What are varicose veins?
Varicose veins are abnormally swollen and tortuous veins, often visible just beneath the skin. They can vary in size from quite small (2-3mm across) to very large (2-3cms across). Very small veins are called "thread veins" or "spider veins". These veins are different to varicose veins because they are situated much closer or within the overlying skin. Although they may be unsightly, they are not the same as varicose veins and can be more difficult to treat. Reticular veins are obvious varicose veins which are present beneath the skin and easily visible, but rather smaller than the larger knobbly veins. Reticular veins may only bulge the skin slightly if at all, whereas varicose veins tend to produce marked bulging of the skin.
What causes varicose veins?
Veins are blood vessels that normally return blood from the leg upwards, back to the heart. Blood flow in the veins should also always travel from the superficial veins to the deeper veins in the legs. Blood will not normally travel downwards in the reverse direction or outwards from deep to superficial veins as there are one-way valves inside the veins that prevent this occurring (see opposite). In some people these valves can fail, and blood is permitted to travel not only towards the heart, but can also travel backwards (reflux) down the leg, especially on standing. Veins that reflux are said to be incompetent or to have incompetent valves.
Because the valves in some veins are not working normally a higher pressure in the veins develops and they gradually become swollen and varicose, although this can take many years. The clinical effects of varicose veins seem to be caused by prolonged high pressures in the veins and without abnormally high pressures symptoms or complications of varicose veins do not develop.
Varicose veins tend to occur with increasing age, in those with a a family history of varicose veins and in association with prolonged standing or following pregnancy, and in some cases following a prior deep vein extra workload. To remove varicose veins in these circumstances would be potentially very dangerous as it would remove an important pathway for blood to drain from the leg back to the heart
Should I have my Varicose Veins Treated?
Varicose veins often cause no symptoms but may be cosmetically unattractive. In some cases, varicose veins cause heaviness aching in the legs, sometimes also with symtoms of cramps and itching. During pregnancy many women notice that their varicose veins become more prominent and more symptomatic. In many patients these problems will settle after the birth of the baby. Unfortunately, symptoms from varicose veins are rather non-specific and it is difficult to correlate the severity of symptoms with the severity of the venous disease, but venous disease has been shown to have significant effects on quality of life. In some cases where the varicose veins are large or long-standing, ulcers can form on the lower leg (venous ulcers), affecting both quality of life. Often these ulcers can be healed with simple dressings and stockings, without the need for surgery or other interventions.
Other problems that can be caused by varicose veins are:
Superficial thrombophlebitis - this is due to blood clots forming in the varicose vein.The superficial varicose veins become red, hot, tender and painful and blood clots form in the superficial veins. This can take many weeks to resolve. Sometimes when a severe phlebitis has resolved the varicose veins may disappear.
Chronic venous insufficiency - the development of brown discolouration of the skin at the ankle (pigmentation), varicose eczema and thickening in the tissues around varicose veins are signs that more extensive tissue damage is occurring.
Varicose ulceration - if the tissue damage becomes bad enough, ulcers can develop in the skin just above the ankle. Many patients are concerned when they hear the term ulceration, but it only means that there has been a loss of skin and that the tissues beneath the skin are exposed.
Bleeding - bleeding from varicose veins is relatively uncommon especially from the large bulbous type varicose veins. If bleeding does occur it tends to be from smaller very superficial venous blebs in the skin.
What should I do about my varicose veins?
If your varicose veins are causing you concern for any reason, then you should seek a medical opinion. If you wish to have treatment for your varicose veins, develop severe symptoms or more serious complications of varicose veins then it is essential you have a consultation with a vascular specialist.
If you are on your feet for long periods of time the best thing to do is to keep moving, as walking tends to lower the pressure in the veins. Compression stockings can be very helpful in lessening symptoms and an improvement in symptoms when wearing stockings can be an indication that treatment for the veins will be helpful.
What happens when you see a vascular surgeon?
When you consult a vascular surgeon a detailed history will be taken with regard to your varicose veins and the nature of your symptoms. An examination of the leg is performed to look at the distribution of the varicose veins and for signs of tissue damage secondary to the varicose veins. Your general health will also be assessed.
It is also important to undergo a detailed ultrasound mapping scan in order that your surgeon can plan the most effective treatment for you. This is particularly important if you have had previous surgery, a history of thrombosis in the veins, valve abnormalities behind the knee or leg ulceration. The scan is called a Colour Flow Duplex scan
Is treatment for my varicose veins essential?
If you have developed complications of varicose veins then it is advisable to proceed with treatment. This will halt the process that has caused the complications and will give the best chance of reversing any changes that may have taken place in the skin or tissues of the leg.
In patients with simple varicose veins that have not caused serious complications, treatment can be considered optional. Most patients decide to proceed with treatment if the varicose veins are causing symptoms or the appearance is unsightly. The choice is yours in consultation with your surgeon after you have weighed up the problems the varicose veins are causing against the treatment recommended.
Can I live without my varicose veins?
Yes. For the vast majority of patients this will not be a concern. The veins that are being removed are not functioning normally in any case. There are some rare situations when varicose veins are present and the deep veins in the leg are blocked. This may make it unsafe to have superficial varicose veins removed. Your surgeon will have checked for this preoperatively. Some patients are concerned that they may need their veins for possible heart or leg bypass surgery later in life. Sometimes varicose veins are unsuitable for use in these situations.
What treatment is available for varicose veins?
To a large extent the treatment will depend on the sites of the major valve problems in the varicose veins, the distribution and tortuosity of the veins and the severity of the varicose veins.
Surgery - this is still a common form of treatment for varicose veins and is a an effective way of removing veins.
RFA (RadioFrequency Ablation) - this is a newer method of treating the source of the varicose veins. It is a replacement for the stripping part of the operation but may need supplementary treatment either with injections or minor avulsions to the visible veins.
EVLT (Endovenous Laser Therapy) - this is a similar to RFA. It is also a replacement for the stripping part of the operation, but also may not deal with all of the visible varicose veins.
Injection sclerotherapy - this is used in all types of varicose veins and a microinjection technique may be used for thread veins. It may not be as effective as other techniques for larger varicose veins.
Compression stockings - these may be all that is required if aching and swelling are the main problems. It is essential that the correct grade of stocking is used after proper fitting. Many patients find these very effective for symptoms although they may be inconvenient particularly in warm weather.
Will treatment remove all of my varicose veins?
Probably not. No treatment can erase every visible varicose vein, but most patients are satisfied with the vast improvement that can be gained by undergoing treatment. Your surgeon should indicate to you before treatment, where you will gain the most benefit and which varicose veins may be difficult to treat. It is more difficult to improve the appearance of spider veins.
Will my varicose veins come back after treatment?
There is no treatment available that does not have a risk of recurrent varicose veins. New varicose veins can sometimes appear even after satisfactory treatment. It is possible to remove existing varicose veins, but it is not possible to remove the tendency to develop varicose veins, whatever the treatment. Sometimes in patients who have had injection treatment the varicose veins that have been injected can reopen as they have not been physically removed.
Reflux (abnormal flow) in deep veins may be a cause of recurrent veins
Varicose veins and pregnancy
Many women find that during pregnancy, they can either develop varicose veins or pre-existing varicose veins can become larger or cause problems. There is no doubt that pregnancy does affect the veins in the legs, but pregnancy does not cause varicose veins, unless there is already an underlying tendency to develop them. Useful links
http://www.nlm.nih.gov/medlineplus/varicoseveins.html - A service from the US National Library of Medicine and the National Institutes of Health in the USA with a series of links to sites with good information on various aspects of diagnosis and treatment of venous disease.