What are varicose veins? Veins are vessels which are designed to carry de-oxygenated blood back to the heart from the tissues of the body. Varicose veins, however, are abnormally dilated veins that cannot perform their function. Varicose veins are larger veins that bulge above the skin surface which are commonly found in association with larger and deeper vein problems. If there is a deeper vein problem can be detected at an initial examination. Dilated blood vessels often cause aching especially after prolonged standing. Although dilated blood vessels do carry blood they are not very efficient and are often not necessary to the circulatory system. The body has an already established alternative route for the blood to travel back more efficiently to the heart (deep venous system). Thus they can be treated without damaging the circulation. In fact, treatment actually improves venous circulation. The probability of a greatly improved appearance following treatment is about 80 per cent depending on the severity of the problem. Treatment will also usually relieve any symptoms caused by the veins.
What causes varicose veins?
Since our ancestors decided to stand upright, our leg veins have been faced with the difficult task of taking the blood up to the heart against the pulling force of gravity. To do this the leg veins depend on the contraction of the calf and thigh muscles to pump the blood. This is why walking is good for your circulation.
So when you walk, the contraction of your leg muscles pumps the blood up. However, as the saying goes “what goes up must come down” which is what happens to blood in the leg veins. Therefore, to prevent the blood from falling back down, nature has designed valves in the leg veins which open in only one direction: upwards. So the valves allow the blood to get through but when it comes back down, the valves shut and stop the blood going all the way down. The next contraction sends the blood even higher until it eventually reaches the heart.
In venous disease, the underlying problem appears to be damage to the valves. The abnormal reticular veins, for instance, act as “feeders” of the spider veins. The blood flow in these feeder veins can compared to a “two-way” street. In other words, blood in the feeder veins can go back and forth. This backward flow through the incompetent valves dilates up the smaller veins (medically called “post-capillary venules”). These dilated post-capillary venules are commonly referred to as “spider veins”.
The same principle applies to varicose veins. The abnormal valve cannot stop the blood from rushing back down. The blood in these veins is oxygen low and in fact carries a lot of toxins. In the case of varicose veins, this “toxic” blood pools in the legs and cannot be returned to the circulation. This is why patients with varicose veins suffer from night cramps and their legs feel heavy at the end of the day.
Varicose veins occur in both men and women. A definitive cause is not known, however a strong family history suggests that some people inherit veins that are more likely to deteriorate. In women, oestrogen may play a role as the onset of puberty, pregnancy and taking oral contraceptives can give rise to vein abnormalities. In pregnancy, the enlarged uterus can restrict blood flow from the legs and promote the development of varicose veins. Spider veins and varicose veins are also associated with obesity. Occupations involving prolonged standing tend to increase the likelihood of veins to develop. Bone fractures and soft tissue trauma can cause localized vein abnormalities
Can we do without varicose veins? Where does the blood go?
Varicose veins serve no useful function to the body’s circulation. They do not return blood to the heart and our body has already established alternative pathways to bypass the abnormal varicose veins. When varicose veins are closed down, the circulatory system improves, as do many of the symptoms. It is important to understand that varicose veins can be a progressive condition and that new veins can develop with time. Ongoing maintenance treatment is likely for most patients
Can vein problems be prevented?
- There is no known method of prevention. Wearing specialised venous support stockings may prevent some dilated blood vessels from developing in some people. Maintaining a normal weight, regular exercise, avoiding constipation and avoiding wearing high heeled shoes may also be helpful.
- Varicose disease is very common, with an estimated 80 million people suffering from varicose veins in the US alone. Perhaps contrary to popular medical opinion, most patients seeking treatment for varicose disease do so primarily because of discomfort or pain.
- The degree of suffering can range from mild discomfort to debilitation, and is not necessarily proportional to the size of the varicosities. The range of symptoms is wide and can include aching, cramping, burning, tiredness, heaviness, itching and restless legs. Complications include swelling, bleeding, superficial thrombophlebitis (occasionally leading to DVT) and intractable ulceration.
- Some patients without symptoms or complications find the appearance of varicose veins and telangectasia distressing. Medical practitioners sometimes underestimate the importance of this and its potential impact on lifestyle (for example, embarrassment, avoidance of social situations and clothing that expose the legs.) Many patients fail to seek treatment because they believe (or have been advised by friends or even their doctor) that surgical stripping is the only treatment available and they wish to avoid surgery, general anaesthesia, scarring, expense or time off work.
- Some who enquire about treatment are wrongly informed that if their veins are not amenable to surgery then there is nothing that can be done.
- Sclerotherapy can have a role in the treatment of varicose disease of almost all forms and degrees, and is relatively inexpensive, effective, safe and proven.
- Compression Therapy is also used to treat varicose veins and consists of stockings, bandages and pump devices.
- Your Doctor will assess and advise on the most appropriate treatment for your varicose and or spider veins.
How are vessels on the legs treated?
In the majority of cases a procedure called “Sclerotherapy” is used. This involves injecting a solution, called a sclerosing solution, directly into the blood vessel with a very fine needle. This procedure has been used for spider veins since the 1930s. The solution irritates the lining of the vessel causing it to swell and stick together. Over a period of weeks the vessel fades from view, eventually becoming barely or not at all visible. Depending on its size, a single blood vessel may have to be injected more than once. Because larger veins (reticular veins) often underlie spider veins these vessels must be treated as well.
Does it hurt?
Different doctors use different solutions. The amount of discomfort you may feel will depend on the skills of the doctor, the solution used, the concentration of the solution and most importantly your pain tolerance! In each treatment session many vessels are injected but in general the treatment involves minimal discomfort because of the tiny diameter of the needles. Some injections give a feeling like a bull ant bite.
Do I need to wear bandages or stockings?
There is debate amongst the experts regarding the use of compression following Sclerotherapy. Those who believe in compression still disagree upon the optimal length of time the compression should be applied. It is commonly believed that compression should be used following treatment of larger varicose veins. This minimizes the formation of haematoma (trapped blood) and pigmentation, reduces the number of treatments necessary, reduces the risk of deep venous thrombosis (blood clot) and reduces the possibility of recurrence. Depending on the opinion of your doctor and the severity of the disease, this can range from 3 days to 3 weeks.
How successful is Sclerotherapy?
After several treatments most patients can expect at least a 75 percent improvement in the appearance of their legs. You may find your legs initially look worse because of bruising. The improvement may be very gradual with some vessels taking up to 3 months to show maximum benefit. Perfection is seldom achieved (but always strived for!).
Is the treatment cost covered by Medicare?
In Australia, Medicare provides a rebate for Sclerotherapy of symptomatic varicose veins larger than 2.5mm in diameter. Charges, however, vary amongst different clinics.
What can I expect following my treatment?
- Red, raised areas at the sites of injection. These should disappear within a day. Bruises may occur at injected site. These will disappear in a few weeks and are probably related to the fragility of blood vessel walls.
- Blood trapped in the sclerosed vein may cause the vein to become more noticeable in the first few weeks following treatment, and is an early sign that the treatment has been successful. Aching in the leg for the first day or two following treatments is another potential side effect. This is usually relieved by walking. You may also take paracetamol to relieve this aching.
Possible side effects of Sclerotherapy:
- Even when a highly experienced physician is performing the treatment, there are a number of possible side effects, including the following:
- Staining of the skin: This is the appearance of brown marks on the skin after treatment. Some studies showing an incidence as high as 16% at 6 months and 5% at 2 years. These pigmented areas are mainly composed of haemosiderin, an iron pigment stored in the blood .This is more likely to occur in patients who have larger veins treated or those patients who have a lot of bruising. In most cases they disappear completely within a year. Persistent pigmentation may respond to laser treatment. In order to minimize this side effect we advise that you do not take any iron supplements (including most multivitamins) before, during or for 3 months after the course of treatment.
- Matting: This is the development of networks of fine red blood vessels near the sites of injection of larger vessels, especially on the thighs. It is reported that about 10% of patients develop these.. Most resolve spontaneously, some resolve with injection treatment, and a few persist. Matting is more common in patients with extensive surface veins, deep vein problems, patients who have a family history of surface veins and in obese patients who have poor muscle tone.
- Ulcers: Very occasionally there is the formation of small, painful ulcers at treatment sites within 2 weeks of injection. These may occur because the solution has escaped into the surrounding skin and sometimes they occur because there is an abnormal connection between small veins and arteries. They are more common in patients who smoke cigarettes. They heal slowly and may leave a small pale scar.
- Allergic reactions: Although on rare occasions (2 per 10,000) such reactions may be serious, they can be treated by immediate injections of adrenaline. Less serious reactions are treated with antihistamines. Minor rashes require no specific treatment but you should inform the doctor if they occur. Rarely, inflammation of the gums (gingivitis) appears as a reaction to a specific sclerosing solution. If this occurs, a different solution can be used for subsequent treatments.
- Phlebitis: This is an inflammation of the treated blood vessels which may also be associated with tender lumps along the line of the treated veins. This is due to the reaction of the sclerosant on the blood vessel wall and entrapment of “old” blood. When it occurs to a large or prolonged extent it may be treated by draining the blood out of the painful lumps by a small needle puncture. Other treatments for this may include anti-inflammatory medication, heat packs, massage with a special cream, compression and regular walking.
- DVT (Deep vein thrombosis): This is a clot in a deep vein. This is quite rare following sclerotherapy especially if compression and regular daily walking are adhered to. It is important to discuss the use of contraceptive pill prior to Sclerotherapy with the practitioner as it may increases the risk of DVT.
- Intra-arterial injection: This is an extremely uncommon complication which may result in muscle and skin damage.
There are no known long term side effects of sclerotherapy.