What are varicose veins?
Like anyone who suffers with varicose veins knows, they can impact what I wear, especially in bare leg season. But there are ways to both treat and disguise them that mean you can banish the long skirts and leggings. We chatted to Mr Adrian O’Callaghan, consultant vascular surgeon at the Beacon Hospital about what options are open for treatment.
What are varicose veins?
Varicose veins are dilated tortuous veins, usually occurring in the legs, which vary widely in their presentation; from causing no symptoms, and perhaps cosmetic upset alone, to skin ulceration in severe cases. In most situations, they present as aching or swollen legs, especially towards the end of the day, and the varicosities themselves can be quite itchy.
Veins are an essential part of the circulatory system; bringing de-oxygenated blood from the extremity back to the heart. Veins have one way valves within them which allow blood to flow back to the heart, but not the other way, so that when we stand up all the blood isn’t drawn by gravity into our legs. In the legs, there are two sets of veins, a deep set underneath the muscles, and a superficial set underneath the skin. The superficial veins are the ones that become varicose and in this respect, there are two main veins; the small saphenous vein runs from the back of the heel to the back of the knee and the great saphenous vein runs from the inside of the ankle to the groin. These veins are like the trunks of a tree, with branches radiating out from them. When a patient develops varicose veins, usually either the great or small saphenous vein has become dysfunctional and the valves no longer work to prevent blood flowing backwards into the vein when the patient stands. This causes over-distention of the veins and the bulges recognisable as varicosities. Years of this abnormally high pressure in the vein can lead to pain, staining of the skin, and ultimately ulceration.
What are the risk factors for developing varicose veins?
Varicose veins are a very common complaint, affecting approximately a third to a half of the population. Causes include:
· Family history: If your parents or siblings have varicose veins, you are more likely to develop them
· Increasing age: As we age, our tissues lose elasticity, causing stretching of the vein walls
· Weight: Being overweight increases the likelihood of development
· Occupation: Prolonged standing or sitting
· Pregnancy: Hormonal changes during pregnancy lead to softening of tissues and varicose vein development. Additionally, blood volume increases and venous outflow from the legs is impeded by the foetus, all of which contribute to varicose veins
· Sex: Traditionally it was felt that varicose veins were more common in females, however more recent population studies show that they occur equally in both men and women
What is the typical age that most people will see them developing?
The majority of people would present for treatment in their early 40s onwards, however it is not at all unusual to see patients presenting in their early 20s (and sometimes younger) with this condition. Veins vary widely from causing no symptoms to severe distress and the outward appearance doesn’t always correlate with the symptoms. The best advice would be to seek an opinion from your doctor if they are bothering you.
Are there any steps that should be taken to try and minimise them forming?
Regarding the risk factors outlined above, we cannot change our family history, or our increasing age, and so the two biggest contributors cannot be controlled . However, we can take steps to minimise the effect and these include maintaining a healthy weight and a regular exercise programme. Both sedentary lifestyle and obesity are linked with their development and weight management and exercise will help with that. Walking is a very effective, and simple, exercise for overall health and it has additional benefits in terms of activating the calf muscles to pump venous blood back to the heart and so reduce venous pressure in the legs.
In terms of treatment, what are the options available?
The options vary widely, based on the patient’s condition and preferences. Treatment always starts with a discussion regarding symptoms and how the patient is affected. An ultrasound scan is then arranged to map out the veins, and identify the root cause of the problem (usually either a dysfunctional great or small saphenous vein), so that targeted therapy can be offered. The options then are either to wear compression socks or consider surgery.
Regarding surgery, although there are a number of options based on the type of varicose veins and cause, in general, treatment will be focused on treating the root cause of the problem and then removing the visible varicosities. Whereas in the past, we employed open surgery (stripping) to treat the root cause, now endovenous (keyhole) surgical techniques have taken over. These have the benefit of being much less invasive, enable an earlier return to normal activities, and are as effective as the open surgical option. Endovenous surgery is a day case procedure; the patient usually walks in and out within a couple of hours, and return to normal activities is very quick – usually within 24 hours. An additional benefit is that the procedure can be carried out under local anaesthetic and light sedation, so proving to be safer overall.
The two dominant endovenous methods are laser or radiofrequency ablation, and both work on the principle of generating heat within the vein to cause it to occlude. Newer endovenous techniques include using a glue to occlude the vein, which has the benefit of needing less local anaesthetic and potentially enabling both legs to be done on one day. Use of glue is still in its early stages, but the results to date have been very encouraging. Following treatment of the root cause, the visible varicose veins are usually removed through very small 2mm incisions.
A slightly separate category is thread, or spider, veins, which are tiny varicosities in the skin itself. These very rarely cause pain, but can cause cosmetic upset. Evaluation includes an ultrasound to identify a root cause and treatment of that if warranted. The spider veins themselves are then treated by sclerotherapy which is the injection of a solution into the veins to stick the walls together. This procedure is almost painless, can be done in the office setting, and typically needs a number of sessions to treat the affected area. However, in general, sclerotherapy is effective and most patients experience a significant cosmetic improvement.
Do support stockings really work?
Compression socks are medically prescribed and fitted to each patient (based on calf circumference) and act to apply a reliable level of compression to the veins to stop them over-filling with blood and so causing pain. Most symptoms can be palliated with compression socks, which carry no risks, but have the drawback of being uncomfortable to wear, especially in warm weather. Compression doesn’t remove the varicosities, it simply masks them, and the cosmetic appearance will be unchanged. In addition, socks need to be worn daily to be effective, and in general compliance with this treatment can be quiet low owing to discomfort and difficult in getting them on.
Compression socks need to be put on first thing in the morning before the patient gets out of bed (at this time the leg is at its smallest and the socks are easier to get on) and worn throughout the day. It’s important to remember that wearing socks all day can cause dry skin, which can then be prone to injury, so I usually advise patients to moisturise well at night time. Additional measures to reduce symptoms include avoidance of prolonged standing, daily exercise (walking in particular as described above) and elevation of the legs when sitting down.
What kind of results can you expect?
The outcomes following surgery are usually excellent – as with all procedures, a pre-operative discussion regarding the patient’s expectations and the likely results from surgery is essential. Surgery is safe, but complications do sometimes occur. Endovenous ablation has proven to be very effective at treating the symptoms of varicose veins and improving quality of life. Owing to the nature of varicose veins, they frequently recur, and many patients we treat will have had prior surgery. However, the good news is that even in recurrent cases there is always something that we can offer and minimally invasive techniques can be applied.