While most of us can’t wait for those long summer days, thousands of Australian’s with varicose veins are dreading those hot days and balmy nights.
Varicose veins can be caused by the back-pressure of blood into the legs, triggering veins to dilate and become varicose. Valves in varicose veins are physically separated due to this enlargement, and gravity causes reverse flow of blood into the legs, instead of flowing back to the heart. Varicose veins are of no functional use, in fact the reverse flow and increased venous pressure overloads normal veins, resulting in more varicose veins. A simple analogy is ‘snakes and ladders’ where blood ascends in normal veins (ladders) to leave the legs, only to tumble back via the varicose veins (snakes).
How do you prevent varicose veins?
Unfortunately there is very little you can do to prevent varicose veins. Support stockings can help tired, aching legs, but their relatively low compression is inadequate to prevent varicose veins from occurring. Venous disease progresses with time, particularly if left untreated. Eradicating varicose veins improves the appearance, relieves symptoms, improves venous outflow and prevents the progression to long-term complications associated with high venous pressures.
There is a growing body of medical evidence suggesting that the surgical stripping of varicose veins promotes the development of more varicose veins. The newer non-surgical techniques do not disturb the regular flow of blood into the groin and should not promote recurrences. Non-surgical procedures can treat varicose veins before pregnancy, between or after children and after surgical stripping.
Some patients suffer no symptoms at all. However burning, stinging, aching (particularly premenstrually), throbbing, heaviness, restless legs and leg cramps are common. The progressive effect of high venous pressure in the legs causes numerous skin changes including brown discolouration, dermatitis of the lower legs, ulcers and scarring. They can bleed, cause ankle swelling and they can thrombose, becoming red, angry and painful due to clotting of the blood.
All patients seeking treatment should have a CW Doppler study. This is a hand-held device that can detect venous reflux and identify abnormal veins that are not visible externally. A duplex scan, which enables the practitioner to see the veins and test their functionality, is significantly more accurate than a Doppler examination, although it is more expensive and not always available.
Varicose veins can be treated by a number of different methods. The non-surgical treatments include Superficial Sclerotherapy, Ultrasound Guided Sclerotherapy and Endovenous Laser Treatment. Most patients find these procedures unpleasant, but tolerable, and we have had some patients giggle through the procedure when using an inhaled analgesic, which is available for anxious patients or those with a low pain threshold.
Superficial Sclerotherapy
Superficial sclerotherapy involves injecting a solution into veins causing them to close, absorb and disappear over a number of months. There are three different sclerosing solutions available in Australia. The procedure has been used for many years and is relatively low risk. Serious complications are rare. It is commonly performed for cosmetic improvement, although underlying varicose veins must be treated first.
Ultrasound Guided Sclerotherapy (UGS)
UGS utilises ultrasound imaging to see veins under the skin that are not visible externally. Small- to medium-sized veins are treated quite successfully by injecting the solution as foam that is readily observed on ultrasound. Larger veins treated by this method can re-open, requiring further injecting, however the treated veins will normally shrink considerably after any one treatment. Serious complications are rare.
Endovenous Laser Treatment (EVLT)
EVLT is a rooms-based procedure performed under local anaesthetic. A laser fibre is fed through the varicose vein to its origin and the laser closes the vein permanently.
Not all varicose veins are suitable for this procedure, particularly if they are superficial or post surgical recurrences. This method has the greatest long-term success rate of any treatment and serious complications are rare.
Conclusion
Surgical stripping of varicose veins is considered obsolete. Surgery is no longer required, even for the largest veins, although it is still commonly performed and recommended to patients. Surgery involves hospital admission, general anaesthetic and days to weeks off work. The procedure has changed little in the past 75 years and commonly involves cutting down onto the varicose vein in the groin. The veins are stripped out in long segments and also pulled out via small cuts in the skin called phlebectomies. It has a much higher recurr-ence rate, a higher rate of risks and complication, as well as significant downtime compared to foam UGS and EVLT.
Varicose veins have a very low mortality rate (rarely a cause of death) although they can cause significant morbidity (pain and suffering) for many people. Patients should consider the risks and benefits of having no treatment versus each of the available treatments when deciding upon a management programme.
Fast facts
• Varicose veins are a common problem that affect up to 30 percent of the population at some stage during their lifetime.
• Women are treated for varicose veins four times more frequently than men, mainly because pregnancy causes varicosities to occur at an earlier age and women are generally more pro-active seeking attention to medical problems and a good cosmetic result is a higher priority for women.
• Hormones also play a role for women – namely the contraceptive pill, Hormone Replacement Therapy (HRT) and pregnancy. Varicose veins can get worse with each pregnancy.
• Varicose veins are often associated with occupations involving prolonged standing.
• Obesity can contribute to more veins being present, simply due to a greater surface area of skin – and the response to treatment is poorer.
• Varicose veins can occur after trauma, often resulting in the appearance of spider veins and may not be externally visible.
• They are presumed to be inherited, however they may simply be a very common problem.
• Crossing your legs does NOT cause varicose veins.
