We have all seen them, we all hope we don’t get them, but unfortunately varicose leg veins are a common problem which affects a high proportion of people. Varicose veins are more common in women than in men and related factors include pregnancy, obesity, menopause, prolonged standing, leg injury and abdominal straining (constipation, prostate enlargement or excessive lifting !). There also seems to be an inherited component to the development of varicose veins, which results in some young people developing the condition, however the prevalence increases with age.
So what exactly are varicose veins? Put simply, they are swollen, enlarged and tortuous veins resulting from incompetent (damaged) leaflet valves within the vein. As blood is pumped around the body, it flows from the heart via arteries through the organs and limbs and returns to the heart via the veins. In medical circles, the term varicose can be applied to veins in many areas of the body including the abdomen and gullet, but generally people recognise the term as referring to large swollen veins in the legs and thighs.
In the legs, the latter part of the circulatory cycle is facilitated by walking and movement. When your calf muscles contracts they squeeze deep veins within them forcing blood along the veins. Essentially your own legs pump blood up the veins and back to the heart. This is why airlines encourage you to move your legs whist you are sitting on an aeroplane flight, simply to move the blood around your legs and prevent the blood clotting and forming a deep vein thrombosis or DVT.
To stop backflow of blood when the muscle relaxes, veins are equipped with a series of one way leaflet valves which keep the blood moving in a forward direction. As we spend most of our time in the upright position, the valves in the leg veins may have to hold back a column of blood up to 1.5 meters high (the distance between the ankle and the heart). If we didn’t have them, blood would pool in our ankles and we would have to stand on our heads to get blood back to the heart! If for any reason the veins stretch and the leaflet valves fail to close properly, blood flow reverses when the muscles relax and the superficial veins under the skin overfill and bulge.
Once the veins are weakened, blood refluxes backwards further stretching the vein and thus a vicious cycle ensues and the pressure within them rises. Fluid escapes from the veins into the tissues making them ache and feel heavy and lumpy veins can be felt just under the skin. Besides cosmetic problems, varicose veins can cause a great deal of stress and are often painful, especially when standing or walking. Whilst serious complications are rare, if untreated serious conditions such as phlebitis, bleeding can occur. At the ankle where the intravenous pressure is at its highest, blood cells and proteins can leak into the skin. Iron is released from the breakdown of red blood cells which discolours the skin and causes varicose eczema. This often itches, and trauma or scratching the area can cause ulcers (which in rare cases may become malignant). Fortunately, if treated early and properly the leg can be restored to normal.
Although varicose veins may seem to only affect one leg, detailed investigation often shows early problems in the other leg. Many doctors will simply assess leg veins in the outpatient clinic by sight and a few tourniquets, but these days this is considered an incomplete test and the leading centres in the UK and USA advocate the use of Doppler ultrasound to assess all symptomatic veins. An inaccurate diagnosis may result in inappropriate surgery and some studies have shown that varicose veins can come back in up to 60% of such cases. At the Specialist Medical Clinic the latest ultrasound diagnostic equipment enables our specialist team to accurately identify the cause of your varicose veins and their stage of development. Ultrasound is painless and identifies the vein and areas where valves have failed. Visual examination on its own cannot achieve this. Ultrasound technology identifies back flow in a vein through a damaged valve and in complicated cases or when previous surgery has been performed Colour Duplex Imaging (CDI) is undertaken.
Not all varicose veins require surgical treatment. For instance, people with only minor varicose veins which are causing no symptoms, the best option is to do nothing. If symptoms are limited to aching after standing for long periods, this can be relieved by wearing below knee graduated pressure support stockings during the day. These come in a variety of colours and are indistinguishable from ordinary hose. Unfortunately they don’t work if they are left in the stocking drawer!!
Spider veins are probably best treated with injection sclerotherapy a treatment which has been used to treat the condition for over 150 years. This gives good cosmetic results and may be all that is necessary to help reduce achy legs. Small unsightly veins arising from isolated sources of incompetence can also be injected or removed under local anaesthetic in the clinic.
The major problems only arise if and when the varicose veins are due to incompetence of the major valves in the main superficial long or short saphenous veins. In these cases the underlying cause must be dealt with to avoid recurrence. Because most of the blood in the legs is returned by the deep veins, the superficial veins, which return only about 10 per cent of the total blood of the legs, can usually be removed or ablated without serious harm.
Traditionally surgeons have operated to strip out the damaged veins, a painful procedure which involves having a general anaesthetic, cuts in the groins and legs, at least one night in hospital and bandages for a number of weeks!! Anyone who has had the procedure will tell you that it is painful and that they didn’t get back to work for at least a week. For this reason surgeons have looked for less painful alternatives. About 7 years ago, foam sclerotherapy became popular. In this procedure a special foam mixture of sclerosant and air is injected under ultrasound guidance into the veins to cause inflammation and stick the walls of the vein together. Some surgeons still use this, but side effects are slowly relegating this to a support therapy to more modern occlusive techniques. In 1996 a report indicated the technique was successful in 76% of cases at 24 months.
These days however, the gold standard for treatment of the major superficial varicose veins is moving towards local anaesthetic percutaneous endovenous occlusion. These treatments are effective in up to 95% of patients at 5 years (against approximately 70 - 80% in surgically treated patients). Percutaneous endovenous occlusion is a walk in, walk out 45 minute procedure performed under local anaesthetic in the outpatient clinic. More nervous patients may wish for sedation, but generally this is not necessary. Following the procedure, patients walk out of the clinic and return to their normal activities often the same day. In the USA and UK, patients even book in to have their veins treated during their lunch hour and whilst learning the technique at the Cadogan Clinic in London, we treated one Consultant Surgeon, who after having the treatment returned to work in the afternoon, and did an NHS and Private operating list the following day!
The technique involves the introduction of a thin fibre under ultrasound guidance into the vein through a small hollow needle. Once placed in the correct position, the fibre is heated and withdrawn slowly. The heat from the fibre occludes the vein thus preventing backflow of blood and reducing the pressure and swelling in the veins. As there are no surgical cuts, and the vein is not stripped out, there is much less pain than the “old fashioned” surgical treatment.
The catheter is heated using either laser (light) or radio-frequency energy. The first technique to be widely used was Endovenous Laser Therapy (EVLT) in which laser energy is used to heat the vein up to over 800ºC. This boils the blood in the vein causing occlusion. The very high temperatures can lead to burn holes in the vein wall and some bruising and pain albeit much less than with surgery. Laser safety is a major issue and great care must be taken that patients and medical staff do not get eye injuries from the laser.
Over the last 18 months or so, a newer Radiofrequency ablation technique (VNUS Closure®) has gained in popularity and is rapidly becoming arguably the preferred endovenous occlusion technique in the UK and USA. As it works at much lower temperatures than EVLT, (120º), there is less risk of making holes in the vein which in turn results in less bruising and pain. As laser light is avoided, the technique poses no danger to patients and staff.
Varicosity recurrence with both techniques is about 5% at 5 years which compares well with conventional stripping, which in the best hands has a recurrence rate of 10 to 30%.Doctors must use ultrasound during the procedure to see what they are doing. Some practitioners also perform phlebectomy or ultrasound guided sclerotherapy at the time of endovenous treatment however recent evidence suggests that once the main veins have been treated less than 30% of patients actually require follow-up treatment.
EVLT and VNUS require specialized training and expensive equipment, however the surgical team at the Specialist Medical Clinic have been trained by the UK’s leading pioneer in this technique and have now started treating patients in both Gibraltar and Puerto Banus.