Patient Information - Varicose Veins
This page has recently been cited as containing
the best overall
information on varicose veins available on the Internet
G. Libertiny, JMT Perkins, TR Magee and RB Galland
European Journal of Vascular and Endovascular Surgery 2000; 20: 386-9
| 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 discolouration. "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. |
| Surgical treament 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 traumatised superficial vein. (further information about leg ulcers can be found by clicking here). 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 anaesthetic 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. |
| 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. |
| 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. |
| 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.
Anaesthetic complications are unusual because the length of surgery is usually relatively short. Cardiac and respiratory complications can occur with any general anaesthetic and are certainly more common in the elderly and in those with pre-existing heart and chest problems. Abnormal reactions or allergies to anaesthetic drugs are uncommon and largely unpredictable. Bleeding is one of the more common complications encountered, since the operation deals directly with blood vessels. Major haemorrhage 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 oestrogen 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 significiantly 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. |
| 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 "pottering" 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 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 |
| Varicose veins can recur even after entirely satisfactoy 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
- barrier methods to make it more difficult for veins
to rejoin, including sewing |
| 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 (see types of treatment above). 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. |
| - 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 !! |
LINKS:
This page was compiled by Brian P Heather MS FRCS
on behalf of the Gloucestershire Vascular Group
