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Varicose Veins - Complications & Treatments

Complications of Varicose Veins
How do varicose veins present
1.
Cosmetic problems - they look bad but don't feel bad.
2.
Localized discomfort - in the leg, especially after standing. Usually at the site of a visible varicose vein.
3.
Generalized discomfort - aching and discomfort particularly at the end of the day.
4.
Night cramps.
5.
Acute bleeding - this can be alarming and even life threatening. It is treated by putting the leg in the air and applying pressure.
6.
Thrombophlebitis - an inflammatory condition in which a portion of a varicose vein becomes red and painful.
7.
Damage to major arteries or veins. This should not occur when the procedure is done by an experienced vascular surgeon.
8.
Discoloration. The varicose veins contain blood, which is made up in part of iron. The iron pigment can lead to a temporary brownish discoloration of the skin. This will usually fade over time but can take weeks to months in severe cases. Most patients state that they are much happier with the color than they were with the veins appearance and over time the discoloration is much better.
9.
Development of the thread veins can occur after venous surgery. These can be easily treated with sclerotherapy if needed.
10.
Deep vein thrombosis. This is rare in healthy patients having uncomplicated varicose vein surgery.
If varicose veins are due to damage to the deep veins, then they may cause itching, brown discoloration round the ankle, swelling of the leg and large ulcers. The latter may last for years and be very resistant to treatment.
Venous Ulcers, Venous Eczema, Venous Skin Changes: When the venous system in the leg fails to work normally the pressure in the leg veins rises. This reduces the circulation in the lower leg particularly around the ankle leading to swelling, discomfort, skin changes and eventually ulceration. Varicose veins are the commonest cause for this.

Eczema & Skin Changes: A form of eczema can occur in the calf, sometimes over an area of varicosity. The skin is red and itchy. Areas of the calf and around the ankle may develop a brown stain in the skin. The ankle area may be prone to swelling towards the end of the day. Sometimes the entire lower leg feels tight and hard, and may look red and inflamed. This may be acute lipodermatosclerosis (LDS) due to the high venous pressure or an infection (cellulitis).

Ulcers: There are many theories to explain why the raised pressure in abnormal leg veins leads to skin problems. The skin becomes vulnerable, and is poor at healing. A small injury, bite, or minor infection, which would normally heal, instead progresses, and an area of skin breakdown results. This is called an ulcer. In the presence of venous disease, the term Venous Ulcer is used.

Treatments
Non operative treatment: Patients with varicose veins usually request treatment for two reasons:
a) cosmetic or
b) because the varicose veins are causing problems.
1.
Compression stockings: These can relieve symptoms, hide veins and slow down deterioration of skin changes. They need to be worn every day - summer and winter. Many people find this irksome. Stockings need to be replaced every six months since they wear out. They need to be graduated - with the highest pressure at the ankle, dropping to 75% at the calf and 50% at the thigh. Most people only need the below knee stockings which are easier to wear than full length ones.

Indications:
a)
Varicose veins developing during pregnancy.
b)
Patients who have varicose veins but don't want or are unfit for surgery.
c)
Patients with secondary varicose veins.
2.
Sclerotherapy: This procedure involves injecting a sclerosant solution into varicose veins. This irritates the inside of the vein wall which is then compressed with a bandage which cause the wall to stick together and obliterate the lumen ( that part through which the blood flows) of the vein. Sclerotherapy is easily done in the consulting room without anesthetic. Bandages remain on for 10 days to 2 weeks and patients are encouraged to walk for about an hour a day until next seen at the clinic. Sclerotherapy is usually around Rs5000/- per session, per leg.

Sclerotherapy has fallen out of favour for treatment of larger veins because of almost 100% recurrence at 4-5 years after the procedure.
Most vascular surgeons feel that patients with incompetence of the long and short saphenous veins and their major branches should have surgery instead of sclerotherapy since the recurrence rate is less.

Indications:
a)
The sclerotherapy works well for patients with isolated varicose veins and thread veins. It is less satisfactory for short veins above the knee than below the knee, since they are more difficult to compress.
b)
Complications of sclerotherapy include - discoloration/skin pigmentation in the injected site ( this usually fades ) and mild pain in the injected vein (usually requiring paracetamol for a week or two). Most people can go back to work the next day.
3.
Surgery: Most varicose vein surgery can be done as day surgery or short stay surgery. It can be done under general, regional or local anesthetic. I prefer the former two methods.

Following surgery I prefer to keep a compression bandage on for 48 hours. This can be replaced by a stocking until the first clinic visit one week later, and then dispensed with. Following surgery patients can walk, carry on with their social activities, go shopping etc. Driving can be undertaken once there is no groin tenderness. Surgery is associated with very little pain or tenderness. Most patients can commence work 4-5 days after surgery or less.

For patients with long saphenous vein incompetence the standard procedure involves a small groin incision. The long saphenous vein is tied off and divided from the femoral vein (together with surrounding branches ). It may then be stripped down to just below the knee (under the skin) or not. The varicose branches (which are premarked before surgery) are avulsed through a series of stab incisions about 2-5mm in length. The lesser saphenous vein is similarly dealt with except that the incision is behind the knee where this vein drains into the popliteal vein.
4.
EVLT : Laser Treatment for Varicose Veins: A new technique - endovenous laser ablation is now available. This involves passing a laser catheter up the long saphenous vein. The laser catheter is then activated and slowly withdrawn down the vein. This heats up the inside of the vein wall causing it to stick together thus obliterating the inside of the vein. This procedure avoids a groin incision. Stab incisions are however still necessary. Patients can be back at work after 36 hours.

This procedure is similar to the radio frequency ablation procedure which was done in the 1990s, in that heat is used to close the veins. No long term follow ups for this procedure are available but as for the RFA procedure which had a fairly high recurrence rate, my personal opinion is that we can expect the same from this as well. In our experience, we do not recommend this procedure to a patient who is fit for surgery as we have seen patients recur within a few months(3-6) of having done the procedure. So apart from the high costs involved the recurrence rate is also higher. As is a natural phenomenon, the body tries to clear any injury or blocks within itself and laser & RFA are basically damaging the vein, and the body tries to heal the damage. The other drawback of this procedure is that it does not treat the perforator veins which most people just treat with sclerotherapy - after having done laser treatment to the main vein in the thigh -which as you already know has a 100% recurrence rate at 4-5 years.

In my opinion the best and long lasting results for varicose vein treatment are by surgery which has to be carried out after a thorough color Doppler examination & any other required investigations, of the venous system of the leg.

Thread veins. These can occur on their own or in association with long or short saphenous vein incompetence. In the latter case the main superficial vein incompetence should be dealt with surgically. Then the thread veins can be injected. This may involve several treatments. Thread veins can also be treated with laser therapy but this may also involve many treatments and may also leave areas of skin pigmentation.