VARICOSE VEINS
VARICOSE VEINS
Chronic Venous Disease (Varicose Veins, Venous leg ulcers, Spider Veins) is a common problem affecting the general population throughout the world. In India, it is estimated that nearly 50% of the adult population is suffering from vein disease. There are a few consistent and practical hurdles in the management of these patients:
a)Lack of awareness
Majority of the patients who suffer from varicose veins are unaware of the disease pathology and the complications it can lead to. Unfortunately, many family physicians and consultants too fail to impress the need for early intervention in these patients. Valuable time (months/years) is lost in alternative therapy of various oils, oral medications, ill designed stockings. Reluctantly, many patients present late with complications such as pigmentation, ulceration or superficial vein thrombosis. A problem which could have been nipped in the bud reaches irreversible stages.
b)Under recognition of deep venous thrombosis
Many a times, deep venous thrombosis is picked up late by clinicians in patients with prolonged hospitalization and lower limb surgeries. Inadequate prophylaxis to avert DVT too is a common culprit. Over a period of time these patients land with chronic venous insufficiency and secondary varicose veins.
c)Affordability for endovenous treatment of varicose veins
The relatively high cost of procedure (predominantly due to the instrumentation being European/US made) is a hindrance for few to seek treatment in private hospitals.
Following are some of the Frequently Asked Questions (FAQs) by patients of Varicose Veins –
1)What are varicose veins?
Varicose veins are enlarged, dilated, tortuous, hypertrophied veins in legs with defunctioning (weakened) valves. The veins affected are the great saphenous vein/short saphenous vein/their tributaries. By definition, varicose veins are 3 mm or more in diameter.
2)What are the symptoms (complaints) caused by varicose veins?
Following are some of the common complaints due to varicose veins:
- Cosmetically ugly-looking leg veins
- Dull aching pain in the calf, more towards the evening
- Swelling over the ankle or foot, which reduces leg elevation
- Fatigue/Restlessness/Cramping of legs
- Pain
- Burning
- Fatigue that increases with prolonged standing or sitting
- Subcutaneous spontaneous haemorrhage
If left untreated, varicose veins cause further complications such as :
a)Superficial thrombophlebitis – The blood in varicose veins gets clotted. The affected area becomes red and painful. Very rarely, this clot can spread to the deep veins and subsequently to lungs (pulmonary embolism). This can lead to a heart attack and can prove life threatening.
b)Bleeding from the dilated veins – This is a scary sight, especially when it occurs for the first time. Tight pressure bandage and limb elevation helps control the bleeding.
c)Pigmentation of the skin around ankle – This occurs due to haemosiderin deposits in skin, and causes itching.
d)Venous eczema – Pigmentation around ankle can further lead to more dry, itchy and scaly skin, which is known as venous eczema.
e)Lipodermatosclerosis – The fat under the ankle skin becomes fibrosed; the entire area becomes toughened, unhealthy. It is prone to intermittent inflammation and eventually ulceration.
f)Venous ulceration – These are painful and notoriously difficult to heal. It affects the quality of life severely, with patients even forced to quit their jobs due to repeated wound related issues.
3)Why do varicose veins occur?
Varicose veins occur due to defunctioning valves in the superficial veins/perforator veins/deep veins. Depending on the reason for the defunctioning valves, varicose veins are of two types :
a)Primary varicose veins –
They occur due to congenital abnormalities in the valves (congenital absence/hypoplasia of valves). Familial tendency is noted in nearly 80% of these patients.
b)Secondary varicose veins
They occur following DVT. During recanalisation, valves get damaged and reflux sets in.
4)Are there any risk factors for development of varicose veins?
Following are some of the risk factors for development of primary varicose veins :
- Profession involving prolonged standing eg. bus conductors, traffic policemen, athletes, nurses, surgeons
- Obesity
- Sedentary lifestyle
- Multiple pregnancies
- Ageing
5)What should be the treatment approach if varicose veins appear in pregnancy?
Wearing class 2 graduated compression stockings till the delivery would be a safe approach in such cases. It will prevent progression of varicose veins. They can then be treated at a later date after delivery.
6)Is there any way to prevent complications of varicose veins?
Following are some of the things to help prevent complications of varicose veins :
- Avoid weight gain
- Regular physical activity such as walking to exercise calf muscles
- Avoid sedentary lifestyle. If your job involves prolonged standing or sitting hours at one place, make sure to take intermittent breaks for a quick walk, leg raises etc
7)Can prolonged sitting cause problems in patients with varicose veins?
Swelling of legs is seen in some patients of varicose veins after prolonged bus journey or airplane travel lasting 10-12 hrs. One can do ‘sewing machine movements’ at ankle joint or calf raises (‘tippy toe movements’) to prevent this.
8)Do the stockings used in varicose veins have specifications?
Yes. These have to be necessarily ‘graduated compression stockings’ (maximum pressure at ankle which progressively decreases at calf and in thighs). Depending on the compression pressure offered they are Class 1 / Class 2 / Class 3. They are available in ‘above knee’ and ‘below knee’ variants. The one best suited to you will be decided by your doctor after your clinical examination and venous doppler report. Majority of the patients are unaware of this information and end up using improper ‘over the counter’ stockings which offer little/no benefit.
9)What is venous doppler and its role in varicose veins?
Venous Doppler is the gold standard in diagnosis of varicose veins. In simple words it is the sonography of the veins in leg which tells your doctor about the exact level and extent of fault in your veins. It also helps to ensure that the deep veins are patent (open) since an obstructed deep vein system is a contraindication for varicose veins laser treatment. It is better to get this test done from the radiologist who is a part of your doctor’s team – it helps in vein mapping and better planning of treatment.
10)What is EVLT?
EVLT is endovenous laser treatment of varicose veins. Under sonography guidance, laser fibre is passed in the diseased vein. 1470 nm diode laser energy is applied to the vein internally (around 60 to 70 joules/cm).This causes the vein to obliterate, fibrose and eventually disappear. As a result of the diseased vein getting obliterated, there is no stasis of blood in the legs. The blood circulation is taken care of by rest of the normal superficial veins and the deep venous system.
11)Do patient need to get admitted for Endovenous Laser Treatment (EVLT)?
At quite a few centres, EVLT is an OPD procedure done under local anaesthesia (LA). But, we at Surekha Varicose Veins Clinic do EVLT under spinal anaesthesirequired and hence 24 hour hospitalisation is required. EVLT is done under SA for the following reasons :
- Absolutely painless for the patient. Under LA, patients (especially those with needle phobia) do complain of some pain/discomfort, which makes it difficult to treat them.
- We treat the multiple varicosities in tributary veins with laser, unlike other centres which use foam sclerotherapy. Laser application in tributary varicosities is a technically challenging procedure, but the results are superior to foam sclerotherapy. Using SA is essential in these cases, since it involves multiple vein punctures.
- Bilateral EVLT can be done in one sitting under SA. With LA, only one limb can be treated in one sitting.
Despite using SA, our patients are discharged in 24 hrs ananreport to work in 48 hours.
12)What are the advantages of EVLT over open surgery of varicose veins?
- Painless
- No scars
- Better results
- Early resumption of activities
- No/minimal complications
13)Are there any complications associated with EVLT?
Few and rare :
– Mild discomfort along the lasered vein
– Minor bruising
None of these complaints require separate treatment . They are self limiting and disappear in few days.
14)What is Radiofrequency Ablation of varicose veins (RFA)? Is it better than Laser Ablation of varicose veins?
RFA uses radiofrequency as energy source to obliterate varicose veins. It does have some advantage in terms of less bruising than laser ablation (however, with 1470 nm laser, the two are comparable). RFA does have its limitations though in tortuous varicose veins though, since its fibre cannot be passed in such veins. Also, the RF fibre is costlier. Long term results of RFA and EVLT are identical.
15)What is sclerotherapy/foam sclerotherapy?
Sclerotherapy is the use of a sclerosant (a liquid which damages the vein wall) to treat varicose veins. In foam sclerotherapy, the same liquid is used to prepare foam by Tessari technique. Though these are cheap and relatively easier methods to treat varicose veins, their complications such as post procedure pigmentation, skin necrosis, embolism or rarely anaphylaxis put limitations on it’s worth. Also, recurrence is more as compared to the laser treatment.
16)What is MOCA and Glue therapy for varicose veins?
MOCA (Mechanico Chemical Ablation) and Glue (closure by cyanoacrylate glue) are both newer techniques to treat varicose veins. Though promising due to their ability to treat patients under local anaesthesia, these techniques have their limitations :
- They are not recommended to be used in veins 12 mm or more in size.
- Their long terms results in terms of efficacy and recurrence are not yet available.
17)Does the patient need to take any special care following EVLT?
a)The patient is asked to wear class 2 graduated compression stockings for 3 months. The stockings are to be worn in morning and used for 8 to 10 hours. They help reduce the leg discomfort/pain after EVLT, if any. Also, they can help in better and optimal closure of the lasered vein.
b)It is recommended that the patient walks daily for 30 minutes after EVLT. Treadmill and gym exercises of weight training etc (which increase the intra-abdominal pressure) can be restarted after 4 weeks.
18)If the patient has an ulcer along with varicose veins, can he undergo laser treatment? How long will it take for the ulcer to heal?
Yes, the patient can (and should) undergo laser treatment at the earliest. The time for the ulcer to heal depends on the size of the ulcer. On an average it may take around 4 to 6 weeks. Regular cleaning and dressing of the ulcer has to be done (patient can do it at home) followed by wearing of class 2 stockings.
19)Will the pigmentation disappear completely along with the varicose veins after EVLT?
The pigmentation accompanying varicose veins is irreversible to a large extent. There is some lighting in patients who take care such as regular use of compression stockings and leg moisturiser.
20)What are the chances of recurrence of varicose veins after laser ablation?
Statistically, the chances of the lasered vein opening up are around 5% at the end of 5 yrs. As mentioned previously, since varicose veins is a progressive disease involving valve degeneration other superficial veins can become varicosed over a period of time. However, if one is vigilant regarding weight gain and regular exercises, the disease can be halted.
21)Is EVLT covered under insurance?
Yes. All major insurance companies offer mediclaim for varicose veins (after a 2 yr waiting period).