What are Varicose Veins?

Veins are the blood vessels that carry blood back to the heart. Varicose veins are abnormally swollen (dilated) veins that are visible beneath the skin. They are a very common complaint and over 50,000 operations are performed in the U.K. annually for their treatment. Varicose veins are not a serious condition and do not cause any significant risk to the health or well being of patients. Nevertheless, in some patients (less than 10%) they may result in inflammation and eczema of the skin, or very occasionally they may bleed or lead to the development of leg ulcers in later life. Furthermore varicose veins may cause pain and discomfort especially in patients who have to stand still for long periods as part of their daily occupation. They may occasionally lead to phlebitis when the varicose veins become painful and tender. This is treated with painkillers and rest and settles naturally. Varicose veins do not cause or increase the risk of deep vein thrombosis, which is a separate and more serious condition.

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Traditional Varicose Vein Surgery

The traditional treatment for varicose veins is surgery. This involves a cut being made in the groin (2-3cm) over the top of the main varicose vein under general anaesthesia. The vein, which is causing the varicose veins, is identified and this is stripped (removed from the thigh). In addition all the varicose veins, which have been marked on your leg are removed through small incisions (less than 5 mm).

The cut in the groin is closed with stitches (these are usually absorbable). The smaller cuts in the leg are closed with adhesive strips or stitches. A dressing will be placed on the cut in the groin, and your leg will be bandaged up to the top of the thigh or alternatively a dressing will be placed on the cut in the groin and you will need to wear a compression stocking.

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Endovenous Laser Treatment (EVLT) Recent advances in vascular surgery have lead to the technique of Endovenous Laser Ablation. Endovenous Laser Treatment of varicose veins can be performed under local anaesthestic. It involves passing a probe into the varicose vein which is then sealed from within with the user of a specialised laser. The procedure takes between 30-45 minutes per leg and can be performed as a day case procedure. Nearly 70% of patients who have not had previous varicose vein surgery are suitable for EVLT. Once the probe is removed the leg is bandaged. What Does Laser Treatment Involve? The procedure begins with an ultrasound scan to mark the vein in your leg to be treated. An injection of local anaesthetic is given to freeze the skin over the vein. A small needle is inserted into a vein at this point and a flexible wire is passed up the vein. You will not feel this. A fine tube is passed over the wire into the vein and the laser filament is threaded up this. The position of the laser fibre is checked with an ultrasound scan. Once the laser fibre is in the right place some more local anaesthetic is injected around the vein to minimise any discomfort when the laser is turned on. The laser works by closing up the vein from the inside. Lasers are powerful sources of energy and you and the staff will wear protective sunglasses whilst the laser is being used When the vein has been sealed up, the laser is removed and a bandage applied to the leg. You should keep this on for 7 days following which a support stocking, which you will be given, is worn for another week What happens after the treatment? After EVLT you will be asked to walk around for 15 minutes, have a drink, and then go home. You should not drive and if travelling by car for more than 1 hour sit on the rear seat with your leg(s) on the seat. You should stop hourly and walk for 5 minutes. During the first few days you may feel some discomfort or tightness over the treated vein. To minimise this we will give you a 3-day supply of an anti-inflammatory drug called diclofenac (Voltarol), which is also a painkiller. We recommend that you take this for the full 3 days. You should not take diclofenac if you have had a stomach ulcer or haemorrhage. If you have, take paracetamol (Panadol) if painkillers are required. If any discomfort remains after 3 days you can paracetamol (Panadol) Normal activity, including work, can be resumed as soon as you like although we suggest avoiding contact sports, the gym and swimming for 2-3 weeks after EVLT. When the bandage is removed after 7 days some minor bruising over the treated vein is normal together with some hardness under the skin. This will setde down. By 6 weeks most of your varicose veins will have shrunk and many may have disappeared. If some remain these can be treated by injection treatment. This is a routine outpatient treatment which we currently use for less severe varicose veins. The injection treatment replaces the small wounds that are made in the leg to remove the lumpy veins during surgery. What are the advantages of EVLT compared to surgery? EVLT has a number of advantages. These are: It is performed using local anaesthetic. The procedure can normally be done as an outpatient, taking 30- 45 minutes/leg. You should be able to resume your normal activities straight away and return to work the following day. It avoids the incisions (scars) required for a normal operation and therefore complications such as wound infection. Patches of numbness on the skin are rare. There is very little discomfort or pain after the procedure. What are the Risks of Varicose Vein Treatment? Varicose vein surgery, either by conventional surgery or EVLT is a very safe operation. The majority of operations carried out for varicose veins are entirely straightforward and considering the large numbers of operations performed; serious complications are rare. However, all patients notice some bruising, in particular along the inner aspect of the thigh. This take approximately 4 weeks to resolve. Some patients may experience pain and soreness following the operation and this will settle over the next 2 weeks. Occasionally, small sensory nerves in the skin, which are close to the vein maybe damaged during the operation leading to small areas of numbness or pins and needles near the incision.  These often recover but, rarely, permanent numb areas remain. Injection Sclerotherapy of Varicose Veins What is injection treatment? Injection treatment is used to close varicose veins by injecting a chemical substance into the vein which causes their walls to glue together and the veins to shrivel up. Although it does not work very well if there a faulty valves in the groin, behind the knee and in the long or short saphenous veins once these have been dealt with by EVLT injection treatment will usually get rid of any veins that do not disappear or shrink following the laser treatment. What happens during injection treatment? Injection treatment is done as an outpatient using a very tiny needle that causes little discomfort. Each injected area will be covered with a pad, and a bandage will be then be applied to the leg, often all the way up from the foot. This puts some pressure on the veins that have been injected until the walls of the vein have ‘glued’ together. What should I do after injection treatment? You should walk briskly for at least 20 minutes after having your injections The bandages must be worn continuously for I week unless otherwise specified. You should not get the bandage wet. Remain as active as you can. Avoid standing still for long periods: if you need to stay standing for more than about half an hour go for a short walk to keep the legs moving. There are no restrictions on your activities and you can return to work immediately after the treatment. It is reasonable to pursue most sports. but avoid very strenuous activities that cause the bandages to loosen. What other effects or problems might there be? The chemical substance can cause inflammation resulting in redness and discomfort. This will settle but if it is troublesome diclofenac or paracetamol will help. Most patients do not require any painkillers. Mild ankle swelling may occur with prolonged standing. It will usually settle if you go for a walk or if you elevate your leg. Deep vein thrombosis is a possible consequence of injecting the varicose veins, but is extremely rare Occasionally (in less than 5% of patients) injections can produce brown staining of the skin in the areas where the veins were. It is not possible to predict the patients in whom it will happen. Although the brown staining may gradually fade it can be permanent. It is also possible that a tiny ulcer may develop at the site of injection. Although this will heal it may leave a small scar. Very rarely, blushes of tiny veins can appear in the skin over areas that have been injected (this can also occur after operation).

 

What is Peripheral Vascular Disease?

The pain in your leg, which occurs when you walk, is called intermittent claudication and is caused by peripheral vascular disease. Peripheral vascular disease results from a blockage or narrowing of the arteries which supply blood to the legs. This is caused by disease in the wall of arteries known as atheroma, which develops gradually over many years. It begins with fats (cholesterol) from the blood stream being deposited within the wall of arteries, which leads to a chain of events resulting in thickening of the artery wall.  This results in a narrowing or blockage of the artery and a reduction of the blood flow to the leg.

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What Causes Atheroma?

High blood pressure, raised cholesterol, diabetes, obesity and lack of exercise, may all lead to atheroma, but cigarette smoking is the most important cause. Atheroma occurs throughout the body and its consequences depend on which part of the body is affected. In the legs, the arteries become narrowed so that there is insufficient blood to supply the exercising muscle. Therefore, the patient gets a pain or cramp in the leg whilst walking, which disappears after a couple of minutes rest.  If the arteries to the heart are affected then this may result in breathlessness, angina (chest pains) or a heart attack. Similarly, a blockage of the blood vessels to the brain may result in a stroke.  Any patient who suffers with peripheral vascular disease (pain in the legs on walking) is likely to have some disease of the arteries that supply the heart and the brain.  Therefore, such patients are at increased risk of heart attack and stroke.

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Treatments Available

The majority of patients with peripheral vascular disease have symptoms of pain in their calf when walking (this is called intermittent claudication). This is caused by a lack of oxygen being delivered to the muscles of the legs when they are active. As a result, the symptoms are relieved by stopping walking for a few minutes. Only a minority of patients with intermittent claudication need treatment because the symptoms can be improved by lifestyle modifications listed below (click here for more information). In the first instance, after a full medical history and examination, you will be offered a duplex scan of the blood vessels of your lower leg (this is a scan using a specialised ultrasound machine that is placed on the leg). This scan will provide information on the extent of disease of the arteries supplying the muscle in the lower legs and whether any further treatment is required.

If the extent of disease of the lower leg arteries is more severe, some patients have symptoms of continuous pain in their feet at rest (with or without ulceration), especially when they are sleeping at night. This is called rest pain and is a more serious symptom as it indicates that the blood supply to the leg is more severely compromised. If you have these symptoms, after your initial appointment you may need an angiogram, an investigation which uses x-rays and dye which is injected into the artery in the groin under local anaesthetic. An angiogram provides more detailed assessment of the lower limb arteries and also allows access to any disease arteries which can be balloon angioplastied or stented at the same time (in a similar fashion to the stenting of coronary arteries in patients with angina).

Occasionally, angioplasty of the disease arteries and stenting is not technically possible and patients with severe lower limb ischaemia may require lower limb bypass surgery. As a specialist in vascular surgery, Mr Crinnion is able to offer all the above treatments.

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The Outlook

If you are suffering with peripheral vascular disease your outlook for the future is good, providing you follow the advice listed below.There is very little risk of developing gangrene or needing an amputation. However, if you continue with your present lifestyle your legs will deteriorate and there will be a high risk of suffering a heart attack or stroke.

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What Should I Do?

1. STOP SMOKING

This is the most difficult but most important lifestyle change you must make.  Stopping smoking will greatly reduce your future risk of stroke, heart attack and amputation.

2. TAKE REGULAR EXERCISE

Research has shown that 30 minutes walking, 3 times a week, will double the distance you can walk without stopping, providing you persist with this regime.   It will also be beneficial in preventing heart disease

3. MEDICATIONS

Patients with peripheral vascular disease can greatly reduce their risk of a heart attack or stroke by taking one tablet of aspirin each day (75mg). A prescription will be given to you so you can start this immediately.  If you are unable to take aspirin then an alternative tablet will be prescribed.

4. DIABETES & HIGH CHOLESTEROL

There is now clear evidence that diabetes and high cholesterol are major factors causing heart attack and stroke. These conditions will be screened in the vascular clinic and abnormal levels will be treated.

5. HIGH BLOOD PRESSURE

It is very important that high blood pressure is corrected to prevent a stroke or heart attack.

6. OBESITY

If you are overweight then weight reduction will reduce the risk of heart attack or stroke and will improve your exercise tolerance. Dietary advice may be obtained from your GP or from dieticians based at the hospital.

7. FOOT CARE

It is important to wash your feet daily and cut your toenails carefully.  You must ensure that your shoes fit properly and do not cause blisters. Patients who suffer with diabetes are at a particularly high risk of developing ulceration of the feet and should be referred to a chiropodist.