What are Varicose Veins?

The vascular system can be described as a vast roadway leading to and from the heart. Nutrient- and oxygen-rich blood is transported throughout the body by the arteries, and then deoxygenated blood is carried back to the heart by the veins. Blood flow through arteries is assisted by force created from the pumping of the heart. The calf muscles work as a “peripheral heart,” forcing blood through the veins. The deep veins are contained within the muscle of the calf, and blood is forced out of them as the calf muscle contracts during physical activity. There are also superficial veins in the leg, just below the skin surface. The main superficial vein is called the greater saphenous vein and travels up the inner part of the leg from the ankle bone to join the deep vein in the groin (the femoral vein). The lesser saphenous vein travels up the back of the calf to join the deep vein behind the knee (the popliteal vein). The deep and superficial systems of veins are connected in the groin (sapheno-femoral junction) and behind the knee (sapheno-popliteal junction).

In the legs, blood flow in the veins must progress upwards, against the force of gravity. For this reason, the veins contain a series of one-way valves that encourage blood to flow in one direction—from the superficial to the deep veins and then from the deep veins back towards the heart.

Varicose veins almost always start with a problem with the valves, specifically the valves in the connection points between the deep and superficial vein systems. If these valves are leaky (incompetent), blood will preferentially flow from the deep vein (high pressure system) out to the superficial vein (low pressure system), opposite the direction it is supposed to. This causes engorgement of the superficial veins, incompetence of the valves in the superficial veins, and dilations in the superficial veins and their branches (varicose veins).

Varicose veins are common – 30-50% of people will develop them. They occur more frequently in women than in men. Often, they are inherited. Increased pressure on the venous system from pregnancy, morbid obesity, leg trauma, leg surgery, or years of prolonged standing can also increase the likelihood of developing varicose veins.

How are Varicose Veins Diagnosed?

There is a spectrum of varicose vein disease, ranging in size from spider veins, to reticular veins, to small varicosities, to large varicosities. All types of varicose veins can cause a feeling of aching, heaviness, or tiredness in the legs with prolonged standing which is relieved with elevation of the legs, exercise, or use of compression stockings. Other complications of varicose veins include blood clot in the vein (thrombophlebitis), bleeding from the vein, and chronic venous stasis disease (skin damage or ulceration and edema).

A venous ultrasound can be done to determine the function of the valves in the deep and superficial veins of the leg.

What Treatment Options are Available for Varicose Veins?

Non-surgical treatment includes use of graduated compression stockings, which compress the superficial veins from the outside, so that they cannot engorge. Exercises which use the calf muscle (walking, biking, swimming) also improve venous flow by pumping blood towards the heart. Periodic leg elevation to “empty” the leg veins is also recommended.

Surgery is considered when the leg discomfort is not relieved with conservative treatment or when complications such as thrombophlebitis, bleeding, or leg ulcers occur. Many patients pursue surgery for cosmetic reasons.

Several procedures are available to treat varicose veins. These include vein ligation, phlebectomy, endovenous ablation, and sclerotherapy. Greater saphenous vein stripping is a surgical procedure which involves removing the length of the vein from the leg. It is rarely performed any longer.

Varicose Vein Ligation and Phlebectomy

Surgical ligation of varicose veins involves tying off (ligating) a vein with an incompetent valve. It is usually used to treat a valvular problem in connecting veins between the deep and superficial vein systems (perforator veins), and can be performed through small (1 cm) incisions on the inner leg or posterior calf. Clusters of large varicosities can also be removed through small incisions, a procedure called phlebectomy. In general, the other veins remaining in the leg take over the work of the veins removed.

The procedure takes approximately 1 to 1-1/2 hours and is usually done in an outpatient setting under a light general or spinal anesthetic. After the surgery, the leg is wrapped for 2 days with an elastic bandage to control swelling and bruising, before resuming regular use of graduated compression stockings. Patients are advised to maintain a moderate level of exercise during the recovery period.

Endovenous ablation

Radiofrequency ablation (RFA) of the greater or lesser saphenous vein is a minimally invasive alternative to vein stripping, It involves sealing the vein closed from the inside using a heat source (radiofrequency energy). The radiofrequency probe is introduced into the vein through a small puncture site at the knee or Achilles region and is guided by ultrasound. Saline solution is instilled around the vein to insulate the vein and protect surrounding tissues, and ACE wrap compression is applied afterwards. The procedure takes less than an hour and can be done in the office under a local anesthetic. Long term success rates are better than that of vein stripping. Typically, radiofrequency ablation is also associated with a lower rate of complications and faster postoperative recovery.

Sclerotherapy for Varicose Veins

Sclerotherapy is a simple, effective treatment for ablating small varicose veins, reticular veins and spider veins. It is most effective when there is no valvular incompetence by ultrasound, or after the superficial venous incompetence has been treated with ligation or RFA.  This procedure involves the injection of a concentrated saline or another solution, such as sodium sotodecol (STS), into the varicose vein. Compression is then applied with an ACE wrap or graduated compression stockings. The goal is to have the vein seal closed. Other veins then assume the function of the obliterated varicose veins. Sclerotherapy is a 15 to 30 minute office procedure and does not require anesthesia. In most cases, treatment involves several sessions of injections, spaced over several weeks. Sclerotherapy reduces symptoms of small varicose veins, decreases complications of varicose veins, and improves appearance of the skin in approximately 85% of people who undergo the procedure.