Sudip A Ray

Treating Varicose and Thread Veins (Print This Section)

Varicose veins are easily recognised as the large, worm-like cords around the thigh, knee and calf which may have a bluish tinge (Figure 1). They are often easier to see at the end of the day and usually disappear when the legs are raised in bed or on a stool. The commonest cause is leaky valves which allow blood in the veins to flow back down the leg with gravity and distend the veins. These faulty valves may be inherited and explains why varicose veins sometimes "run in the family".

Varicose veins are found in around 20% of the female population, and 10% of men. They are commoner following pregnancies due to the pressure of the baby in the pelvis as well as hormonal changes which relax the vein walls. Although varicose veins are often only of cosmetic concern, they may cause discomfort and aching or feelings of heaviness, especially towards the end of the day. Occasionally the veins become inflamed ("phlebitis") or bleed and, in the longer term, they may contribute to the development of permanent skin changes (Figure 2), eczema or ulceration.

Treatment of varicose veins

For patients who have symptoms, relief may be gained by the wearing of elastic support stockings obtained from the local chemist or hospital. Although these do not treat or reduce the varicose veins they can decrease the aching from them, and do not carry any harmful side-effects if properly fitted. For a more permanent improvement, injections (sclerotherapy) or surgery are required. The former can be performed in the outpatient department where a small amount of liquid sclerosant is injected into the varicose veins, followed by a few weeks of bandaging (see information sheet below). This procedure may be repeated later if some veins are still left present, but can be sore for a while and leave some thickening or discolouration afterwards.

Surgery is the best treatment of extensive varicose veins or where injections have failed. Many patients are reluctant to undergo operation because of the prospect of scars, bruising, skin numbness and weeks of recuperation, especially where the veins are "stripped". However, new surgical techniques such as VNUS closure and laser ablation have been developed which successfully treat varicose veins using a keyhole method.

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VNUS closure procedure for keyhole treatment of varicose veins (Print This Section)

A heated probe is inserted via a tiny puncture at the ankle or knee and used to destroy the long vein in the thigh that causes the varicose veins (Figure 3). This method avoids the need for large cuts or stripping and leads to less bruising and a quicker recovery. This operation is usually performed under general anaesthesia and was the first keyhole procedure for varicose veins to be approved by the government health advisor, NICE. Patients require a detailed and painless ultrasound examination first to determine whether they are suitable. Following the VNUS procedure they can be home within a few hours, and are usually able to perform normal activities 24-48 hours later (Figure 4).

NB If you are having this procedure you should read the section on "postoperative instructions" and "complications following varicose vein surgery" below

Results of VNUS closure after 1 week

Laser ablation procedure for keyhole treatment of varicose veins

A keyhole alternative to VNUS closure is laser ablation of varicose veins. In my opinion this is particularly appropriate if a patient requires/wishes a local anaesthetic procedure or if the long thigh vein is large. There appears to be a slight increase in aching afterwards compared to VNUS but long-term results are similar.

NB If you are having this procedure you should read the section on "postoperative instructions" and "complications following varicose vein surgery" below

Traditional open varicose vein surgery

If patients are not suitable for either the VNUS closure or laser ablation they may be offered traditional surgery with groin or knee cuts together with small incisions over the visible varicose veins as described below.

Long saphenous stripping

A horizontal cut (usually about 5cm) is made in the groin crease (Figure 5). The long veins which runs from here to the knee is removed with a special device ("stripper") and exits through a 5-10mm cut below the knee (Figure 6). The cuts are closed with dissolving stitches or surgical tape. You are likely to suffer bruising and aching in the thigh over the next 2-3 weeks. You may also notice some numbness around the ankle (paraesthesia) which usually improves over the next six months.
Short saphenous ligation

A horizontal cut (approx 5cm) is made at the back of your knee (Figure 7). This is closed with a dissolving stitch. Occasionally you may have some numbness on the outer side of the foot but this should not affect your walking, and should improve over the next six months.
Avulsions

Very small (2-3mm) cuts are made over your varicose veins to remove them (Figure 8). The cuts are closed with surgical tape, which can be removed after 48 hours (Figure 9). It is normal to have bruising or a "lumpy" feeling there afterwards, but this improves over the next 4-6 weeks. The cuts eventually form small scars, the appearance of which may be unpredictable, but are particularly likely to be visible if you have had bad scarring before, or have pale skin.

NB If you are having these procedures you should read the section on "postoperative instructions" and "complications following varicose vein surgery" below

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Postoperative Instructions for Patients Undergoing Varicose Vein Surgery (Print This Section)

In hospital: After your operation you will return to the ward to rest for at least an hour in bed. You must not get up without the help of a nurse. When resting move both feet at regular intervals to aid the circulation and drink fluids to prevent dehydration. You will normally be allowed home on the day of surgery, but may need to stay overnight if surgery has been extensive or involves both legs. The day after surgery the bandages can be removed to allow inspection of the wounds, and an elastic stocking will be fitted.

At home: You should aim to go for a 20 minute walk twice a day, avoid standing still for long periods, and elevate the legs when sitting. You should wear the stockings when up on your feet but can remove them for bathing and at night. It is normal to have lumpy bruising in the thigh and around the incisions and this will fade over a four week period. You may remove the butterfly strips during your first bath, but may need to replace an elastoplast over the larger incisions. Occasionally one of the wounds bleeds a little but this will settle by compression with a bandage and elevation of the leg. If you are concerned about any part of your recovery please call your admitting hospital or GP. An outpatient appointment will normally be made in any case.

Activities: You can undertake light exercise (treadmill, gentle swimming) after around 3 days, depending on the extent of bruising and soreness. More vigorous exercise (aerobics, running) should be delayed for approximately a week, assuming all is well. You may drive when you can perform an emergency stop without hesitation or pain, usually around 7-10 days. These are estimates but recovery following keyhole surgery tends to be quicker.

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Complications of Varicose Vein Surgery (Print This Section)

Varicose vein surgery is one of the commonest operations performed in the UK. Although the vast majority of these are straightforward with quick recovery times and improvement in the symptoms and appearance, there are occasional problems (complications) which delay recovery time or require further assessment and treatments. Most of these complications are unavoidable and a direct result of the procedure itself. You should read this leaflet before having surgery and ask your GP or specialist if you do not understand any of the information.

1. Infection.

It is not uncommon to notice some redness or hardness in your wounds but if there is associated discharge or you have a temperature then there may be infection. You should consult your GP or specialist who may prescribe a course of antibiotics. Usually this is all that is required but, very occasionally, you may require admission for drainage of infected fluid.

2. Bruising

A degree of bruising is always present following vein surgery and usually resolves within 4 weeks. The bruising may be most marked in the thigh if the long vein is stripped, and can be quite lumpy. Bruising may be worsened if you are regularly taking aspirin/clopidogrel or anticoagulants such as warfarin and you should always inform your surgeon if this is the case. Some patients take Arneca capsules or lotions to reduce the bruising but we have no real evidence that this makes a significant difference.

3. Numbness (paraesthesia)

Occasionally the surface nerves supplying areas of skin are close to the varicose veins and become damaged when the veins are removed. This may result in areas of numbness in the skin but these often reduce or disappear with time as the nerves regain function, or other nerves supply the affected area. A common area affected is the inner aspect of the thigh, calf or ankle when the long saphenous vein is stripped, or the outer aspect of the foot if the short saphenous vein is treated. You should mention this on your postoperative clinic appointment for our records, but it may take several months for recovery to be complete. It is very rare to have any weakness of the leg following this type of surgery, and this should be reported as soon as possible to your GP or specialist.

4. Residual varicose veins

Although this is not strictly a complication many patients will notice some varicose veins remaining after their operation. One must remember that surgery is performed to improve the symptoms of varicose veins rather than to remove every visible abnormality. However, once surgery has been performed it may be easier to inject any remaining veins in the outpatient department if they are still aching or painful.

5. Deep vein thrombosis (DVT)

This is a possible complication of any surgery but is more common if you are overweight, a smoker, take the high-dose oral contraceptive pill, have a previous history or family history of vein thrombosis, are having repeat vein surgery, and if you are very immobile after the operation. If you are being considered for surgery you may therefore be asked to lose weight, give up smoking, stop the pill etc. Additionally we may give you a blood thinning injection during surgery if appropriate, and would ask you to keep moving during your recovery, or elevate your legs when resting. If you are likely to undergo any long (more than 2 hours) car or airplane journeys within a couple of weeks after surgery you should alert your specialist beforehand. If you notice that one calf is much more swollen or painful than the other following your operation it may be wise to consult your GP. If a DVT is detected you will require daily injections and then warfarin tablets for between 6 weeks and 3 months.

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Treatment of thread, flare and spider veins (Print This Section)

Thread or spider veins ("red or blue biro lines", Figure 10) on the thighs and calves are often present alongside varicose veins, and are very common following pregnancy or after prolonged use of the oral contraceptive pill. These are never harmful or painful, and are essentially cosmetic blemishes. They can sometimes be successfully treated by microinjections, thermocoagulation with a fine heated probe (Figure 11) or laser therapy, and do not usually require bandaging afterwards. All of these are performed as an outpatient without need for anaesthetic and can be repeated as and when required.

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Varicose Vein Injections (Print This Section)

1. About the treatment.

Injection (sclerosant) therapy is usually only suitable for relatively small varicose veins and thread veins. It works by making the vein wall stick to itself, thus obliterating it, and the compression applied after the injection is an essential part of the therapy.

2. Before your injection.

You may have to stop taking the oral contraceptive pill, which could increase the risk of a serious thrombosis or "clot". This should be stopped one month before your appointment but it is very important to think about other contraception methods. There is little evidence that low dose "mini-pills" and hormone replacement therapy (HRT) need to be stopped.

You may need to be given a test injection to check that you are not allergic to the treatment.

If you have a job that involves a lot of standing, please arrange to have a few days off after the injection or ask for you to be given a dispensation to sit down or walk regularly.

3. At the clinic.

A small amount of fluid is injected into the vein at one or more sites and a cotton wool pledget or rubber pad applied (Figures 12,13). A bandage is then put onto the leg and a stocking applied to prevent the bandage from working loose.

Please do not drive yourself home from the clinic. Arrange for somebody to collect you or take a bus or taxi.

4. Afterwards.

Take a few short 20 minute walks every day and try to avoid standing still for any length of time.

After 48 hours you may remove the bandage and cotton wool pads and replace the stocking. This should be worn at all times during the day but can be removed in bed and when taking a bath or shower. You may drive once the bandages and pads have been removed.

The success of the injection treatment relies upon the pressure that the bandages and stocking apply to the injected area. Wear the stocking until the leg is completely comfortable on standing and for at least 1-2weeks, unless the doctor tells you that it can be removed earlier. The stocking may be removed temporarily for bathing and whenever the leg is elevated, or at night.

5. What to expect after the injections.

Over the first few weeks following the injection there may be slight discomfort, hardness or tenderness at the injection site(s) and this should gradually subside. If there is excessive redness, swelling or tenderness, this means you should rest more with the leg raised so that the heel is higher than the hip.

While most patients experience no problems after injection of varicose veins, a small number may experience one or more of the following:

A persistent hard "cord" in the line of the vein.
Brown staining of the skin in the line of the vein.
Rarely, ulceration of the skin at the injected site.
Failure of the injection to obliterate the vein.

It is impossible to predict which patients may have this. For the future it may be advisable for you to wear light support stockings or tights to try to prevent the occurrence of further varicose veins.

6. Eventual result

The aim of the injections is to reduce the size of the varicose veins and make them less visible. Hopefully this will reduce the amount of aching from them. However, some patients do not find any improvement following injections, and other methods such as surgical removal may then have to be used. As with any kind of intervention it is impossible to guarantee any particular cosmetic result.

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