Varicose Veins

Understanding Varicose Veins

Veins are important part of the circulatory system and veins return blood to the heart. Upper limb, lower limb and body surface veins have valves keep the bloodflow in one direction. These venous valves prevent the backflow of blood.

Varicose veins often occur because of degeneration or damage to the venous valve. High venous pressure and venous blood accumulation further damage the veins. With time, varicose veins will slowly form.

Mild varicose veins cause only slight discomfort or poor cosmesis. However, severe varicose vein scan seriously affect the normal activities of patients, and can lead to limb disability or limb loss.

Varicose Veins causes

Causes of varicose veins are as follows:

• Genetic
• Aging
• Obesity
• Prolonged standing and working jobs, such as nurses, salesmen, waiters, etc.
• Women affected by estrogen, such as pregnancy, puberty, menopause, etc.
• Abdominal tumors impeding lower limbs venous return(Rare)

Mild symptoms include:

• on and off leg heaviness, aching or burning pain, more obvious after prolonged sitting or standing
• slight swelling in the feet and ankles
• on and off itchy skin over varicose vein

Serious symptoms include:

• persistent leg heaviness, aching or burning pain shortly after sitting or standing
• dark brown or purple skin pigmentation / discoloration
• dry thin skin
• persistent itchy skin
• skin inflammation or bacterial infection
• skin ulcers
• bleeding

Most patients complain about several groups of spider veins or tortuous and dilated veins in their lower limb. A small portion of patients will presented as skin discoloration, skin irritation, hardening of skin and subcutaneous, lower limb infection, lower limb wound, or venous ulcer bleeding.

Clinical assessment and grading of varicose vein: The CEAP classification employs a description of the clinical class (C) with objective signs, the etiology (E), the anatomical (A) distribution of reflux and obstruction in the superficial, deep and perforating veins, and the underlying pathophysiology (P), whether due to reflux or obstruction.

CEAP classification of chronic venous disease:

• C0: No visible or palpable signs of venous disease
• C1: Telangiectasia or reticular veins
• C2: Varicose veins
• C3: Edema
• C4a: Pigmentation or eczema
• C4b: Lipodermatosclerosis or athrophie blanche
• C5: Healed venous ulcer
• C6: Active venous ulcer/li>

Spider vein is a form of red or dark red dilated capillaries (telangiectasia) often appearing as a central area with outward radiations resembling the legs of a spider.

Reticular veins are dilated veins larger than spider veins. They are dilated blue net like veins below the skin.

The presence of them signified venous insufficiency and they are early signs of future large varicose vein formation.

Spider veins or reticular veins are similar to large varicose vein but they will not rise about the skin surface significantly. They are more common on the face or the legs of ladies. Female are few times more common to have spider veins or reticular veins than male. Pregnancy or taking oral contraceptive pills may increase the risks of developing spider veins or reticular veins.

Varicose veins are dilated, raised and tortuous diseased veins. They commonly found in medial thigh, medial leg, posterior leg or lateral leg. They are easily visible dark blue, dark red or skin color dilated, raised and tortuous diseased veins.

Lower Limbs Varicose Veins investigation

Before deciding treatment or surgery, experienced surgeon will perform Colour Doppler Ultrasound Scan for the affected lower limb.

Colour Doppler Ultrasound Scan helps to:

• identify the reflux locations
• confirm the deep vein patency
• confirm the site of treatment or surgery
• Colour Doppler Ultrasound Scan

Varicose Veins - Treatments

Varicose vein is a common surgical disease. Majority of the patients are having mild to moderate disease. Early treatment can prevent the disease progression to a severe status or even complications. Treatments can be grouped into non-surgical and surgical treatments.

Non-surgical Treatments:

• mild varicose veins can be improved by lifestyle changes, medication and wearing compression stockings to relieve symptoms
• avoid prolonged sitting or standing
• frequently legs elevation improves venous blood circulation
• wear compression stocking over legs +/- thigh /li>
• avoid compression garment at the trunk
• avoid female hormone treatment/li>
• medications:
• pulsed laser and radiofrequency pen can be used to treat spider vein and reticular veins, and improve cosmesis

• Sclerosant injection varicose vein therapy
  Experienced surgeons inject the sclerosant with tiny needles to the diseased veins with visual or ultrasound scan guidance.Sclerosant (e.g.Fibrovein) injection is suitable to treat varicose veins, spider veins and reticular veins. Experienced surgeons inject the sclerosant to the diseased veins with very tiny needle. The sclerosant seals the diseased vein, stops blood flow, and turn the diseased vein to scar tissue. After sclerosant injection, the diseased veins will fade and shrink in few weeks time. This procedure requires 2 - 3 sessions, approximately 6 to 8 weeks apart. The possible side effects are bruising, hyperpigmentation and venous inflammation.
• Foaming agent injection varicose vein therapy
  Experienced surgeons inject the foaming agent with tiny needles to the diseased veins with visual or ultrasound scan guidance. Foaming agent injection is suitable to treat varicose veins, spider veins and reticular veins. Experienced surgeons inject the sclerosant to the diseased veins with very tiny needle. The sclerosant seals the diseased vein, stops blood flow, and turn the diseased vein to scar tissue. After foaming agent injection, the diseased veins will fade and shrink in few weeks time. This procedure requires 2 - 3 sessions, approximately 6 to 8 weeks apart. The possible side effects are bruising, hyperpigmentation and venous inflammation.
• Traditional open surgery with multiple ligations and stripping for varicose veins
  With multiple 2-5cm skin incisions, surgeons bring out the varicose veins above the skin and perform multiple varicose veins ligations and stripping of the long saphenous vein of the thigh. This surgery is very painful and requires general or spinal anesthesia in the hospital. Patients need to take 1 - 3 weeks of sick leaves and can walk normally afterwards.
• Minimal invasive intravascular mechanical rotary irritation and sclerosant injection(ClariVein®)
  An infusion catheter is introduced percutaneously into the diseased vein under ultrasound guidance by an experienced surgeon. The catheter tip is positioned below the saphenous femoral junction. The motorized handle is turned on and rotates the catheter tip creating venous wall spasm. Liquid sclerosant is being injected gradually to the spasm diseased vein during catheter pullback. This procedure can be done under local anesthesia in the clinic. No tumescent anesthesia is required. After the 30-60 minutes procedure is complete, patients can return to normal office work on the same day.
• Minimal invasive Endovenous Laser Treatment (EVLT) for Varicose Veins)
  EVLT is a minimal invasive surgery. It is being performed under ultrasound scan guidance by an experienced surgeon. A tiny cut of 1-2 mm is being made around the knee and a long narrow laser fiber is inserted to the sapheno-femoral junction. EVLT uses laser energy to burn the inner surface of the diseased vein. After laser burn, the diseased vein will form scar, shrink and seal off. EVLT is suitable for large and medium size varicose vein. It takes 30-60 minutes to perform and the recurrence rate is low. Tumescent anesthesia is required to reduce the intra-operative and post-operative pain, and at the same time protect the normal tissue around the varicose vein by forming a cool water cushion. It is a short procedure and can be done under local anesthesia in the clinic or general anesthesia in hospital. Patient is required to wear compression stocking for few days after procedure. Patients can resume normal walking immediately after the surgery and can return to their office work on the next day.
• Minimal Invasive Endovenous Radiofrequency Ablation (EVRF) of Varicose Vein
  EVRF is a minimal invasive surgery. It is being performed under ultrasound scan guidance by an experienced surgeon. A tiny cut of 1-2 mm is being made around the knee and a long narrow radiofrequency fiber is inserted to the sapheno-femoral junction. EVRF uses radiofrequency energy to burn the inner surface of the diseased vein. After laser burn, the diseased vein will form scar, shrink and seal off. EVRF is suitable for large and medium size varicose vein. It takes 30-60 minutes to perform and the recurrence rate is low. Tumescent anesthesia is required to reduce the intra-operative and post-operative pain, and at the same time protect the normal tissue around the varicose vein by forming a cool water cushion. It is a short procedure and can be done under local anesthesia in the clinic or general anesthesia in hospital. Patient is required to wear compression stocking for few days after procedure. Patients can resume normal walking immediately after the surgery and can return to their office work on the next day.
• Minimal incision varicose vein extraction
  Minimal incision varicose vein extraction is a new minimal invasive surgery. Experienced surgeons make a tiny incision of 1-3mm over the varicose vein and extract the varicose vein by a venous hook. Varicose veins are avulsed, ligated, or cauterized. This procedure can remove large to small varicose veins and has very good cosmetic result. As the incisions are small, large numbers of varicose veins can be treated the same time. This procedure can be performed under local anesthesia in the clinic or under general or spinal anesthesia in the hospital. After surgery, patients need to wear elastic stocking for few days. Patients can resume normal walking immediately after the surgery and can return to their office work on the next day. Minimal invasive varicose vein extraction

Precautions Before and After Surgery

• Remember to bring identity card
• Inform doctor for special medical condition(s) and current drug(s) use
• Have a shower in the morning before surgery to reduce the bacterial load around the wound
• Void immediately before surgery and relax

• Take a rest of about 15-30 minutes in the clinic
• Go home after learning the steps of wound care
• Wear elastic stocking and loose pants for few days after surgery
• Keep wound dry all the time
• Raise and rest the leg if possible
• Avoid prolonged walking or standing
• Avoid strenuous exercise and handle heavy objects
• On day 5-7, 2-3 weeks and 2-3 month after surgery, return tothe clinics for reassessment.
• 4 weeks after surgery, resume exercise gradually, e.g. jogging, football, swimming

• Remember to bring along your identity card
• Inform doctor for special medical condition(s) and current drug(s) use/li>
• Have a shower in the morning before surgery to reduce the bacterial load around the wound/li>
• Keep nil by mouth six hours before operation
• Void immediately before surgery and relax

• Take a rest in the hospital
• Go home after learning the steps of wound care after the evening round
• Wear elastic stocking and loose pants for few days after surgery
• Keep wound dry all the time
• Raise and rest the leg if possible
• Avoid prolonged walking or standing
• Avoid strenuous exercise and handle heavy objects
• On day 5-7, 2-3 weeks and 2-3 month after surgery, return to the clinics for reassessment.
• 4 weeks after surgery, resume exercise gradually, e.g. jogging, football, swimming

Varicose Veins prevention

Patients can relieve varicose vein associated discomfort and prevent progression of varicose veins, spider veins, and reticular veins by the followings:

• Weight control
• Exercise regularly to improve muscle strength and venous blood flow
• Elevate the legs and frequent leg movement improve venous blood circulation
• Lie flat during resting to prevent venous stasis
• Avoid prolonged sitting or standing
• Do some leg exercise every 30 minutes during prolonged sitting
• Shift the weight of the body every few minutes during prolonged
• Avoid wearing high heels for a period of long time
• Wearing leg compression stockings/li>
• Avoid body constraint clothes over the trunk, hip and thigh
• Avoid female hormone treatment if possible

FAQ

Q: I have some raised blue, dilated and twisty leg veins. Am I suffering from varicose veins?
A: It is possible. If you suspect yourself suffering from varicose veins, please find an experienced doctor to confirm the diagnosis and have early treatment.

Q: When can I return to work after varicose vein surgery?
A: Minimal invasive varicose vein surgery involves much smaller incisions than traditional varicose vein surgery. Most of the minimal invasive surgeries treating varicose veins involve less trauma to the patients and thus less post operative pain. Nearly all patients can walk immediately after their minimal invasive varicose vein surgery. Majority of the patients return to their office work on 1-3 days after their minimal invasive varicose veins surgeries. However, after traditional varicose vein surgery, patients may need to take a 2-3 weeks of sick leave.

Q: How big are the wounds for varicose veins surgeries?
A: At present, the newest minimal invasive varicose vein surgery wound size is about 0.1- 0.3cm. Traditional varicose vein surgery required wound size of 2-5cm.

Q: Is there any chance of relapse after varicose vein surgery? What do I need to do if there is a relapse?
A: Varicose veins are mainly caused by degeneration or damage of the superficial leg veins. It is important to have regular follow up for varicose veins. Better clinical and cosmetic results can be achieved if the disease relapse is being treated in its early stage. Nowadays, experienced surgeon can treat recurrent varicose veins in their clinic using minimally invasive surgical methods. For example, eexperienced surgeons can perform minimal incision venous hook varicose vein extraction. This procedure can be performed under local anesthesia. It causes very little pain, and has very good cosmetic result. Patients can resume normal walking immediately after the surgery and can return to their office work on the next day.

Q: Endovenous radiofrequency ablation (EVRF)　and endovenous laser treatment (EVLT) of varicose veins treat varicose vein by damaging these veins with high energy. Are they safe?
A: Yes. Experienced surgeons treat only the diseased superficial varicose veins and protect the deep veins. EVRF and EVLT are commonly used methods to treat varicose veins by burning the wall inside the vein, causing fibrosis of the varicose veins and shutting down the flow of the varicose veins. Blood flows back to the heart through the normal healthy deep veins.