Varicose Veins and Venous Ulcers

Varicose veins are swollen veins that can be seen through the skin, often appearing as blue, bulging and twisted veins just beneath the skin’s surface (superficial veins of the legs).

They are caused by the veins stretching and the valves within the veins weakening due to increased periods of standing or sitting which cause blood to ‘pool’ and the venous blood pressure to increase, as the body works harder to pump blood against gravity and back towards the heart.

Varicose veins can cause aching and feelings of fatigue in the lower limbs particularly feet and claves, and when left untreated, are likely to worsen over time.

Severe cases of varicose veins can lead to an increased risk of deep vein thrombosis (DVT), a serious condition requiring urgent medical attention.

Women are more likely to develop varicose veins than men, and smoking, lack of exercise, as well as being overweight are also contributing factors.

Venous ulcers are the most common of chronic leg ulcers (6 out of 10 ulcers seen in our community), which usually occur in the lower calf due to venous hypertension (pooled blood that gathers in the lower leg due to damaged valves in the vein allowing blood to flow back into the leg instead of carrying it towards the heart).

This causes the blood pressure to increase, and is often associated with calf and ankle swelling.

Frequently venous ulceration develops in a patient with a long history of varicose veins associated with skin pigmentation, chronic swelling and other advanced changes such as lipodermatosclerosis.

Venous ulcer can heal spontaneously but most of the time the healing process takes significant period (weeks to months) and commonly it can reoccur.

Despite popular belief these ulcers are very painful and require diligent dressing care and compression therapy to allow healing.

Diagnostic techniques:

  • Physical examination
  • Venous Duplex Ultrasound (Chronic Venous Insufficiency study)

Treatment options

Endovenous Thermal Ablation techniques:

  • Radiofrequency Ablation (RFA) therapy – it’s a forms of ablation technology that destroys the incompetent vein segment which the body eventually absorbs. It generates high temperature inside the treated vein and subsequently changes the structure of the vein wall causing that vein to collapse.  This technique requires a small catheter to be inserted into the vein using ultrasound guidance. The tissue surrounding the vein segment planned to be addressed is infiltrated with diluted local anaesthetic (tumescent anaesthesia) preventing local thermal injury and pain. Thermal energy (120 degrees of Celsius) is applied directly to the vein wall. At the completion of the RF Ablation patient applies graduated compression stockings which are worn for 2 weeks during the day only.
  •  Endovenous Laser Ablation Therapy (EVLT) – This is another thermal ablation therapy which utilizes focused laser beam to generate high temperature inside the treated vein. EVLT use the same principle as RFA and requires patient to wear compression stockings following the procedure.

Both RFA and EVLT have advantage of providing patients with rapid postprocedural recovery with speedy return to normal activities (usually within 3-5 days). Those methods are associated with a significantly lesser degree of postprocedural pain, bruising and swelling. Access site is hardly visible therefore cosmetic appearance after procedure is extremely pleasing.

RFA and EVLT are performed under local anaesthetic only and are rooms based procedures. No admission to the hospital is required.

Non-Thermal Endovenous Treatment Methods

  • VenaSeal procedure – This particular option is one of the newest endovenous minimally invasive techniques available. VenaSeal is based on ultrasound guided (controlled) delivery of a special tissue glue (cryoaccelatate) to the incompetent vein which otherwise would have to be treated with thermal ablation (RFA or EVLT) or open surgery. The unique characteristics of that glue allow it to set rapidly on exposure to blood contained within the treated vein. As such only single injection of local anaesthetic is required to allow introduction of very small delivery tube (catheter) into the vein. VenaSeal delivered inside the vein causes no pain and works immediately. Thus, there is no need to wear compression therapy during recovery. VenaSeal provides patients with rapid and painless recovery and to the date remains the least invasive method available to treat varicose veins.

Open Varicose Vein Surgery

This procedure requires an incision to be made in the groin and a smaller incision to be made lower in the leg that allows a small metal or plastic rod to be inserted through the incompetent vein to remove the damaged section of vein. This part of the procedure is commonly known as “vein stripping”.

The Surgeon will tie the vein prior to cutting it, to stop the blood flow (high ligation) and the associated varicose veins will be removed separately using a hook-like tool and by making a series of incisions into the affected veins (multiple phlebectomies or multiple stab avulsions).

A general anesthetic is required for this procedure.

Usually patients remain in hospital overnight and require to wear compression stockings for at least 2 weeks postoperatively.

Open varicose veins surgery has the long history and has been performed for more than 50 years.

It offers reliable solution but required significantly longer time to recover and return to normal activities.

It carries very small risk of major complications (less than 1%) such as Deep Vein Thrombosis (DVT) and infections requiring administration of intravenous antibiotics.

Cosmetically open surgery leaves patients with number of small incisions.

Open varicose veins operations are the main method used for treatment of large recurrent varicose veins.

Ambulatory Phlebectomies

This open approach to varicose veins addresses only visible bulging but cannot remove underlying source of those veins which usually is incompetent vein in the thigh (Long or Greater Saphenous Vein) or/and in the calf (Short or Lesser Saphenous Vein).

Ambulatory phlebectomies can be performed in the clinics, however generally safer environment, providing patient with better pain controlled and lesser risk of postprocedural infection, exists in operating theatres.

Sclerotherapy (injection treatment)

Sclerotherapy – a chemical is injected into the varicose veins to make them collapse and eventually disappear.

This method has been widely utilized to treat different types of varicose veins.

The most common indication to use sclerotherapy as a primary method is presence of spider veins (telangiectasiae).

These very small thread-like veins are located within the skin as oppose to bulging varicose veins (truncal varicose veins) located under the skin.

Sclerotherapy also affectively treats larger spider veins (reticular veins) as well as small isolated truncal varicose veins and recurrent varicose veins.

The general success rate is approximately 70-80% following single injection treatment session.

There is no requirement for any anaesthetic as generally injections are well tolerated. If skin sensitivity is an issue, patients can apply local anaesthetic cream (EMLA Cream) 30-60 minutes prior to the scheduled sclerotherapy session.

Generally graduated compression stockings are required and worn over a period of 10-14 days. Some surgeons are happy to address spider veins with sclerotherapy without patient applying stockings after the treatment.

Variable types of sclerotherapy have been developed to address wide range of varicose veins.

These include:

  1. Microsclerotherapy
  2. Foam Sclerotherapy
  3. Ultrasound guided foam sclerotherapy

Sclerotherapy doesn’t interfere with one’s lifestyle and majority of treated patients can return to normal duties within a few days.