Varicose Veins - Principles of Treatment -
SURGERY / RF HEAT ABLATION
Symptoms and Diagnosis
Many abnormal veins are unsightly but cause no symptoms. Others can cause mild or severe aches. Abnormal veins can cause problems such as blood clots in the veins (thrombophlebitis), skin rashes (eczema) or skin ulcers.
The bursting of small veins can cause permanent brown stains in the skin. This is common.By examining your legs, the surgeon will determine the type and extent of abnormal veins. Your surgeon may do an ultrasound test, which uses sound waves to give a picture of the veins. The test causes no pain or discomfort. The cause of varicose veins is not known. Most stories about the cause are folklore. They have no known link to diet, constipation, tight garments, garters, crossing the legs, sunbathing, waxing the legs or lack of exercise.
After a thorough examination, your surgeon can discuss the diagnosis with you. Your surgeon may then recommend Surgery, Heat Ablation with Radio Frequency or Laser energy, injection treatment, or other options.
In some patients, serious problems may occur if they refuse treatment. For these people, the surgeon will strongly advise treatment. Full assessment of the circulation superficial and deep veins and arterial and lymphatic assessment may be necessary to find whether the problem is more serious or whether it would fit as a cosmetic diagnosis even though there are large unsightly veins.
In some of these patients, there may be no medical reason why surgery or injection treatment should be done. However, where veins are large or unsightly, these treatments should improve the leg's appearance.
If the major surface veins (the long or short saphenous veins) are varicose, removal of the function of the trunk with Surgery, RF or Laser offer satisfactory outcomes. Surgery has been tested over a longer time. If these major veins are functioning well, injection treatment or surgery is an option. For very small veins, treatment is usually by injection.
The decision to have treatment
The decision to have treatment is made after discussion with your surgeon. If the varicose veins are likely to cause serious problems, your surgeon will recommend the best treatment for you. However, if your concern is only the unsightly appearance of the veins, then you must decide whether you want treatment. When making this decision, you must keep in mind that the surgeon cannot guarantee that the treatment will make the leg look normal or even improve the appearance of the leg.
Giving your full medical history to your surgeon
Your surgeon will ask you about any health problems you may have had. Some health problems may interfere with surgery, anaesthesia and care after surgery. Your surgeon needs to know your medical history to help plan the best possible treatment.
Give your surgeon a list of all medicines you are taking now or have been taking recently. This includes aspirin, cough medicines, hormone replacement medicines, or the contraceptive pill. Tell your surgeon if you have ever had an allergy or bad reaction to antibiotics or any other medicine.
BLEEDING OR BLOOD DISORDERS
Tell your surgeon if you bleed heavily when you are injured or have surgery, or if you have any blood disorders, such as haemophilia or espescially if you are using blood thinners.
Surgery or injection treatment is usually not done during pregnancy. However, if the reasons for treatment are good, there is little point in delaying treatment between pregnancies. Delays in treatment may cause unnecessary suffering and increase the risk of problems getting worse.
Surgical support stockings and bandages reduce the bad effects of the pressure which comes to the surface through the saphenous or perforating veins. They can be used to tightly cover the skin and press the walls of the varicose veins closer together, which helps blood flow in the veins.
Many types of surgical support stockings are available. The choice depends on how bad the symptoms and problems are. Whichever type is chosen, the stocking should be fitted for the patient. Tightness should be checked by the surgeon. For patients with disease of the deep veins, wearing support stockings is often the only treatment available. Concomitant problems with arterial blood flow may force modification of the usual pressure of the stockings recommended. Also pre existing deep vein disease may affect all the options for treatment and assessment of function should be part of all preliminary workup.
Bandages and Dressings
The type of bandage chosen depends on how tight it needs to be. Bandages can give more compression than stockings alone and may be required for problems such as thrombophlebitis, eczcma or skin ulcers. The bandage must be firm and should cover all the leg from the toes to at least the knee and usually above.
Treatment of Skin Ulcers
Various types of dressings are used to treat skin ulcers. Compression by bandages or surgical support stockings is the most important part of treatment when the cause is simple venous reflux and elevated gravitational hydrostatic pressure at the ankle, but other causes need to be appropriately looked for and excluded or if discovered, appropriately treated. When the patient first sees the surgeon, a short course of antibiotics may be given to treat any infection. The surgeon may prescribe a cortisone cream for eczema.
For most people, skin ulcers can be healed without having to go into hospital and without a skin graft. To prevent an ulcer from coming back, the surgeon will usually treat the varicose veins. Usually, this is done after the ulcer has healed. Ulcer biopsy may be necessary as skin cancers may sometimes appear to be a venous pressure ulcer, particularly if they are chronic and have become large. Lymphoedema may be an associated primary and complicating factor. It may cause the skin to swell and split and be associated with recurrent infection.
Some doctors will prescribe drugs for the varicose veins, but benefits are uncertain. For some patients, the surgeon may prescribe a "diuretic" drug, which reduces swelling of the legs by increasing the amount of urine passed, this is usually ineffective unless there is some other explanation for the swelling such as mild heart failure.
Surgery may be needed for some people. Usually, the results of surgery are more attractive than the appearance of large varicose veins. Most scars or stains resulting from surgery are faint, but sometimes they are permanent and unsightly.
Not all surgeons use the same technique. Ask how the surgery is to be done.
RF Ablation has replaced standard Surgery in My Practice over the last few years. Initial trials have shown it very effective and durable over at least 5 years.
About two in 10 patients who have veins treated by surgery will develop new varicose veins in the long term. The surgeon can give no guarantee that varicose veins will never come back however these "recurrences" with surgery are often due to new vein development whereas after sclerotherapy for larger trunk veins it is more likely persistence of vessels that have not fused together with the treatment.
Many patients ask, "Where does the blood flow after the veins have been removed?" Most of the blood flow in the leg is through the deep veins (not touched by surgery) and not through the surface veins. Varicose veins do not function effectively when the person is standing. In fact, the veins are actually carrying blood the wrong way. Other normal veins have had to take over the function of these veins. Therefore, treating varicose veins improves the circulation in the leg,
The patient is usually admitted to hospital on the day of the operation. It is sensible to plan skin preparation by washing with antibacterial soap which leaves an active residue (e.g. Phisohex) 5 days preop.
The patient should not shave her or his legs pre theatre, they will be trimmed in the hospital. Early shaving has been found to increase infection, but cl;ipping or waxing or depilation is acceptable.
The veins are marked by a pen before surgery. Often Duplex Ultrasound mapping is required almost always now for major trunk problems and the best marker is Whiteout.
The surgeon may carry out the operation in various ways. Some surgeons simply tie off the saphenous vein while others remove or "strip" some or the entire vein.
The surgeon may make a small cut high in the groin (for the long saphenous vein) or at the back of the knee (for the short saphenous vein). More very small incisions are needed for other surface varicose veins, which must be removed.
Over the decades I have been practicing this surgery I have found the stripping of the whole length of the trunk veins have given the the most effective and durable results. With the change to RF ablation this principal has resulted in the best results also.
RF Ablation does not require a groin incision so there is a considerable reduction in risk of infection and lymph problems.
There is often a discussion about the lessening of pain with RF Ablation but I found little problem even with surgery; however with both types especially with bruising from large collateral veins pain can be troublesome.
Making several small incisions gives a better cosmetic result than making a few large incisions. Some small veins are too small to be removed surgically and may need injection treatment later.
Care After Surgery
After surgery, the leg is usually firmly bandaged to reduce bruising. This feels tight at first but is tolerable. Dressings and bandages are changed within the next day or two, a Fitted Compression Stocking is used.
Supplied from our Clinic, pick-up before admission.
Walking reduces discomfort.
Many patients say they only require one Panadol for pain postop.
Very very rarely pain may be bad enough for the patient to be given a needle.
When resting by all means keep the leg elevated but you must keep the knees bent, (see our research on DVT).
Patients who have the more major interventions usually leave hospital on the next morning; especially if they require significant dressings to be changed. Some who are likely to have minimal bruising or leak from their wounds may be discharged on the same day, typical for RF Ablation.
As with injection treatment, the patient should walk for at least half an hour every day (not counting walking around the house),
Bandages are left dry and alone for 10 days and are then taken off in the surgeon's rooms, where any skin stitches can be removed.
A compression stocking may be needed for up to 4 more weeks depending on the size and mass of the varicose veins removed.
The surgeon may need to inject any remaining veins, I prefer to do this when the reaction from surgery has settled and when bruising has settled down usually some months after the procedure.
Time off work and other heavy activities, depends on the mass of veins treated and early progress and common sense.
Individuals with supervisory roles can return within days.
Heavy physical jobs where trauma to the leg, risk of water soaking or contamination which might risk infection may require up to 10 to 14 days off work.
The surgeon usually will want to examine the patient a few weeks after the operation and again several months later to make sure that no varicose veins are still present. After surgery, new varicose veins may appear. Although these are often minor and can be treated by injection treatment, some need surgery.
OTHER EFFECTS OF SURGERY
While surgery on varicose veins is considered to be safe and effective, there are a few side effects.
Scars usually fade, but sometimes they are permanent and unsightly. Healing and fading of scars can take a few months.
Patients should not get the legs sunburnt during this time. Sunburn may make the scars worse.
Brown discolouring can occur over some of the treated area. Although the colour usually fades, sometimes it is permanent and unsightly.
Sore lumps may be due to bruises (in the space left where the veins came from) or blood clots within remaining short lengths of vein. These lumps usually shrink and lose their soreness over a few weeks.
Some nerves run close to surface veins. They may be injured during surgery. This may cause some numbness or annoying "pins and needles" and sometimes pain. Small superficial areas usually recover quickly, a few months. Usually deeper superficial nerve irritation or damage recovers though often slowly. It may take up to two years in some people. Sometimes a small patch of numbness is permanent.
Extremely rarely, important deep nerves can be damaged during surgery, but very unlikely with RF ablation unless perforator veins are being treated close to deep nerve location.
Swelling of the ankles or feet is common and may last for a few weeks. Swelling is due to the operation and not to a blockage of blood flow, unless you rest with your legs up and extended.
If the ankles or feet were swollen before the operation, then swelling may continue due to problems in the deep veins or lymphatics.
Wearing support stockings through the day reduces swelling.
Loss of long saphenous veins
Removal of the long saphenous vein can prevent its future use as a heart artery bypass. Therefore it is usually not removed in patients who have diabetes, high blood pressure, heart disease or artery disease in the legs or arms. However, a badly diseased long saphenous vein is of no use as a heart artery bypass.
Side Effects of Anaesthesia
Modern anaesthesia is safe with few risks. However, a few people may have serious reactions to anaesthetic drugs. If you have ever had a reaction to an anaesthetic drug, tell your surgeon.
Complications after Surgery
Fortunately, serious problems after surgery are uncommon. Infection may occur in wounds, especially in patients who have ulcers.
Blood clots can occur in the deep veins: appropriate management can go a long way to prevent this. If you have any concerns or want to know more about possible problems, ask your surgeon.