WHAT ARE VARICOSE VEINS
WHY DO I GET VARICOSE VEINS
POTENTIAL COMPLICATIONS AND RISKS OF
FACTORS OF VARICOSE VEINS
POTENTIAL COMPLICATIONS ARISING FROM
RECURRENCE – CAN VARICOSE VEINS COME BACK AFTER TREATMENT
SUCCESS RATE OF DIFFERENT
ARE VARICOSE VEINS
raised varicose veins or the small unsightly surface veins which are both
commonly termed Varicose Veins.
In the large, raised veins, the blood flows in the wrong direction, ie
downwards instead of up towards the heart, because of the broken valves.
These valves can be broken in the groin, the back of the knee or sometimes
When a valve is broken, the flow of blood is reversed with gravity, flowing
downwards instead of flowing up, causing pressure to be applied to the
superficial veins making them enlarge.
The superficial veins in the leg, that is the veins outside the muscles
sitting just under the skin, are arranged in the form of a tree. There are two major trunks or straight
veins going up and down the leg, and multiple branches of these trunks that
go around the leg forming varicose veins. The trunks are called saphenous
veins and the branching veins are simply called tributary
varicosities. At the tops of the
saphenous trunks are major valves, one in the groin and one at the back of
the knee, which are supposed to keep the blood from flowing backwards down
those saphenous trunks.
'deep' veins in the leg don't form varicose veins because they are supported
and surrounded by muscle. Only the superficial veins outside the muscle are
subject to the pressure to form the large varicose veins.
Unsightly, blue, zig zagging reticular veins or 'spider veins' giving the
appearance of red or blue blotches , which are unsightly. Sometimes they are so superficial that
they are actually part of the skin itself. These unsightly surface veins can
exist by themselves or in conjunction with the larger true varicose veins.
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WHY DO I GET VARICOSE VEINS
The most significant reason is family
history. 70% of patients have a first degree relative who has varicose veins.
The weak walled valves and veins are inherited and at some stage the veins
enlarge, causing the problems with varicose veins.
Women get them 5 times more frequently than men due to hormonal differences
In addition to the genetic factors there
are also 'lifestyle' factors which can effect the veins. Standing jobs, obesity, lack of
exercise or the number of pregnancies are all factors which can worsen your
varicose your veins. Genetics
also mean that you inherit the tendency to form spider veins, with or without
the larger ones or vice versa.
It can of course be a combination of all factors involved in your problem.
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Patients come to see the doctor for all manner
of leg problems which may or may not relate to varicose veins. Some patients may see the small veins
and want to know if the problem is serious. Others may be experiencing aches,
pain, restlessness or swelling which they need to know about. At this stage it is important to have
a proper diagnosis to determine whether the problem relates to veins or to
something else. The patient is looked at clinically and then the veins are
assessed with ULTRASOUND. This may be a hand held unit or a larger unit with
a TV screen call a DUPLEX SCAN. This gives a picture of which way the blood
is flowing, where valves are broken and where the high pressure points
are. This is the accurate method
used to determine exactly what the problems are with your veins and it helps
in determining what type of treatment should be offered to that particular
set of varicose veins.
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1. Reassurance when the veins are not the cause of the problem.
2. Support stockings in half or full length, pantyhose etc. These can
support the veins and muscles making the legs feel better and hiding the
varicose veins. These support
stockings vary in strength and thickness. The strong ones should be fitted
properly so they do not irritate the leg.
Medication – Naturopathic supplements and Medications:
These are treatments that you can take to
help strengthen the vein walls and possibly improve the symptoms in your legs
and slow the deterioration of the veins.
These include rutins, bioflavonoids, horse chestnut, gingko, or
similar products from your pharmacy or from health food shops.
Tablets or capsules can be taken to relieve
the symptoms. PAROVEN which is made from the extract of rubber plant root,
may help the symptoms of aches, pain, restlessness and cramp in the legs.
4. Injection treatment –
This involves injecting into the varicose
veins or the spider veins an irritating solution or a foam to inflame the
lining of the veins. This is
followed by compression of the veins using stockings or bandages. Compression apposes the vein walls,
pushing the walls together, thus shrinking the veins down, causing them to
fibrose and almost disappear. If
the veins to be injected are large, stronger solutions are required, causing
quite a strong inflammation in the target vein. Compression has to be quite strong and
for up to 4 weeks at a time for these large veins. Compression would be less strong and
for a shorter time for smaller veins.
Patients must walk a lot in the first 10 days after injection
treatment to avoid one of the complications, which is thrombosis.
The solutions available to inject varicose
veins in Australia
include Aethoxysklerol, Fibrovein, and hypertonic saline solution. Different patients may react
differently to each solution, so outcomes may vary from patient to patient.
Injections into these varicose veins can be performed directly while looking
at the vein, or injections can be performed under ultrasound guidance, so the
ultrasound allows us to image the vein and watch the needle entering the
vein, which is located deep to the surface and would otherwise not be seen.
After injection treatment (sclerotherapy),
compression and mobility are important to obtain a good result. Complications can still occur. These
complications or unwanted side-effects of sclerotherapy include:
Allergy to the
– anaphylaxis to the solution injected
phlebitis – the target vein and the surrounding veins become lumpy and
tender due to inflammation and some retained blood.
thrombosis – ie a clot occurring in the deep veins of the leg following
injection treatment to the superficial veins. This is rare.
– brown staining on the skin over the injecting vein. This complication is minimized by good
compression after injections. The
body absorbs the staining after some weeks or months.
ulceration – if the injected solution has a strong reaction in the skin
overlying the veins, the skin can die in a small patch over the vein. This skin then peels off and becomes
an injection ulcer. This is rare but
can spoil the outcome of the injections.
An injection ulcer takes weeks to heal.
formation – some patients form new small spider veins around a
previously injected area. This is
their body’s response to the inflammatory solution. For patients who form this problem,
perhaps injection treatment should not be continued.
5. Surgical Removal of Varicose Veins
In patients with large bulging varicose
veins, there is usually a broken or malfunctioning vein valve in the groin or
at the back of the knee, allowing backward flow of blood down the trunks of
the superficial (saphenous) vein trunks and into the numerous tributaries
(branches) that can spread all over the leg. Surgery for this condition involves a
day in hospital, or perhaps an overnight stay, a general anaesthetic,
ligating or tying off the broken valves, removal of some or all of the
backward flowing trunks of the saphenous veins and removing the enlarged
tributary or branching veins through small cuts on the skin. Techniques for varicose vein surgery
have improved greatly over the last few years and with accurate pre-operative
marking of the veins and the use of small cuts, followed by 3-4 days of
compression bandaging, most patients are able to resume work in a week. If you are working from home, you can
resume work the day after the operation.
Patients are out of bed and walking quite quickly after surgery
(usually within 2-3 hours) and are encouraged to be mobile despite the tight
bandages for 3-4 days. The bandages
Varicose vein surgery is reserved for
patients with quite extensive and severe varicose veins. The surgery treats the broken valves,
the backward flowing trunks and the tributaries all at the one procedure.
Complications of varicose vein surgery can
arise. Cuts and bruises are
always going to be present, sometimes a few and sometimes many. Anti-bruising cream and Vitamin E to
improve the scarring helps a lot.
Numb or tingling areas on the skin in spots particularly around the ankle
can occur. This is because when
the veins are removed, sometimes sensory nerves are stretched. Infection in
the cuts in the groin occurs rarely.
Antibiotics may be given to avoid this complication. Deep vein thrombosis (a clot in the
deep veins) can rarely occur after varicose veins surgery. These are noticed by the patient in
about 1% of cases and are either treated with blood thinners or simply by
encouraging the patient to walk.
Thermal Ablation of Saphenous Trunks Using Laser or Radiofrequency Energy
With this treatment, the trunks of the
saphenous veins are destroyed using heat. This obliterates the inside of the
saphenous trunks and stops the backflow down the trunks. The heat is generated using laser
energy or radiofrequency energy.
These methods of obliterating the upper
part of the saphenous trunks began in the USA around 2001. These techniques have been evolving
since then and continue to improve.
The laser probe or the radiofrequency probe is placed inside the
diseased saphenous trunk, usually from the knee going up towards the
groin. Energy is then applied to
heat the probe. The heat in the
probe destroys the vein wall from within as the probe is withdrawn downwards
along the vein. This procedure
can be performed under local anaesthetic or under general anaesthetic. Compression stockings are required
following this thermal ablation process.
Additional treatment is required to treat the branching varicose veins
and the superficial tributaries, as the laser does not treat them
directly. This additional
treatment may be in the form of sclerotherapy or mini-surgery to remove the
This technique of heat destruction of the
trunks of the saphenous veins is effective but it sometimes causes soreness
and possibly some damage to the adjacent tissues, such as the sensory
nerves. This passes in most
cases. Compression is required
following the treatment by way of stockings for a couple of weeks and
subsequent treatment is required to the branching veins.
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POTENTIAL COMPLICATIONS AND
RISKS OF VARICOSE VEINS
The small spider and unsightly veins may cause stinging and aching but do not
pose a serious risk of complications.
It is the larger, raised true varicose veins that deliver the high pressure
into the leg which can cause the complications.
These can include:
1. Clotting — either in the superficial varicose veins themselves or
the deep veins of the leg which can be a serious problem.
2. Pigmentation – The varicose veins can make the skin down towards the
lower leg and ankle become itchy and hot. This is varicose eczema and the skin
becomes scaly and increases in dark colour.
3. The soft fatty layer of tissue near the ankle can become hard and
lumpy-known as "woody leg" or lipodermatosclerosis.
4. Varicose veins may cause the skin in the lower leg to break down causing a
5. Bleeding from the varicose vein is not an unusual complication. This occurs when the vein comes
through the skin and starts to bleed unexpectedly eg in the shower or when using
a towel to dry after a shower or after scratching.
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POTENTIAL COMPLICATIONS ARISING
Patients have to be aware that all
treatment options carry some small risk of complications - although the
chance of complications is very small indeed. In many cases however it is
more of a risk to leave the veins untreated.
POTENTIAL COMPLICATIONS OF VARICOSE VEIN
A general anaesthetic may be involved and
is very safe. However, there is always a minimal risk with anaesthetics.
Some cuts, bruising and pain but all settle fairly quickly.
The three serious complications regarding surgery are:
2. Nerve Damage
This relates to suffering a clot in the deep veins and can occur after
any surgery. It is no more common after varicose vein surgery than any other.
Precautions can be taken such as females going off the pill or hormone
replacement therapy, or in over 40 year olds, an injection of Heparin to thin
the blood. Early mobilisation after the operation is also very important.
When removing a lot of superficial veins, it possible to injure or
stretch cutaneous nerves, i.e. sensory nerves lying next to the veins. This may lead to numb or tingly
patches on the skin, most commonly down near the ankle. This does not usually disable or
prevent the patient from walking but can be annoying. In most cases this
subsides after some months.
Varicose vein surgery is regarded as clean surgery but the patient is
sometimes given prophylactic antibiotics to avoid any infections. If the wounds do become red or look as
though they are becoming infected, you can get antibiotics from your surgeon
or family doctor as soon as possible.
Overall, varicose veins surgery is extremely safe.
POTENTIAL COMPLICATIONS FOLLOWING
INJECTION TREATMENT FOR VARICOSE VEINS
Patients can be allergic to the solution injected. The commonly used solutions to inject
varicose veins in Australia
today are: Aethoxysklerol,
Fibrovein, and a strong salt solution.
No matter which solution used, there is a possibility you could be sensitive
or allergic to it. This is extremely rare but some cases have been reported.
If the solution injected leaks out it can cause damage to the surrounding
tissue and even the skin. The skin can form a scab which can peel off.
Occasionally the patient can get a scab overlying the vein. The damage does heal but can be
painful or annoying for a few weeks.
Very rarely, patients who have injection treatment to the superficial
veins can develop a clot in the deep veins. To help prevent this, patients
are encouraged to walk regularly — 20 minutes, 2-3 times a day —
to circulate the blood so it does not stagnate or clot.
If there is a strong reaction to the solution, there may be brown staining
over the vein. This may take some months to absorb, but will disappear in
New Vessel Formation
Sometimes the response to the injections can be the formation of very fine
red veins in the local area. If this happens, no more injections should be
attempted until it settles spontaneously. If it does not settle, cease this
form of treatment.
Having said all that, injection treatment is still a very popular, common and
well tolerated method of treatment for suitable veins. It is quite a safe method of
RECURRENCE – CAN VARICOSE
VEINS AND SPIDER VEINS COME BACK AFTER TREATMENT – YES THEY CAN
If you have a genetic disposition or family tendency to develop varicose
veins or spider veins all the veins in the legs have weak walls in them. No matter what form of treatment is
used to treat your varicose veins initially – injection treatment
(sclerotherapy), surgical removal or obliteration of the trunks using heat
(eg. laser), new veins almost always develop and the chance of this increases
over time. All patients who have
had treatment for varicose veins should be on the look out for new veins
arising. They need to have these
veins treated earlier rather than later and hopefully this will involve some
simple injection treatment, avoiding the need for any further surgery or
obliteration of big veins using heat.
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SUCCESS RATES OF TREATMENTS FOR
The success rate of a varicose veins treatment is difficult to define and
changes over time. More than one
method of treatment is often used on a single patient eg. Varicose vein surgery
followed by injections, or laser followed by surgery or injection treatment,
or injection treatment combined with removal of tributary veins
surgically. Injection treatment
for smaller surface veins in patients with no reflux (backward flow) in the
saphenous vein trunks is very beneficial, offering 60-70% improvement in
appearance and symptoms. Surgery
for varicose veins treats the broken valves, removes the trunks and the large
tributaries. It will not fix the
spider veins and these need some follow-up injections. Laser or radiofrequency thermal
obliteration of the saphenous trunks is an alternative to surgically removing
the trunks. It is very effective
but additional treatment is then required for the veins below the knee and
for the branching tributary varicose veins and spider veins.
You must discuss with your doctor realistic
expectations of the outcome following treatment. These realistic expectations have to
be explained and miracles and magic solutions are not on offer. Varicose vein treatment considerably
improves the situation but problems can arise and new vessels can
appear. All of this has to be
discussed with your treating doctor before treatment is undertaken.
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