Is surgery a reasonable choice for my varicose veins?
Traditionally surgery was the only effective treatment for varicose veins, but the role of surgery in treating veins is definitely being re-evaluated in the the light of the development of new treatments over the last 15-20 years. Surgery still has a place in the modern treatment of varicose veins, but modern vein surgery is definitely not the surgery of even 15 years ago. By borrowing from some aspects of the newer techniques modern surgery has become less traumatic and minimally invasive. It is still often the best option for the largest varicose veins which will be completely removed. It is also effective for smaller varicose veins in favourable patterns. Surgery will not help thread or spider veins which are found within the most superficial layers of the skin itself and cannot be physically removed. Smaller reticular veins are also best treated by sclerotherapy.
In general the more pronounced the varicose veins the greater the benefit from varicose vein surgery. Other common treatments that are available and effective are radiofrequency ablation (RFA), endovenous laser treatment (EVLT) and foam sclerotherapy. The field of vein treatments is becoming more cluttered with steam powered devices, glues and rotating devices that damage veins and simultaneously inject.
Preventing deep venous thrombosis
The risk of developing a significant blood clot after surgery is very low, but bruising is common. Compression stockings and bandages are used around the time of treatment to reduce the risk of thrombosis or DVT. Early mobilisation after surgery and ankle exercises, such as those advised when undertaking long distance travel, are useful additional measures to reduce the risk of thrombosis. Simple flexing of the ankle and pointing the toes while lying in bed forces blood to move in the veins and return to the heart. It is a very effective way to reduce the risk of thrombosis.
Sometimes your surgeon may feel it necessary to prescribe injections of heparin for you around the time of your surgery. This is particularly important if you have had a previous deep venous thrombosis, but is being used increasingly frequently in all types of surgery. Heparin injections thin the blood and reduce the risk of thrombosis.
Before your varicose vein operation
You will be seen by the surgeon who is to perform the operation and the position of the veins will be marked while you are standing. This is important because when you are lying down during the operation, the veins are much less visible.
The anaesthetist will also visit you. Many people are concerned about anaesthetics, so please ask the anaesthetist if you have any specific worries. The nurses on the ward will also have talked with you about the nursing procedures and post operative care. All of these people are ready to answer any questions you may have, so ask if you have any concerns. Contrary to popular belief vein surgery can be performed without a general anaesthetic but it is often the most convenient way to manage the treatment.
The surgery for your varicose veins
The important thing to remember about surgery for varicose veins is that it has evolved over the years and although the principles are similar the surgery is more targetted and less invasive than it has been previously. Modern varicose vein surgery in my practice, with ultrasound planning and ultrasound available in theatre is far removed from procedures performed in the past or even during my training. The operation is usually performed under a general anaesthetic and you are asleep and unaware throughout the procedure, although the procedure can be carried out under local anaesthetic with tumescent anaesthesia or spinal anaesthesia.
The commonest operation (high tie or saphenofemoral ligation) is where a cut is made in the groin over the top of the main varicose vein. The cut is about 2cms long. This is then disconnected where it meets the deeper veins (femoral vein). This operation was first pioneered by a Liverpool surgeon William Thelwall Thomas in the 1890s. A main varicose vein (greater saphenous vein) on the inner aspect of the leg is then removed (stripped). Ultrasound guided tumescent anaesthesia is a technique where fluid (a combination of local anaesthetic and salt solution) is injected at the time of surgery around and along the vein to be stripped. This requires the use of intraoperative ultrasound which can also be used to identify important veins during the operation to facilitate surgery. The technique of tumescent anaesthesia minimises any discomfort but also significantly reduces any bleeding into the stripping track that remains after the vein has been removed. Although a vein that was carrying blood has been removed blood can still flow up the leg back to the heart along deeper, unaffected veins. It is also important to remember that the vein removed was not functioning normally and so blood flow in the leg had already compensated for this problem before your treatment. The cut in the groin is closed with a stitch which is absorbable and does not require removal. Other veins marked before the operation are then pulled out of tiny cuts (avulsions, phlebectomies). These cuts are usually only 2-3 mm long and are closed with adhesive strips and only occasionally with stitches.
A coating of skin glue will be placed on the cut in the groin, and your leg will be bandaged up to the top of the thigh. The bandages put on at the operation will stay on your leg for 24 hours when they are changed to compression stockings. Regimes vary slightly between different surgeons. A single dose of antibiotics may be given during the operation to minimise the already low risk of wound infection (Mekako, 2010).
Other veins may also be affected, especially a vein behind the knee and a similar operation to that in the groin may need to be undertaken at this site (saphenopopliteal ligation). This is an operation where it is especially useful to have ultrasound available in theatre. EVLT/RFA can also be used to treat the small saphenous vein at this location. Ultrasound guide foam scerotherapy does not appear to be as effective in the small saphenous vein.
How successful is varicose vein surgery?
Varicose vein surgery has been shown to be clinically effective as well as cost effective (Michaels et al 2006, Ratcliffe J et al 2006). In a UK study of high tie with or without stripping, 88% of patients were satisfied with the results of their original surgery, even after 11 years (Winterborn et al, 2004). This was despite an overall recurrence rate of 62% at 11 years. A recent study (Sam RC, 2006) has also demonstrated the benefits of superficial venous surgery on quality of life. The benefits in terms of the improvement in the quality of life for patients undergoing venous surgery was as great as that for patients undergoing laparoscopic cholecystectomy (removal of the gall bladder)
We know that performing the stripping operation is beneficial in terms of both the overall appearance, venous function and the subsequent risk of recurrent varicose veins (Sarin S et al. 1994, Bergan JJ 1996). Stripping the greater saphenous vein was shown to decrease the risk of re-operation by 60% (Winterborn RJ et al, 2004), although it did not affect the risk of recurrent varicose veins in this study.
Comparison with other treatments
There are newer techniques available to destroy the greater saphenous vein (GSV) in the thigh, without physically removing the vein by stripping. The alternative techniques in common use are VNUS Closure (also known as Venefit) radiofrequency ablation (RFA) and endovenous laser ablation (EVLA), of which there are many competing products. Both techniques seem to be effective in the short to medium term, although not every pattern of varicose veins is suitable for these treatments. There is now reasonable evidence that radiofrequency ablation, particularly with the newer ClosureFast technology, is a slightly superior procedure especially for perioperative bruising and pain when compared with endovenous laser (Nordon IM, 2011, Shepherd et al 2010) but the durability of these procedures in the longer term is still unclear (Sharif et al 2006, Mundy et al, 2005). Radiofrequency ablation, apart from some clinical advantages, also requires less expensive additional equipment and there is no requirement to comply with laser regulations. The other difficulty peculiar to endovenous laser is that there are many competing products with different laser wavelengths all claiming better clinical results on the basis of inadequate evidence.
Surgery remains the gold standard against which other techniques must be judged and for the first time a randomised trial has compared results in a group of 500 patients from Denmark comparing surgery, EVLT, RFA and foam sclerotherapy. At one year all treatments were effective but the highest technical failure rate was in patients undergoing sclerotherapy (16%) with the lowest in the surgery and RFA groups (both at 4.8%). Interestingly the mean pain scores after intervention were highest in the EVLT group and lowest in the RFA group. The mean time off work for all groups was between 3 and 4 days. It is clear that surgery and RFA are at least comparable treatments, especially when surgeons use tumescent anaesthesia, although discomort and recovery is slightly better with RFA.
Neither EVLT or RFA have been shown more effective than tried and tested surgical technique when it comes to the risk of recurrent varicose veins developing in the long term. It is also important to remember that EVLT and RFA are only a replacement for the high tie and stripping part of conventional surgery. Separate procedures are required to deal with any other remaining varicose veins and this may take the form of foam sclerotherapy or surgical phlebectomy. One particularly awkward situation to treat with EVLT or RFA is the patient who has sizeable veins running across the front and outside of the thigh (antero-lateral thigh veins). If these originate right at the sapheno-femoral junction then EVLT or RFA will not be effective.
The Triflex device sucks veins out of the leg using a custom made instrument. This technique appears to have no particular advantage and has not been shown to be superior to conventional avulsions and still involves making cuts in the leg (Chetter IC et al 2006). Other techniques such as Duplex guided foam sclerotherapy rarely treat the veins at a single session and may require multiple sessions to achieve an equivalent short term result, but the longer term results are not clear. Most techniques, including sclerotherapy, cannot efficiently disconnect the sapheno-femoral junction (high tie) in the same way as surgical ligation. In the study of Winterborn the presence of reflux at the saphenofemoral junction two years after surgery increased the risk of developing clinically recurrent veins. The results of surgery for varicose veins will vary. In general, a detailed pre-operative assessment followed by surgery targetted to the sources of reflux feeding the varicose veins will produce a better result. The assessment and surgery should be performed by a vascular specialist.
Globally, many clinicians are involved in treatment of varicose veins. These include sclerotherapy specialists, dermatologists, appearance medicine practitioners and general surgeons. There is a risk of recurrent varicose veins, whoever is involved in your care and whatever claims they may make. There are two main reasons for this. Firstly the nature of the disease will always put patients at risk. It is a life-long inherited tendency and over years new veins can appear whatever the treatment, no matter how carefully performed. Secondly, some techniques if not applied correctly may lead to increased risk of recurrence. Recurrence rates are difficult to compare because definitions of what constitutes recurrence vary from study to study. For instance if the development of thread veins is considered a recurrence, then the majority of patients will develop recurrent veins. This is because thread veins are so common and present in the majority of people over the age of 50 years. The development of larger veins is less common.
After your varicose vein surgery
Following an anaesthetic for 48 hours you should not:
- drink alcohol
- drive a car
- operate any dangerous machinery
- sign any legal document or make important decisions
- look after children on your own
Keep wounds as dry as possible for the first 48-72hrs. The bandages can be removed at 24 hours and you can change into stockings which will be given to you before you leave hospital. There are no stitches to be removed. You should not get the adhesive strips on your leg wet for the first 7 days. Care will be needed when washing. You should wear the stockings day and night for two weeks, after which you may leave them off at night. If you feel fine and the stockings do not seem to be helping then it is fine to stop wearing them after the first 2 weeks or sooner if they become a real problem. However, if you find they are helpful there is no harm in using them for as long as they continue to help, but just wear them during the day. Shower or bath in the usual way, after removing the stocking.
You will notice that the inside of the thigh can become bruised after the operation where the vein has been stripped. This will gradually resolve over the next three to four weeks.
It is fine to do whatever you feel able to do but in general recovery is assisted if you don’t overdo activities. It is better to be active more frequently but for shorter periods. When sitting during the first week, sit with the feet elevated so that your heels are higher than your hips to aid the drainage of excess fluid from the tissues and assist healing. Three times a day take a short walk (a few hundred yards will do, but more if you wish) to avoid stiffness of the muscles and joints. Generally try to keep moving when on your feet, as this helps to reduce pressure in the veins and minimises the risk of thrombosis occurring. Slight discomfort is normal. Occasionally, more severe local twinges of pain may occur in some patients and may persist for some months. In the first week after the operation you may need to take a mild painkiller such as paracetamol to relieve discomfort.
You should avoid driving for about one week from the operation because, in an emergency, your response time may be prolonged. It is essential that you are able to perform an emergency stop and routine driving manoevres without pain or having to protect the operated leg. If in doubt, delay driving until you are happy and check with your motor insurance company. Swimming and cycling are allowed after the dressings have been removed. It is virtually impossible to damage the surgery that has been performed but listen to your body and take breaks and rest when required.
Possible complications of varicose vein surgery
Sometimes a little blood will ooze from the wounds during the first 12-24 hours. This usually stops on its own. If necessary, lie down, elevate the leg and press on the wound for ten minutes. If bleeding continues after doing this twice, phone your General Practitioner or the ward. Occasionally hard, tender lumps appear near the operation scars or in the line of the removed veins. These can be present even some weeks after the operation and need not be a cause for concern. However, if they are accompanied by excess swelling, redness and much pain, they may represent a wound infection and you should see your General Practitioner. There is a very small risk of developing a deep vein thrombosis. Approximately 1 in 20 people can develop a DVT following varicose vein surgery, but these clots are usually small and confined to the calf veins and unlikely to cause longer term problems (van Rij AM et al, 2004). The best way to prevent DVT is to be active. Walking is the best exercise.
Rarely numbness can develop in a part of the lower leg or foot. This usually occurs due to traction on nerves during the operation. If the skin is not completely numb, then the symptoms usually settle after some weeks or months. The scars on your legs will continue to fade for many months.
You will have been warned that not every visible vein will disappear as a result of your operation and there is a chance that in the future, further varicose veins may develop, as you are clearly disposed to them. The taking of regular exercise, the avoidance of becoming overweight, and the wearing of light support tights or stockings will all help prevent you being troubled by varicose veins in the future. There is no foolproof way of preventing varicose veins.
Returning to normal activity
You can return to work when you feel sufficiently well and comfortable. This will vary from person to person. After an operation on one leg about two weeks rest from work is advised. If you have had surgery to both legs, it will probably be nearer three weeks before you are able to consider returning to work. If you have a job that involves much standing and your varicose veins were particularly severe, you may need longer. Your General Practitioner will advise you about returning to work in the light of your progress after the operation. It is possible to perform desk work and light duties virtually from the beginning.
Slow loading but detailed site with some pictures from an American surgical perspective
Extensive review on surgical treatment and comparison with sclerotherapy.
Commonsense information from the American Bureau of Consumer Protection regarding the actual benefits of treatment for your varicose veins as opposed to some of the claims that are made.
Thelwall-Thomas W. Operative treatment of varicose veins of the lower extremity by ligature and division of the internal saphena vein at the saphenous opening, &c. Liverpool Medico-Chir J 1896; 31:278-290.
Sarin S, Scurr JH, Coleridge-Smith PD. Stripping of the long saphenous vein in the treatment of primary varicose veins. Brit J Surg 1994; 81: 1455-1458.
Bergan JJ. Saphenous vein stripping and quality of outcome. Brit J Surg 1996; 83: 1025-1027.
Michaels JA et al. Randomised clinical trial comparing surgery with conservative treatment for uncomplicated varicose veins. Brit J Surg 2006; 93: 175-181.
Ratcliffe J et al. Cost-effectiveness analysis of surgery versus conservative treatment for uncomplicated varicose veins in a randomised clinical trial. Brit J Surg 2006; 93(2): 182-6.
Winterborn RJ, Foy C, Earnshaw JJ. Causes of varicose vein recurrence: late results of a randomised controlled trial of stripping the long saphenous vein. J Vasc Surg 2004;40: 634-9.
Rasmussen LH, Lawaetz M, Bjoern L, Vennits B, Blemings A, Eklof B. Randomised clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for greater saphenous varicose veins. Brit J Surg 2011; 98: 1079-87.
Sam RC, Darvall KAL, Adam DJ, Silverman SH, Bradbury AW. A comparison of the changes in generic quality of life after superficial venous surgery with those after laparoscopic cholecystectomy. J Vasc Surg 2006; 44: 606-610.
Mekako AI, Chetter IC, Coughlin PA, Hatfield J, McCollum PT. Randomised controlled trial of co-amoxiclav versus no antibiotic prophylaxis in varicose vein surgery. Brit J Surg 2010; 97: 29-36.
Nordon IM, Hinchliffe RJ, Brar et al. A prospective double-blind randomized controlled trial of radiofrequency versus laser treatment of the great saphenous vein in patients with varicose veins. Ann Surg 2011; 254: 876-881.
Shepherd AC, Gohel MS, Brown LC et al. Randomized clinical trial of VNUS® ClosureFASTTM radiofrequency ablation versus laser for varicose veins. Brit J Surg 2010;97: 810-818.
Sharif MA et al. Endovenous laser treatment for long saphenous vein incompetence. Brit J Surg 2006; 93: 831-835.
Mundy L, Merlin TL, Fitridge RA, Hiller JE. Systematic review of endovenous laser treatment for varicose veins. Brit J Surg 2005; 92: 1189-94.
Chetter IC et al. Randomised clinical trial comparing multiple stab incision phlebectomy and transilluminated powered phlebectomy for varicose veins. Brit J Surg 2006; 93: 169-74.
van Rij AM, Chai J, Hill GB, Christie RA. Incidence of deep vein thrombosis after varicose vein surgery. Brit J Surg 2004; 91: 1582-1585.