Varicose veins are tortuous dilated veins presenting most commonly in the leg. Besides their unpleasant appearance, they can cause symptoms that include but are not entirely limited to burning, itching, aching and mild swelling which all tend to become more prominent at the end of the day. The number of people who suffer with varicose veins ranges from approximately 25-35% of the adult population with men and woman being affected equally.
Why do they Occur?
Our veins contain valves which should only allow the passage of blood back to the heart for recirculation from the limbs. In varicose veins these valves are defective allowing blood to pool in the leg and giving the appearance that people find unpleasant. (See figure 1) Nobody fully knows why varicose veins develop, although there is a strong genetic component as they tend to run in families.
Other risk factors include older age, being inactive, previous leg injury, pregnancy, smoking, oral contraceptive pill, hormone replacement therapy and being overweight.
Occupations that involve prolonged periods of standing and sitting have been associated with disease but have not been proven to be causative. They can however exacerbate the symptoms once the condition has developed making people like likely to consult surgeons for help.
Why do I get symptoms?
Blood passes into the leg in the arteries under pressure. It then permeates through the tissues of the leg to deliver oxygen and nutrients. This reduces its pressure and then it is then collected by the veins to pass back to the heart under low pressure. Transport occurs in the veins through muscle contraction in the leg and breathing in the chest to push and suck the blood up the leg respectively. To keep the blood moving in the right direction the veins contain one-way valves. It is failure of these valves that leads to varicose veins (VV). This means that blood can be sat in the veins when normally it should be moving back to the heart. With the veins engorged with blood they become prominent, dilated and elongated giving the symptoms people experience.
Can they lead to other problems?
There are strong associations between VV and DVT in a general practice population. Special medical attention is paid to patients with VV and a history of previous venous thromboembolism, comorbid malignancy, recent hospital discharge, or a combination of these factors are considered for surgical procedures. This increased risk can be partially reduced with appropriate blood thinning medication but must not be taken lightly when planning surgery.
In patients who have had VV for a long time there is an increased risk of developing thrombophlebitis. This is a condition where the veins become inflamed and tender. Although this condition is rarely serious it can be extremely unpleasant, unsightly and painful for the patient. The condition is mostly self-limiting, but the incidence of recurrence can be reduced by treating VV.
Another long-term consequence of VV is the development of chronic venous insufficiency. This is a spectrum of skin disease caused by the failure of the veins to effectively clear the blood from the legs. Initially this manifests itself as eczema (dry skin) but if left untreated it can develop into brown skin staining (Haemosiderin), skin thickening (Lipodermatosclerosis) and eventually ulceration. Even small cuts or bruises can also ulcerate and fail to heal normally if the skin is damaged by the presence of VV. (See figure 3)
How will treatment affect my leg?
The leg is designed with two systems of veins for drainage of blood back towards the heart.
1. The deep system runs with the arteries and the bones of the leg and cannot be seen. (This system is where DVT develop)
2. The superficial system runs in the skin and is visible as VV when the valve fail.
The superficial system drains into the deep system at multiple places throughout the leg, returning blood to the heart. In VV a valve controlling this drainage has failed so blood that should be draining into the deep system is sitting in the skin. By treating the VV we are removing the leaking valve and restoring the direction of flow of blood from the superficial into the deep system. This means that blood is not sitting in the leg where it shouldn’t be and hopefully relieves your symptoms and reduces swelling whilst improving the appearance of the leg.
What to expect when you attend for your consultation
On your first consultation, your consultant will greet you and introduce themselves. They will enquire as to your symptoms and how they affect your life. They will go on to ask you questions related to your medical history to look for any potential problems in your care and will enquire as to your regular medications. They may well ask questions related to your occupation and any planned holidays if surgery is going to be performed.
Your consultant will now examine you in and assess your legs with visual inspection and palpation.
You will then undergo an ultrasound venous duplex scan (USS) of the VV to assess the site where the VV originate and this will allow your surgeon to plan your surgery.
The consultant will explain his or her findings to you in clear language that you can understand and make his recommendations of further imaging (if deemed necessary) or for intervention as appropriate. The pattern of disease is variable and there is often more than one good option for treatment.
The consultant will explain to you the benefit and risk of the interventions he/she has recommended which will allow you to make an informed decision as to your care.
Your consultant will be hoping to improve the symptoms in your legs. As described previously these are numerous and are the main-focus of the consultation.
Your consultant will also be looking to improve the cosmetic appearance of your leg and ward off any further problems that they may cause.
If you are suffering with ulcers the surgeon will be looking to improve healing and reduce the future risk of ulceration.
As with all operations/procedures there are unfortunately risks involved.
Risks which are common to all varicose veins operations are bleeding from incisions, bruising and phlebitis (inflammation of the vein), infection, deep vein thrombosis, pulmonary embolus and occasionally people do react to dressings and develop skin burns from them.
Further intervention specific risks will be described by your consultant when he discusses your options for surgery.
A full clinic letter will be sent to yourself and your general practitioner explaining the consultation and the treatment plan that has been agreed between yourself and your consultant.
Holidays and Flying
It is not recommended that you fly for six weeks following your surgery. There is a definite increased risk of DVT with even a short haul flight. Holidaying without flying is acceptable but avoid long journeys wherever possible. If essential then regular movement breaks are recommended.
Fig 1: Valve failure in varicose veins
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Fig. 3: Chronic venous leg ulcer (click image to enlarge)
Figure 2: Symptoms of Varicose veins
Fig. 4: Before and after varicose vein treatment
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