WHAT ARE VARICOSE VEINS WHY DO I GET VARICOSE VEINS PROPER DIAGNOSIS TREATMENT OPTIONS POTENTIAL COMPLICATIONS AND RISKS OF FACTORS OF VARICOSE VEINS POTENTIAL COMPLICATIONS ARISING FROM TREATMENT RECURRENCE – CAN VARICOSE VEINS COME BACK AFTER TREATMENT SUCCESS RATE OF DIFFERENT TREATMENTS WHAT ARE VARICOSE VEINS Large raised varicose veins or the small unsightly surface veins which are both commonly termed Varicose Veins. Large Veins In the large, raised veins, the blood flows in the wrong direction, ie downwards instead of up towards the heart, because of the broken valves. These valves can be broken in the groin, the back of the knee or sometimes the calf. When a valve is broken, the flow of blood is reversed with gravity, flowing downwards instead of flowing up, causing pressure to be applied to the superficial veins making them enlarge. The superficial veins in the leg, that is the veins outside the muscles sitting just under the skin, are arranged in the form of a tree. There are two major trunks or straight veins going up and down the leg, and multiple branches of these trunks that go around the leg forming varicose veins. The trunks are called saphenous veins and the branching veins are simply called tributary varicosities. At the tops of the saphenous trunks are major valves, one in the groin and one at the back of the knee, which are supposed to keep the blood from flowing backwards down those saphenous trunks. The 'deep' veins in the leg don't form varicose veins because they are supported and surrounded by muscle. Only the superficial veins outside the muscle are subject to the pressure to form the large varicose veins. Surface Veins Unsightly, blue, zig zagging reticular veins or 'spider veins' giving the appearance of red or blue blotches , which are unsightly. Sometimes they are so superficial that they are actually part of the skin itself. These unsightly surface veins can exist by themselves or in conjunction with the larger true varicose veins. Back to the top WHY DO I GET VARICOSE VEINS The most significant reason is family history. 70% of patients have a first degree relative who has varicose veins. The weak walled valves and veins are inherited and at some stage the veins enlarge, causing the problems with varicose veins. Women get them 5 times more frequently than men due to hormonal differences and pregnancy. In addition to the genetic factors there are also 'lifestyle' factors which can effect the veins. Standing jobs, obesity, lack of exercise or the number of pregnancies are all factors which can worsen your varicose your veins. Genetics also mean that you inherit the tendency to form spider veins, with or without the larger ones or vice versa. It can of course be a combination of all factors involved in your problem. Back to the top PROPER DIAGNOSIS Patients come to see the doctor for all manner of leg problems which may or may not relate to varicose veins. Some patients may see the small veins and want to know if the problem is serious. Others may be experiencing aches, pain, restlessness or swelling which they need to know about. At this stage it is important to have a proper diagnosis to determine whether the problem relates to veins or to something else. The patient is looked at clinically and then the veins are assessed with ULTRASOUND. This may be a hand held unit or a larger unit with a TV screen call a DUPLEX SCAN. This gives a picture of which way the blood is flowing, where valves are broken and where the high pressure points are. This is the accurate method used to determine exactly what the problems are with your veins and it helps in determining what type of treatment should be offered to that particular set of varicose veins. Back to the top TREATMENT OPTIONS 1. Reassurance when the veins are not the cause of the problem. 2. Support stockings in half or full length, pantyhose etc. These can support the veins and muscles making the legs feel better and hiding the varicose veins. These support stockings vary in strength and thickness. The strong ones should be fitted properly so they do not irritate the leg. 3. Medication – Naturopathic supplements and Medications: These are treatments that you can take to help strengthen the vein walls and possibly improve the symptoms in your legs and slow the deterioration of the veins. These include rutins, bioflavonoids, horse chestnut, gingko, or similar products from your pharmacy or from health food shops. Tablets or capsules can be taken to relieve the symptoms. PAROVEN which is made from the extract of rubber plant root, may help the symptoms of aches, pain, restlessness and cramp in the legs. 4. Injection treatment – Sclerotherapy This involves injecting into the varicose veins or the spider veins an irritating solution or a foam to inflame the lining of the veins. This is followed by compression of the veins using stockings or bandages. Compression apposes the vein walls, pushing the walls together, thus shrinking the veins down, causing them to fibrose and almost disappear. If the veins to be injected are large, stronger solutions are required, causing quite a strong inflammation in the target vein. Compression has to be quite strong and for up to 4 weeks at a time for these large veins. Compression would be less strong and for a shorter time for smaller veins. Patients must walk a lot in the first 10 days after injection treatment to avoid one of the complications, which is thrombosis. The solutions available to inject varicose veins in Australia include Aethoxysklerol, Fibrovein, and hypertonic saline solution. Different patients may react differently to each solution, so outcomes may vary from patient to patient. Injections into these varicose veins can be performed directly while looking at the vein, or injections can be performed under ultrasound guidance, so the ultrasound allows us to image the vein and watch the needle entering the vein, which is located deep to the surface and would otherwise not be seen. After injection treatment (sclerotherapy), compression and mobility are important to obtain a good result. Complications can still occur. These complications or unwanted side-effects of sclerotherapy include: · Allergy to the solution injected · Severe allergy – anaphylaxis to the solution injected · Superficial phlebitis – the target vein and the surrounding veins become lumpy and tender due to inflammation and some retained blood. · Deep vein thrombosis – ie a clot occurring in the deep veins of the leg following injection treatment to the superficial veins. This is rare. · Pigmentation – brown staining on the skin over the injecting vein. This complication is minimized by good compression after injections. The body absorbs the staining after some weeks or months. · Injection ulceration – if the injected solution has a strong reaction in the skin overlying the veins, the skin can die in a small patch over the vein. This skin then peels off and becomes an injection ulcer. This is rare but can spoil the outcome of the injections. An injection ulcer takes weeks to heal. · New vessel formation – some patients form new small spider veins around a previously injected area. This is their body’s response to the inflammatory solution. For patients who form this problem, perhaps injection treatment should not be continued. 5. Surgical Removal of Varicose Veins In patients with large bulging varicose veins, there is usually a broken or malfunctioning vein valve in the groin or at the back of the knee, allowing backward flow of blood down the trunks of the superficial (saphenous) vein trunks and into the numerous tributaries (branches) that can spread all over the leg. Surgery for this condition involves a day in hospital, or perhaps an overnight stay, a general anaesthetic, ligating or tying off the broken valves, removal of some or all of the backward flowing trunks of the saphenous veins and removing the enlarged tributary or branching veins through small cuts on the skin. Techniques for varicose vein surgery have improved greatly over the last few years and with accurate pre-operative marking of the veins and the use of small cuts, followed by 3-4 days of compression bandaging, most patients are able to resume work in a week. If you are working from home, you can resume work the day after the operation. Patients are out of bed and walking quite quickly after surgery (usually within 2-3 hours) and are encouraged to be mobile despite the tight bandages for 3-4 days. The bandages minimise bruising. Varicose vein surgery is reserved for patients with quite extensive and severe varicose veins. The surgery treats the broken valves, the backward flowing trunks and the tributaries all at the one procedure. Complications of varicose vein surgery can arise. Cuts and bruises are always going to be present, sometimes a few and sometimes many. Anti-bruising cream and Vitamin E to improve the scarring helps a lot. Numb or tingling areas on the skin in spots particularly around the ankle can occur. This is because when the veins are removed, sometimes sensory nerves are stretched. Infection in the cuts in the groin occurs rarely. Antibiotics may be given to avoid this complication. Deep vein thrombosis (a clot in the deep veins) can rarely occur after varicose veins surgery. These are noticed by the patient in about 1% of cases and are either treated with blood thinners or simply by encouraging the patient to walk. 6. Endovenous Thermal Ablation of Saphenous Trunks Using Laser or Radiofrequency Energy With this treatment, the trunks of the saphenous veins are destroyed using heat. This obliterates the inside of the saphenous trunks and stops the backflow down the trunks. The heat is generated using laser energy or radiofrequency energy. These methods of obliterating the upper part of the saphenous trunks began in the USA around 2001. These techniques have been evolving since then and continue to improve. The laser probe or the radiofrequency probe is placed inside the diseased saphenous trunk, usually from the knee going up towards the groin. Energy is then applied to heat the probe. The heat in the probe destroys the vein wall from within as the probe is withdrawn downwards along the vein. This procedure can be performed under local anaesthetic or under general anaesthetic. Compression stockings are required following this thermal ablation process. Additional treatment is required to treat the branching varicose veins and the superficial tributaries, as the laser does not treat them directly. This additional treatment may be in the form of sclerotherapy or mini-surgery to remove the tributaries. This technique of heat destruction of the trunks of the saphenous veins is effective but it sometimes causes soreness and possibly some damage to the adjacent tissues, such as the sensory nerves. This passes in most cases. Compression is required following the treatment by way of stockings for a couple of weeks and subsequent treatment is required to the branching veins. Back to the top POTENTIAL COMPLICATIONS AND RISKS OF VARICOSE VEINS The small spider and unsightly veins may cause stinging and aching but do not pose a serious risk of complications. It is the larger, raised true varicose veins that deliver the high pressure into the leg which can cause the complications. These can include: 1. Clotting — either in the superficial varicose veins themselves or the deep veins of the leg which can be a serious problem. 2. Pigmentation – The varicose veins can make the skin down towards the lower leg and ankle become itchy and hot. This is varicose eczema and the skin becomes scaly and increases in dark colour. 3. The soft fatty layer of tissue near the ankle can become hard and lumpy-known as "woody leg" or lipodermatosclerosis. 4. Varicose veins may cause the skin in the lower leg to break down causing a leg ulcer. 5. Bleeding from the varicose vein is not an unusual complication. This occurs when the vein comes through the skin and starts to bleed unexpectedly eg in the shower or when using a towel to dry after a shower or after scratching. Back to the top POTENTIAL COMPLICATIONS ARISING FROM TREATMENT Patients have to be aware that all treatment options carry some small risk of complications - although the chance of complications is very small indeed. In many cases however it is more of a risk to leave the veins untreated. POTENTIAL COMPLICATIONS OF VARICOSE VEIN SURGERY A general anaesthetic may be involved and is very safe. However, there is always a minimal risk with anaesthetics. Some cuts, bruising and pain but all settle fairly quickly. The three serious complications regarding surgery are: 1. Thrombosis 2. Nerve Damage 3. Infection Thrombosis This relates to suffering a clot in the deep veins and can occur after any surgery. It is no more common after varicose vein surgery than any other. Precautions can be taken such as females going off the pill or hormone replacement therapy, or in over 40 year olds, an injection of Heparin to thin the blood. Early mobilisation after the operation is also very important. Nerve Damage When removing a lot of superficial veins, it possible to injure or stretch cutaneous nerves, i.e. sensory nerves lying next to the veins. This may lead to numb or tingly patches on the skin, most commonly down near the ankle. This does not usually disable or prevent the patient from walking but can be annoying. In most cases this subsides after some months. Infection Varicose vein surgery is regarded as clean surgery but the patient is sometimes given prophylactic antibiotics to avoid any infections. If the wounds do become red or look as though they are becoming infected, you can get antibiotics from your surgeon or family doctor as soon as possible. Overall, varicose veins surgery is extremely safe. POTENTIAL COMPLICATIONS FOLLOWING INJECTION TREATMENT FOR VARICOSE VEINS Patients can be allergic to the solution injected. The commonly used solutions to inject varicose veins in Australia today are: Aethoxysklerol, Fibrovein, and a strong salt solution. No matter which solution used, there is a possibility you could be sensitive or allergic to it. This is extremely rare but some cases have been reported. Injection Ulcers If the solution injected leaks out it can cause damage to the surrounding tissue and even the skin. The skin can form a scab which can peel off. Occasionally the patient can get a scab overlying the vein. The damage does heal but can be painful or annoying for a few weeks. Clotting Very rarely, patients who have injection treatment to the superficial veins can develop a clot in the deep veins. To help prevent this, patients are encouraged to walk regularly — 20 minutes, 2-3 times a day — to circulate the blood so it does not stagnate or clot. Pigmentation If there is a strong reaction to the solution, there may be brown staining over the vein. This may take some months to absorb, but will disappear in most cases. New Vessel Formation Sometimes the response to the injections can be the formation of very fine red veins in the local area. If this happens, no more injections should be attempted until it settles spontaneously. If it does not settle, cease this form of treatment. Having said all that, injection treatment is still a very popular, common and well tolerated method of treatment for suitable veins. It is quite a safe method of treatment. RECURRENCE – CAN VARICOSE VEINS AND SPIDER VEINS COME BACK AFTER TREATMENT – YES THEY CAN If you have a genetic disposition or family tendency to develop varicose veins or spider veins all the veins in the legs have weak walls in them. No matter what form of treatment is used to treat your varicose veins initially – injection treatment (sclerotherapy), surgical removal or obliteration of the trunks using heat (eg. laser), new veins almost always develop and the chance of this increases over time. All patients who have had treatment for varicose veins should be on the look out for new veins arising. They need to have these veins treated earlier rather than later and hopefully this will involve some simple injection treatment, avoiding the need for any further surgery or obliteration of big veins using heat. Back to the top SUCCESS RATES OF TREATMENTS FOR VARICOSE VEINS The success rate of a varicose veins treatment is difficult to define and changes over time. More than one method of treatment is often used on a single patient eg. Varicose vein surgery followed by injections, or laser followed by surgery or injection treatment, or injection treatment combined with removal of tributary veins surgically. Injection treatment for smaller surface veins in patients with no reflux (backward flow) in the saphenous vein trunks is very beneficial, offering 60-70% improvement in appearance and symptoms. Surgery for varicose veins treats the broken valves, removes the trunks and the large tributaries. It will not fix the spider veins and these need some follow-up injections. Laser or radiofrequency thermal obliteration of the saphenous trunks is an alternative to surgically removing the trunks. It is very effective but additional treatment is then required for the veins below the knee and for the branching tributary varicose veins and spider veins. You must discuss with your doctor realistic expectations of the outcome following treatment. These realistic expectations have to be explained and miracles and magic solutions are not on offer. Varicose vein treatment considerably improves the situation but problems can arise and new vessels can appear. All of this has to be discussed with your treating doctor before treatment is undertaken. Back to the top Home • About Dr Malouf • Contact