Healthy Times Magazine

Dr Sanjay Nalachandran

Varicose veins

These are enlarged, tortuous, unsightly veins that usually appear on the legs. Varicose veins are a common condition and it affects up to 25-40% of all females and 10-15% of males. It estimated to affect nearly 15 – 20% of all adults.

What causes varicose veins?

Risk factors are age, family history and pregnancy whereas obesity, prolonged standing, infection and trauma have been known to make varicose veins worse.

The main problem is that these veins have “faulty or damaged” valves. These one- way valves are located throughout the length of the inside of these veins. “Faulty or damaged” valves are also known as incompetent valves.

Veins normally return blood from the legs to the heart and usually these one-way valves prevent the blood from flowing backwards (reflux). When these valves are “faulty or damaged”, the blood now flows in both directions thereby causing pooling. This pooling of blood in the leg veins over a period of time causes the vein to bulge and protrude from the skin surface.

What are the symptoms?

Some patients have no symptoms whilst others may experience:

• Calf aches
• Calf heaviness
• Swelling of the legs
• Nocturnal calf cramps
• Itching
• Ezcema
• Discolouration of the skin
• Hardening of the skin
• Thrombophebitis
• Bleeding
• Ulcer formation

Diagnosis

Before treatment can be instituted, a duplex ultrasound should be performed. The ultrasound will be performed by our surgeon. It is performed to determine the exact pattern of abnormal blood flow (reflux) and the location of the abnormal or “faulty” valves.

Treatment for varicose veins is targeted at the superficial leg veins or the long saphenous vein(LSV). It is important that the deep leg veins are assessed before treatment to ensure they are normal.

The duplex ultrasound is performed in the clinic with conduction gel, there is no downtime, no pain or needles.

The results of the scan are immediate and with this result, the best treatment plan can be tailored for each individual patient.

What are the treatments?

The treatment of varicose veins depends on the results of clinical examination and duplex scan. Only the superficial vein or LSV is treated for varicose veins, these veins have “faulty or damaged” valves and hence are non- functioning. After treatment of the superficial vein or LSV, the blood from the legs now flows upwards through the deep vein system. There are many treatment options and the best option will be catered for each individual patient, in some cases, a combination of the treatment options may be useful.

• EVLT (Endovenous laser therapy)
• Conventional vein surgery
• Injection sclerotherapy
• UGFT (Ultrasound guided sclerofoam therapy)
• Ambulatory phlebectomy
• Conservative management which involves a combination of support/compression stockings, lifestyle modification and medication

Endovenous Laser Therapy( EVLT)

This procedure is the latest treatment for varicose veins, it is the minimally invasive alternative to conventional vein surgery. It is safe, fast and effective.

A fine needle puncture is perfomed into the thigh vein( LSV) around the knee area, through this needle puncture, a laser fibre is inserted. This is performed using ultrasound guidance.

The thigh vein is called the long saphenous vein and it is this vein that has the “faulty” valves that cause varicose veins. The laser fibre is heated and damages the inner lining of the “faulty” vein, this causes the vein to collapse and close, the collapsed vein disappears over time.

This procedure is performed under sedation or regional/general anesthesia and is usually done as a day case. EVLT of a single leg usually takes less than an hour.

All patients walk home after the procedure and usually return to normal activity within a few days. There is no lengthy hospital stay, no scarring and minimal pain. Patients are encouraged to walk as much as possible after EVLT.

Possible complications include haematoma, bruising, numbness and phlebitis which are all not serious.

Maximum benefit can be observed after 4- 6weeks and residual varicosities can be treated either by injection sclerotherapy or ambulatory phlebectomy.

The most recent studies have shown EVLT to have good results up to a maximum of 5 years and a success rate of > 98%.

Most patients will wear elastic stockings for two weeks after treatment, depending on the size and extent of the veins treated.

Conventional Vein Surgery

This procedure has been done for decades and has been proven to be safe and effective, it has a success rate of > 95%. It involves a small incision in the groin and removal of the “damaged” vein ( LSV) via the groin incision. Other small incisions are made below the knee to remove varicose veins.

This procedure requires general or regional anesthesia. It requires hospitalization, longer recovery period and has more post operative pain/scarring when compared to EVLT.

This procedure has also been proven to have more bleeding, wound infection rates as compared to EVLT.

Conventional vein surgery is still recommended for some patients who some reason or other may not be suitable for EVLT.

Ultrasound guided sclerofoam therapy( UGFT)

Using a fine needle, sclerofoam is injected carefully into these spider veins and reticular veins. Sclerofoam is mixture of sclerosant( liquid) and air. The sclerofoam damages these small veins and causes them to collapse, these veins are then reabsorbed by the body.

This procedure is performed in the clinic, it requires multiple sessions, approximately 6-8 weeks apart. UGFT is performed with topical anesthetic cream, there is no downtime and patients can resume normal activity immediately. Possible complications include bruising, bleeding or staining but all of these are not serious.

Ambulatory Phlebectomy

This procedure involves making small incisions along the varicose veins and removing them using special tools. It may require multiple incisions and local anesthesia is needed.

It can be performed in the clinic with minimal downtime/pain and the patient can resume daily activity within 24 hrs.It can be performed as an adjunct to EVLT and possible side effects include, bleeding and haematoma and numbness.