Patient Information - Varicose Veins General Information

'The information contained in this patient information sheet is not a substitute for medical advice or treatment, and the Society recommends consultation with your doctor or health care professional'

1. What are Varicose Veins?

Varicose veins are veins under the skin of the legs, which have become widened, bulging, and tortuous. They are very common and do not cause medical problems in most people.

Blood flows down the legs through the arteries, and back up the legs through the veins.
There are two main systems of veins in the legs - the deep veins which carry most of the blood back up the legs to the heart, and the veins under the skin, which are less important and which can form varicose veins.
All these veins contain valves, which should only allow the blood to flow towards the heart. Failure of the valves allows blood to flow backwards down the veins and produce a head of pressure when standing. This excess pressure leads to dilation of the veins and the appearance of varicose veins.

2. How do varicose veins present clinically?

Varicose veins often appear first in pregnancy, when hormones relax the walls of the veins and when the womb presses on the veins coming up from the legs. People who are overweight are more likely to get varicose veins and to find symptoms from them troublesome. There is some tendency for bad varicose veins to run in families, but this is by no means always the case. Usually there is no special cause for varicose veins.
Very many people have no symptoms at all from their varicose veins, except for the fact that they are noticeable, and their appearance can be embarrassing. Simply having varicose veins is not a good reason for going to a doctor or having treatment.
Other than cosmetic embarrassment the commonest symptoms from varicose veins are aching, discomfort, and heaviness of the legs, which are usually worse at the end of the day. Sometimes the ankle can swell, too. These symptoms are not medically serious, but can be treated if they are sufficiently troublesome.
Although varicose veins can get worse over the years, this often happens very slowly and worry that "they might get worse" is not a good reason for treatment if the veins are not causing symptoms.
In a few people the high pressure in the veins causes damage to the skin near the ankle, which can become brown in colour, sometimes with scarred white areas. Eczema (a red skin rash) can develop.

If these skin changes are allowed to progress, or if the skin is injured, an ulcer may result. Skin changes are therefore a good reason for going to see your GP and for referral to a specialist.
In many areas there are special leg ulcer bandaging clinics, supervised by the skin specialists and run by specially trained nurses. Your GP may refer you there, rather than to a surgeon in the first instance.
Other problems, which varicose veins can occasionally produce, are phlebitis and bleeding. Phlebitis (sometimes called thrombophlebitis) means inflammation of the veins, and is often accompanied by some thrombosis (clotting of blood) inside the affected veins, which become hard and tender. This is not the same as deep vein thrombosis (DVT) and is not usually dangerous. It does not mean that the varicose veins necessarily have to be treated.
The risk of bleeding as a result of knocking varicose veins worries many people, but this is very rare. It will always stop with firm pressure and the veins can then be treated to remove the risk of further bleeding.
Varicose veins are associated with DVT in some patients. It is not clear whether varicose veins themselves increase the risk of DVT, but certainly DVT leads to varicose veins and skin damage around the ankle.

3. What tests can be used to investigate varicose veins?

Most varicose veins originate from leaking valves at groin level or behind the knee. It is important to accurately locate the site of the valve leaks.
In Outpatients, your Surgeon will use a small probe to assess your veins. It is called continuous wave Doppler. The probe can detect the direction of blood flow, both in the skin veins and in the deep veins. It shows where the veins have come from and helps in the planning of any operation that might be required.
Sometimes a more comprehensive scan, called a Duplex scan, will be required if the simple Doppler probe doesn’t give the whole answer. This is done by appointment. It looks in detail at the skin veins and deep veins. It can detect leaking valves and evidence of previous blood clots in the deep veins (deep vein thrombosis or DVT).
Very occasionally, if the scan isn’t clear, an Xray of the veins, called a venogram, may be required. This involves the injection of dye (contrast) into a vein in the foot. The contrast can be seen outlining the veins in the calf and thigh, and is the best way of detecting previous damage to the deep veins.

4. Who is at risk?

Varicose veins are very common and affect women more than men.
Pregnancy is often the time when varicose veins first begin. They often disappear after the first pregnancy, but tend not after subsequent pregnancies.
Jobs involving long periods of standing often make the symptoms of aching worse

A previous history of DVT predisposes to varicose veins and skin damage around the ankle (lipodermatosclerosis), which may lead on to ulceration.

5. Do I need treatment?

Very large numbers of varicose vein operations are performed each year in the UK. Traditionally, many have been done for purely cosmetic reasons, and many have been fairly minor.
The Government, through the NICE (National Institute for Clinical Excellence) guidelines, has provided guidance to help us determine who should be treated on the NHS.
The highest priority is to treat those with ulcers or a previous history of ulcers.
Bleeding from varicose veins, usually around the ankle, is also regarded as a high priority.
A previous history of phlebitis, the presence of large varicose veins, and aching in the leg are regarded as the less important indications for treatment.
Simple non-symptomatic and smaller varicose veins carry the lowest priority.
The aim of all operations for varicose veins is to minimise the risk of developing skin changes or ulceration later in life. Surgery is very effective in achieving this.

6. What does treatment involve?

Stockings: Support stockings, either to just below knee or full length will usually control the symptoms of aching from varicose veins. They can be prescribed by your GP or you can buy them from any good Chemist.
Injections: Injections of varicose veins used to be widely available in the past. Though injections will deal with the visible varicose veins, they rarely get at the cause of the problem, so recurrence is the rule. In addition, injections often leave blemishes in the skin and there can sometimes by a brown staining along the line of the vein.
Injections only really work when there are no demonstrable leaky valves. In this situation the varicose veins are certain to be very small, or may only be thread veins. Treatment for these is not available on the NHS.
A chemical is injected directly into the vein, where it causes the blood to clot. If the veins are then compressed with a stocking or bandage the clot will stick to the walls of the vein ‘glueing them together’. Over 6-8 weeks, the blood clot slowly shrinks. If adherent to the walls of the vein, then the vein will shrink down too rendering it less visible or even invisible.

Surgery: Surgery to varicose veins is the best treatment. Operation is performed under general anaesthesia. Through tiny incisions, the varicose veins are removed. This deals with the cosmetic problem.
To deal with the cause of the veins, an incision is usually made in the groin. The main skin vein is tied off and divided. It is then stripped out of the thigh to knee level where there is another tiny incision to retrieve it.
Sometimes if the main vein on the back of the knee contains leaky valves, a further horizontal incision is required here to ligate it as well.
Perforator surgery: Some patients have leaky valves in perforator veins, which are veins connecting the deep and skin vein systems. This occurs particularly in the calf on its inner aspect. Ligation of these veins may occasionally be indicated. It can be done either through a long incision down the back of the calf, or more commonly now using a keyhole technique.
The keyhole technique (subfascial endoscopic perforator surgery or SEPS) involves a small incision in the upper calf through which a telescope is passed under the skin. The perforators are then ligated under direct vision without any other skin incisions.

7. Is treatment successful?

Injection of very small varicose veins can be successful, but if there are valve leaks associated with the varicose veins, recurrence is bound to happen.
Surgery is followed by recurrence in about 1 in 7 over a ten year period. This recurrence may be due to poorly planned or performed surgery, or due to new valve leaks beginning elsewhere.

8. Can I help myself?

Simple measures such as wearing support stockings will control the symptoms for many people. Stockings may help to prevent progression or enlargement of varicose veins.

SD Parvin MD FRCS
Sunday, 26 September 2004
Version 2004/4/

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