Veins are blood vessels which carry blood back to the heart. The leg veins carry blood from the legs to the right side of the heart. The blood vessels which take the blood back to the heart from the lower half of the body are the vena cava, a large vein which runs down the right side of the body to the level of the fifth lumbar vertebra, and a small vein called the inferior vena cava. The blood is then pumped to the right atrium, and through the tricuspid valve to the right ventricle, which pumps it to the lungs. In the lungs, the blood takes up oxygen, and releases carbon dioxide.
Varicose veins are dilated, tortuous, elongated superficial veins that are usually seen in the legs. They occur when the valves in the veins do not work properly, so that the blood does not flow effectively to the heart. In order to understand why this happens, it is helpful to know more about the anatomy of the leg veins and how the blood flows from the heart to the legs. This will be described briefly below.
Non-Surgical Treatment Options
Compression therapy has been observed to be effective in controlling and reducing the symptoms of varicose vein. With graduated compression stockings, the pressure is greatest at the ankle and decreases as it goes up the leg. The pressure exerted by the stocking helps to push the blood at the surface of the skin back up the leg to the deep venous system, and thus prevent it from pooling in the veins. As a result, there is alleviation of the leg pain and discomfort associated with the varicose veins. While symptoms such as leg edema and skin discoloration have also been shown to improve with compression therapy. Various studies have shown the effectiveness of compression therapy on varicose veins, with one randomized control trial providing evidence that using compression stockings for one week was able to reduce pain significantly more than no intervention. Another trial indicated that compression therapy is as effective as leg elevation or use of nonsteroidal anti-inflammatory drugs on leg pain. This data clearly demonstrates that compression therapy is markedly beneficial for individuals who are seeking relief from their varicose vein symptoms. Although the results are not necessarily long term or cosmetic, some may prefer to use compression therapy as it is non-invasive and there is no downtime. Another non-surgical treatment option is sclerotherapy. Sclerotherapy involves the injection of an irritant solution into the veins with a micro-needle, which triggers an inflammatory response and over time allows the veins to fibrose and close off. This method of treatment is normally used to relieve symptoms and improve the appearance of the veins. It is generally recommended for smaller varicose or reticular veins and for residual veins after surgery. Sclerotherapy may also be indicated for patients who are considered to be poor surgical candidates. Cautery sclerotherapy and standard sclerotherapy have been known to be quite effective in trials, however ultrasound-guided sclerotherapy has the best evidence of being effective and is equal to surgery for main vein reflux. This method has a smaller rate of complications in comparison to surgical removal, and can provide long-term relief from the symptoms of varicose veins.
Compression Therapy
Compression therapy is a technique used to help shrink the size of varicose veins. The basic idea is to wear a tight stocking or bandage encapsulating the affected limb. The increased pressure helps muscles and veins to move blood in a more regulated manner. It prevents the pooling or reflux of blood in the veins and can thus prevent further deterioration of the veins. Compression therapy is a low-cost approach to controlling symptoms of varicose veins and slowing down the possible progression of the disease. It can be used together with surgery, both pre- and post-operatively, in order to maximize results and reduce the occurrence of new varicose veins. Results vary depending on the compression method used, but generally cause resolution of symptoms in the legs or an improvement. While compression therapy cannot eliminate existing varicose veins, it is very good at preventing new ones from forming. This form of treatment is suggested for mild conditions when there is less intense discomfort or less extensive anatomical change in the affected limb.
Sclerotherapy
At present, a wide variety of sclerosing agents including detergents, osmotic agents, and chemicals which damage the intima of the vein are in use. Most are hypertonic and can cause tissue necrosis if extravasated. These agents are less suitable for foam production, as their ability to cause endothelial damage and potentially more serious side effects is magnified. Studies have shown the efficacy of these agents to be similar when follow up is short term. For long term resolution, agents which cause the vein to thrombose either through direct damage to the endothelium or though an inflammatory reaction are believed to be more effective. A variety of ultrasound guided techniques to apply these agents have been developed to improve the precision of injection and to allow for the treatment of veins which are not visible on the skin surface. The mechanical methods involve the insertion of a wire or needle into the vein which is visualized on duplex ultrasound and advanced to a point near the sapheno-femoral or sapheno-popliteal junction. This can be followed by injection of the sclerosant, or in the case of endovenous laser treatment, the use of the wire or needle is an adjunct to the method of vein closure. Random contrast of foam sclerosant with liquid sclerosant has shown greater efficacy with the former, and since associated pulmonary embolism was not observed with foam in this study, it is now considered the gold standard for sclerotherapy.
Surgical Treatment Options
Only partial stripping of the greater saphenous vein is performed within the groin in the surgical option called “subfascial endoscopic perforator surgery” (SEPS). According to Masuda and Matsuda, when compared to the standard high ligation and stripping surgery, more than 90% of SEPS patients have no recurrence of varicose veins after 5 years. However, postoperative pain and bruising are more marked in the SEPS patients. An unexpected finding was that the cumulative survival rate of SEPS patients was significantly higher than that of the standard surgery cases. The authors attribute this to the fact that SEPS is performed under locoregional rather than general anesthesia, and it is not so invasive a procedure. This illustrates a scenario in which choosing the least invasive surgical option results in a procedure with a better risk-to-benefit ratio, and this is a choice that all varicose vein patients should be looking to make.
Ruby says that while this is effective, it is associated with significant morbidity and often requires general anesthesia and time off work. Studies have shown that in 20% of patients, the varicose veins recur in the same leg within 5 years of vein stripping surgery. Varicose veins also recur in many other patients because relatively aggressive and effective treatment is reserved for the relatively severe end of the spectrum of disease, and most patients have milder forms for which they still seek better treatment options.
Veins with damaged valves will not return to normal, even with the use of elastic stockings. Therefore, the best and definitive treatment is to correct the backward flow of blood. This has traditionally been achieved by “tying off” the abnormal vein and stripping it out. Following this, incisions are made at the sites where the abnormal veins are closest to the skin, and a tool is used to pull the vein out.
Vein Stripping
Vein stripping is a commonly performed surgical procedure for patients with advanced chronic venous insufficiency. The patient is placed under general anesthesia, thus the postoperative period is associated with longer disability and delayed return to normal activities. During the procedure, an incision is made in the groin, the saphenous vein is tied off higher up, and a flexible instrument is threaded through the vein to pull it out. The incisions are left open to heal. Traditional vein stripping and high ligation address only the saphenous vein, while several branches remain unligated and the incompetent perforator veins in the lower leg are not addressed. The procedure has shown to be durable, with good long-term relief of symptoms and ulcer resolution. However, it is historically associated with significant morbidity and complications, leading to the development of less invasive techniques of saphenous ablation and selective treatment of perforator veins. Newer techniques and technologies have allowed vein stripping to be avoided altogether in select patients, and have made vein stripping itself safer and more tolerable. With better patient selection of procedures and continued improvement of techniques, traditional vein stripping will likely become less common in the future.
Endovenous Laser Ablation
Under ultrasound guidance, a needle is inserted into a distal part of the GSV and a guidewire passed through it. An introducer sheath is then passed over the guide wire and more wire used to persuade the sheath to a position 2-3cm distal to the saphenofemoral junction. The laser fiber is then introduced into the sheath and using more wire is manipulated so that the fiber is in a position at least 5cm distal to the SFJ. The sheath is then pulled back so that it is again 2-3cm distal to the SFJ. This process is then repeated so that the whole saphenous vein from the knee to the groin has been treated. A study of 54 consecutive patients treated by this commence suggests that EVLT is a safe and effective method of treating GSV reflux. This was reflected in the improvement in their disease-specific and generic QOL scores, improvement in venous disease and quality of life scores. EVLT was superior to the patients’ previous surgery, and their general health scores actually improved from before they first had treatment to immediately after EVLT. This may reflect the minimally invasive nature of this procedure and the fact that patients can return to their normal activities the next day.
This technique was first described in 1992-3. The principle is to introduce a laser fiber of specific wavelength inside the lumen of the refluxing Great Saphenous Vein and to deliver laser energy with the intent of causing collagen denaturation and subsequent occlusion of the lumen. The patients receive a single shot of Cefuroxime 1.5g and are sent to the ward where the leg to be treated is prepared with sterile drapes.
Ambulatory Phlebectomy
Ambulatory phlebectomy can be very successful in completely removing a vein from an area where it is cosmetically bothersome or symptomatic. However, it is a very technique-dependent procedure, and if not done correctly, can result in skin staining or a poor cosmetic result. It is also important to distinguish that ambulatory phlebectomy is a technique of physically removing a vein, whereas sclerotherapy is injecting a vein to make it disappear. Ambulatory phlebectomy has a quicker result than sclerotherapy and is often more definitive.
Ambulatory phlebectomy is a minimally invasive procedure that can be performed in the office setting under local anesthesia. It is the technique of removing varicose veins on the surface of the legs through small micro incisions. It is ideal for removing surface varicose veins that are too large to be treated with sclerotherapy, but too small for surgical stripping. Common areas to treat are the veins of the inner or outer thigh, and the smaller ropey veins on the lower leg. After local anesthesia is administered, a small incision is made in the skin, and a phlebectomy hook is inserted to remove the vein. The vein is then hooked and pulled through the incision, a segment at a time. The vein is visualized as it is being removed, and any attempt to excise too much vein at one time can result in excessive tension on the vein, and potential injury to a deep vein. Therefore, it is important to remove the vein in multiple segments to avoid excessive force on the vein. Segments that have no side branches are usually the easiest to remove. Often times, the area where the vein was removed will clot and have some bruising, so it is important to keep pressure on the area as it heals.
Considerations for Varicose Vein Surgery
Happily, such skin changes and ulcers can once again be treated very effectively by a combination of methods. First, public demand for mesh hose has led to recent efforts in Europe to produce a clinically available version. This is in contrast to the various forms of stockinettes and multilayered bandages that appeared in the early 20th century but were largely supplanted by graduated compression hose. Development of a softer material makes the modern form of mesh or compression hose more comfortable and acceptable to the patient. Compression therapy for postthrombotic syndrome has seen major advances in the last decade with the availability of inelastic ACE bandages for red pitting edema and new forms of multilayered bandages. These can be useful adjuncts in treating the postthrombotic patient with significant edema. Treatment with diuretics alone is ineffective.
It is not advisable for a patient to undergo surgery for breathing leg edema after the saphenous vein is treated because the increased drainage from the deep veins into the saphenous vein can result in milder recurrent skin changes or even a recurrence of the ulcer. This is unusual and requires a Duplex to prove that it is the cause of the new skin changes. However, the occurrence of an ulcer on the same leg in a location other than the one treated is said to be deceptive because it is not necessarily related to superficial or perforator vein incompetence.
Risks and Complications
The problem of recurrent varicose veins can be classified as either recurrent saphenofemoral/saphenopopliteal junctional incompetence or recurrent long saphenous/great saphenous vein or small saphenous vein reflux. The former is less common and can be due to incorrect ligation of the saphenofemoral or saphenopopliteal junction, the use of a high ligation instead of complete junctional disconnection, and occasionally spontaneous recanalization of the ablated vein. It is often best investigated with color duplex and managed with a combination of image-guided foam sclerotherapy or endovenous glue ablation and open surgical correction of the junction. Simulation for the ligation or disconnection site with a probe or needle is considered a sterile technique and runs a risk of procedure site infection and thrombophlebitis.
The major complications of varicose vein surgery are deep vein thrombosis, pulmonary embolism, nerve damage, wound infection, hematoma, postoperative leg pain, and recurrent varicose veins. Several randomized trials have shown the overall incidence of DVT and PE to be around 2% with the newer forms of EVLT and RFA, but slightly higher with PIN stripping. One trial reported a DVT rate of 4.3% and a PE rate of 2.5%. The incidence of nerve damage varies in the literature but is frequently reported as high as 15%. In many cases, this is temporary but can be permanent and cause pain and functional disability in otherwise successful operations.
Recovery and Aftercare
Taking into consideration the length of time to regain rewarding performance of the legs after varicose vein surgery, preoperative contemplation, i.e. weighing of treatment alternatives, is significant. It has been well established at this point in time that the sorting outstanding results in data and derogatory prospects for varicose vein patients is endovenous thermal ablation in contrast to surgical treatment. On the other hand, because this landscape of less intrusive methods is considerably efficacious, it is complementary time away from these methods in which recompense is once again in the disfavor of open surgical treatment at the present step in time.
Recovery and aftercare are two of the most considerable elements in our judgment to undergo a surgical procedure. It is predominantly imperative for a patient contemplating varicose vein surgery to perceive that although the treatment itself may be completed with minor wounds or needle pricks, the postoperative phase of vein surgery can be of extensive length and considerably restrict their day-to-day activities. After the surgery is completely discussed, with the use of inflammatory injection and matting avulsion, it is generally an extended wait of up to 2 weeks before a patient can stroll beyond that completed easy outpatient treatment. Up to 6 weeks is generally recommended before a patient can engage in any kind of challenging activity. The expected wait before a patient can return to work is up to 2 weeks. In addition to this, it is sensible to consider taking unpaid leave of absence or a vacation from work during the first 2 weeks post-surgery. This can be a factor in the surgery being reprogrammed to a more ideal time, taking into consideration aspects such as work deadlines, holidays, or downtime during sports seasons.
Choosing the Right Surgeon
Vascular surgeons are dedicated to the treatment of arterial and venous disease. The dedicated training in venous disease has taken off in the form of postgraduate courses and international fellowships. There are now many vascular surgeons well qualified to treat varicose veins. It is now recognized by the vascular community that varicose veins are not a cosmetic issue and that patients with varicose veins should have appropriate access to a vascular surgeon. This is not to say that all patients with varicose veins need a vascular surgeon, and there are general surgeons and other specialists with a special interest and expertise in treating varicose veins. Unfortunately, at this time there are still doctors from all disciplines treating varicose veins. This may reflect poorly on the attitudes and referral patterns of today’s medical community. The patient should be in some way assured of the training and expertise of the treating doctor. This could be in the form of a referral from another doctor, public or private practice, hospital appointment, or teaching position at a recognized university. A point of interest is that, in the private health sector, many doctors who work in public hospitals will treat varicose veins in a private hospital. This does not mean the patients automatically receive a better service. Public hospital waiting lists are long, and many senior doctors in teaching positions or those with a recognized expertise in venous disease do not have the time to also treat private patients.
Finding the right surgeon to treat varicose veins is an important consideration. Choice of surgical procedure is not as important as choice of the right surgeon. The choice of the right surgeon can determine the best outcome rather than a good outcome. It is important that the surgeon explains the procedure fully and that the patient understands the procedure, knows the risks and benefits, the expected outcome, recovery period, and the follow-up required.
