Understanding varicose veins with King’s College Hospital London

Varicose veins affect approximately 30% of the population, and whilst the severity can fluctuate significantly from person to person, most cases are relatively easy to treat with very minimal disruption to daily life. Tim Lees, Consultant Surgeon at King’s College Hospital tells us more…

Varicose veins are enlarged, twisted and bulging veins occurring predominantly in the leg. There is a spectrum of severity from the very small thread veins or spider veins seen in the skin through to the largest varicose veins.

There are two main systems of veins in the leg:

Deep veins: These are deep inside the leg and the leg muscles squeeze them during walking so that they carry most of the blood back to the heart.

Superficial veins: These are near to the skin and are less important for carrying blood to the heart.

Varicose veins usually involve the superficial veins and they are often visible and can be felt as compressible swellings in the leg.

It is not fully known why varicose veins occur but current knowledge indicates that the wall of vein becomes weakened and the vein then enlarges.  This causes the one way valves in the leg to stop working and blood tends to pool in the veins.  Varicose veins are often more common in individuals with a family history of the condition and they tend to be more common in females than males. Hormonal factors including puberty, pregnancy, the menopause, the use of birth control pills, and hormone replacement therapy can all affect the disease.

Pregnancy: It is very common for pregnant women to develop varicose veins during the first trimester. Pregnancy causes increases in hormone levels and blood volume which in turn cause veins to enlarge.

In addition, the enlarged uterus causes increased pressure on the veins. Varicose veins due to pregnancy often improve within 3 months of delivery. However, with successive pregnancies, abnormal veins are more likely to remain. Other predisposing factors include ageing, standing for long periods of time, obesity and leg injury.

Thread veins are very common, even in normal individuals, and even though they can be associated with underlying varicose veins they can also occur in isolation with no underlying venous disease.

Varicose veins may cause many symptoms such as aching & discomfort, heavy tired legs, ankle swelling and itching. Sometimes varicose veins can also lead to problems with the skin around the ankle including ulceration.  In many individuals however they give no symptoms but can be cosmetically embarrassing.

Thread veins in isolation do not usually cause any symptoms and are treated for cosmetic reasons. Reticular veins are similar but around the ankle they can sometimes lead to bleeding as the vein walls are very fragile and close to the skin.

You will need an ultrasound scan of your veins.  This is a non-invasive scan similar to the scans used in pregnancy.  It will involve scanning your leg from the groin or lower abdominal level down to the ankle. A water based jelly is applied to the leg and a probe applied to the skin. The scan will identify if you have an abnormality in the larger veins which would need treating before treating your thread veins.  If your larger veins need treatment it will also help to determine which treatments are suitable for you.

Modern treatments of varicose veins are minimally invasive and many can be done on a “walk in walk out” basis with minimal disruption to normal activity and daily life.

Liquid Sclerotherapy

This is particularly suitable for the treatment of reticular veins and thread veins/spider veins. Multiple veins can be treated in one session using a very fine needle. A sclerosant liquid is injected into the veins and this causes the vein to block.  It is not unusual for the veins to appear swollen and inflamed immediately after treatment but this will settle down and your body will then reabsorb the vein and it will gradually disappear.  Several sessions of treatment may be required depending on the extent of your thread veins.

Foam Sclerotherapy

This treatment involves injecting the larger varicose veins with a sclerosant liquid which is made into a foam.  Similar to injecting thread veins the aim of this treatment is to cause damage to the lining of the vein and this in turn causes the vein to clot off and your body will gradually remove the clotted vein. This treatment has the advantage that it can be done in clinic under local anaesthetic in the clinic.  Following treatment you will need to wear a compression stocking but you will be able to continue with your normal activities after treatment, other than driving which should be avoided on the day of treatment only.

Endothermal Ablation

Sometimes your veins will be too large to respond well to either foam or liquid sclerotherapy.  In this situation it is usually still possible to perform a minimally invasive treatment, called endothermal ablation.  A fine catheter is inserted into the vein through a needle and laser or radiofrequency energy is applied to the wall of the vein through this catheter. This heats the vein wall and shrinks and damages the vein to the point where the vein occludes. Following this the body reabsorbs the vein and it disappears and it therefore avoids the need for surgical ligation and stripping. This treatment is used particularly for varicose veins associated with backflow in the great saphenous vein in the thigh and the small saphenous vein in the calf.  It is associated with less post-operative pain and discomfort than surgery and allows an earlier return to normal activity.

Endothermal ablation is used to treat the larger truncal veins.  The local varicose veins in the leg will tend to shrink following treatment of the truncal veins but they can also be treated with foam sclerotherapy or with phlebectomy:

Phlebectomy

The visible varicose veins in your leg can be removed through very small incisions over the veins using a specially designed vein hook. No stitches are required, and the small wounds from this treatment are closed with steristrips. This technique ensures a good cosmetic result. It can be performed under both local and general anaesthetic.

Very rarely some varicose veins are not suitable for endothermal ablation or are too large for foam sclerotherapy and in this circumstance surgical ligation and stripping remains the best treatment.  This treatment can still be performed as a day case with a rapid return to normal activity:

Surgical Ligation and vein stripping

This involves an incision in the groin or behind the knee and the vein is tied off close to its junction with the deep veins.  The great or small saphenous vein is then disconnected from the deep vein and removed in the thigh or calf.  This conventional method of treatment works well and has been performed for many years for varicose veins but is associated with more short term bruising than the less invasive treatments. It is performed as a day case i.e. you will be able to return home the same day after your surgery.

Following all the treatments you will need to wear an elastic compression stocking. Following injection treatment of thread veins you will be asked to wear the stocking for 5 to 7 days but you can continue your normal activities straight away. There are no limitations to what you can do after treatment. Similarly following foam sclerotherapy of larger veins you will need to wear a compression stocking for a total of 12 days. You should not drive on the day of treatment but other than that you can continue your normal activities. Following endothermal ablation we encourage you to return to normal activity as soon as possible following treatment, this is normally within 2 to 3 days.  Similarly after surgery you will be up and about on the same day as your surgery and the sooner you can get back to normal mobility the better, although this can take a little longer than with the other treatments. Walking is a helpful exercise and you should start taking daily walks following surgery.