Varicose veins are enlarged, swollen, and twisted veins that often appear blue or dark purple. They occur when faulty valves in the veins allow blood to flow in the wrong direction or to pool. Though they can develop in any vein, they are most commonly found in the legs and feet due to the pressure of standing and walking. The vascular system is a huge network of veins, arteries and capillaries with the heart at the very center. Oxygen and nutrient rich blood is transported by the arteries, and is delivered back to the heart through the veins. Blood-flow in the veins must move upwards, against the force of gravity. To deal with this, the veins have a series of one-way valves that open and close to allow the blood to flow upwards. When these valves are weak or broken, blood pools in the legs causing varicose veins. This condition is known as venous insufficiency.
RISK FACTORS FOR VARICOSE VEINS
Varicose veins generally have a genetic risk with females having a higher risk than males. Other factors do play a role. These include obesity, pregnancy, pelvic masses, smoking, family history of venous insufficiency, previous venous thrombosis, inactivity, sedentary lifestyle, and prolonged periods of standing or sitting.
APPEARANCE & SYMPTOMS
Varicose veins usually occur closer to the surface of the skin and are often found on the back of the calf or on the inside of the leg. Symptoms typically include:
- A feeling of heaviness, tiredness, and aching, especially at the end of the day or after periods of prolonged standing.
- Swelling of the feet and ankles (due to stagnant blood leaking through the walls of the veins into surrounding tissues).
- Changes in skin colour.
- Continual itching of the skin above the vein.
- The development of non-healing ulcers at the ankles.
Varicose veins often get worse over time and can cause significant complications including increased pigmentation, inflammation, eczema, superficial thrombophlebitis and skin ulcers above the ankle.
TREATMENTS AVAILABLE
Treatment programs are customized to each patient and take into consideration all important factors. Treatment options typically include support hosiery ( compression bandaging and stockings), radiofrequency ablation (VNUS) , surgery (Trendellenburg stripping, stab avulsions), glue injections ( Veneseal) and foam sclerotherapy. For certain conditions, you may receive a combination of the above treatment options. Some procedures can be staged at different times to achieve better outcomes.
SUPPORT HOSIERY OR GRADUATED (GRADED) COMPRESSION STOCKINGS
These are special garments which provide exert a pressure over the leg which gradually decreases from ankle upwards. This helps emptying of the superficial vein system. They can be used prior to surgery to relieve symptoms and heaviness caused by varicose veins, decrease swelling and aid in healing skin ulcers caused by venous disease. These garments are also used postoperatively to decrease thrombosis (clot) risk and bleeding under the skin. They are available through our wound care facility or at an orthotist of your choice.
There are many different types of compression garments with a range of graduated compression classes. Most garments range from class I to class IV. Class I garments have lower compression and is used mainly for prevention of disease ( to avoid flight thrombosis, limb swelling after a long flight, office workers, people in standing professions, and pregnant ladies). Class II stocking are generally for people with established vein problems ( varicose veins, current or previous vein thrombosis and vein ulcers). Class III and IV garments have much higher compression and is generally used for bad venous pathologies and severe lymphoedema. Class I stockings are generally of the shelf and do not require a prescription while the higher grade of stockings will require a script after you have had a vascular assessment.
STAB AVULSIONS
This refers to the surgical removal of the small rope- like veins. It is mostly performed under local / tumescent anaesthesia via small incisions between 3-5mm in diameter. They are taped closed with steristrips at the end of the procedure. This procedure is usually used as an adjunct to the other procedures below.
TRENDELLENBURG STRIPPING
This procedure is performed exclusively in theatre under a general anaesthetic with stab avulsions. While it was the treatment of choice until the early 2000s it is now reserved for patients who don’t qualify for the minimally invasive techniques. This procedure involves a groin incision and a lower leg incision through which the vein is removed.
RADIOFREQUENCY ABLATION
The VNUS Closure Fast Procedure (Venefit) is an incredibly effective, relatively new solution for the treatment of varicose veins.
During the procedure, a catheter / heater probe is position in the vein under the guidance of an ultrasound. A combination of cold Saline and local anaesthetic is injected around the vein with a pump (tumesccent anaesthesia). The catheter is then activated allowing the catheter to touch the wall of the vein from the inside. Next, radiofrequency energy is transmitted from the generator through the catheter tip, heating the vein wall and causing contraction of the vein wall resulting in closing down of the vein.
The VNUS procedure has little or no discomfort associated with it. With over 99% of veins being permanently closed, this procedure has a high degree of success. It is generally accompanied with small stab avulsions. This procedure can be performed in hospital under general anaesthetic or as an office based procedure under local anaesthetic.
VENESEAL PROCEDURE
This procedure is also performed with ultrasound guidance. A glue is injected in the affected superficial vein in a systematic manner. This procedure does not require the use of tumesccent anaesthesia unless stab avulsions are performed at the same setting. The Veneseal procedure is generally performed exclusively in an office based setting.
CLARIVEIN
This procedure involves injection of foam with via a special vibrating probe in the diseased superficial vein under ultrasound guidance. It is almost exclusively performed in an office-based setting. This procedure also does not require tumescent anaesthesia unless combined with stab avulsions.
SCLEROTHERAPY
A treatment for spider veins that involves injecting a chemical into a vein causing it to fade. The vein turns into scar tissue and blood flow shifts to a nearby healthy blood vessel. It works best for varicose veins which are not under pressure from leaky valves higher up in the veins of the leg and you will be advised whether your veins are suitable for this kind of treatment.
Most varicose veins that are suitable for injection treatment are not medically harmful and treatment is seldom essential. It is done for people who dislike their varicose veins and the symptoms they cause. This treatment is considered cosmetic. Recovery time for radiofrequency ablation and sclerotherapy is rapid. Most of our patients return to work and normal activity the next day or soon after that.
WHAT TO EXPECT AFTER THE PROCEDURE
What is the risk?
There is a minor risk of bleeding and infection to the wounds. With any varicose vein procedure there is a small risk of damage to superficial skin nerves which can sometimes cause uncomfortable pins and needles or numbness.
5%-10% of varicose veins recur. Most recurrences occur after 5-10 years and can be treated with minimally invasive techniques.
Duration of hospitalization?
The patients are admitted at 6:00 in the morning of surgery. The operation usually involves only a one night stay and patients usually go home the following morning. Depending on the severity of disease some patients are discharged on the day of the procedure. Should you wish to be discharged on the evening of the procedure please discuss this with the doctor prior to the procedure.
What about after the operation?
You should come back from theatre with elastic compression bandages. These will be released by the staff prior to discharge and replaced with the compression stockings. If the bandage is too tight the outer layer (pink) can be released for 30min whilst you are in bed and then reapplied from the foot upwards.
You will be discharged with Micropore tape or plastic dressings which can be left on for a long time as it helps with wound healing. Change only if dirty. It is perfectly acceptable to shower with these dressings on. Please do not use a bath , spa bath or swimming pool until wounds have healed (+- 2 weeks). If you have plastic dressings, these can be removed after a couple of days.
You will be able to get up and go to the toilet with assistance on the day of the operation, and should be able to walk around on the day after operation. Mobilisation should proceed gently. Return to normal activity is a very individual process. This can be discussed with your doctor upon discharge. Active walking is encouraged, but when you are not walking actively, you should be resting with your legs elevated. Do not sit or stand for long periods.
What about elastic stockings?
The ward sisters will apply the stockings onto your leg/s prior to discharge. You can sleep with the stocking on, on the night of discharge. Thereafter, it is recommended that you take these off at night, and re-apply them after showering in the morning. They should be worn for between 3-6 weeks after the operation.
Many people find it comfortable to wear them intermittently for longer periods. We generally prescribe a class 2 stocking after surgery. Your measurement for the stocking should be taken by either the wound care sister or the orthotist prior to the procedure. Most patients are fitted with a thigh level stocking, however, the doctor and / or orthotist may occasionally prescribe knee level, hip level or pantyhose depending on body habitus and suitability. These stockings can be worn later as flight stocking, or after foam sclerotherapy so please do not discard them after use.
What about bruising?
It is totally normal after the procedure to have some bruising, which will persist for about 3 – 6 weeks.
What about stitches?
We do not generally use sutures during most procedures. If sutures are used then dissolvable sutures are placed. The small wounds usually do not have any stitches and are closed with steristrips and / or micropore.
Can I put anything on the wounds?
We recommend flesh coloured Micropore tape for 3 – 6 weeks after the operation. Evidence in wound healing shows that keeping a wound moist, warm and out of the sun is beneficial from a cosmetic point of view. Vitamin E based creams or Aqueous cream can also be used.
When can I play sports?
This is based on an individual basis depending on severity of disease and procedure performed. If no stab avulsions are performed then you can return to normal sporting activity after 72 hours. If stab avulsions are performed then you will probably have to wait a week and then restart with light lower limb exercises first and gradually increase sporting activity over 2 weeks. Please ensure to wear your stocking during sporting activities. You can also enquire about sport compression hosiery from the orthotist or wound care sister
What do I need to worry about?
- If your leg or calf becomes swollen and tender, or if you develop chest pain and shortness of breath; notify your doctor immediately.
- Some mild redness of the wounds is normal but it is accompanied by severe throbbing pain or a yellowish pus-like discharge; notify your doctor immediately.
- Some mild bleeding from the small wounds can occur on the discharge day after mobilising the first time. If it happens, immediate direct pressure on the wound with dry gauze and elevation of the legs for 30 minutes is usually sufficient to stop the bleeding. Try mobilising thereafter with the stocking on. Call your doctor immediately if the bleeding persists.
Pelvic congestion syndrome (PCS)
Chronic pelvic pain can be caused by multiple pathologies which include irritable bowel syndrome, endometriosis, adenomyosis, typical menstrual pain, urologic disorders, and psychosocial issues. It is essential that these pathologies are excluded before a diagnosis of pelvic congestion syndrome(PCS) is considered. PCS is often associated painful urination, heaviness, pain during sex, pain with passing stools and non-specific lower abdominal and pelvis. Symptoms are generally worse during menstruation and often occur after pregnancies. Patients often have varicose veins in pelvic and perineum areas.
The choice of non-invasive testing largely depends on institutional expertise. Transabdominal and transvaginal ultrasonography showing large ovarian veins. CT scan and MR can also be used to better visualize large pelvic and ovarian veins. Invasive testing like venography should generally be used to confirm the diagnosis with intervention being performed at the same setting.
Endovascular therapies are now the preferred approach for pelvic congestion syndrome. These techniques include a combination of embolization of internal iliac vein tributaries and ovarian varices using coils, plugs, and/or sclerosing agents and relieving mechanical obstruction of the iliac vein (May-Thurner Syndrome), nutcracker syndrome and retroaortic renal vein with venous stents. Most women ( 73-78%) have relief of symptoms or cure within 2 weeks of treatment.
Biography:
Dr Pradeep P. Mistry
MBChB (Pret) MMed Surg (Pret) FCS (SA) and Cert Vascular Surgery
Graduated in Bachelor of Medicine and Surgery at the University of Pretoria. Thereafter completed his Master in Surgery and Fellowship in Surgery. Completed the fellowship in Vascular Surgery and received the CJC Nel award from VASSA ( Vascular Society of Southern Africa) for excellent performance during the fellowship exams. Currently has a private practice at Life Fourways hospital, Netcare Sunninghill Hospital and Wits Donald Gordon Medical Centre. Also involved as a Lecturer at the Wits Vascular Unit. Current Secretary and President-Elect of VASSA.