Treatment of varicose veins

Surgery remains the gold standard treatment option, says Mr Robert Galland.

Right thigh above the knee showing extensive venous flare formation
Right thigh above the knee showing extensive venous flare formation

Varicose veins affect 32 per cent of women and 40 per cent of men in the western world.1 Associated symptoms include aching, heaviness, ankle swelling, phlebitis, pruritus and sometimes muscle cramps; these are often worsened by prolonged standing or warm weather.

Assessment and investigation
Symptoms are often non-specific and other causes need to be excluded before the patient is diagnosed as having symptomatic varicose veins.

It is important to establish whether patients have true varicose veins, for example, veins which are dilated, lengthened or tortuous, blue veins or flares. Blue veins are slightly enlarged blue-coloured veins that can be seen just under the surface of the skin. Venous flares (spider veins, telangiectasia or thread veins) are blood-filled capillaries.

Microsclerotherapy or cutaneous lasers are the best way of dealing with them, but this article will focus on true varicose veins.

Significant features in the history include a family history, previous DVT, trauma to the limb and whether the patient is on the contraceptive pill or HRT.

Varicose veins affecting the thigh are generally long saphenous in origin. Short saphenous varicose veins arise from the saphenopopliteal junction in the popliteal fossa and are generally situated on the back of the calf and track down towards the lateral malleolus.

Swelling and the presence of an inverted champagne bottle deformity should be noted. Skin at the gaiter area should be examined for discolouration, eczema and ulceration.

Handheld Doppler examination can confirm whether there is long saphenous incompetence or reflux in the popliteal fossa. Duplex need not be carried out in all patients but should be performed in those with recurrent varicose veins, evidence of reflux in the popliteal fossa and those with clear evidence of chronic venous insufficiency or a history of DVT.

Conservative treatment
Class II compression stockings can alleviate aching and heaviness, but may be uncomfortable, particularly during warm weather. Four layer compression bandaging will result in about 75 per cent of venous ulcers being healed within three months.

With an ankle brachial pressure index (ABPI) of 0.8-1.3, compression therapy is the first-line treatment for venous leg ulcers. Below 0.8 and above 1.3, compression bandages should only be applied by clinicians with special training and expertise (such as leg ulcer nurse specialists or tissue viability nurses).

With an ABPI ≤0.5, no compression and urgent referral to the vascular team is required.2 Surgery of the underlying venous disease can effectively reduce risk of recurrence once healing has occurred. Class II support stockings should then be worn.

Surgical treatment
Surgery remains the gold standard. Principles of the operation are proximal ligation (of saphenofemoral or saphenopopliteal junctions), stripping of the long saphenous (or short saphenous) trunks and avulsion of non-truncal varicose veins.

Most procedures can be carried out as day cases. Postoperatively the leg is bandaged to control bruising. Bandages are removed the next day and a TED (anti-embolism) stocking worn for seven days.

Patients should be encouraged to mobilise. Most are driving within two days and back to work or normal leisure activities within two weeks.

Surgery can improve quality of life.3,4 Recurrence rates of up to 50 per cent at 10 years have been reported.5 Complications include bruising, particularly in the lower medial thigh following stripping and wound infection and lymph leaks.

Approximately a quarter of patients, six weeks postoperatively, have some numbness.6 This is generally temporary. The risk of clinical DVT is <0.5 per cent. However, if postoperative duplex scanning is carried out the prevalence is approximately 5 per cent.

Alternatives to operation
Recently, alternatives to surgery have been introduced, paradoxically, at a time when PCTs have started to ration varicose vein treatment. In our unit this has resulted in a reduction in varicose vein procedures of about 80 per cent.7

Foam sclerotherapy, radio frequency ablation (RFA) and endovenous laser treatment all occlude the long saphenous vein (and perhaps the short saphenous vein), so avoiding proximal ligation and stripping.8 Short-term results appear equivalent to those obtained by operation.9

Initial occlusion rates of >90 per cent are obtained, with laser treatment having the best results. Recanalisation, at an average follow up of about 12 months, occurs in up to 15 per cent, with laser treatment again producing the best results.

The advantages of these techniques are that they: avoid dissection of the groin or popliteal fossa; can be carried out under local anaesthetic; and are associated with a quicker return to normal activities. However, there are cost implications and long-term results are uncertain. A proportion of patients will require avulsions of non-truncal varicose veins once the main trunks have been occluded.

Each technique is associated with complications. Paraesthesia and skin burns have been noted in up to 20 per cent of cases following RFA. DVT also appears to be higher in RFA compared with the other techniques, occurring in up to 16 per cent of cases.

Clinical DVT following laser therapy is <1 per cent, while foam sclerotherapy is associated with significant phlebitis in up to 5 per cent, but the main problem is of foam microemboli.

Visual disturbances following sclerotherapy have been reported in up to 6 per cent of cases.

Key points
  • Referral is appropriate for varicose veins if conservative treatment fails or there is evidence of complications.
  • Surgery is the proven means of dealing with varicose veins.
  • Of the alternatives, laser treatment to occlude truncal veins is most likely to produce good results.
  • Mr Galland MD, FRCS is a consultant at the Royal Berkshire Hospital and the Spire Dunedin Hospital, Reading

References
1. Darwood RJ, Theivacumar N, Dellagrammaticas D, et al. Randomized clinical trial comparing endovenous laser ablation with surgery for the treatment of primary great saphenous varicose veins. Br J Surg 2008; 95: 294-301.

2. RCN. The nursing management of patients with venous leg ulcers. London, RCN, 2006. www.rcn.org.uk/__data/assets/pdf_file/0003/107940/003020.pdf

3. Durkin MT, Turton EP, Wijesinghe LD, et al. Long saphenous vein stripping and quality of life. Eur J Vasc Endovasc Surg 2001; 21: 545-9.

4. MacKenzie RK, Paisley A, Allan PL, et al. The effect of long saphenous vein stripping on quality of life. J Vasc Surg 2002; 35: 1197-203.

5. Winterborn RJ, Foy C, Earnshaw JJ. Causes of varicose vein recurrence: late results of a randomized controlled trial of stripping the long saphenous vein. J Vasc Surg 2004; 40: 634-9.

6. Wood JJ, Chant H, Laugharne M, et al. A prospective study of cutaneous nerve injury following long saphenous vein surgery. Eur J Vasc Endovasc Surg 2005; 30: 654-8.

7. Bajwa A, Magee TR, Galland RB. Reduction in varicose vein services: impact on operative training. Ann R Coll Surg Engl 2007; 89: 789-91.

8. Thava B, Galland RB. Novel therapies for varicose veins. In: Taylor I (ed). Recent Advances in Surgery 32. London, RSM Press, 2009.

9. Jarvid M, Lovegrove RE, Magee TR, et al. Treatment of long saphenous varicose veins: a meta-analysis of novel therapies versus conventional surgery. Br J Surg 2008; 95 (53): 184.

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