What are Varicose Veins?
Varicose veins are veins under the skin of the legs that have become widened, bulging, and twisted. They are very common and do not cause medical problems in most people.
Blood flows down the legs through the arteries, nourishing all the tissues, and flows back up the legs through the veins. There are two main systems of veins in the legs - the deep veins which carry most of the blood back up the legs to the heart, and the veins under the skin, which are less important and which can form varicose veins. All these veins contain valves that should only allow the blood to flow upwards. If the veins become widened and varicose, these valves no longer work properly. Blood can then flow backwards down the veins and produce a head of pressure when standing, walking about, or sitting. Lying down or “putting your foot up” relieves this head of pressure and usually makes the leg feel better. Both symptoms and treatment depend on how badly the valves in the veins are working. The symptoms vary from person to person.
Varicose veins often appear first in pregnancy, when hormones relax the walls of the veins and when the womb presses on the veins coming up from the legs. People who are overweight are more likely to get varicose veins and to find symptoms from them troublesome. There is some tendency for bad varicose veins to run in families, but this is by no means always the case. Usually there is no special cause for varicose veins.
Most people have no symptoms at all from their varicose veins, except for their appearance which can be embarrassing. Simply having varicose veins is not a good reason for going to a doctor or having treatment. Other than cosmetic embarrassment, the commonest symptoms of varicose veins are aching, discomfort, and heaviness of the legs. These are usually worse at the end of the day. Sometimes the ankle can also swell. These symptoms are not medically serious, but can be treated if they are sufficiently troublesome.
Although varicose veins can get worse over the years, this often happens very slowly and worrying that “they might get worse” is not a good reason for treatment if the veins are not causing symptoms.
In a few people, the high pressure in the veins causes damage to the skin near the ankle, which can become brown in colour, sometimes with scarred white areas. Eczema (a red skin rash) can develop. If these changes are allowed to progress, or if the skin is injured, an ulcer may result. Skin changes are therefore a good reason for going to see your GP and for referral to a specialist. In some areas, there are special leg ulcer bandaging clinics, supervised by the skin specialists and run by specially trained nurses. Your medical practitioner may refer you there, rather than to a surgeon in the first instance.
Other problems that varicose veins can occasionally produce are phlebitis and bleeding. Phlebitis (sometimes called thrombophlebitis) means inflammation of the veins, and is often accompanied by some thrombosis (clotting of blood) inside the affected veins, which become hard and tender. This is not the same as deep vein thrombosis and is not usually dangerous. It does not mean that the varicose veins necessarily have to be treated. The risk of bleeding as a result of knocking varicose veins worries many people, but this is very rare. It will always stop with firm pressure and the veins can then be treated to remove the risk of further bleeding.
What treatments are there for varicose veins?
Most people with varicose veins need no special treatment. The main medical reason for advising treatment is skin damage (leading to eczema, ulcers, or bleeding) that only a small proportion of people with varicose veins will ever get. However, if varicose veins are causing troublesome aching, or other symptoms, treatment may well be worthwhile.
There are three main methods of treatment – support hosiery, sclerotherapy (injections) and surgery.
It is always important to consider the pros and cons carefully before deciding on treatment. It may be helpful to talk with your medical practitioner, your family, and perhaps with friends who have had varicose veins treated, as well as getting advice from a specialist. Being overweight makes varicose vein problems worse, and, if you are overweight, you would be well advised to diet, or to seek advice from your medical practitioner about how to lose weight. This also applies if you are considering any kind of treatment for your varicose veins.
Are special tests needed before treatment of varicose veins?
The only reason for any special tests on varicose veins is if treatment is being considered. The tests aim to show whether there are important “leaky valves” allowing blood to flow the wrong way in the veins (reflux), and so putting a head of pressure on them. These leaky valves are commonest in the groin and behind the knee. In general, varicose veins that are under pressure from leaky valves are better dealt with by an operation than by injection treatment, for the prospect of a long-term cure.
Specialists use Doppler ultrasound machines to examine blood flow in the veins: these “listen” to the blood flow through the skin. A small hand held Doppler machine will often provide all the information that is required. More detailed scans using a “duplex” scanner (which produces pictures of the veins as well as blood flow information) are needed in some cases, and duplex scans are used on all patients by some specialists.
This means support stockings or tights, which can be effective in relieving symptoms of aching and heaviness caused by varicose veins.
They can be bought from clothing shops or chemists. Stronger support hosiery (“graduated compression stockings”) is even more effective. They are made in above or below knee lengths, and in three different “classes” of compression (Class 1 are a little stronger than ordinary support tights; Class 2 are most often advised by doctors for patients with vein problems; and Class 3 provide very firm compression when there is a particular need). Graduated compression stockings can be obtained by a doctor’s prescription, although a wider range is available for purchase from specialist surgical supply outlets. Different colours are available. If worn regularly each day, graduated compression stockings need to be renewed every four to six months.
INJECTION TREATMENT FOR VARICOSE VEINS
What is injection treatment?
Injection treatment is used for closing off varicose veins by injecting a chemical substance into them that causes their walls to stick together.
It works best for varicose veins which are not under pressure from leaky valves higher up in the veins of the leg and you will be advised whether your veins are suitable for this kind of treatment.
Most varicose veins that are suitable for injection treatment are not medically harmful and treatment is seldom essential. It is done for people who dislike their varicose veins and the symptoms they cause.
What happens during injection treatment?
This is done as an outpatient procedure. The doctor will explain to you what they intend to do and will then give you one or more injections into the veins. Each injected area will be covered with a pad, and a stocking or bandage will then be applied all the way up from the foot.
The chemical substance (sclerosant) that is injected into the vein works like a glue. For the glued surfaces to become firmly and permanently fixed, they must be clamped together until the vein walls have stuck together. In the case of your veins, bandages and stockings act as a “clamp” to hold the vein walls together. If they are removed before the two surfaces have become firmly glued, the veins will re-open and the result may be unsatisfactory.
What should I do after injection treatment?
Advice varies, but the following recommendations are typical.
- You should walk briskly for at least 20 minutes after having your injections.
- The bandages and/or stockings must be worn without interruption for the length of time specified (usually 2-3 weeks). This means that you will not be able to bath or shower normally because you should not get the bandage wet. If bandages become loose, they need to be reapplied.
- Whilst wearing the bandages or stockings, try to remain as active as you can. Avoid standing still for long periods: if you need to stand for more than about half an hour, go for a short walk to keep the legs moving. It is more important to walk about frequently than to go for a long walk, but you may walk as far as you wish. When sitting for long periods, elevate the foot, if possible.
In general, there are no restrictions on your activities and it is reasonable to pursue most sports. It is sensible to avoid very strenuous activities that cause the bandages to loosen and also contact sports that might damage your legs. Avoid getting the bandage wet.
What other effects or problems might there be?
The chemical substance injected into the veins can cause inflammation, resulting in redness and discomfort. This will settle but if it is troublesome, then it is reasonable to take painkillers. Anti-inflammatory painkillers, such as ibuprofen, are particularly helpful but paracetamol is usually adequate. Any inflammation will settle quite quickly.
Some ankle swelling may occur which may be worse if you spend a lot of time standing. Swelling will usually settle if you go out for a walk or if you elevate your leg.
Occasionally, inflammation can be very troublesome although it will disappear.
Deep vein thrombosis is a possible consequence of injecting the varicose veins, but this is very rare - the deep veins are quite different from those that you have injected. The usual sign of a deep vein thrombosis is persistent swelling of the leg.
In the longer term, injections can produce brown staining of the skin in the areas where the veins were. This occurs in just a few people and is unpredictable. This brown staining may fade but can be permanent. Very rarely, tiny veins can appear in the skin over areas that have been injected. Very occasionally, blistering can occur at injection sites. This will resolve spontaneously, but may leave a small scar.
How long lasting is injection treatment?
The result may be permanent for small varicose veins. However, if there is a head of pressure on the veins from leaky valves, then new varicose veins may gradually appear over the years. If this is a nuisance, then they may be suitable for further injection treatment, or for an operation.
OPERATIONS FOR VARICOSE VEINS
How can varicose veins be treated by an operation? A cut is made over the top of the main varicose vein and it is tied off just where it joins the deep vein in the groin. This cut is closed with stitches, which are hidden under the skin (see picture).
The main vein under the skin is removed by passing a fine wire down it – either to just below or just above the knee (“stripping” the vein). This helps to guard against varicose veins forming again. Blood flows up the many other veins in the leg after this vein has been removed.
Varicose veins marked before the operation, are removed through tiny cuts in the skin. These cuts can be closed with stitches or adhesive strips.
Other veins under the skin with important connections to the deep veins may need to be dealt with. This may require special scans before the operation, and this will be explained to you.
How long will I have to wait for my varicose vein operation?
Surgeons do not like to keep people waiting for long periods of time, but have to deal with patients according to their medical priorities. Those with more serious symptoms, such as skin changes or ulcers as a result of varicose veins, take priority over those with aching or cosmetic embarrassment.
Due to heavy demands on staff and resources, treatment sometimes is not available unless varicose veins are starting to cause skin damage.
What about the anaesthetic?
The anaesthetic is one of the main concerns for all patients. Many feel they are handing over control of their life to another person. This worry is understandable but modern anaesthetics are very safe, and serious complications are uncommon. The operation is usually conducted under a general anaesthetic, and lasts about one hour for each leg.
If I have an operation, how long will I spend in hospital?
This depends on whether you are able to have surgery as a day-case.
If you are medically fit and have somebody at home with you, then a day-case operation may well be possible. If you need an operation to one leg only, then you are more likely to be offered surgery as a day-patient than if you have varicose veins in both legs. As a day-patient, you are able to return home on the day of your operation.
If it is thought best that you come into hospital as an in-patient, you will usually be admitted the day before your operation for the doctors and nurses to assess your needs.
WHAT HAPPENS BEFORE THE OPERATION
After coming into hospital, you will meet the nurses (one of whom will be specially allocated to look after you), junior doctors, and the anaesthetist. They will conduct some basic tests and will answer any questions for you.
The consultant or a member of their team will check that all the necessary preparations have been made and will mark your varicose veins with a felt tip pen. Be sure that all the veins you would like dealt with have been marked, and ask about any that have not.
The consent form
The hospital requires you to sign a consent form, as for any operation.
Because an empty stomach is important before a general anaesthetic, you will not be allowed anything to eat or drink immediately before your operation. Usually, you will be told to have no food for 6 hours before the operation, but you will be allowed small quantities of clear fluids, tea or coffee up to 2 hours before the operation.
If you are going to have a cut in the groin, this area will need to be shaved, but there will be no need to shave all the pubic hair. Usually, the whole of each leg requiring surgery needs to be shaved. This makes marking of your varicose veins easier and means that hairs do not get into the wounds during the operation. If you are a day-patient you may be asked to shave yourself before coming into hospital, but even if you are to be an in-patient, it is often more convenient to have shaved yourself.
AFTER THE OPERATION
How much does it hurt afterwards?
Most surgeons inject a long-acting local anaesthetic into the groin wound at the end of the operation: this is usually the most uncomfortable area. People vary in the amount of pain they experience after the operation, though most experience discomfort only. It is more uncomfortable to get up and walk after operation on both legs than when only one leg has been dealt with.
In either case, you will be allowed to get up and walk on the day of your operation when the effects of the anaesthetic have worn off sufficiently.
Painkillers (usually paracetamol or similar tablets) will be prescribed for you to take after the operation. You should ask the nurses for these in hospital, or take them yourself at home if you are uncomfortable. It is important that you should take painkillers if you need them to walk about and to rest with comfort. You should not need them for more than a few days, but the duration of discomfort varies from person to person.
How will I manage in the days following my operation?
After two or three hours on the ward, you should feel fit enough to go home. Before you leave, the ward staff will check your leg. They will give you a note for your general practitioner, and some painkillers to take with you. You will also be provided with an advice sheet. If the dressings are to be changed in the next day or two, the hospital will arrange for a nurse to call. She will check on you and may change your bandages for a special support stocking.
You will usually be able to get up within a few hours of the operation. The bandages on your leg may be changed on the day after the operation for a special support stocking, but some surgeons apply bandages that are left on for several days – this will be explained to you. You will be able to go home as soon as you and the doctors agree that you are sufficiently well and mobile – usually, on the first or second day after the operation.
What about my wounds?
Sometimes, a little blood will ooze from the wounds during the first 12-24 hours after the operation. The amount is likely to be very small and bleeding usually stops on its own. If necessary, press on the wound for ten minutes with a dressing or a pad of paper tissues. If bleeding continues after doing this twice, phone the ward or your medical practitioner. If you cannot get through to the ward, come to the Accident and Emergency Department.
It is common for the area under the groin wound to feel tender for a few days and thickened for a few weeks. Areas of tender lumpiness may also be felt elsewhere on the legs. This is caused by some blood clots under the skin in the places where varicose veins were removed. It is not harmful and will gradually go away, but this may take several weeks.
Will my legs be bruised?
Bruising is common after varicose vein operations. This is sometimes quite extensive and may take a month or more to settle. In particular, it can occur on the inner side of the thigh, where there may be no cuts: this is caused by stripping out the main vein under the skin from this area.
Will I have dressings or stitches?
Frequently, no dressing is used in the groin. However, if a dressing has been used, it can generally be removed 2-3 days after the operation. From that time, the groin wound can be washed normally with soap and water. Avoid talcum powder for the first few days. The leg may be dressed with a bandage which may be left in place for about a week or changed for a stocking after a few days.
Stitches may be placed under the skin in the groin that do not have to be removed: they simply dissolve. The small cuts further down the leg are closed with adhesive strips, and some surgeons use no dressings or stitches at all on the tiny wounds. If any stitches do need to be removed, you will be advised about this. If adhesive strips have been used, you may be told not to bathe or shower for about seven to ten days, unless you can do so without getting the adhesive strips wet. About seven to ten days after the operation, you can remove the strips yourself: this is often easiest in a bath or shower that helps to loosen them.
When adhesive strips are used to close the wounds, it is often not possible to wash off all traces of antiseptic or blood from your legs at the end of the operation. All this will be removed when you bathe or shower after removing the dressings.
What about bandages and support stockings?
If you are advised to wear stockings during the days after the operation, these may be worn all the time, but if you find them uncomfortable at night, they can be taken off before you go to bed and then put on again in the morning. They are mainly intended to support the leg while you are up and about during the day. You should get clear advice about when to discard stockings – usually about ten days after the operation. Sometimes, the leg is dressed with bandages which you remove yourself after 8-10 days.
How far should I walk?
You can start to walk about as soon after the operation as you are able. Getting up the next day is sometimes a little uncomfortable, particularly where the groin has been operated on. The whole leg may be stiff, and tender to touch in places. You will not damage any of the wounds by walking. Take painkillers if you need them.
You should aim to walk about every half hour or so during the day for the first week or two. For many people this simply means getting back to their active daily routine as rapidly as possible. There is no special advantage in going for a single long walk during the day, although you may walk as far as you wish. Frequent walking is more important than walking a long distance.
When you are not walking about, try to put your foot up - either on a couch or on your bed. Avoid standing, or sitting with the feet on the floor, as much as you can for about two weeks after the operation.
When will I be fully back to normal?
This varies a lot between different people, and depends on how large and extensive your varicose veins were, which dictates the size of operation you will have had. In particular, your recovery will depend on whether you have had an operation on one leg or both legs.
If you have had surgery to one leg only:
You are likely to feel tired for the first two or three days after the operation, and your leg will be stiff after walking long distances during the first week. By two weeks after the operation, you are likely to be walking longer distances with little discomfort, even though the leg may still be bruised and a little tender.
If you have had surgery to both legs:
You may feel quite tired for the first week, especially after longer walks. You may need to rest two or three times a day for the first few days and it could be two or three weeks after the operation before you are walking comfortably. Your legs may be a little tender and bruised for a month or more.
When can I drive a car?
You can drive as soon as you feel confident that you can make an emergency stop without pain. This is often about a week after surgery to one leg, or ten days after surgery to both legs. If you are concerned, check with your insurance company.
When can I return to work and play sports?
You can return to work and sporting activities as soon after the operation as you feel sufficiently well and comfortable. If your job involves prolonged standing or driving, then you should not consider going back for at least two weeks. It is unusual to need more than about three weeks off work after surgery to one leg, or four weeks after surgery to both legs.
Avoid violent sports while you are still in support stockings or bandages, and thereafter start with some gradual training, rather than in immediate competition. Do not go swimming until you are out of support stockings and all the wounds are dry.
What problems can occur after the operation?
Serious complications are uncommon after operations for varicose veins. Some bruising is usual, and occasionally, the leg becomes very bruised. This bruising may appear during the first few days after the operation: it will disappear over a period of weeks.
- Aches, twinges, and areas of tenderness may all be felt in the legs for the first few weeks after the operation. These will all settle down, and should not discourage you from becoming fully active as soon as you are able.
- Tender lumps under the skin are common and are caused by a blood clot that has collected in the places where the veins were removed. They are not dangerous and will gradually be digested by the body, this can take a few months. Occasionally, they can be quite painful during the first two weeks or more.
- Infection is an occasional problem (under 5%), particularly in groin wounds. It usually settles with antibiotic treatment. If the wound was closed by a stitch under the skin, this may need to be removed to allow the infection to clear up. If an abscess forms then a further operation may be required to drain it, and the area will need to be dressed regularly until it has healed.
- Rarely, a collection of clear fluid (lymph) can appear as a lump in the groin (or on the lower leg). This almost always settles down without treatment. Less commonly still, a leak of clear lymphatic fluid can occur from the groin wound, and this may take days or weeks to dry up.
- Complications in groin wounds are more common in people who are obese, and in patients who have had previous surgery in the groin.
- The scars on your legs are easily noticeable to start with, but will continue to fade for many months after the operation. Very occasionally, some people develop a little brown staining where the veins were removed, or areas of tiny veins appearing in the skin nearby: this is unpredictable and uncommon.
- Nerves under the skin can be damaged when removing varicose veins close to them. This is uncommon (occurring to a varying degree in 10-15 % of cases), but will give an area of numbness in the leg, which settles or gets smaller over weeks or months. Permanent numbness or pain from nerve injury is less common (under 1%), but can occur. If varicose veins on the foot are removed, damage to small nerves is a special danger. If a nerve lying alongside one of the main veins under the skin is damaged, then a larger area of numbness can be caused. If this happens after stripping the main vein on the inner side of the leg, then numbness will result over the inner part of the lower leg and foot. If a main vein behind the knee needs to be dealt with, then there is a risk to the nerve that conducts feeling from the skin on the outer part of the lower leg and foot. There is also a minuscule danger to the main nerves that move the leg and foot. The risk of nerve damage is increased when surgery is done after previous operations in the same area.
- Damage to major arteries and veins can happen during varicose vein operations, but these are very rare complications.
- Deep vein thrombosis causes swelling of the leg and can result in a blood clot passing to the lungs. It is a possible complication after varicose vein surgery, but is particularly unlikely if you start moving your legs and walking frequently soon after the operation. Sometimes, injections are given to make the blood clot less than normal: these reduce the risk of blood clotting but increase bruising. If you are taking the contraceptive pill, your risk of thrombosis is increased, and the surgeon will discuss with you the pros and cons of stopping the pill and taking special action to reduce your risk of a thrombosis. If you start taking the contraceptive pill while waiting for your operation, let the hospital know.
- Any general anaesthetic carries risks, but considerable precautions are taken to keep these risks as low as possible. The risk of death as a result of varicose vein surgery is less than one in a thousand.
Will my varicose veins come back?
Some people develop new varicose veins during the years after a varicose vein operation, but this is uncommon after thorough surgery. The risk of recurrence is probably about 20% within the 10 years following your operation. Rarely, varicose veins simply re-grow in the areas that have been dealt with, or else they develop in a different system of veins that was normal at the time of the original operation. If veins develop again they can be dealt with by injections or a further operation.
This information was produced as a service to medicine by VASCUTEK, a TERUMO Company