Patients with varicose veins may suffer from acute varicose complications such as variceal bleeding, dermatitis, thrombophlebitis, cellulitis, and ulceration. They may confront with worsening chronic symptoms or a variety of other situations including aesthetic issues. Treatment that does not properly address the patient's primary concerns cannot result in a satisfactory overall outcome.
Chronic symptoms include leg heaviness, exercise intolerance, pain or tenderness along the course of a vein, pruritus, burning sensation, restless legs, night cramps, edema, skin changes, and paresthesia.
Subjective symptoms are usually more severe in the early stages of progression of the disease, less severe in the middle phases, and worse again with advancing age. Symptoms do not correlate with the size or extent of visible varices or with the volume of reflux.
Not all patients are aware of the occurrence because the onset may be extremely gradual. After treatment, patients are often surprised to realize how much chronic discomfort they had been undergoing, yet believed to be normal.
Pain caused by venous insufficiency is often lessened by walking or by elevating the legs in contrast to the pain of arterial insufficiency, which is worsened with ambulation and elevation.Pain and other symptoms may worsen with the menstrual cycle, with pregnancy, and in response to exogenous hormonal therapy (eg. oral contraceptives).
These factors increase the risk of developing varicose veins:
Age: The risk of varicose veins increases with age;
Sex: Women are more likely to develop the condition. Hormonal changes during pregnancy, pre-menstruation or menopause may be a factor because female hormones tend to relax vein walls. Taking hormone replacement therapy or birth control pills may increase risk of varicose veins;
Family history ;
Standing or sitting for long periods of time.
Complications of varicose veins, although rare, can include:
Ulcers: Extremely painful ulcers may be formed on the skin near varicose veins, particularly near the ankles. Ulcers are caused by long-term fluid build-up in these tissues, caused by increased pressure of blood within affected veins.A discoloured spot on the skin usually begins before an ulcer is formed.
Thrombophlebitis: The disease rarely leads to deep vein thrombosis.
Bleeding: Occasionally, veins that are very close to the skin may burst. This usually causes only minor bleeding. But any bleeding warrants medical attention because there's a high risk of it happening again.
There's no way to completely prevent varicose veins. But improving circulation and muscle tone can reduce risk of developing varicose veins or getting additional ones. The measures that help prevent varicose veins include:
· Keeping tab on weight
· Eating a high-fibre, low-salt diet
· Avoiding high heels and tight hosiery
· Elevating the position of legs
· Changing the sitting or standing position regularly
Fortunately, treatment usually doesn't mean a hospital stay or a long, uncomfortable recovery. Thanks to less invasive procedures, varicose veins can generally be treated on an outpatient basis.
Self-care - such as exercising, losing weight, not wearing tight clothes, elevating legs, and avoiding long periods of standing or sitting - can ease pain and prevent varicose veins from getting worse.
Wearing compression stockings all day long is often the first approach tried by many treatment centres before moving on to other treatment options. The stockings steadily squeeze the legs, helping veins and leg muscles move blood more efficiently. The amount of compression varies by the type and brand used. According to National Institute for Health and Care Excellence guidelines, compression stockings are given to those patients for whom interventional treatment is unsuitable.
Indications of varicose vein treatment:
· Bleeding varicose vein.
· Symptomatic primary or symptomatic recurrent varicose veins.
· Lower‑limb skin changes, such as pigmentation or eczema, thought to be caused by chronic venous insufficiency.
· Superficial vein thrombosis (characterised by the appearance of hard, painful veins) and suspected venous incompetence.
· A venous leg ulcer (a break in the skin below the knee that has not healed within 2 weeks).
· A healed venous leg ulcer.
· Cosmetic reason.
Interventional treatment for varicose veins (NICE guidelines)
· For people with confirmed varicose veins and truncal reflux:
· Offer endothermal ablation (Endovenous laser therapy orendovenous radiofrequency ablation)
· If endothermal ablation is unsuitable, offer ultrasound‑guided foam sclerotherapy
· If ultrasound‑guided foam sclerotherapy is unsuitable, offer surgery.
· If incompetent varicose tributaries are to be treated, consider treating them at the same time.
Management during pregnancy
· No interventional treatment for varicose veins during pregnancy other than in exceptional circumstances.
· Consider compression hosiery for symptom relief of leg swelling associated with varicose veins during pregnancy.
Endothermal ablation of varicose veins
(Endovenous laser therapy-EVLT)
Outline of the procedure
Under ultrasound guidance and local anaesthesia, a catheter is placed into the long saphenous vein. A laser fibre is passed through it and positioned below the saphenofemoral junction. An anaesthetic agent is then injected, and the fibre is slowly withdrawn while energy from a diode laser (810 nm or 940 nm wavelength) is applied in short pulses. This is repeated along the entire length of the vein until the long saphenous vein is closed from the saphenofemoral junction to the point of access. The procedure may be done under local anaesthesia or femoral and saphenous nerve blocks. Use of epidural anaesthesia or general anaesthesia is also practised in some centres.
Saphenous vein closure rate is between 90% and 100%.
The most common complications reported in the studies were pain and bruising. In a case series report of 423 patients, 90% (381) of patients reported feeling tightness along the limb and 24% (102) of patients experienced bruising; it was resolved within 1 month of the treatment.
Phlebitis was also reported in between 5%
(21/423) and 12% (10/85) of patients.