Varicose Veins

What are Varicose Veins?

Dilated, Palpable, tortuous veins greater than 4 mm in diameter that do not discolor the overlying skin are called varicose veins.

What are Telangiectasies?

Veins between 0.1 and 1mm are called Telangiectasies.

What are Reticular Veins ?

Veins between 1.0 mm and 4.0 mm are called reticular veins or spider veins.

Telangiectasiasis and reticular veins need to be treated only for cosmetic reasons!

What Causes Varicose veins?

There are two systems of veins in the leg. One that lies just under the skin is called superficial system and the one that lies deep in the muscle is called the deep venous system.

Blood is directed from the superficial to the deep venous system, which then takes the blood back to the heart for purification. There are two main valves linking the two systems. The main one is in the groin and it is called the sapheno-femoral junction and another large one is behind the knee called the sapheno-popliteal junction. There are also other links between the systems along the leg called perforators. All these links have valves as well. The valves normally only allow blood to go from superficial to deep. When the valves do not work (they become incompetent), blood is allowed to reflux back from the higher-pressure deep system to the superficial system. This makes the veins under the skin bulge and stick out. These are called varicose veins. The higher pressure in the varicose veins causes the symptoms of varicose veins.

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Sometimes reflux of blood from deep to superficial can be caused when there is an obstruction to the outflow of blood from the deep veins. This obstruction can be caused by clots in the deep veins (DVT) or by external compression of the veins by tumours or other masses in the pelvis; the commonest cause being pregnancy.

What are the symptoms of varicose veins?

The increased pressure in the varicose veins causes the symptoms of varicose veins; the medical term for it being Chronic Ambulatory Venous Hypertension.

The symptoms include

• Unsightly bulging veins
• Dull ache or tiredness in the calves
• Bleeding from the veins
• Oedema or swelling
• Eczema or dry, flaky skin
• Pigmentation (dark discolouration)
• Lipodermatosclerosis (pigmentation + hardening of the skin)
• Ulceration

Ulceration is the most feared complication and can be difficult to treat.

What investigations should be done to assess varicose veins?

Most times clinical examination including a hand held Doppler examination should suffice.

On occasions, especially if there have been previous attempts to treat the varicose veins, there is a previous history of DVT or if there has been major trauma to the leg in question, a duplex ultrasound examination is essential.

Very rarely a venogram may be necessary.

How are varicose veins and their complications treated?

Ideally, varicose veins should only be treated by a vascular surgeon as they have the best knowledge, experience and expertise to treat venous diseases.

Treatment is aimed towards reducing the pressure in the superficial veins and removing the unsightly veins. The different methods of achieving this are by

Compression Therapy
• Surgery
• Endo-venous occlusion of the incompetent veins (Laser, Foam or Radio frequency ablation).

Compression Therapy.

This is done using graduated compression hosiery or compression bandaging. The compression pressure is more near the toes and reduces as it goes up the leg, thus creating a squeezing effect.

Ideally the compression hosiery should be made to measure for the individual patient. The compression hosiery should be worn at all times and the lower limb must be kept elevated when it is removed. The hosiery should be changed when it is no longer effective (when it becomes loose). Compression therapy can be used life long or till definitive treatment is done.

Surgery

This usually comprises of tying off the leaky valves either in the groin or behind the knee, removing the main superficial vein in the thigh and avulsing the bulgy varicosities.

Surgery is the most commonly done procedure to treat varicose veins. ( See link to varicose vein operation)

Endo-venous therapies

These are also called keyhole therapies and generally involve sclerosing or burning the leaky vein close to the valve junctions. The heat for burning the vein is provided either by laser or Radio frequency .

A laser or Radio-frequency catheter passed up the leaky vein and heat is applied to the vein walls thus causing the closure of the vein. This procedure is less painful when compared to surgery and the results seem to be as good as or better than surgery. My personal preference is to use Radio-Frequency ablation as the results from this seem to be superior to laser ablation of the veins

The above picture shows the steps of Radio-Frequency ablation. After both procedures compression should be worn for at least 10 days. I do not use foam sclerotherapy, as there is a small risk of causing a stroke.