VARICOSE VEINS

Venous disease (varicose veins, chronic venous insufficiency) is a common problem affecting the general population throughout the world. In India, it is estimated that around 15-20% of population is suffering from vein disease. As a clinician, I have come across 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, 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 valves. The veins affected are the great saphenous vein/short saphenous vein/their tributaries. By definition, their size is 4mm and above.

2)What are the symptoms/problems caused by varicose veins?

​Dilatation of veins : cosmetically unsightly – Dull aching pain in the calf, more towards the evening – Swelling over ankle, foot which resolves overnight If left untreated varicose veins cause further problems, though, it is difficult to predict who will develop the complications and in what time.

​Following are the complications which can arise :

​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).

b)Bleeding from the dilated veins – This is a frightening thing (especially the first time). However, tight pressure bandage and limb elevation stops the bleeding in some time.

​c)Pigmentation of the skin around ankle – due to haemosiderin deposits in skin; this is irreversible in majority cases (even after treatment).

​d)​Venous eczema – the skin around ankle becomes dry, itchy and scaly.

​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 notorious for non-healing

​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

-Multiple pregnancies

– Ageing However, as mentioned earlier, only those with valve abnormalities might develop varicose veins.

​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 formation of varicose veins?

​Since it is a disease of valve degeneration, nothing much can be done except for two things (which may help) – Using class 1 or class 2 graduated compression stockings, if one’s profession involves prolonged standing hours-Calf strengthening exercises

​7)​Can walking/prolonged standing/exercise worsen varicose veins?

​Yes. One can use graduated compression stockings to slow down the progress of the disease but eventually treatment is necessary.

​8)​Can prolonged sitting cause problems in patients with varicose veins?

​In some cases it can. Swelling of legs is seen in some patients of varicose veins (after prolonged bus journey, airplane travel lasting 10-12 hrs). One can do ‘sewing machine movements’ at ankle joint/calf raises (‘tippy toe movements’) to prevent this.

​9)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.

​10)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.

​11)What is EVLT?

​EVLT is endovenous laser treatment of varicose veins. Under sonography guidance, laser fibre is passed in the faulty vein. Using the latest 1470 nm diode laser laser energy is applied to the vein internally (around 60 to 70 joules/cm).This causes the vein to obliterate, fibrose and eventually disappear (over a period of 3 months). As a result of the faulty vein getting obliterated, there is no stasis of blood in the legs. The blood circulation is taken care by rest of the normal superficial veins and the deep venous sustem. This leads to cessation/ improvement of symptoms.

​12)​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. But, we at SUREKHA VARICOSE VEINS CLINIC, SAMATA HOSPITAL (one of the few centres in Thane district for endovenous treatment of varicose veins) do EVLT under spinal anaesthesia for the following reasons : Better patient compliance especially if multiple punctures are to be taken during the procedure. – Easier to combine phlebectomy (removal of large veins by a 5mm incision) – This is sometimes required in patients if the vein is large in size (more than 12 mm). Patients require hospitalisation for 24 hrs and can report to work in 48 hours.

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​13)What are the advantages of EVLT over open surgery of varicose veins?

​- Painless

– Scarless

– Better results

– Early resumption of activities

– No/minimal complications

– In patients with bilateral varicose veins, both limbs can be treated at the same time; in surgery, one has to wait 3 months before treating the second limb

​14)Are there any complications associated with EVLT?

​Few and rare :

– Vague pain in the leg

– Minor bruising

– Numbness along the inner aspect of ankle

None of these complaints require separate treatment . They are self limiting and disappear in few days.

​15)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 in very tortuous varicose veins since its fibre cannot be passed in such veins. Also, the RF fibre is costlier. Long term results of RFA and EVLT are identical.

​16)What is sclerotherapy/foam sclerotherapy?

​Sclerotherapy is 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 extremely cheap and relatively easier methods to treat varicose veins, their complications such as post procedure pigmentation, skin necrosis and rarely, embolism or anaphylaxis put limitations on it’s worth. Also, recurrence is more as compared to the laser treatment.

​17)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 : a)They are not recommended to be used in veins 12 mm or more in size. b)Their long terms results in terms of efficacy and recurrence are not yet available.

​18)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 :

a)They are not recommended to be used in veins 12 mm or more in size. b)Their long terms results in terms of efficacy and recurrence are not yet available.

​19)Does the patient need to take any special care following EVLT?

​Yes. The patient is required to wear class 2 graduated compression stockings for 4 months. The stockings are to be worn in morning (within 30 minutes of getting up, after morning rituals of bathing etc). They are to be removed at night time while going to bed. The usage of stockings helps in better and optimal closure of the lasered vein. Apart from this, patient can go about his routine work after 72 hrs (walking/climbing up and down the stairs/travelling). In fact, it is recommended that the patient walks for 30 minutes daily (obviously with the stockings). Treadmill/gym exercises of weight training etc (which increase the intra-abdominal pressure) can be restarted after 4 weeks.

​20)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.

​21)Will the pigmentation disappear completely along with the varicose veins after EVLT?

​The pigmentation accompanying varicose veins is irre‐ versible. There is definite improvement; however, the leg will never be returned to its original appearance. Ideally, such patients have to take care of the leg continually (applying moisturiser/coconut oil at least once per day to avoid dryness). Hence, it is important to seek treatment of varicose veins before the complications set in.

22)Does the patient need to use stockings lifelong even after EVLT?

​In patients below the age of 60 yrs and especially if they are leading an active lifestyle, it is better they continue usage of class 1 or class 2 stockings. The reason being – varicose veins is a progressive disease of valve degeneration. The faulty vein is treated by laser but other superficial veins (there are many of them in the leg) are prone to varicosities. Usage of stockings will help the calf muscle pump to perform better thereby preventing/delaying the progress of disease.

​23)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 varicose over a period of time. However, even if happens, it is generally not of the same magnitude. Minor varicosities appearing can be dealt with foam sclerotherapy or microphlebectomy (if they are symptomatic).

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​24)Is EVLT covered under insurance?

Yes. All major insurance companies offer mediclaim for varicose veins (after a 2 yr waiting period). To summarise, early diagnosis and treatment of varicose veins is a classic case of the adage – ‘A stitch in time saves nine’.