Varicose veins are dilated tortuous veins with weakened walls and valves that no longer close when they should. They occur in the lower extremities and are important for the health of the skin and superficial tissues. They appear as bulges under the skin of the erect individual and disappear when the limb is elevated above the heart.
The valves inside the veins normally close in cycles when the blood flows through them or when pressure is applied from above. Their role is to prevent backflow (reflux) in the vein. Historically, these valves are of great importance because they were the critical clue (in 1628) that proved the circulation is designed to flow in one direction only. When valves fail to work properly the blood does flow back and forth in two directions and the vein no longer functions properly.
The pressure in lower extremity veins sustains high levels when an individual stands up and the valves fail to close (reflux). This reflux contributes to further weakening of the already abnormal vein wall and progressive enlargement of the veins occurs. Since refluxing veins do not conduct blood flow efficiently in the proper direction their value of returning blood to the heart is diminished and the circulation suffers; in fact, the circulation is improved when refluxing veins are eliminated.
The bulging of the walls gives rise to discomfort with aching and heaviness in some cases, or may be entirely free of symptoms in others. Whether they cause discomfort or not, varicose veins are sources of abnormal circulation in the skin and underlying tissue; over time this reflux may cause significant damage to the skin and tissues of the lower leg. The ultimate result can be swelling, discoloration, thickening, and even ulceration of the leg in up to 20% of long-term varicose vein cases.
TREATMENT OF VARICOSE VEINS
The requirement for success in treating varicose veins is to eliminate superficial veins that have leaking valves by one means or another. The varicose veins that are visible are usually the branches of underlying veins (saphenous veins) that communicate with the central veins of the body at the groin or at the knee. Success in treatment is best when the saphenous veins that have abnormal valves are eliminated first and the actual varicose veins with weak walls and their own abnormal valves are separately treated. These two steps are managed as one procedure at the KVC in most cases.
Procedures to accomplish this have been greatly simplified in the past decade and now can be done effectively in the office setting with only local anesthesia (like the dentist uses). This is done by ‘minimally invasive’ techniques of either internal heating of the saphenous vein or by injection of a chemical to cause the vein to block up. With these methods the treated person can get up and walk from the treatment site with minimal discomfort as soon as the dressings are applied. The patients are walking on the evening of treatment and can resume most of their normal activities the next day. Most return to work within 2-3 days; seldom is there need to be away from work for more than one week. It is unusual to need even the mildest of pain pills (Aspirin, Tylenol) after the first day of treatment; about half of the patients who have this done don’t use any pain pills at all.
The age-old standard for treatment is a surgical procedure known as vein ‘stripping’. This is very successful in eliminating the superficial vein and gives good long term results, but it requires open surgery and leaves a scar, and has the reputation of being a painful ordeal. The endovascular ‘minimally invasive’ procedures cause the vein to become blocked rather than removing the vein, but they achieve the same result of eliminating the vein from the circulation. The advantages of the minimally invasive approach are less pain with the procedure, less injury to the tissue, absence of scars, and quicker recovery. The ultimate effect of the surgical and minimally invasive approaches has been scientifically compared and found to be the same with the advantage that the healing is quicker and the discomfort is less with the new methods.
The most widely practiced minimally invasive method involves placing a treatment catheter into the vein of the calf and passing the catheter up to the groin. The vein is treated with heat to shrink the vein shut. This causes the vein to close and eliminates the vein from the circulation, similar to the effect of stripping the vein out of the body. There are two kinds of catheters: those that deliver heat by way of a radiofrequency current or those that use a laser current. The two types give similar results. The radiofrequency current was the first one to appear and has been used for most of cases at KVC because it causes less tissue reaction and less patient discomfort in the early post treatment phase.
ISOLATED VARICOSE VEINS
Sometimes veins of the leg or thigh become dilated and cause symptoms without saphenous vein involvement. This can occur as a single vein somewhere on the extremity not connected to any other vein or it can occur when there is a ‘perforator’ vein (connects the deep veins to the surface veins) has leaking valves and dilated walls. In both of these circumstances treatment is directed at the site of varicose veins or perforator vein itself, rather than the saphenous vein. These veins can be treated by injection methods, sometimes guided by ultrasound, or by a local surgical incision called ‘phlebectomy’. These treatments are also done in the office setting and do not cause disability in their aftercare.