Westchester Sugery
Specializing in general and vascular surgery - minimally invasive, maximum results.
Specialty Orthopaedics

Varicose Veins

What are varicose veins?

Varicose veins are "dilated tortous veins associated with incompetent venous valves" They are very common and predominately affect the legs although they can affect any part of the body. They are more pronounced when you stand up and often described by patients as being "unsightly".

Why do we get them ?

In short, people with varicose veins often have a genetic tendency to developing them. This is further affected by factors such as occupation (standing for long periods) or during pregnancy. All veins in the legs have valves to ensure blood travels in one direction only (upwards) each time the calf muscle squeezes. Failure of either the valves or the calf muscle pump system results in patients being susceptible to having varicose veins. The result is the development of a pressurised venous system. This manifests itself as varicose veins over the course of time.

The main sites of valvular incompetence arise in the groin (in the groin crease) or behind the knee where the large superficial veins drain back into the larger deep veins. There can be other sites of incompetence throughout the leg but in the vast majority of individuals these 2 sites are their main problem.

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Symptoms

Varicose veins are very common and in some people causes very little in the way of symptoms. However, the following are symptoms described by patients who do suffer with varicose veins:

Aching, heavy legs usually worse at the end of the day.

Ankle swelling

Discoloration around the veins, usually a brownish color (Hemosiderin deposits)

Skin over the veins may become dry, itchy and thin, resulting in venous eczema

The skin above the ankle may shrink because the fat underneath the skin becomes hard and scarred (Lipodermatosclerosis)

Patients may suffer with phlebitis, which is a painful inflammatory condition of the varicose veins

Bleeding which can be quite significant (sometimes caused by a minor injury).

Venous leg ulcers (if skin changes start occurring, such as discoloration above the ankle, itching dry skin or scarring, then there is a risk for future skin breakdown and leg ulcer development)

Treatment

A clinic assessment will establish the presence of varicose veins/ thread veins and whether they may or may not be contributing to your symptoms. Also, an assessment of the distribution of the varicose veins and the underlying "leaky" valves is necessary in order to plan treatment. This can be performed by means of a hand held doppler machine or by ultrasound technology. More often, Duplex ultrasound scans are necessary to evaluate the site of valvular incompetence and also to assess whether the veins are suitable for the less invasive techniques such as Endovenous Laser Therapy (EVLT) or Radiofrequency (e.g. VNUS). Trigonal open surgery is a "tried and tested" technique which also provides excellent results.

The fundamental principle for successful treatment involves:

  1. Identification of the underlying valvular incompetence ("leaky valves") which are usually in the groin or behind the knee.
  2. Treatment of the valvular incompetence and trunk vein (e.g. the long thigh vein) by EVLT or traditional surgery ("Stripping of the veins" )
  3. Treatment of the visible varicose veins themselves by means of phlebectomy ("multiple avulsions") or sclerotherapy. Phlebectomy involves making a small (1-2mm) cut over the vein and avulsion of the varicose vein using a special hook instrument. It provides excellent results leaving a very satisfactory cosmetic appearance. Sclerotherapy involves injection of a sclerosant fluid into the varicose vein. This deliberately irritates the vein and closes it. It tends to work better with very small veins and thread veins.

Information you need to know about your operation

Before the operation

You should not eat any food for up to 6 hours before surgery but you can have a couple of glasses of water up to 2 hours before your operation.

Coming into hospital

The operation may be performed as a day case. However, if both legs need surgery or if you have any medical problems, it is usual to remain in hospital overnight. On admission to the ward, a nurse will take details about you and take your temperature, pulse and blood pressure. Your leg and groin area will be shaved. Your varicose veins will be marked whilst you stand and it may be necessary to use Doppler ultrasound machine to confirm the site of your operation. The operation will be explained and consent obtained by Prof M Baguneid. White elastic stockings will be fitted.

Traditional surgical procedure

This will be explained in detail by Prof M Baguneid. The main feeder vein and "leaky valve" are tied off through an incision in the groin and /or behind the knee. All the pre-marked visible varicose veins are then removed (avulsed) through a series of small incisions (<2mm in length).

Endovenous laser therapy (EVLT)

This will be explained in detail by Prof M Baguneid. The faulty vein in the thigh or behind the knee is cannulated under ultrasound guidance with a needle. A catheter and laser fibre is introduced into the vein. The vein is then ablated from within by activating the laser fibre whilst it is withdrawn. All the pre-marked visible varicose veins are then removed (avulsed) through a series of small incisions (<2mm in length). The entire procedure can be performed under local anaesthetic (usually with sedation). It can be performed under a general anaesthetic (asleep) if the patient is keen not to have a local anaesthetic.

After your operation

When you wake up after your operation you will have a bandage on your treated leg(s). A wool bandage and socking will be underneath the outer bandage.

If you had traditional surgery, you will have dissolvable stitches in your groin wound and/or knee wound. There will not be any groin or knee incisions with EVLT. The avulsion sites will have adhesive paper strips. You will be allowed something to eat and drink after a couple of hours. You will usually be asked to elevate your legs in bed until the next morning. A little discomfort is to be expected and you will be provided painkillers if required. Do not attempt to get up for the first time without a nurse, as fainting is common.

Going home

Stockings: If you stay overnight, the bandage will be removed by a nurse the following day and the white elastic stockings will be put on. This stocking is to be kept on day and night for the first week and throughout the day for three weeks following this. If you go home on the same day, you will need to take your bandage off the following day and apply your stocking yourself. In that situation, you will need to unwrap your outer bandage and underlying wool bandage (if present). Then, take off the stocking that is already in place and don't worry if any paper stitches come off at the same time. Finally, put on the white elastic stocking that was provided over the paper stitches.

Pain: Most people describe the leg as sore and uncomfortable when they get home. These feelings increase steadily from the second postoperative day and are usually at their worst on the 8th-10th postoperative day. The discomfort usually resolves 12-14 days after the operation. There may be tenderness, lumpiness and bruising over the inner thigh and calf. This is normal. However if swollen, red and painful lumps appear near the operation scars you should see your GP in case there is an infection.

Exercise: Walking for five minutes every hour is good, gradually building this up until you are fully mobile.
You should avoid standing still or sitting with your legs down for the first week. Keep active in general in order to reduce your risk of developing a deep vein thrombosis.

Shower: It should be fine to shower after 2 days when your wounds have dried and settled. You can take your stockings off for the time you shower then reapply them once you have dried your legs gently. (Don't worry if any paper stitches come off as the puncture wounds will heal well either way). If bleeding occurs from any of the puncture site’s lie down, raise the leg, and over the bleeding point apply pressure for seven minutes with a towel or handkerchief. Bleeding is always easy to stop. The paper stitches should be removed after 7 days but don't be worried if any come off sooner (even 1st day following surgery).

Return to normal activities

Driving: You should not drive for the first week following traditional surgery, and should not begin to do so until you feel you can perform an emergency stop without pain. It is likely that following EVLT, driving should be possible very soon after treatment.

Work: You can return to work when you feel sufficiently well and comfortable, generally 2 weeks after surgery. With EVLT, you should be able to return to work within the 1st week depending on your occupation and if you can return to light duties.

Sports: Swimming and cycling are allowed after the adhesive strips have been removed (roughly after 7 days).

Flying: You should not fly for at least 4 weeks following your operation (or EVLT) and if you are considered higher risk for DVT, it may be wise to wait longer (up to 3 months).

Benefits & Risks

Surgery or EVLT will eliminate varicose veins, although 1 in 15 patients will develop recurrence over a ten-year period.

Not all leg symptoms in patients with varicose veins are caused by these veins. Aching, itching and swelling may be improved by surgery but not in every case.

The cosmetic result is usually good but incisions become red and quite obvious over the first 6-9 months. The redness then fades.

Wound infections are unusual but may occur in approximately 1 in 50 patients. A small nerve to the skin may be damaged while avulsing varicose veins causing numbness for 2-3 weeks after which the absence of sensation, which is permanent, is no longer noticeable.

Deep vein thrombosis may occur following any surgery, particularly under general anaesthetic. Without treatment to prevent this, the risk is only 7 per 1000 operations but we will thin the blood in.