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Patient Information - Varicose Veins
causes of varicose
veins
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Varicose veins - distended, visible superficial veins on the legs - are almost
always the result of problems with valves within the venous system of the
leg. All leg veins contain one-way flap valves which are designed to help
the flow of blood in the veins in an upward direction on its return to the
heart.
When one or more of these valves fails to function correctly ("leaks"), some
blood is able to flow back down into the leg - in the wrong direction - and
tends to overfill and distend branches of superficial veins under the skin.
Over a period of time, this additional pressure of blood causes the veins
to stretch, bulge and become visible. At the same time, tiny capillary branches
of the veins are also overfilled with blood, producing multiple spider veins
and purple discoloration.
"Leaky" venous valves can occur at any site in the leg but the great majority
of varicose veins are caused by faulty valves in the groin or behind the
knee. At both these sites there is a major junction at which superficial
veins (those subject to varicose veins) flow into the important deep veins
of the leg, with a one-way valve to control flow at the junction.
There is evidence that a weakness of these important valves may be inherited
in some people and the valves may also be stretched and caused to leak by
obesity and pregnancy. It is unlikely that prolonged standing actually
causes varicose veins, although people who spend a great deal of time
on their feet are certainly more likely to notice their veins and any symptoms
from them.
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indications
for operation
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Surgical treatment of varicose veins may be appropriate for a number of reasons
including:
symptoms - such as aching, throbbing or tenderness of the veins
cosmetic appearance
medical complications - such as eczema around the ankle with or without
actual skin ulceration, thrombophlebitis (clotting and acute tender inflammation
of the varicose veins) and occasional bleeding from a traumatized superficial
vein.
If none of the above indications apply, it may be entirely reasonable
to leave varicose veins, particularly minor ones, untreated. In all cases
it is important for both surgeon and patient to be clear about the reasons
for which treatment is being undertaken and to balance the expected benefits
of any surgery against the obvious disadvantages of having a surgical operation
(inconvenience, post operative pain, time off work, potential anesthetic
and surgical complications etc).
In general, most surgeons would not recommend surgery for relatively minor
varicose veins on a preventative basis (i.e. in case problems develop in
the future) but would base a decision to treat on current problems
or symptoms. A decision not to operate can always be reviewed in the
future if the situation changes.
Properly fitted elastic stockings may be a useful short or long term
method of alleviating the majority of symptoms or avoiding complications
if either patient or surgeon is keen to avoid surgery.
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types of
operation
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Most varicose vein operations will include one or more of the following elements:
- a surgical exploration to locate and deal with the underlying "leaking"
valve - most commonly this will involve a 3-4 cm incision in the groin and/or
behind the knee. The underlying vein and its connection with the deep veins
of the leg are identified. All associated superficial branches are carefully
cut and tied and the superficial vein itself is tied and divided at its junction
with the deep vein. This part of the operation is extremely important since
it corrects the basic underlying cause of the varicose veins.
- surgical stripping of any long, straight segments of superficial
veins suspected of containing further faulty valves. This stripping is most
usually carried out in conjunction with an exploration of the groin, when
removal of superficial veins in the thigh can ensure more thorough disconnection
of varicose veins lower in the calf and reduce the risk of future recurrence.
- surgical removal of some of the larger varicose veins themselves,
which will have been marked on the skin surface prior to operation. This
is usually carried out by making a series of tiny stab incisions over the
marked veins and avulsing (pulling out) sections of vein with fine forceps.
This element of an operation is often largely cosmetic and thus a balance
has to be struck between the size of veins which can be avulsed and the resulting
permanent scars.
A few patients will develop varicose veins as a result of malfunctioning
valves in sites other than the groin or behind the knee. Throughout the leg,
but especially in the calf, the superficial veins under the skin are connected
to the deep veins within the leg by multiple perforating veins. These perforating
veins are also equipped with one way valves, designed to permit blood flow
only from superficial into deep veins. Damage to these valves can allow the
escape of relatively high pressure blood from the deep veins into the superficial
system, producing varicose veins.
There is some debate as to the importance of leaky valves in these sites
but, in certain cases, surgical treatment of faulty perforating veins may
be helpful. This can be carried out by appropriately placed longitudinal
scars in the leg or, more recently, by means of a telescope and camera which
can be passed for some distance under the skin through a single small incision.
Patients are frequently concerned about the effect of tying and removal of
veins on the circulation of their leg. In fact, the veins which are removed
in varicose vein surgery are superficial veins collecting blood only from
the skin and contributing very little overall to the major blood drainage
from the leg, which occurs through quite separate deep veins within the leg.
Fortunately, the leg contains a complex interconnected network of both
superficial and deep veins, with considerable spare capacity, so that blood
can easily find another route out of the leg after varicose veins are tied
or removed. |
pre operative
investigation
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For any of the above operations to be carried out successfully, it is essential
that the anatomy of the abnormal varicose veins is understood and that the
sites of any faulty, "leaky" valves are identified so that these can be explored
and the problem corrected.
For the great majority of primary (previously unoperated) cases, a simple
clinical examination by an experienced surgeon may be all that is necessary
to establish the cause (and therefore the treatment) of the varicose veins.
Most surgeons would supplement the clinical examination by using a hand-held
ultrasound probe - a rapid and extremely useful method of identifying sites
of faulty venous valves. In such cases, nothing further is required other
than the immediate pre operative marking on the skin of varicose veins to
be avulsed.
In a few cases it can be difficult to be certain of the exact anatomy and
sites of abnormal valves with a simple Outpatient examination. This is
particularly likely to be the case when varicose veins have recurred following
previous surgery or when varicose veins arise from a faulty valve behind
the knee, where anatomy can be quite variable. In such a situation it is
now common practice to arrange a detailed ultrasound examination (duplex
ultrasound scan ) before making a decision on the details of any necessary
surgery.
A duplex scan is an Outpatient investigation, taking approximately 30 minutes
per leg, performed with a sophisticated ultrasound scanner, capable of producing
both visual images of veins and information on direction of blood flow within
them. Such a scan produces a detailed "roadmap" of superficial and deep veins
in the leg and can be an invaluable aid in the planning of more complex varicose
vein surgery.
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complications
of operation
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The majority of operations carried out for varicose veins are entirely
straightforward and, particularly considering the large numbers performed,
serious complications are uncommon. Nevertheless, no surgical procedure is
completely free of risk and the possibility of complications should be borne
in mind when considering the pros and cons of surgical treatment for varicose
veins.
Anesthetic complications are unusual because the length of surgery is usually
relatively short. Cardiac and respiratory complications can occur with any
general anesthetic and are certainly more common in the elderly and in those
with pre-existing heart and chest problems. Abnormal reactions or allergies
to anesthetic drugs are uncommon and largely unpredictable.
Bleeding is one of the more common complications encountered, since the operation
deals directly with blood vessels. Major hemorrhage is uncommon but can
occur if one of the main veins is damaged while disconnecting or stripping
superficial connections. Small postoperative collections of blood can occur
within the surgical wounds, occasionally requiring re-operation but usually
settling without specific treatment.
Wound infection can occur in any of the surgical wounds and is more common
after long procedures, in obese patients and when operations have to be performed
in the presence of contaminated ulcers on the leg. Slight redness, swelling
and inflammation of wounds is extremely common and usually represents a reaction
around dissolving suture material rather than clinically significant infection.
Damage to surrounding anatomical structures is uncommon in first time varicose
vein surgery but there is always a small risk of damage to the main arteries,
veins and even major nerves of the leg in explorations at the groin and behind
the knee. Injury to small sensory nerve branches in the skin is extremely
common and largely unavoidable when veins are stripped or avulsed. This can
result in small patches of numbness, burning or altered skin sensation close
to surgical scars or where varicose veins have been avulsed in the calf.
Deep vein thrombosis (DVT) is an uncommon but serious complication of varicose
vein surgery and can very occasionally lead to detachment of blood clot from
veins in the leg and pelvis which then migrates to the heart and lungs (pulmonary
embolus). A major pulmonary embolus can result in sudden cardiac arrest and
death. Since varicose vein surgery is frequently carried out in women of
child bearing age, the question of the importance of the contraceptive pill
in increasing venous thrombosis risk often arises.
Most estrogen containing contraceptive pills do increase the risk of
post-operative thrombosis by a factor of 2 or 3 and the only completely safe
advice is to stop the pill for 6 weeks before operation. This may, however,
prove impractical if for no other reason than that many hospitals are unable
to give 6 weeks notice of a planned admission date.
The medical risks from accidental pregnancies if the pill is stopped are
also considerable and may actually exceed the risk of DVT. Many surgeons
therefore take the practical approach of advising continuation of the pill
and using injections of heparin to reduce blood coagulation for a day or
two around the time of operation. The disadvantage of this approach is that
it can significantly increase the extent of post operative bleeding and
bruising.
All the complications detailed above are significantly more common in operations
for recurrent varicose veins, particularly when these involve re-exploration
of an existing scar in the groin or behind the knee. For this reason, most
surgeons would only advise "redo" surgery for significant recurrent vein
problems and only after careful consideration of the possible risks.
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post operative
care
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In the majority of cases, the patient will return to the ward after varicose
vein surgery with a firm bandage from the foot to mid thigh. A lightweight
stocking or length of "Tubigrip" is often applied over the bandage to help
keep it in place. No further attention is generally needed to bandages or
dressings before discharge.
Severe post operative pain is unusual and any discomfort from avulsion or
stripping sites in the leg or from groin and knee explorations can be controlled
with simple oral painkillers - the patient will usually be given 2 or 3 days
supply of suitable painkillers before discharge.
On returning home on the day of surgery or after one night in hospital, the
patient should plan for 3 or 4 days of quiet rest at home - limiting activity
to "puttering" about the house and spending much of the time resting with
the leg elevated on cushions.
After 3 or 4 days, bandages can be removed at home. Slight oozing of blood
from stab wounds on the leg is usual and can lead to the bandage or dressing
sticking. This is easily overcome by first removing any covering stocking
or "Tubigrip" and then soaking the entire leg and bandages in a simple warm
bath for 10 to 15 minutes, after which the bandage can be removed without
difficulty. A further light-weight protective stocking is often supplied
to be put on after the leg has been dried and is then left in place for a
further week or so.
Surgical wounds in the groin or behind the knee will usually have been sutured
using a dissolving stitch material buried beneath the skin. These wounds
can be left uncovered after the first day or two and no further attention is
usually needed. Stab wounds on the leg will usually have been sealed with
paper adhesive strips ( "Steristrips" ). These will often float off when
the bandages are removed in the bath and further dressings are not needed.
After removal of bandages, levels of activity can gradually be increased,
still resting with the leg elevated whenever possible. In most cases, fairly
normal activity and return to work with only slight residual discomfort should
be expected after about 2 weeks.
Areas of superficial bruising, lumpiness and swelling in surgical wounds
and where veins have been stripped and avulsed are extremely common. These
will slowly resolve without specific treatment although it may well be 2
to 3 months before the leg returns fully to normal and the final result of
the operation can be assessed.
Since the great majority of varicose vein operations are entirely uneventful,
many surgeons do not arrange routine Outpatient follow up after straightforward
varicose vein surgery but leave it to the patient or GP to request an appointment
if there is a specific problem or query. |
recurrent varicose
veins
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Varicose veins can recur even after entirely satisfactory surgical treatment
although their reputation for doing so is often overstated. Reasons for the
later re-appearance of varicose veins may include:
Inadequate initial operations can lead to the early recurrence of
varicose veins. Dissection in the groin and behind the knee to disconnect
superficial veins from the deep system, at a site of valvular incompetence,
needs to be carried out with meticulous care. The anatomy is often quite
variable but it is essential that all small communicating branches of the
veins are identified, tied and divided completely otherwise these provide
a route for rapid refilling of superficial veins.
Similarly, failure to appreciate that there is more than one separate
site of valve leakage at the pre-operative assessment will lead to early
failure of the operation if all significant sites of incompetence are not
dealt with.
Regrowth of tiny vein branches (neovascularisation) is a somewhat
contentious cause of recurrent varicose veins, the probable importance of
which is only just beginning to be appreciated. Recent research, much of
it carried out in Gloucestershire, has demonstrated conclusively that multiple
tiny vein branches can grow and develop through scar tissue in a matter of
months, providing a new connection between deep and superficial veins even
after an entirely adequate initial disconnection operation. Recognition of
this fact has led to a number of modifications of surgical technique aimed
at reducing the incidence of the problem. These include:
- wide resection and diathermy destruction of disconnected
branches.
- routine stripping of the long saphenous vein in the
thigh to make communication
with calf varicose veins more difficult if
neovascularisation occurs in the groin.
- barrier methods to make it more difficult for veins
to rejoin, including sewing
adjacent tissue over the stump of tied vein
and covering the divided end of the
vein with a patch of artificial material such
as PTFE.
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injection
sclerotherapy
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It is possible to obliterate varicose veins in some positions in the leg
by injecting an irritant substance (sclerosant) in a segment of the vein
and then bandaging firmly over a small pressure pad. The injected sclerosant
produces damage and inflammation of the lining of the vein. Opposite walls
of the vein will then adhere together if the vein is kept empty and compressed.
This method enjoyed great popularity in the 1970s, particularly since it
avoided hospital admission and surgery.
Current opinion is that injection treatment alone has a high recurrence
rate, since the underlying sites of leaking valves are not dealt with at
the same time. Since leaking valves in the groin or behind the knee can only
really be dealt with by a formal surgical operation, it is generally considered
better to deal with any visible varicose veins during the same operation
by the technique of stab avulsions.
Injection sclerotherapy still has a small part to play in subsequent Outpatient
cosmetic "tidying up" of any bulging varices not completely removed during
surgery. A few specialists have also further developed the technique, using
tiny needles and a slightly milder sclerosant, in order to deal with tiny
capillary spider veins when these are considered a cosmetic problem. This
technique has not become widely available since it is time consuming and
only of cosmetic benefit.
Complications of injection treatment include skin ulceration if the sclerosant
substance is injected or leaks outside the vein and permanent brown staining
of the skin in some patients.
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The information collected
here has been developed over searches on the internet. We are not in any
way responsible for, or endorse, information on other web sites, it is
here for public information. Your doctor is the best source of leg
health information and treatment. We hope you find this information
helpful. This article has been provided courtesy of Ames Walker Hosiery
(ameswalker.com) and may be reproduced for personal use provided no part
of this article (including the text contents) has been changed.
Copyright ©
2003 Ames Walker International Inc.
-Please note that the information on this page
has been provided for general guidance and information only. Not all cases
of varicose veins are identical and surgeons may vary in their preferred
methods for investigation, treatment and aftercare. If you have any questions
about your own treatment - ask your
surgeon !!
Back to Frequently Asked Questions |
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