NORMAL CIRCULATION
Healthy arteries and veins act as ‘one-way streets’, allowing blood to flow in one direction only. The beating heart directs blood through arteries to the entire body. Blood is then returned to the heart through the veins. The contraction of the leg muscles acts like a pump to move blood up the veins, against the force of gravity. The one-way valves in the leg veins prevent the backflow of blood down towards the feet.
There are two systems of veins: deep and superficial. Deep veins are located well below the skin, often within the muscles, and are crucial in maintaining a healthy circulation. Superficial veins are located near the skin surface, and drain into the deep veins through junctions. Superficial veins are also connected to deep veins through multiple small connections called ‘perforating veins’. Valves inside the perforating veins and junctions prevent the flow of blood back into the superficial veins. Blood thus naturally flows from the superficial veins into the perforating veins and junctions, which connect to the deep veins and then back to the heart.
Saphenous veins are the main superficial veins in the legs. Saphenous veins collect blood from other surface veins and drain it into the deep veins. The longest, the Great Saphenous Vein, is located in the inner aspect of the leg and travels from the ankle to the groin. The Small Saphenous Vein is located at the back of the calf muscle and travels from the outer ankle to the back of the knee. The Great Saphenous Vein is the vein that is most commonly ‘stripped’ in varicose vein operations.
ABNORMAL VEINS
Abnormal veins have weak walls. These veins collect and contain more blood than normal veins, causing distension in the vein. Because of this distension, the valves no longer function properly, which causes a ‘leakage’, ‘reflux’ or ‘backflow’ in the affected vein. A vein demonstrating reflux is termed ‘incompetent’.
There are three types of abnormal veins, which are frequently seen in combination. ‘Spider veins’ (telangiectasias) are the fine red capillary veins. The larger blue veins are called ‘reticular veins’, and are slightly deeper below the skin’s surface. Varicose veins are the largest of the abnormal veins, and may bulge above the skin’s surface.
Backflow from larger veins into smaller capillaries causes their distension and the formation of so-called ‘spider veins’. This is why treatment of spider veins in the presence of an underlying varicose vein is not considered appropriate, because it does not address the underlying problem. Backflow also leads to congestion of blood in the leg veins, which can cause symptoms such as pain, fatigue, heaviness, aching, burning, throbbing, cramping and restless legs. Symptoms are often made worse by prolonged standing. The presence of a skin rash, small blue veins on the feet, skin discoloration and ulcers usually indicate advancing vein problems. Severe varicose veins can compromise the nutrition of the skin and lead to eczema, inflammation or even ulceration of the lower legs. Treating the abnormal veins will lead to improvement of the symptoms in the majority of patients.
Vein disorders are not always visible; diagnostic techniques are important tools in determining the cause, severity and extent of the problem. Apart from physical examination, non-invasive ultrasound is often used to assist with assessment of the veins. Ultrasound investigation can accurately measure vein diameter, assess reflux and contribute to a precise map of both normal and abnormal veins of the leg.
WHAT CAUSES VARICOSE AND SPIDER VEINS?
A definitive cause is not known; however, a strong family history is a common indication, suggesting that some patients inherit veins that are more likely to deteriorate. Women are more likely to suffer from varicose veins at an earlier age than men. Up to 30% of men and women are affected. In women, varicose veins may worsen with fluctuations of hormones, such as during puberty, pregnancy and menopause, and with the use of birth control pills. It is common for pregnant women to develop varicose veins during the first trimester. Pregnancy results in elevated hormone levels and blood volume, which in turn cause veins to enlarge. In addition, the enlarging uterus causes increased pressure on the leg veins. Varicose veins occurring in pregnancy will often improve significantly within three months after delivery. However, with successive pregnancies, abnormal veins are likely to get worse. Other predisposing factors include ageing, standing occupations, obesity, lack of mobility, previous venous thrombosis and leg injury.
DO WE NEED OUR VARICOSE AND SPIDER VEINS?
Varicose and spider veins are unhealthy superficial veins that do not function correctly and fail to return blood back to the heart.
Varicose veins impose an extra burden on the deep veins, which can lead to their deterioration. To compensate for the lack of function in varicose veins, deep veins have to work harder, and in some cases, they become abnormal. Once varicose veins are removed, the blood circulation will improve. In general, varicose veins are not suitable for use in heart by-pass operations, because they are damaged.
Spider veins are unsightly, abnormal veins and do not serve a biological purpose.
WHEN DO YOU NEED TO TREAT YOUR VEINS?
Early treatment of varicose veins may reverse the symptoms of venous congestion and minimise the risk of varicose vein-related complications and further progression of the disease. Treatment becomes more urgent if there are coexisting complications such as bleeding, inflammation (phlebitis), clots (thrombosis), dermatitis or ulcers. In general, it is much easier to treat varicose veins when they are smaller, as early treatment tends to be less complicated and less involved. It is recommended that varicose veins be treated before pregnancy, since complications such as clotting and bleeding can develop during pregnancy. Varicose veins that have worsened during pregnancy may not fully recover after pregnancy, requiring more involved and complicated treatment than would have been required before pregnancy. Spider veins should be treated only after the varicose veins have been successfully treated.
HOW CAN A PHELEBOLOGIST HELP?
Phlebologists have considerable expertise in using vascular ultrasound, which assists in achieving a more accurate diagnosis and management of venous disease. New ultrasound and laser technology, along with the introduction of foam sclerotherapy, have significantly advanced the non-surgical treatment of varicose veins. Phlebologists certified by the Australasian College of Phlebology are highly skilled at assessing venous disease and can offer a wide range of treatment options.
INVESTIGATIONS
Before treating varicose veins, duplex ultrasound studies are organised to map the abnormal veins. Deep vein thrombosis (DVT) scans may also be required if there is a history of clotting. Patients with a personal or family history of blood clots will require blood tests to assess their relative risk. Patients with concurrent arterial disease may need additional ultrasound studies to assess their arterial blood supply. Once tests arecompleted, the phlebologist will be able to determine the most appropriate course of treatment.
TREATMENT OPTIONS
Microsclerotherapy
Microsclerotherapy involves injecting a sclerosing agent into abnormal surface veins using a fine needle. This procedure is usually reserved for the treatment of small, blue superficial veins (reticular veins), spider veins and sometimes for small visible varicose veins. Successfully treated veins will fade as the body gradually removes them. In many patients, sclerotherapy can relieve the symptoms caused by varicose veins. With this procedure, veins can be dealt with at an earlier stage, helping to prevent further complications.
Some veins may need to be injected more than once for optimum results. Generally, normal activities can be resumed straight after sclerotherapy. Medically prescribed compression stockings are essential to achieving the best outcome, and may need to be worn for several days or weeks to assist in resolution of the veins.
The procedure is performed in the doctor’s office and usually causes minimum, transient discomfort. Microsclerotherapy is considered the gold standard in treatment of spider veins of the legs.
Ultrasound Guided Sclerotherapy (UGS)
UGS is a modern technique that is reserved for treating advanced varicose veins that are hidden beneath the skin. UGS is a versatile procedure that can treat saphenous veins, perforating veins, and other hidden varicose veins.
The ultrasound precisely displays the abnormal veins, as well as adjacent structures such as deep veins and arteries. With ultrasound guidance, the phlebologist can inject the hidden abnormal veins while observing the process on the ultrasound monitor. Once injected, the treated vessel will be gradually absorbed by the body and will disappear with time. A number of injections will be required along the length of the vein to achieve complete closure. Another significant advantage of this method is that it allows the phlebologist to monitor the effect of each injection, while ensuring the safety of all adjacent structures. The use of sclerosant as foam, rather than solution, has made this procedure much more effective.
The treatment may take up to half an hour. Following the procedure, patients are fitted with graduated compression stockings and asked to go for a 30-40 minute walk to promote blood flow in the deeper veins.
Catheter Guided Sclerotherapy (CGS)
CGS involves using a long catheter to deliver the sclerosing agent. This technique is used to seal off the incompetent saphenous veins. A local anaesthetic is used to numb the area and a catheter is inserted into the abnormal vein under ultrasound guidance. The sclerosing agent is then injected as the catheter is slowly withdrawn from the vein.
This technique increases the safety of the treatment, because the placement of the catheter ensures that the solution is injected only into the abnormal vein, away from other structures. This method involves minimal injections and therefore is more comfortable than some other techniques. This technique is also called Extended Long Line Echosclerotherapy (ELLE), and was first developed by Australian phlebologists.
Endovenous Laser Ablation (EVLA)
EVLA is the latest method for the treatment of large saphenous veins that would previously have been subjected to surgical stripping under general anaesthetic.
EVLA involves a combination of laser and ultrasound technology, and does not require admission to hospital or general anaesthesia. Published research of the technique performed on more than 1000 patients has shown a low risk of complications and superior results when compared with surgery and UGS (excellent results in over 90% of patients).
EVLA is used to treat the main trunks of abnormal saphenous veins. A fine laser fibre is inserted into the target vein, under local anaesthetic. Laser energy is then delivered into the vein, causing the vein to collapse and seal shut. Following the procedure, compression stockings are prescribed and a daily walk is advised.
To treat the remaining abnormal branch veins, UGS or phlebectomy (see below) may be required.
Ambulatory Phlebectomy
Ambulatory phlebectomy is the surgical removal of superficial varicose veins. This is usually done in the office, using local anaesthesia. Incisions are tiny (stitches are generally not necessary) and scarring is minimal. After the vein has been removed, a bandage and/or compression stockings are worn for a short period of time.
Surgery
Surgical techniques include ligation (tying off the vein), stripping (removal of an extensive segment of vein by pulling it out) and phlebectomy (removal of veins through tiny incisions). Surgery may be performed using local, spinal or general anaesthesia, with most patients returning home the same day as the procedure. Surgery has traditionally been used to treat large varicose veins, but recent studies indicate a poor long-term success rate.
Vascular Lasers & Intense Pulse Light
These techniques have proved disappointing in treating spider veins of the leg. Light-based treatment is generally only suitable for small veins above the waist, and is best used to treat vascular lesions such as birth marks (such as port-wine stains) and facial veins.
Sclerotherapy remains the gold standard for treatment of superficial leg veins.
IMPORTANT GENERAL MEASURES
A number of simple measures should be followed to prevent further deterioration of varicose veins.
1. Activate your calf muscles (by walking, jogging, running). This will encourage the muscles to contract, which will stimulate blood flow through the venous system and the return of blood back to the heart.
2. Elevate the legs when you can. This will help the return of blood to the heart.
3. Wear graduated compression stockings. These provide more compression near the ankles and less further up the limb, which encourages the flow of blood back to the heart.
4. Avoid prolonged sitting and standing. Exercise activates your calf muscles and helps to empty your veins. When sitting or standing cannot be avoided, activate the calf muscle pump by flexing your feet, to lift your heels off the ground. At work or during long distance travel, get up from time to time and go for a walk.
5. Lose weight. Excess weight can worsen varicose veins and cause both venous and lymphatic problems.
WHAT ARE THE POSSIBLE COMPLICATIONS IF I DO NOT HAVE ANY TREATMENT?
With large varicose veins, spontaneous blood clots may develop in the superficial veins and, more rarely, in the deep veins. Clots in the deep veins (deep vein thrombosis or DVT) can dislodge and travel to the lungs, which can cause pulmonary embolism?a life-threatening condition. Skin changes, including increased or decreased pigmentation, hardening of the skin and underlying fat (lipodermatosclerosis) and ulcers, may develop in the lower legs. Ulcers may become weepy, infected and painful, and take longer to heal.
Spider veins may indicate an underlying varicose vein disease, but otherwise are mainly a cosmetic concern.
HOW CAN I GET MORE INFORMATION?
A visit to a phlebologist will help answer your questions, and he/she can evaluate your problem, determine what testing is appropriate, and discuss the available treatment options.
To obtain a list of specialists in your local area, please either search our online member database at www.phlebology.com.au or contact the ACP by phone or email.