Varicose Veins - Treatment and Prognosis

Treatment of varicose veins

Exercise
There is an exponential rise in the prevalence of venous disease as the amount of daily movement is reduced, therefore exercises that emphasize ankle flexion are encouraged. Activation of the musculo-venous pump provides periods of lowered venous pressure and improves function of the calf muscle pump.

Elevation
Raising the feet above the level of the heart for 15-30 minutes per day reduces symptoms and oedema.

Compression hosiery
Compression reduces the diameter of the veins, increases the blood flow velocity and lymphatic flow and reduces oedema. It is the first-line therapy in patients who are unwilling or unfit for surgery, or if there is a possibility that the symptoms are not from venous disease. Response to compression stockings usually indicates that surgery will be beneficial.

Elastic compression comes in four classes based on the pressure exerted at the ankle. The pressure is reduced further up the leg to create a gradient to encourage venous flow. Elastic therapy may reduce the severity of symptoms and halt progression of disease but poorly fitting stockings can lead to a 'tourniquet effect', creating an opposite gradient and worsening the reflux.

Inelastic compression is more effective in augmenting venous pumping, as the semi-rigid compression ensures that the muscular pump directs blood towards the heart, rather than a circle of pumping blood in and around muscles which can occur with elastic hosiery; however, compliance is more difficult.

Laser therapy
Laser therapy is increasingly used for the treatment of telangiectasia and venous flaring. Laser and light therapy produce foci of high-intensity heat which potentially cause less inflammation and chemical irritation as the target tissue absorbs different wavelengths of light compared to surrounding structures. To date these methods are unsuitable for coloured skin.

Surgical management

High tie strip and avulsions
Surgery is indicated in patients with skin changes, venous ulceration and intractable pain. The decision for surgical treatment is less straightforward for patients with symptomatic trunk varices with no skin changes as it is impossible to determine which of these patients go on to develop ulceration.

High tie strip and avulsions is the preferred operation for long saphenous reflux. A short oblique incision 2 cm below and lateral to the pubic tubercle is made along the groin crease. The five specific tributaries are identified and ligated. A stripper is placed down the distal part of the disconnected saphenous vein to as far down as 5 cm below the knee and a ligature placed proximally. An oblique 1.5 cm incision is made at the tip of the stripper and the distal vein ligated and divided. The stripper is then pulled down, stripping the saphenous vein from groin to knee. Stab avulsion incisions are made for the remaining varicosities and pulled out using a hook and artery forceps. At the completion of the operation a crepe bandage is applied firmly from ankle to mid thigh in order to aid haemostasis and minimize postoperative bruising.

For short saphenous reflux a 3-5 cm incision is made in the popliteal fossa targetted to the sapheno-popliteal junction using a hand-held Doppler. The vein is disconnected at the junction using a similar technique to that above, with or without avulsions. The deep fascial layer is closed with care to avoid the potential of popliteal hernia developing. Extreme attention is paid not to damage the nearby sural nerve.

Complication of varicose vein surgery:

Complications of surgery are saphenous or sural nerve neuralgia (10%), postoperative bruising (90%), wound infection (2%), and transient lymphocele (2%). Recurrence is 20-30% at 10 years from surgical therapy. The most common cause is failure to identify and ligate all the saphenous vein tributaries. In the past many surgeons would tie and ligate the saphenous vein in isolation without stripping. This method has a high rate of recurrence secondary to venous recanalization.

Sclerotherapy
Intravenous injection of sclerosants (such as sodium tetradecyl sulphate) causes venous fibrosis and obliteration. This method of treatment is usually reserved for residual varicosities after surgery. Its use as first-line treatment lost favour due to high recurrence rates, skin staining and the risk of ulceration and deep venous thrombosis. An important principle in successful sclerotherapy is the prevention of exposure of the sclerosant to normal vessels.


Latest developments in varicose vein’s treatment:

Radiofrequency endovenous occlusion is a technique that uses radiofrequency energy delivered through an endovenous electrode). Heat dissipates within the lumen of the vessel leading to vein shrinkage and occlusion by contraction of venous collagen. Vein occlusion rates are reported as high as 97% at 1 week, 95% at 6 weeks, and 92% at 1 year. The major complication of this technique is the creation of venous thrombus (1%). Other side effects include phlebitis (6%), skin burn (3%) and temporary paraesthesia (18%).

Endovenous laser therapy (EVLT) is a laser version that works in a very similar manner.

Prognosis of Varicose Veins:
The natural history of patients with varicose veins is very variable. In patients who undergo surgery, the recurrence rates are low.

Varicose Veins - Causes, Symptoms and Complications
Diagnosis of Varicose Veins
Varicose Vein - Treatment and Prognosis