Treatment of Varicose Veins
Endovenous laser therapy is a novel way to treat varicose veins. In essence, this procedure involves the introduction of a fine fibre-optic tube into the vein, through which short bursts of energy are aplied to damage the vein. The vein will scar and shrink away, to return via another channel, usually shunted into the deep venous system.
What are varicose veins?
In short, varicose veins are dilated enlarged veins, usually in the lower legs. These present as bulging veins, which can sometimes be unsightly.
Why do they occur?
The cause of varicosities in the lower limbs is related to increased pressure in the veins. There are several causes, but the most important to rule out is deep vein thrombosis - clots in the major venous drainage system in the legs.
In the lower limbs, the drainage system is broadly divided into the deep system and the superficial system. Their location is as described - the superficial system is just under the skin, and can be visible particularly when dilated. They drain into the larger deep system, which lies deeper with the major arteries of the lower limbs. When these are damaged, either from clots developing or from failure in development as an error of birth (congenital disease), the superficial system becomes the main drainage system and cannot be removed.
Commoner causes of varicose veins include damage to the valves, leading to incompetence and backflow, which is commonly termed reflux. This can result from prolonged standing, increased pressure in the abdomen from pregnancy, or large abdominal growth, obesity, or damage of the valves due to infection, previous clots or other inflammatory causes.
What problems do they cause?
Long-term venous hypertension can result in pigmentation of the skin. This is related to chronic leakage of blood cells. Chronic venous hypertension can cause pain. As a result of poor circulation, the skin can thicken or break-down, leading to ulcers, which can take a long time to heal. Chronic long-standing ulcers can also transform into cancer. These are known as Marjolin's Ulcer, and are fairly rare, a result of chronic neglect.
How do you evaluate varicose veins?
At the clinic, the doctor will assess for the location and severity of the disease. The main investigation is Ultrasound Doppler study of the venous system. This is usually performed by the ultrasound technician with a high frequency probe while the patient is standing. The ultrasound technician will look for:
- deep vein thrombosis
- incompetence of the valve at the major junction between the deep and the superficial vein, and behind the knee.
- reflux in the long saphenous system which extends below the knee and the measurement of this vein around the knee.
- other reflux of the minor connections between the deep and superficial system - the so-called perforator incompetence.
- the site of the varicose veins.
How are varicose veins treated?
Treatment is directed to the cause of the problem, the associated complications and the varicose veins. Where there is a primary correctable problems, such as deep vein thrombosis or obesity, these are confronted. Ulcers should be cleaned and dressed, and with leg elevated to encourage healing. Suspicious areas should be biopsied and treated accordingly.
With regards to the varicose veins, treatment is broadly characterised into conservative or non operative, and operative treatment.
Non operative treatment includes the use of support compression stockings, to divert the blood flow from the superficial to the deep system, and medications that increase venous pressure, such as Daflon.
With surgical correction of the varicose veins, it is important to rule out obstruction of the deep venous system, such as from clots. This would represent a contra-indication to surgical management.
Treatment is given to prevent backflow and reflux from the major junctions, commonly the high ligation and stripping of the veins, and ligation of the incompetent perforators - the minor communicating veins. Newer treatments are a variation of this theme, using either a laser fibreoptic or radio-frequency ablative device. The former has proved more popular because of ease of use, cost and better aesthetic results.
ENDOVENOUS LASER TREATMENT
Vascular surgeons and interventional radiologists use this treatment to treat reflux and incompetence of the major junctions at the groin and behind the knee. It is also useful for treating tributaries along the major superficially veins with reflux that are long and straight.
The procedure requires needle puncture of the superficial vein around the knee, usually under ultrasound guidance. Once access is obtained, a fine guidewire is inserted and directed to the desired location and the needle exchanged for a thin narrow tube, also known as a catheter. This is usually less than 2 mm in diameter. When the catheter is placed in a suitable position, which is confirmed on ultrasound, the wire is exchanged for the laser fibre. Dilute local anaesthetic is then injected around the dilated vein to collapsed it. The laser is then activated and this emits short bursts of energy, heating the vein up and sealing it closed. The peri-venous local anaesthetic also acts as a heat sink, to prevent burns to the skin. The laser is slowly pulled along the vein, allowing the entire length of the vein to be closed.
Endovenous laser treatment may be carried out under local anaesthetic, with the addition of a mild sedative to make the patient more comfortable.
The leg is bandaged tightly after the procedure and although pain initially is unusual in view of the peri-venous local anaesthesia, it may occur a few days later. Affected areas may also be bruised.
However, this is an improvement compared to the classical high ligation and stripping in terms of aesthetic results and post operative pain.
Prevention
It is not always possible to prevent varicose veins occurring, but there are steps that you can take to help reduce the risk of developing them. Preventing varicose veins mainly involves improving your circulation and muscle tone. There are a number of ways that you can do this:
- Exercise - regular exercise is a great way of getting your legs moving. It will help to improve your circulation and also to improve your general health.
- Lose weight - losing excess weight will take any unnecessary pressure off your circulatory system and it will be easier for your heart to pump blood around your body.
- Stop smoking - this will reduce your risk of developing varicose veins and will also greatly improve your general health.
- Avoid tight fitting clothes - tight fitting underwear and clothes can restrict your circulation. You should also avoid wearing high heeled shoes.
- Take regular breaks - where possible, try to take regular breaks throughout the day. You should also try to keep your legs raised while you are resting. Ideally, you should raise your legs above the level of your heart.
- Avoid sitting or standing still for long periods - if you have to sit or stand still for long periods, make sure that you change position frequently, and try to move around at least every 30 minutes. You should also avoid crossing your legs because this can adversely affect your circulation.
