What are varicose veins?
Veins are vessels which are designed to carry de-oxygenated blood back to the heart from the tissues of the body. Varicose veins, however, are abnormally dilated veins that cannot perform their function.
Varicose veins are larger veins that bulge above the skin surface which are commonly found in association with larger and deeper vein problems. If there is a deeper vein problem can be detected at an initial examination.
Dilated blood vessels often cause aching especially after prolonged standing. Although dilated blood vessels do carry blood they are not very efficient and are often not necessary to the circulatory system. The body has an already established alternative route for the blood to travel back more efficiently to the heart (deep venous system). Thus they can be treated without damaging the circulation. In fact, treatment actually improves venous circulation. The probability of a greatly improved appearance following treatment is about 90 per cent depending on the severity of the problem. Treatment will also usually relieve any symptoms caused by the veins.
What causes varicose veins?
Since our ancestors decided to stand upright, our leg veins have been faced with the difficult task of taking the blood up to the heart against the pulling force of gravity. To do this the leg veins depend on the contraction of the calf and thigh muscles to pump the blood. This is why walking is good for your circulation.
So when you walk, the contraction of your leg muscles pumps the blood up. However, as the saying goes "what goes up must come down" which is what happens to blood in the leg veins. Therefore, to prevent the blood from falling back down, nature has designed valves in the leg veins which open in only one direction: upwards. So the valves allow the blood to get through but when it comes back down, the valves shut and stop the blood going all the way down. The next contraction sends the blood even higher until it eventually reaches the heart.
In venous disease, the underlying problem appears to be damage to the valves. The abnormal reticular veins, for instance, act as "feeders" of the spider veins. The blood flow in these feeder veins can compared to a "two-way" street. In other words, blood in the feeder veins can go back and forth. This backward flow through the incompetent valves dilates up the smaller veins (medically called "post-capillary venules"). These dilated post-capillary venules are commonly referred to as "spider veins".
The same principle applies to varicose veins. The abnormal valve cannot stop the blood from rushing back down. The blood in these veins is oxygen low and in fact carries a lot of toxins. In the case of varicose veins, this "toxic" blood pools in the legs and cannot be returned to the circulation. This is why patients with varicose veins suffer from night cramps and their legs feel heavy at the end of the day.
Varicose veins occur in both men and women. A definitive cause is not known, however a strong family history suggests that some people inherit veins that are more likely to deteriorate. In women, oestrogen may play a role as the onset of puberty, pregnancy and taking oral contraceptives can give rise to vein abnormalities. In pregnancy, the enlarged uterus can restrict blood flow from the legs and promote the development of varicose veins. Spider veins and varicose veins are also associated with obesity. Occupations involving prolonged standing tend to increase the likelihood of veins to develop. Bone fractures and soft tissue trauma can cause localized vein abnormalities.
How to treat Varicose Vein?
The aim of varicose vein treatment by any method (surgical or non-surgical) is to close or remove the diseased and incompetent superficial varicose vein. Since most of the blood in the legs is returned to heart by the deep veins, and the superficial veins only return about 10 per cent, they can be sacrificed without serious harm.
Elevating the legs provides relief. Regular exercise has not shown to cure varicose vein. The wearing of graduated compression stockings with a pressure of 30-40 mmHg has been shown to provide temporary relief from the leg swelling. Anti-inflammatory medication such as ibuprofen or aspirin can be used as part of treatment for superficial thrombophlebitis along with graduated compression stockings.
1. Open Surgery
Traditionally, open surgery was the only choice for treatment of varicose vein till few years. It involved stripping the diseased varicose vein from the body. This operation is done under general or spinal anesthesia as an inpatient procedure. Multiple cuts are made on the legs at various places starting from the groin till the ankle. The vein is stripped through the open cuts. This usually is a prolonged surgery with blood transfusion. Patient is admitted in the hospital for about five days. The post-operative period is often painful with risk of bleeding from the incision sites. Multiple surgical scars on the legs are produced due to surgery. The patient is advised rest for a period of six weeks following surgery.
The higher rate of deep vein thrombosis, pulmonary embolism, and wound complications including infection and bleeding are discouraging for a patient to undergo open surgery for varicose vein.
The open surgery has a high recurrence rate (five to 60 per cent), and a risk of nerve damage up to 15 per cent. Hence now open surgery for varicose vein is less commonly performed worldwide.
2. Endovenous Laser Ablation (EVLA)
Recent advances have improved lasers, making laser surgery a preferred method of treatment for varicose vein. By LASER, the whole lining of the diseased superficial varicose vein is destroyed, and hence a chance for new collateral veins to grow is almost zero.
The Endovenous Laser ablation for varicose vein is done under local anesthesia from a single pinhole in the leg. There is no need for any cutting or stitching on the leg. The patients walk out of the Laser suite after the procedure. Normally EVLA is done as an out patient procedure or 6 to 8 hour hospitalization may be recommended.
The Laser energy seals the abnormal vein completely and permanently. The most modern 1470 nm diode laser system produces the highly wavelength, which safely passes through the skin and is selectively absorbed by the targeted blood vessel. The vein will gradually disappear, leaving the skin intact. A crepe bandage is applied on the leg for 48 hours continuously. The patient will be advised oral pain killer for five days following the procedure. Crepe bandage or stockings are worn for a couple of weeks on the calf from morning to evening. A monthly follow-up twice with Doppler scan following the LASER ablation of varicose vein is recommended.
I. Advantages of EVLA
The advantages of Endovenous LASER ablation are many. Due to the optimal absorption spectrum of 1470 nm, the veins get closed in without affecting the neighboring tissue. The closed vein remains in its natural position in the body, which reduces the invasiveness of surgery to a minimum.
The procedure is done under local anesthesia, and there is no risk of blood transfusion. The patient does not require postoperative rest, and can resume routine activities on the next day of the procedure. The treatment duration is just about half an hour. Also, there is reduced risk of infection.
The Laser Ablation for varicose vein is well tolerated and has few side-effects. Some patients may experience a slight ache along the shrunken veins, for which local cooling and anti-inflammatory drugs will provide quick relief. Some patients may experience bruising or paraesthesia, which are self-limiting in a few days time.
3. Radio Frequency Ablation
Radio frequency ablation of varicose vein is less invasive than open surgery, but more invasive than LASER ablation and recurrence rates are lower than open surgery but higher than LASER ablation. Not many centers across the world are now practicing RF ablation for varicose vein treatment after the advent of LASER as a modality to treat varicose vein.
Sclerotherapy is a non-surgical approach in the treatment of varicose and spider veins of the legs. A sclerosing solution is injected directly into the vein, causing it to quickly disappear. It has a recurrence rate as high as 70 per cent. It is never used as a sole method of treatment for varicose vein. It can be an added therapy with other mainstay treatment.
Varicose vein is prevented by avoiding prolonged standing. Sitting for a few minutes during prolonged standing helps prevent the disease. A good compression stocking (pressure gradient of 30 to 40 mm Hg) should be worn by persons who stands for a prolonged period routinely. Maintaining a normal weight, regular exercise, avoiding constipation and avoiding wearing high heeled shoes may also be helpful.
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Dr. Sibasankar Dalai, MD, FACP
Fellow Australasian college of Phlebology
Member American College of Phlebology
National Faculty, Interventional Radiology
National Faculty, Interventional Neuroradiology
Consultant Interventional Radiologist & Neuroradiologist,
Seven Hills Hospital, Vizag, AP
Formerly Faculty, KEM Hospital, Mumbai
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