1. Causes of vein disease

Understanding vein diseases is important before starting its treatment. These vein diseases are the primary cause for blood circulation related complications in a person. The venous system of the human body is quiet complex and a good level of understanding is required to identify these vein diseases.

The venous system forms an important part of the circulatory system that helps return deoxygenated blood through veins to the heart and vice versa. This circulation of blood in the body keeps it healthy and fit. The smallest part of this system is the capillaries that feed blood to the larger superficial brains. Therefore, any problem in the circulation of blood in the body due to clotting and similar kind of problems is the main cause of vein diseases.

Varicose vein disease is mainly due to dilated or twisted veins in certain parts of the body. This sort of disease can occur in any portion of the body. However, the main area where this disease strikes is the legs in the body. In certain parts, veins have one-way valves that help the blood to get back to the heart against the pull of gravity. When these valves start to leak, the increased pressure prevents the blood from draining out properly.

This failure in circulation of blood is the root cause for varicose vein disease. Many individuals tend to develop this disease with advancing age or when they have a family history of this condition. In certain occupations where prolonged standing is necessary part of work routine, there is a big possibility of this disease being developed in such people.

Pregnancy or menstruation period happens to be conditions for women where there is onset of this disease. Varicose vein disease tends to cause heaviness and tiredness in the legs that makes it difficult to stand. The legs appear enlarged and there are snake-like blue veins that can be seen under the skin of the person. Those suffering from this disease will be able to feel a creeping sensation developing across their skin with cramps in their legs.

 

 

2. Varicose veins

These are enlarged, tortuous, unsightly veins that usually appear on the legs. Varicose veins are a common condition and it affects up to 25-40% of all females and 10-15% of males. It estimated to affect nearly 15 - 20% of all adults.

What causes varicose veins?

Risk factors are age, family history and pregnancy whereas obesity, prolonged standing, infection and trauma have been known to make varicose veins worse.

The main problem is that these veins have “faulty or damaged” valves. These one- way valves are located throughout the length of the inside of these veins. “Faulty or damaged” valves are also known as incompetent valves.

Veins normally return blood from the legs to the heart and usually these one-way valves prevent the blood from flowing backwards (reflux). When these valves are “faulty or damaged”, the blood now flows in both directions thereby causing pooling. This pooling of blood in the leg veins over a period of time causes the vein to bulge and protrude from the skin surface.

What are the symptoms?

Some patients have no symptoms whilst others may experience:

• Calf aches
• Calf heaviness
• Swelling of the legs
• Nocturnal calf cramps
• Itching
• Ezcema
• Discolouration of the skin
• Hardening of the skin
• Thrombophebitis
• Bleeding
• Ulcer formation

Diagnosis

Before treatment can be instituted, a duplex ultrasound should be performed. The ultrasound will be performed by our surgeon. It is performed to determine the exact pattern of abnormal blood flow (reflux) and the location of the abnormal or “faulty” valves.

Treatment for varicose veins is targeted at the superficial leg veins or the long saphenous vein(LSV). It is important that the deep leg veins are assessed before treatment to ensure they are normal.

The duplex ultrasound is performed in the clinic with conduction gel, there is no downtime, no pain or needles.

The results of the scan are immediate and with this result, the best treatment plan can be tailored for each individual patient.

What are the treatments?

The treatment of varicose veins depends on the results of clinical examination and duplex scan. Only the superficial vein or LSV is treated for varicose veins, these veins have “faulty or damaged” valves and hence are non- functioning. After treatment of the superficial vein or LSV, the blood from the legs now flows upwards through the deep vein system. There are many treatment options and the best option will be catered for each individual patient, in some cases, a combination of the treatment options may be useful.

• EVLT (Endovenous laser therapy)
• Conventional vein surgery
• Injection sclerotherapy
• UGFT (Ultrasound guided sclerofoam therapy)
• Ambulatory phlebectomy
• Conservative management which involves a combination of support/compression stockings, lifestyle modification and medication

Endovenous Laser Therapy( EVLT)

This procedure is the latest treatment for varicose veins, it is the minimally invasive alternative to conventional vein surgery. It is safe, fast and effective.

A fine needle puncture is perfomed into the thigh vein( LSV) around the knee area, through this needle puncture, a laser fibre is inserted. This is performed using ultrasound guidance.

The thigh vein is called the long saphenous vein and it is this vein that has the “faulty” valves that cause varicose veins. The laser fibre is heated and damages the inner lining of the “faulty” vein, this causes the vein to collapse and close, the collapsed vein disappears over time.

This procedure is performed under sedation or regional/general anesthesia and is usually done as a day case. EVLT of a single leg usually takes less than an hour.

All patients walk home after the procedure and usually return to normal activity within a few days. There is no lengthy hospital stay, no scarring and minimal pain. Patients are encouraged to walk as much as possible after EVLT.

Possible complications include haematoma, bruising, numbness and phlebitis which are all not serious.

Maximum benefit can be observed after 4- 6weeks and residual varicosities can be treated either by injection sclerotherapy or ambulatory phlebectomy.

The most recent studies have shown EVLT to have good results up to a maximum of 5 years and a success rate of > 98%.

Most patients will wear elastic stockings for two weeks after treatment, depending on the size and extent of the veins treated.

Conventional Vein Surgery

This procedure has been done for decades and has been proven to be safe and effective, it has a success rate of > 95%. It involves a small incision in the groin and removal of the “damaged” vein ( LSV) via the groin incision. Other small incisions are made below the knee to remove varicose veins.

This procedure requires general or regional anesthesia. It requires hospitalization, longer recovery period and has more post operative pain/scarring when compared to EVLT.

This procedure has also been proven to have more bleeding, wound infection rates as compared to EVLT.

Conventional vein surgery is still recommended for some patients who some reason or other may not be suitable for EVLT.

Ultrasound guided sclerofoam therapy( UGFT)

Using a fine needle, sclerofoam is injected carefully into these spider veins and reticular veins. Sclerofoam is mixture of sclerosant( liquid) and air. The sclerofoam damages these small veins and causes them to collapse, these veins are then reabsorbed by the body.

This procedure is performed in the clinic, it requires multiple sessions, approximately 6-8 weeks apart. UGFT is performed with topical anesthetic cream, there is no downtime and patients can resume normal activity immediately. Possible complications include bruising, bleeding or staining but all of these are not serious.

Ambulatory Phlebectomy

This procedure involves making small incisions along the varicose veins and removing them using special tools. It may require multiple incisions and local anesthesia is needed.

It can be performed in the clinic with minimal downtime/pain and the patient can resume daily activity within 24 hrs.It can be performed as an adjunct to EVLT and possible side effects include, bleeding and haematoma and numbness.

Spider Veins These are unsightly red/blue or purple sunburst or web patterns made by small veins. They can appear on the face, arms or legs and are located just below the skin surface. Up to 40% of all females are affected by spider veins and some of these spider veins may be associated with varicose veins. Spider veins can be connected to deeper veins called reticular veins. It is important to treat these reticular veins as well, in order to achieve good aesthetic results. Spider veins usually have no symptoms but some may grow larger, bleed or even cause itching. What Are the Causes? The cause of spider veins is unclear, for some patients it is familial whilst for others, it develops due to certain risk factors like occupations with prolonged standing, hormonal changes and pregnancy. Treatment involves a combination of laser and sclerotherapy. Some spider veins may reappear but can still be effectively treated. Success rates can vary from 50-90% and depends on numerous individual patient factors. Treatment Injection Sclerotherapy Injection   This procedure involves using a fine needle to inject a sclerosant( liquid) into these small veins. The sclerosant damages the lining of the veins and causes it to collapse. The veins are then reabsorbed by the body. The procedure requires multiple sessions, approximately 6 to 8 weeks apart and possible side effects can be bruising,   hyperpigmentation and inflammation. This procedure is performed in the clinic with topical anesthetic cream, takes about 30-45 minutes and there is no downtime. Normal activity can be resumed immediately. About 10-20% of these spider veins may never disappear even after treatment. If the spider veins reappear, it is usually a result of underlying venous reflux and as a courtesy to our patients, we would recommend a thorough assessment of the entire venous system. Injection sclerotherapy can also be performed after EVLT treatment for varicose veins to improve the aesthetic appearance of the leg, it is safe and effective. Injection sclerotherapy is best for spider veins, reticular veins and some small varicose veins. Laser treatment Laser      This is the latest modality for the treatment of spider veins. It is fast, safe, easy and effective. The laser beam heats up the blood in these veins and causes the veins to collapse. The procedure is performed in the clinic with topical anesthetic cream and takes approximately 30-45 minutes. There is minimal or no pain and no downtime, the   patient can resume normal activity immediately. This treatment should be performed 6-8 weeks apart and for best results. Avoidance of direct sunlight to the treated area is recommended for a period of 4-6 weeks to maximize results. Some possible side effects are inflammation, bruising and hyperpigmentation. This is the best treatment for fine spider veins and reticular veins This article was written by Dr Sanjay Nalachandran, General/Vascular Surgeon, Vein & General Surgery Clinic, Gleneagles Medical Centre, Singapore .

 

 

3. What are varicose veins?

These are enlarged, tortuous, unsightly veins that usually appear on the legs. With the latest laser technology (EVLT) these varicose veins can be treated easily and effectively.

What are the symptoms?

Some patients have no symptoms whilst others may experience:

• Calf aches
• Obvious unsightly leg veins
• Calf heaviness ( usually at the end of the day)
• Swelling of the legs
• Nocturnal calf cramps
• Itching
• Eczema
• Discoloration of the skin
• Bleeding from the veins
• Ulcer formation

If you have any of the above symptoms, you may be suffering from symptomatic varicose veins

What causes varicose veins?

Some people are more prone to varicose veins because of their family history or their gender (women more than men) whereas certain conditions like obesity, prolonged standing, infection and trauma increase the pressure on the leg veins causing them to enlarge and bulge.

Veins normally return blood from the legs to the heart. These veins have one –way valves that are located throughout the length of the inside of these veins and usually these one-way valves prevent the blood from flowing backwards (reflux).

When these valves are “faulty or damaged”, the blood now flows in both directions thereby causing pooling. This pooling of blood in the leg veins over a period of time causes the vein to bulge and protrude from the skin surface.

How is the diagnosis of varicose veins made?

A duplex ultrasound should be performed to determine the exact pattern of abnormal blood flow (reflux) and the location of the abnormal or “faulty” valves.

Treatment for varicose veins is targeted at the superficial leg veins or the long saphenous vein (LSV). It is important that the deep leg veins are assessed before treatment to ensure they are normal.

The duplex ultrasound is performed in the clinic with conduction gel; there is no downtime, no pain or needles. The results of the scan are immediate and with this result, the best treatment plan can be tailored for each individual patient.

What is the treatment for varicose veins?

Varicose veins can be treated in 2 ways, either with conventional vein surgery or with EVLT. Conventional surgery involves removing the varicose veins through an incision in the groin. Though, effective, it has more pain, more complications, longer recovery period and more surgical scarring as compared with EVLT.

Endovenous Laser Therapy (EVLT)

This procedure is the latest treatment for varicose veins; it is the minimally invasive alternative to conventional vein surgery. It is safe, fast and effective.

A fine needle puncture is performed into the thigh vein (LSV) around the knee area, through this needle puncture, a laser fibre is inserted. This is performed accurately using ultrasound guidance.

The thigh vein is called the long saphenous vein and it is this vein that has the “faulty” valves that cause varicose veins. The laser fibre is heated and damages the inner lining of the “faulty” vein, this causes the vein to collapse and close, the collapsed vein disappears over time.

This procedure can be performed under sedation or regional/general anesthesia and is usually done as a day case. EVLT of a single leg usually takes less than an hour. There is no groin incisions, no surgical scarring, minimal pain and the recovery period is short.

Author :  Dr Sanjay Nalachandran, General/Vascular Surgeon, Vein & General Surgery Clinic, Gleneagles Medical Centre, Singapore .