Dr Melas Nikolaos Vascular & Endovascular Surgeon MD, MSc, PhD

Vericose veins are veins that have become enlarged and tortuous. The term commonly refers to the veins on the leg, although varicose veins can occur elsewhere. Veins have leaflet valves to prevent blood from flowing backwards (retrograde flow or reflux). Leg muscles pump the veins to return blood to the heart (the calf muscle pump mechanism), against the effects of gravity. When veins become varicose, the leaflets of the valves no longer meet properly, and the valves do not work (valvular incompetence). This allows blood to flow backwards and they enlarge even more. Varicose veins are most common in the superficial veins of the legs, which are subject to high pressure when standing. Besides being a cosmetic problem, varicose veins can be painful, especially when standing. Severe long-standing varicose veins can lead to leg swelling, venous eczema, skin thickening (lipodermatosclerosis) and ulceration. Life-threatening complications are uncommon, but Varicose veins may be confused for deep vein thrombosis, that may be life-threatening. Non-surgical treatments include sclerotherapy, elastic stockings, elevating the legs, and exercise. The traditional surgical treatment has been vein stripping to remove the affected veins. Newer, less invasive treatments which seal the main leaking vein are available. Alternative techniques, such as ultrasound-guided foam sclerotherapy, radiofrequency ablation and endovenous laser treatment, are available as well. 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. Secondary varicose veins are those developing as collateral pathways, typically after stenosis or occlusion of the deep veins, a common sequel of extensive deep venous thrombosis (DVT). Treatment options are usually support stockings, occasionally sclerotherapy, and rarely limited surgery. Varicose veins are distinguished from reticular veins (blue veins) and telangiectasias (spider veins), which also involve valvular insufficiency, by the size and location of the veins. Many patients who suffer with varicose veins seek out the assistance of physicians who specialize in vein care or peripheral vascular disease. These physicians are called vascular surgeons, phlebologists or interventional radiologists.

Signs and symptoms

• Aching, heavy legs (often worse at night and after exercise).
• Appearance of spider veins (telangiectasia) in the affected leg.
• Ankle swelling, especially in evening.
• A brownish-yellow shiny skin discoloration near the affected veins.
• Redness, dryness, and itchiness of areas of skin, termed stasis dermatitis or venous eczema, because of waste products building up in the leg.
• Cramps may develop especially when making a sudden move as standing up.
• Minor injuries to the area may bleed more than normal or take a long time to heal.
• In some people the skin above the ankle may shrink (lipodermatosclerosis) because the fat underneath the skin becomes hard.
• Restless legs syndrome appears to be a common overlapping clinical syndrome in patients with varicose veins and other chronic venous insufficiency.
• Whitened, irregular scar-like patches can appear at the ankles. This is known as atrophie blanche.

Investigations

Traditionally, varicose veins were only investigated using imaging techniques if there was a clinical suspicion of deep venous insufficiency, if they were recurrent, or if they involved the sapheno-popliteal junction. This practice is not now widely accepted. All patients with varicose veins should now be investigated using Duplex doppler ultrasound scanning. The results from a randomised controlled trial (RCT) on the follow up of patients with and without routine Duplex scan has shown a significant difference in recurrence rate and reoperation rate at 2 and 7 years of follow up.

Complications

Most varicose veins are reasonably benign, but severe varicosities can lead to major complications, due to the poor circulation through the affected limb.

• Pain, heaviness, inability to walk or stand for long hours, thus hindering work
• Skin conditions / Dermatitis which could predispose skin loss
• Skin ulcers especially near the ankle, usually referred to as venous ulcers.
• Development of carcinoma or sarcoma in longstanding venous ulcers. There have been over 100 reported cases of malignant transformation and the rate is reported as 0.4% to 1%.
• Severe bleeding from minor trauma, of particular concern in the elderly.
• Blood clotting within affected veins. Termed superficial thrombophlebitis. These are frequently isolated to the superficial veins, but can extend into deep veins becoming a more serious problem.
• Acute fat necrosis can occur, especially at the ankle of overweight patients with varicose veins. Females are more frequently affected than males.
• The afflicted person suffers tenderness in that region

Stages

• C0 no visible or palpable signs of venous disease
• C1 telangectasia or reticular veins
• C2 varicose veins
• C3 edema
• C4a skin changes due to venous disorders: pigmentation, eczema
• C4b skin changes due to venous disorders: lipodermatosclerosis, atrophie blanche
• C5 as C4 but with healed ulcers
• C6 skin changes with active ulcers (venous insufficiency ulceration)

Causes

The illustration shows how a varicose vein forms in a leg. Figure A shows a normal vein with a working valve and normal blood flow. Figure B shows a varicose vein with a deformed valve, abnormal blood flow, and thin, stretched walls. The middle image shows where varicose veins might appear in a leg. Varicose veins are more common in women than in men, and are linked with heredity. Other related factors are pregnancy, obesity, menopause, aging, prolonged standing, leg injury, and abdominal straining. Varicose veins are not caused by crossing the legs or ankles. Less commonly, but not exceptionally, varicose veins can be due to other causes, as post phlebitic obstruction or incontinence, venous and arteriovenous malformations See also for differential diagnosis- 1. Klippel-Trenaunay syndrome, 2. Parkes-Weber syndrome

Treatment

1. Conservative

The symptoms of varicose veins can be controlled to an extent with the following:

• Elevating the legs often provides temporary symptomatic relief.
• Advice about regular exercise sounds sensible but is not supported by any evidence.
•  The wearing of graduated compression stockings with variable pressure gradients (Class II or III) has been shown to correct the swelling, nutritional exchange, and improve the microcirculation in legs affected by varicose veins^. They also often provide relief from the discomfort associated with this disease. Caution should be exercised in their use in patients with concurrent arterial disease.
• The wearing of intermittent pneumatic compression devices have been shown to reduce swelling and increase circulation
• Diosmin/Hesperidine and other flavonoids.
• Anti-inflammatory medication such as ibuprofen or aspirin can be used as part of treatment for superficial thrombophlebitis along with graduated compression hosiery – but there is a risk of intestinal bleeding. In extensive superficial thrombophlebitis, consideration should be given to anti-coagulation, thrombectomy or sclerotherapy of the involved vein.
•  Topical gel application, helps in managing symptoms related to varicose veins such as inflammation, pain, swelling, itching and dryness. Topical application-Non invasive and has patient compliance^.
•  Topical application of Theraputic Grade Essential oils such as lemongrass, cypress, and geranium^.

2. Active

Active medical intervention in varicose veins can be divided into surgical and non-surgical treatments. Some doctors favor traditional open surgery, while others prefer the newer methods. Newer methods for treating varicose veins such as Endovenous Thermal Ablation (endovenous laser treatment or radiofrequency ablation), and foam sclerotherapy are not as well studied, especially in the longer term.

3. Surgical

Several techniques have been performed for over a century, from the more invasive saphenous stripping, to less invasive procedures like ambulatory phlebectomy and CHIVA.

a. Stripping

Stripping consists of removal of all or part the saphenous vein (great/long or lesser/short) main trunk. The complications include deep vein thrombosis (5.3%),pulmonary embolism (0.06%), and wound complications including infection (2.2%). There is evidence for the Great Saphenous Vein growing back again after stripping. For traditional surgery, reported recurrence rates, which have been tracked for 10 years, range from 5-60%. In addition, since stripping removes the saphenous main trunks, they are no longer available for use as venous bypass grafts in the future (coronary or leg artery vital disease)

b. Other surgical treatments are:

• Ambulatory phlebectomy
• Vein ligation
• Cryosurgery- A cryoprobe is passed down the long saphenous vein following saphenofemoral ligation. Then the probe is cooled with NO₂ or CO₂ to a temperature of -85^o. The vein freezes to the probe and can be retrogradely stripped after 5 second of freezing. It is a variant of Stripping. The only point of this technique is to avoid a distal incision to remove the stripper.

4. Non-surgical treatment

Sclerotherapy Management

A commonly performed non-surgical treatment for varicose and “spider” leg veins is sclerotherapy in which medicine (sclerosant) is injected into the veins to make them shrink. The medicines that are commonly used as sclerosants are polidocanol (POL), sodium tetradecyl sulphate (STS), Sclerodex (Canada), Hypertonic Saline, Glycerin and Chromated Glycerin. STS (branded Fibrovein in Australia) and Polidocanol (branded Asclera in the United States, Aethoxysklerol in Australia) liquids can be mixed at varying concentrations of sclerosant and varying sclerosant/gas proportions, with air or CO₂ or O₂ to create foams. Foams may allow more veins to be treated per session with comparable efficacy. Their use in contrast to liquid sclerosant is still somewhat controversial. Sclerotherapy has been used in the treatment of varicose veins for over 150 years. Sclerotherapy is often used for telangiectasias (spider veins) and varicose veins that persist or recur after vein stripping. Sclerotherapy can also be performed using foamed sclerosants under ultrasound guidance to treat larger varicose veins, including the great saphenous and small saphenous veins. A study by Kanter and Thibault in 1996 reported a 76% success rate at 24 months in treating saphenofemoral junction and great saphenous vein incompetence with STS 3% solution. A Cochrane Collaboration review concluded sclerotherapy was better than surgery in the short term (1 year) for its treatment success, complication rate and cost, but surgery was better after 5 years, although the research is weak. A Health Technology Assessment found that sclerotherapy provided less benefit than surgery, but is likely to provide a small benefit in varicose veins without reflux. This Health Technology Assessment monograph includes reviews of the epidemiology, assessment, and treatment of varicose veins, as well as a study on clinical and cost effectiveness of surgery and sclerotherapy. Complications of sclerotherapy are rare but can include blood clots and ulceration. Anaphylactic reactions are “extraordinarily rare but can be life-threatening,” and doctors should have resuscitation equipment ready. There has been one reported case of stroke after ultrasound guided sclerotherapy when an unusually large dose of sclerosant foam was injected.

Endovenous thermal ablation (LASER, RF)

The Australian Medical Services Advisory Committee (MSAC) in 2008 has determined that endovenous laser treatment/ablation (ELA) for varicose veins “appears to be more effective in the short term, and at least as effective overall, as the comparative procedure of junction ligation and vein stripping for the treatment of varicose veins.” It also found in its assessment of available literature, that “occurrence rates of more severe complications such as DVT, nerve injury and paraesthesia, post-operative infections and haematomas, appears to be greater after ligation and stripping than after EVLT”. Complications for ELA include minor skin burns (0.4%) and temporary paraesthesia (2.1%). The longest study of endovenous laser ablation is 39 months.

Two prospective randomized trials found speedier recovery and fewer complications after radiofrequency ablation (ERA) compared to open surgery. Open surgery for small saphenous vein reflux is obsolete. Myers said these veins should be treated with endovenous techniques, citing high recurrence rates after surgical management, and risk of nerve damage up to 15%. In comparison, ERA has been shown to control 80% of cases of small saphenous vein reflux at 4 years, said Myers. Complications for ERA include burns, paraesthesia, clinical phlebitis, and slightly higher rates of deep vein thrombosis (0.57%) and pulmonary embolism (0.17%).One 3-year study compared ERA, with a recurrence rate of 33%, to open surgery, which had a recurrence rate of 23%.

ELA and ERA require specialized training for doctors and expensive equipment. ELA is performed as an outpatient procedure and does not require the use of an operating theatre, nor does the patient need a general anaesthetic. Doctors must use high frequency ultrasound during the procedure to visualize the anatomical relationships between the saphenous structures. Some practitioners also perform phlebectomy or ultrasound guided sclerotherapy at the time of endovenous treatment. Follow-up treatment to smaller branch varicose veins is often needed in the weeks or months after the initial procedure.