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Patient Information - Varicose Veins
causes of varicose veins
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
discoloration.
"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.
indications for operation
Surgical treatment 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 traumatized superficial vein.
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 anesthetic 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.
types of operation
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.
pre operative
investigation
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.
complications of
operation
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.
Anesthetic complications are unusual
because the length of surgery is usually relatively short. Cardiac and
respiratory complications can occur with any general anesthetic and are
certainly more common in the elderly and in those with pre-existing heart
and chest problems. Abnormal reactions or allergies to anesthetic drugs
are uncommon and largely unpredictable.
Bleeding is one of the more common
complications encountered, since the operation deals directly with blood
vessels. Major hemorrhage 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 estrogen 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 significantly
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.
post operative care
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 "puttering" 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 be
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.
recurrent varicose
veins
Varicose veins can recur even after
entirely satisfactory 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 with calf varicose veins more
difficult if neovascularisation occurs in the groin.
- barrier
methods to make it more difficult for veins to rejoin, including sewing
adjacent tissue over the stump of tied vein and covering the divided end
of the vein with a patch of artificial material such as PTFE.
injection
sclerotherapy
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.
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 !!
SOURCE: Courtesy of Ames
Walker Hosiery
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