Varicose veins are enlarged (dilated) and tortuous veins which are located just under the surface of the skin - usually on the leg and are often easy to see, as they look thick and knobbly. They may be less obvious if you are overweight, as they are hidden by fatty tissue under the skin. However, many people develop a closely grouped network of small veins called reticular veins or like a star burst pattern - spider veins which usually don’t require treatment except for cosmetic reasons.
There are no accurate figures for the number of people with varicose veins. In Western countries early disease can be seen in almost 20-60% of people. More advanced disease is seen in about 5% of people and almost 1 -2% have active or healed ulcers.
Understanding normal leg veins
Veins are blood vessels which take blood back to the heart. There are three types of veins in the legs:
- Superficial veins, just below the skin and often seen or felt. The superficial leg veins are the ones that may develop into varicose veins.
- Deep leg veins, which pass through the muscles. You cannot see or feel these.
- Communicating (perforator) veins- take blood from the superficial veins into the deep veins.
When we stand there is quite a height of blood between the heart and legs. Gravity tends to pull the blood back down and blood is pumped back to the heart against gravity by muscle pumps present in our calf and soles. Backflow of the blood is prevented by presence of one-way valves at intervals inside these lower leg veins. These valves also ensure that blood flows from superficial veins to deep veins and then into larger veins going towards the heart.
Defect in these valves located at various locations leads to backflow and pooling of blood in the legs causing varicose veins. Blood pools in the lower part of the legs causing impaired circulation and damage to legs.
Who develops varicose veins?
Most people with varicose veins do not have an underlying disease and they occur for no apparent reason. However, varicose veins is more commonly associated with advancing age, female sex, strong family history and obesity (BMI >30). People with BMI > 40 can have venous symptoms without evidence of varicose veins suggesting obesity itself causes venous insufficiency. Prolonged standing is often said to cause varicose veins. However, there is little scientific evidence to support this theory. Varicose veins tend to appear, or become worse, during pregnancy but often improve after childbirth when the pressure on the veins eases. This is partly due to the baby causing extra pressure on the veins and partly because hormones during pregnancy tend to relax vein walls.
Sometimes an underlying disease may cause varicose veins - for example: A previous blood clot (thrombosis) or injury in a deep leg vein, swelling or tumour in the pelvis or presence of abnormal blood vessels - if some of the veins or arteries have not formed in the normal way.
What are the symptoms of varicose veins?
Majority of patients with varicose veins have no symptoms. Some people are concerned about the appearance of the veins. Larger varicose veins can cause heaviness, tiredness, itching of the skin, nocturnal cramps, throbbing and aching of the legs (worsened by prolonged standing) Leg swelling / calf area enlargement, dark coloured skin in lower leg/ulcers, bleeding / painful veins (thrombophlebitis). Symptoms are worse at the end of the day, and symptomatic relief may be achieved by leg elevation, mobilization, and exercise.
Are there any complications of varicose veins?
Most people with varicose veins do not develop complications. Complications develop in small (1-2%) cases and develop several years after the varicose veins first appear.
However, it is impossible to predict who will develop complications. The visible size of the varicose veins is not related to whether complications will develop.
Possible complications include: Inflammation of the vein (thrombophlebitis), swelling of the foot or lower leg, skin changes over the prominent veins. The possible skin changes are discolouration, varicose eczema, skin ulcers, or lipodermatosclerosis - hardening of the fat layer under the skin, causing areas of thickened, red skin. Rarely, varicose veins may bleed.
First aid for bleeding varicose veins: bleeding happens only rarely. If a varicose vein does bleed then you need to stop the bleeding quickly by applying local pressure, lie down and raise the leg.
Do I need treatment for varicose veins?
Except for cosmetic reasons, most people with very early varicose veins – reticular/spider veins do not need any treatment.
All patients with gross visible veins and having symptoms or developing complications will need treatment.
What needs to be done before the treatment is started?
A clinical examination, this includes history, general examination of major organs and assessment of the legs extent of the problem. Any other co-morbidities involving any major organ/system like heart, lungs, liver brain etc is looked into including diabetes, hypertension, etc. Tests and treatments are explained below.
Which tests might I have?
Doppler or a duplex scan which is a type of ultrasound scan is the most important investigation before starting any treatment. This helps to show how the blood is flowing in both the superficial and deep system of veins. It will also show which superficial system i.e. “Great Saphenous Vein” (GSV) or “Short Saphenous Vein” (SSV) is involved causing backflow of blood due to defective or damaged valves. This is useful to know when planning treatment.
Circulation in the legs should be examined before starting compression stockings as almost 20% people can have a combination of varicose veins and poor circulation of the legs. In suspected or in those with weak or absent pulses the arterial circulation is also evaluated by using a Doppler ultrasound.
What are the treatment options for varicose veins?
- Avoid prolonged standing or sitting still.
- Try to put your feet up frequently (sit or lie down and raise the feet above the level of your hips). You can, for example, use extra pillows under your feet on a bed or footrest). This helps to reduce blood pooling in the veins.
- Use a moisturising cream or ointment to protect the skin in the affected area if it is dry, flaky or itchy.
- Weight loss and exercise are unlikely to make varicose veins disappear but may prevent them from developing in the first place.
Treatment options have roughly been divided into 3 groups:
- Compression therapy
- Surgical treatment
- Minimally invasive Endo-Venous Thermal Ablation methods- a) Radiofrequency Ablation (RFA), b) Endovenous Laser Ablation (EVLT)
- Non Thermal Ablation- Ultrasound Guided Foam Sclerotherapy (UGFS)
Compression Stockings: These counter the extra pressure in the veins. They may help to ease symptoms such as ache, although there is little proof as to how well they work. They may be difficult to put on, particularly by people who have arthritis in their hands. Current guidelines do not recommend that they be used routinely unless treatments to seal the veins are not suitable or do not work. If you do need compression stockings, below-knee class 1 (light) or class 2 (medium) are usually the most suitable. Ideally, they should be put on first thing in the morning, before you get out of bed, then taken off when going to bed at night. Custom made compression stockings are better than ready to wear stockings as the shape and size of each individual is different.
Open Venous Surgery: Surgery is still the main treatment being offered in our country for various reasons. This involves disconnecting the main vein: GSV at the point where it joins the deep vein in the groin or back of the knee. Compared to conventional technique at Kailash Hospital we offer surgery under ultrasound guidance which requires a small groin incision and a puncture incision at knee. Stripping of GSV is then done using flexible/wire stripper under local anesthesia as a day care procedure in appropriately selected patients. Very obese patients will need spinal/epidural anesthesia and the incision size will also increase. Compared to other newer methods it is cheaper, almost 100% effective and can be done anywhere where Ultrasound machine is available. However, the recovery time and pain is slightly more for initial few days compared to other newer modalities i.e. laser/ radiofrequency ablation.
Endovenous Methods: These include the “Thermal” “Radiofrequency Ablation” (RFA), “Endovenous Laser Ablation” (EVLA) to achieve luminal obliteration by causing thermal injury of inner lining of the vein ( endothelium) resulting in shrinkage and occlusion of the vein. Both the techniques are safe, and highly effective achieving GSV obliteration rate of more than 90- 95%. These are minimally invasive requiring no cut but small skin puncture only. It is performed under ultrasound guidance using local anaesthesia and is done on outpatient basis. Although compared to surgery the technique is more expensive but it causes less postoperative pain, early return to work and time off work. Side effects include a small risk of deep vein thrombosis (DVT) (~0.2%), thrombophlebitis (7%), thermal skin injury (<1%), bruising, haematomas and numbness of skin etc.
Ultrasound Guided Foam Sclerotherapy (UGFS) involves injection of sclerosing agent (Polidocanol and Sodium Tetradecyl Sulphate (STD) as foam under Ultrasound guidance [UGFS] in dilated veins causing chemical endothelial damage leading to their obliteration. Foam is produced by mixing sclerosing agents with air / CO2 in a ration of 1:4.
Traditionally UGFS has been used to treat below knee varicosities. However, it has been used as a popular modality to treat the main veins (GSV & SSV). Although the success rate of around 75 - 85% is less compared to RFA/ EVLA it is popular because it is very cheap, easy to do, requiring no anesthesia leading to fast postoperative recovery and less pain. UGFS is also very useful in treating perforator incompetence, SPJ incompetence, recurrences after surgery, elderly frail patients unfit for surgery and also in those with venous ulcer and skin changes with no visible veins etc. The other disadvantage is that the procedure needs to be repeated in almost 25-30% patients especially if vein is very dilated ( > 10mm in diameter) or patient is very obese (BMI >35).
Side effects include skin necrosis, telangiectatic matting, allergic reaction, hyperpigmentation. There is small but potential risk of deep-vein thrombosis ( 0.3% to 3%,), and also to enter the systemic circulation, possibly the eye or brain via an atrial septal defect causing transient visual disturbance (2.8%) and transient ischaemic attack (0% to 0.3%) of patients.
After any procedure i.e. surgery, RFA/ EVLT or foam sclerotherapy the limb is bandaged using 6” soft cotton, crepe bandage and third layer of Grade II graduated elastocrepe stockings upto thigh. Patient has to walk for a minimum of 30 minutes before discharge. The dressing will be removed after 2-3 days and patient continues to use stockings during daytime for another 8 weeks. After that based on patients symptoms stocking upto knee will be used.
Note: if you have arterial disease in the legs, you will need a medical assessment of your circulation to decide if compression stockings are suitable.
Thread veins and spider veins. These do not cause the same problems as varicose veins, and do not need treating except for cosmetic reasons.
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. All reasonable care has been taken in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions.
Ultrasound guided minimally invasive surgery under local anaesthesia
Prof. (Dr) R.S. Mohil
Senior Consultant & Laparoscopic Surgeon
Kailash Hospital and Neuro Institure, Sector 71, NOIDA