the small clusters of veins and has to be followed by the avulsions [pulling the veins out through small incisions]. It is different than the laser used for thread veins

c. VENUS closure [Radiofrequency endovenous heating]

A probe is positioned inside the major venous trunk [LSV] under Ultrasound guidance and a radiofrequency generator produces electric current that heats the end of the probe to 85° C, in order to destroy the vein from the inside. The probe is pulled gradually down the vein up to the knee. Normal avulsions have to follow, to remove the clusters of the visible veins.

These techniques have some advantages and disadvantages. The main difference from classical surgery is that they avoid the groin incision and the stripping [pulling out] of the main trunk. Avulsions [small skin incisions] have to be done to remove the varicose veins. They may be associated with faster recovery However, they cannot be used to all types of varicose veins, as veins that originate from the short saphenous, as the two latter methods are more likely to cause nerve damage, neither to recurrent varicose veins when there is a main branch communicating with the deep veins. Only patients with moderate or small size varicosities can be treated with these alternative techniques. They can be done under local anasesthesia only when there is no need for avulsions. The immediate result is comparable to the classical treatment , but the risk of recurrence is probably higher [80-90% at 1-2 years], as they are not able to disconnect all the vein tributaries from the deep vein at the groin. Finally, they are longer procedures and far more expensive that the golden standard which continues to be the classical surgical treatment.

YOUR VARICOSE VEIN OPERATION

1. Before your operation

If you are taking the contraceptive pill you will have an injection to thin the blood before the operation.

You may be called for a pre-admission visit about a week before the actual date to make sure you are fit and well for the operation. The latter is usually performed as a day case. However, if you are having both legs operated upon, or if you have any medical problems, it is usual to remain in hospital overnight.

Day case surgery means that after surgery, when you recover from anaesthesia [3-4 hours] your escort will take you home, with all instructions given to you before [by the surgeon] and after surgery [by the nursing staff].

2. Coming into hospital

You will be asked to come in either the day before [rarely] or the morning of your operation without drinking anything after midnight. Please bring with you all the medicines you are taking to show to the doctor.

You will be received in the ward by a nurse who will note your personal details and ask about any other conditions you suffer from. You will be also visited by the surgeon who is to perform your operation, who will mark the position of the veins, and the doctor who will give you anaesthesia. Many people are concerned about anaesthetics, so please ask the anaesthetist if you have any specific worries so that he may reassure you. All of these people are ready to answer any questions that you may have, so please ask.

You will be asked to sign a consent form that the procedure has been explained to you and you agree to go ahead.

For complicated varicosities [like perforator or short saphenous varicose veins] a preoperative special painless ultrasound scan may be needed to localize the diseased veins and mark them on the skin. This makes surgical exposure and tying of the reflux site a lot easy.

3. The operation

This is usually performed under general anaesthesia. Local anaesthesia may be used for small varicose veins that need to be avulsed only.

The commonest operation is the one performed for primary varicose veins affecting the long saphenous trunk with a faulty proximal valve. A cut is made in the groin, at the femoral crease, over the top of the main superficial venous trunk, where it joins the deep veins. It is completely disconnected from the deep vein, while the main vein trunk and its tributaries is tied off. In most of the cases the main vein in the inner aspect of the thigh is stripped out over a stiff catheter, down to the knee level. Stripping has no effect on blood flowing up the leg, as it does so along the deep healthy veins. The cut in the groin is usually closed with a dissolvable stitch, buried underneath the skin.

The other visible veins, marked before surgery, are then pulled out [avulsed] through tiny cuts. These are then closed with adhesive strips [covered by an airstrip] or stitches.

If the faulty valve is in the short saphenous vein, then the cut to tie off the vein is made behind the knee [is not found as easy as in the groin]. If there are incompetent perforator veins, then a longitudinal cut [3-5cm] is made over the area where either the surgeon thinks it is located [by his physical examination] or was marked preoperatively using a special ultrasound scan. The interconnecting vein is found [not as easy as the main trunks behind the knee and the groin] and is tied off.

A dressing will be placed over the groin cut and the leg will be bandaged to the top of the thigh [circular, medium stretch crepe bandages]. The bandage put on immediately at the end of the procedure will be replaced either the next day [for in-patients] or when you are discharged [for day cases] by a grade II compression stocking reaching the top of the thigh. You should wear these stockings day and night for 2-3 days. This external compression is a necessary measure for two reasons: first to eliminate the small tunnel that is left after stripping the vein [avoid thrombus] and secondly to avoid haemorrhage as the perforators and avulsed veins may bleed.

4. Mobilisation and going home

You will be able to make a few steps and go to the bathroom when you recover from anaesthesia and then walk to the car that will take you home. The earlier the patient is out of bed and walking the better; however, for the first week take things easy. You will increase your activities gradually.

For the first week you should sit with the feet elevated so that your heels are higher than your bottom, to aid drainage of the excess fluid from tissues and assist healing. Three times a day take a short walk [a few hundred meters would do, but more if you wish] to avoid stiffness of the muscles and joints. Some slight discomfort is normal.

In the first week after surgery you may need to take a mild pain killer, such as paracetamol, to relieve discomfort. Some times the surgeon may prescribe a stronger pain killer [diclophenac] for the first 3 days. Occasionally, some severe local twinges of pain may occur in some patients and may persist for a couple of months.

You should wear the thigh stocking day and night for the first 4-5 days, after which you may leave it off at night. You may take a shower as usual after removing the elastic stocking [day 5] but avoid bathing. The airstrips are waterproof and will not come off. However, for the first 7-10 days you should not get the adhesive strips wet, so care will be needed when washing [better with a sponge, without shower].

5. What next?

A week to ten days after surgery you should go into the bathroom, get into the bath, soak all the remaining airstrips and steri-strips well and peel them off.
You should continue using the thigh stocking for one-two weeks. Following that you can use the below knee stockings.
You should avoid driving for 10-14 days, for two reasons: driving for prolonged time increases the venous pressure and in an emergency, because of pain, your response time may be prolonged; it is essential that you are able to perform an emergency stop without pain. If in doubt, delay until you are happy.
Walking, swimming and cycling are allowed after the dressings have been removed.
Avoid lifting heavy objects for the first two weeks.
To ensure a good therapeutic result it is recommended that you should wear a support stocking [to the knee level] for the first 6 weeks up to 3 months.
In the majority of cases there is no need for follow-up. However, if you feel so, or if you have any problem the surgeon will be happy to see you again.

6. What complications should you look for?

Sometimes a little blood will ooze from the wounds for the first 12-24 hours. This usually stops on its own. If necessary, elevate the leg and press on the wound for 10 minutes. If bleeding continues after doing this twice, phone your General Practitioner or the ward.
Some skin bruising is usually present after 2-3 days [especially with stripping] but should cause no concern as it disappears in 2-4 weeks.
Occasionally hard, tender lumps appear near the operation scars or in the line of the removed veins. These can appear even some weeks after the operation and need not be a cause of infection. They represent clot formation from haematomas that will disappear in time. However, if they are accompanied by excess swelling, redness and much pain they may represent wound infection and you should see your General Practitioner or the surgeon.
Sometimes, 2-4 weeks after surgery, the main incision [groin] may become red and look like being infected. This is not an infection. It is a reaction to the dissolvable stitch in the wound. Your doctor can pull it out with a forceps and the inflammation will settle quickly.
Rarely, there is numbness around the wound or ankle and extremely rarely a burning sensation. This is unavoidable and is due to pulling on nerves during the operation. It usually settles after some weeks or in 1-2 months.
The groin or knee scars are along the crease skin lines and are not easily visible after 1-2 months. The scars in your leg will continue to fade for 6-12 months and quite often they are not visible at all.

7. Return to normal activity?

You can return to work when you feel sufficiently well, generally after a week to ten days. If you have a job that involves much standing and your varicose veins were severe, you may need up to six weeks off work. Your General Practitioner will advise you about returning to work in the light of your progress after the operation.

8. How about the future?

You will have been warned that not every visible vein will disappear after surgery. Occasionally, adjuvant sclerotherapy or avulsions may be performed for these residual veins. There is also a small chance [10% for primary, 20-25% for recurrent or when the vein was not stripped] in the future that further varicose veins may develop, as you are clearly predisposed to them.

The taking of regular exercise, modification of your life style, the wear of light support stockings and the avoidance of risk factors and becoming overweight will all help prevent you being troubled by varicose veins in the future.

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Please note:
A written referral from a general practitioner is helpful but is not essentially required in order to make an appointment to see a consultant specialist.

This page was last updated on 01/10/2006