Guide to Varicose Veins

What are Varicose Veins?

Varicose veins are veins that are swollen, twisted, look blue and are close to the surface of the skin. They are unsightly and uncomfortable. Veins bulge, throb and feel heavy. The legs and feet can swell. The skin can itch. Varicose veins may occur in almost any part of your body. They are most often seen in the back of the calf or on the inside of the leg between the groin and the ankle. Hemorrhoids, veins around the anus, can also become varicose.

Veins can become enlarged with pools of blood when they fail to circulate the blood properly. These visible and bulging veins, called varicose veins, are often associated with symptoms such as tired, heavy, or aching limbs. In severe cases, varicose veins can rupture, or open sores (called "ulcers") can form on the skin. Varicose veins are most common in the legs and thighs.

What are spider veins?

Small "spider veins" also can appear on the skin's surface. These may look like short, fine lines, "starburst" clusters, or a web-like maze. Spider veins are most common in the thighs, ankles, and feet. They may also appear on the face.

Dr, Patrick C. Alguire and Dr. Barbara M. Mathes conducted a MEDLINE search to review the current state of knowledge and treatment of chronic venous insufficiency and ulceration. Here are some of their findings:
Venous valves control the flow of blood from the superficial veins to the deep veins in a distal to proximal direction. Incompetent valves allow backflow of blood when the muscles of the leg relax, contributing to venous pressures that are higher than normal. This venous hypertension is a major factor in chronic venous insufficiency. A patient with chronic venous insufficiency will typically present with varicose veins, tan or reddish brown changes in skin color and weeping, excoriated skin. These symptoms can progress to lipodermatosclerosis, the development of induration at the medial ankle or even to the mid-leg area. Ultimately, a brawny edema above and below the area of fibrosis can be seen. Ulcerations may develop in the fibrotic areas.
Venous stasis ulcers are more common in older women. These ulcers are chronic and frequently recurrent. Postphlebitic syndrome is the combination of chronic leg edema with deep venous thrombosis, pigmentation and ulceration.

Diagnosis is achieved by duplex ultrasonography (both B-mode and directional pulsed Doppler). Descending venography does not correlate as well as duplex scanning with the amount of venous reflux. Since the treatment for venous ulcers is not appropriate in cases of arterial insufficiency, the latter must be ruled out. One way of screening for arterial insufficiency is with the ratio of ankle blood pressure to brachial blood pressure (ankle/brachial index), which is also measured with Doppler ultrasonography. A normal score is greater than or equal to 0.9, claudication is indicated by a score of 0.5 to 0.9, and patients with resting ischemic pain usually score less than 0.5.

What Causes 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. Weakened valves in the legs allow blood to pool in the veins, twisting and stretching them. They usually develop in the calves and inner thighs and can cause aching, fatigue, itchiness, nocturnal cramps, swelling, and tenderness. Varicose veins are caused by genetics and gravity. Nothing can be done about one's hereditary predispositions, but it is possible to stave off the effects of gravity. Varicose veins occur when the veins are enlarged and no longer able to properly push blood from the lower leg to the upper leg. Too much blood often causes the valves in the veins to break, reducing circulation from the lower to the upper leg. The vein walls become too thin and lose their elasticity. 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.

Who is Likely to Have Varicose Veins?

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.

Less commonly, varicose veins are caused by such diseases as phlebitis or congenital abnormalities of the veins. Venous disease is generally progressive and cannot be prevented entirely. However, in some cases, wearing support hosiery and maintaining normal weight and regular exercise may be beneficial.

Varicose and spider veins can occur in men or women of any age but most frequently affect women of childbearing years and older. Family history of the problem and aging increase one's tendency to develop varicose and spider veins.

Although men and women are equally susceptible, pregnancy is a major catalyst. Fluid retention and the baby's weight compress blood flow, boosting pressure in the veins and impeding circulation. The veins most likely to become varicose are the superficial ones directly under the skin.

Other Causes and Risk Factors:

Prevention & Treatment

Certain measures can help ease the discomfort, or even prevent varicose veins in the first place. The Department of Health & Human Services Office of Women’s Health and other health organizations offer the following steps you can take:

Typically, the first line of therapy for varicose veins is compression therapy. The patient wears support stockings, which prevent veins from over-filling with blood and prevent broken veins. The support stockings reduce the pooling or backward flow of blood. Put on stockings as early in the morning as possible. Elevate your legs for a few minutes to empty veins of blood before putting stockings on. Companies like Ames Walker carry compression stockings and socks in in various compression levels.

The study we mentioned above discusses treatment options as well:
Treatment of chronic venous insufficiency consists of elevating the legs above heart level for at least 30 minutes three or four times daily, using compression stockings and using wet or dry nonadherent dressings or bandages. Compression stockings should apply a gradually decreasing amount of pressure from the ankle to the knee and should be applied on awakening. Some stockings have zippered backs or Velcro closures, making them easier to apply. For obese patients or those with a great deal of edema, intermittent pneumatic compression pumps may be used, although the pumps should not be used in patients with uncompensated congestive heart failure. Studies of various dressings have shown no significant difference in the rate of healing of venous ulcers, although patients seem to prefer the occlusive-type dressings because of their convenience.

The authors conclude that severe edema occasionally may require treatment with short-term diuretics. Topical antibiotics have not been shown to improve healing of the ulcer, although systemic antibiotics may be required for clearly infected ulcers or for cellulitis. Topical antiseptics, such as povidone-iodine, should be avoided because of cellular toxicity. The effectiveness of enzymatic debriding agents has not been proved. Some studies advocate the use of silver sulfadiazine, but other studies have shown no improvement in healing of the venous ulcers. Surgery has a very limited role in the treatment of chronic venous insufficiency.

A Review of Sclerotherapy and Surgical Options

Sclerotherapy

Varicose veins are frequently treated by eliminating the "bad" veins. This forces the blood to flow through the remaining healthy veins. Various methods can be used to eliminate the problem veins, including, most commonly, surgery or sclerotherapy.

"Sclerotherapy" uses a fine needle to inject a solution directly into the vein. After the solution is injected, the vein's surrounding tissue is generally wrapped in compression bandages for several days, causing the vein walls to stick together. This solution irritates the lining of the vein, causing it to swell and the blood to clot. The liquid contains an irritant that causes inflammation and fibrosing of the vein -- closing off the affected area of the vein. The vein turns into scar tissue that fades from view. This forces the rerouting of blood through more healthy veins.

Patients whose legs have been treated are put on walking regimens, which forces the blood to flow into other veins and prevents blood clots. This method and variations of it have been used since the 1920's. In most cases, more than one treatment session will be required.

Some doctors treat both varicose and spider veins with sclerotherapy. Today, the substances most commonly used in the United States are hypertonic saline or Sotradecol (sodium tetradecyl sulfate).

According to the Mayo Clinic, Sclerotherapy is often the treatment of choice for smaller varicose veins. However, most people require further injections within a few years, and this can discolor the skin for many months or longer.

Surgery

A more invasive treatment for varicose veins is surgery. When defective valves in a vein allow backflow that distorts many smaller branches, surgery is a more effective treatment. When there are flaws in the valves at the top of the saphenous veins, some surgeons prefer simply to tie off these veins. Other surgeons prefer removing (stripping) part or all of the vein, regardless of whether other valves are healthy. Then there is no chance that those valves will eventually go bad.

Stripping

The surgical treatment referred to as “stripping” is usually done under local or partial anesthesia, such as an epidural. In traditional vein stripping, the surgeon makes a long incision in the leg. A special wire is inserted into the incision and down through the vein. Here, the problematic veins are stripped out by passing a flexible device through the vein and removing it through an incision near the groin. The procedure leaves a long empty channel in which blood can accumulate. Smaller tributaries of these veins also are stripped with this device or removed through a series of small incisions. Those veins that connect to the deeper veins are then tied off. This stripping method has been in use since the 1950's.

The surgery causes a lot of trauma to the limb and a lot of post-operative pain and discomfort. Patients generally require a two-day stay in the hospital for recovery.

Ambulatory Phlebectomy

Some doctors are using a less invasive surgical technique for the treatment of varicose veins. The surgery is known as an ambulatory phlebectomy. Several tiny puncture incisions (four or five, about two inches apart) are made along the skin over the affected vein. A special small hook is placed through the incision and under the vein. As the surgeon lifts the hook, the vein is gently pulled out through the incision.

The vein is then clamped and that section of the vessel is removed. The procedure is repeated through each incision until the desired length of vein is removed. Since the procedure is less invasive and less traumatic, the patient only requires a local anesthetic. The surgery can even be done in the doctor's office or in an outpatient hospital setting. The tiny puncture wounds heal very quickly and usually leave no scars. As with traditional surgery, there is still a small risk of nerve injury with the ambulatory phlebectomy.

Commonly Asked Questions About Sclerotherapy and Surgery

Do these procedures hurt?

For all of these procedures, the amount of pain an individual feels will vary, depending on the person's general tolerance for pain, how extensive the treatments are, which parts of the body are treated, whether complications arise, and other factors.

Because surgery is performed under anesthesia, you will not feel pain during the procedure. After the anesthesia wears off, you will likely experience pain near the incisions. For sclerotherapy, the degree of pain will also depend on the size of the needle used and which solution is injected. Most people find hypertonic saline to be the most painful solution and experience a burning and cramping sensation for several minutes when it is injected. Some doctors mix a mild local anesthetic in with the saline solution to minimize the pain.

What types of doctors provide treatments for varicose and spider veins?

Doctors providing surgical treatment include general and vascular surgeons. Sclerotherapy is often performed by dermatologists. Some general, vascular, and plastic surgeons also perform sclerotherapy treatments. You may want to consult more than one doctor before deciding on a method of treatment. Be sure to ask doctors about their experience in performing the procedure you want.

What are the side effects of these treatments?

Carefully question doctors about the safety and side effects for each type of treatment. Thoroughly review any "informed consent" forms your doctor gives you explaining the risks of a procedure.

For surgical removal of veins, the side effects are those for any surgery performed under anesthesia, including nausea, vomiting, and the risk of wound infection. Surgery also results in scarring where small incisions are made and may occasionally cause blood clots.

For sclerotherapy, the side effects can depend on the substance used for the injection. People with allergies may want to be cautious. For example, Sotradecol may cause allergic reactions, occasionally severe. Hypertonic saline solution is unlikely to cause allergic reactions. Either substance may burn the skin (if the needle is not properly inserted) or permanently mark or "stain" the skin. (These brownish marks are caused by the scattering of blood cells throughout the tissue after the vein has been injected and may fade over time). Occasionally, sclerotherapy can lead to blood clots. Laser and electro-cautery treatments can cause scarring and changes in the color of the skin.

How long do results last?

Many factors will affect the rate at which treated veins recur. These include the diagnosis, the method used and its suitability for treating a particular condition, and the skill of the physician. Sometimes the body forms a new vein in place of the one removed by a surgeon. An injected vein that was not completely destroyed by sclerotherapy may reopen, or a new vein may appear in the same location as a previous one.

Many studies have found that varicose veins are more likely to recur following sclerotherapy than following surgery. However, no treatment method has been scientifically established as free from recurrences. For all types of procedures, recurrence rates increase with time. Also, because venous disease is typically progressive, no treatment can prevent the appearance of new varicose or spider veins in the future.

Is one treatment better than another?

The method you select for treating venous disease should be based on your physician's diagnosis, the size of the veins to be treated, your treatment history, your age, your history of allergies, and your ability to tolerate surgery and anesthesia, among other factors. As noted above, small spider veins cannot be surgically removed and can only be treated with sclerotherapy. On the other hand, larger varicose veins may, according to many studies, be more likely to recur if treated with sclerotherapy.

Be wary of claims touting "major breakthroughs," "permanent results," "unique treatments," "brand-new," "painless," or "absolutely safe" methods. Always ask for specific documentation for claims made about particular recurrence rates or fewer health risks or cosmetic side effects.

How expensive is the procedure? 

Sclerotherapy can cost anywhere from a few hundred dollars to several thousand dollars, depending on the number of injections and treatment sessions required and the area of the country where the procedure is performed. Surgery can cost approximately $600 - $2,000 per leg for the surgeon's fee, plus charges for anesthesia and hospitalization. Most vein surgery can be performed on an outpatient basis. Costs can vary depending on how many veins must be removed and the area of the country where the procedure is performed. You may want to check to see if the procedure is covered under your medical insurance. Many policies do not cover costs for elective cosmetic surgery.

Is treatment always necessary?

No. Varicose and spider veins may be primarily a cosmetic problem. Severe cases of varicose veins, especially those involving ulcers, typically require treatment. Check with a doctor if you are uncertain.

An In-Depth Look at Surgical Options

A more detailed description and explanation of the surgical options for varicose veins.

Surgical treatment of varicose veins may be appropriate for a number of reasons including:

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 surgery

Most varicose vein operations will include one or more of the following elements:

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.

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.

The National Institutes of Health has a good overview of other medical procedures to treat varicose veins.

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 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 Surgery

The majority of operations carried out for varicose veins are entirely straightforward and, 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 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 childbearing age, the question of the effect 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 wounds on the leg is usual and can cause the bandage or dressing to stick. 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 lightweight protective stocking is often supplied to be put on after the leg has been dried and is then left in place for another 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:

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.

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