WHAT ARE VARICOSE VEINS?

Varicose veins represent chronic insufficiency of venous valve function leading to symptoms like tortuous, bulging veins, swelling on the feet, skin discoloration, and ulcerations.

THE NORMAL VENOUS FLOW AS AGAINST FLOW IN VARICOSE VEINS

In a healthy venous system, the flow of blood is through the superficial veins into the deep veins through connecting veins called perforating veins. This blood flow is up the leg and towards the heart. Valves are present in the superficial, deep, and perforating veins which allow only one-way flow of blood through the veins towards the heart.

Incompetence of any of these valves can lead to a disruption in the unidirectional flow of blood toward the heart. Pooled blood and increased pressure in the veins leads to venous dilatation causing greater insufficiency of the venous valves. Over time, with more and more local dilatation, adjacent valves sequentially fail and ultimately, the entire superficial venous system becomes incompetent.

CAUSES OF VARICOSE VEINS

• Increasing age and female gender are the consistently identified risk factors for varicose veins.
• Incompetent venous valves causing increased blood pressure in the veins, most commonly at the saphenofemoral junction (at the topmost end of the thigh).
• Prolonged standing.
• Pregnancy: hormonal changes cause venous wall and valve weakness which is further worsened by increased circulating blood volume. In late pregnancy, the enlarged uterus compresses and hampers venous return from the lower extremities.

SYMPTOMS AND SIGNS

Mild forms of venous insufficiency are merely annoying or cosmetically disfiguring. Initially, the symptoms include leg pain, heaviness, burning, cramping, and muscle fatigue.

COMPLICATIONS OF VARICOSE VEINS

• When the chronic condition is left untreated, there is initially mild selling which progresses to discoloration, inflammation, recurrent or chronic cellulites, ulceration, and even malignant degeneration of the tissues.
• Sever venous disease can produce serious effects and lead to loss of limb.

INVESTIGATION

Venous Doppler examination can directly show whether flow in a suspect vein is antegrade, retrograde, or to-and-fro.

TREATMENT

CONSERVATIVE

• Early varicose veins can be managed conservatively with tight compression stockings to be worn during the day and off during the night. These are available as below-knee and above-knee (covering the thigh) varieties. Avoid prolonged standing. Activity and exercise are advocated.
• Pregnancy induced varicose veins and only superficially dilated veins which appear dark blue are not treated surgically.
• No oral or topical medications are useful in the treatment of varicose veins.

LASER

This procedure has a recurrence rate of 30%-40% and is generally reserved for patients who are unfit for surgery.

SURGERY

Surgery is reserved for pipe-like dilated veins or worsening skin symptoms despite conservative management.

The operation is called the Trendelenburg operation. It involves tying up (ligation) of the SFJ, removal of 3-4 perforator veins, and use of Laser for destroying the intermediate vein. There are no adverse effects of sacrificing this superficial vein. Other veins are pulled out of tiny cuts and avulsed. These cuts are usually only 2 mm - 3 mm long and are closed with adhesive strips and only occasionally with stitches.

A separate procedure could be needed for the SPJ for the correction of varicosities because of saphenopopliteal incompetence.

The skin is closed with stitches or staples. Small dressings are kept in place at the operated site.

POST OPERATIVE INSTRUCTIONS

• Mobility allowed after 2 days.
• The stitches are removed after 15 days.
• Use of compression stockings for a month.