You may be able to see all 3 types on your leg. The first type, the saphenous veins and the main tributaries, are the ones that usually do well with an operation.
The main cause of large varicose veins is leaking (incompetent) valves. Blood does not flow upwards as it should. Instead, it leaks back through the valves and pools in the superficial veins at the skin surface. This can give rise to complications. The stagnant blood can clot in the veins, a condition called phlebitis.
The superficial veins swell and pressure rises inside them. As the pressure rises, fluid builds up in the tissues causing ankle swelling. Blood cells leak through the walls of the veins causing skin staining and leading to eczema. The tissues do not get enough oxygen and can break down, forming ulcers. Very rarely, after many years, the ulcers may become malignant.
As the pressure and swelling increase, the valves leak even more, making the condition worse.
The incompetent veins, where the valves are leaking, are usually, the long saphenous vein, often some perforating veins and less often, the short saphenous vein. Special tests with Doppler scanners will help identify the problem veins, before any operation. The largest varicose veins you see are usually the tributaries that drain into the saphenous veins and not the saphenous veins themselves.
The leaky valves may be due to many things; such as an inherited weakness, long periods of standing, damage by clotting or pressure from a swelling in the pelvis.
The other 2 types of varicose vein are often separate from the first type. They are usually treated in a different way. This may be with injections or cautery (heat) using tiny electric currents.
The aims are to stop the backflow of blood down the superficial veins and to remove the unsightly veins.
We tie off the long saphenous vein where it joins the deep vein in the groin. The short saphenous vein is tied off where it meets the deep vein behind the knee, as needed. Incompetent perforating veins are removed. The swollen superficial veins are removed, either in long lengths (stripping) or bit by bit through many tiny cuts in the skin.
If there are varicose veins in both legs, they can usually be operated on at the same time.
The operation should cure the symptoms. Swollen ankles should settle down. Ulcers should stay healed. There should be no more phlebitis or bleeding. Eczema should fade away. Staining of the skin tissues should improve to a degree.
Are there any alternatives?
If you just have some obvious varicose veins without any problems, leaving things as they are usually does no harm. It may be 5 or 10 years or more, before they slowly develop problems.
If you have any of the complications and do nothing, they will probably get worse much more quickly.
Injections to scar up the veins are effective, if the veins are only seen below the knee. Injections are useful to control any small veins still present after an operation.
The technique of passing a special electric current through a vein to destroy it is still under development.
For an unfit patient, just doing the tie-off operation in the groin may be best.
Elastic stockings are helpful, if you are not keen on an operation. They can be uncomfortable, hot and need frequent replacement. They are useful to find out if leg pains are due to varicose veins.
Laser treatment, ointments, and drug treatment are not helpful for most types of varicose veins.
Camouflage make-up is helpful to cover up small flare veins.
Who should have it done?
People with complications of varicose veins should have the operation. This prevents the complications from getting worse, but the patients must be fit enough for the operation. Many people are upset by the appearance of varicose veins. The operation may not be essential, but greatly improves their sense of well-being.
Who should not have it done?
If the veins are small and the valves are seen to be working in the groin on the Doppler scans, then injection treatment may be better than surgery.
Patients who have previously had clotting (thrombosis) in the deep veins of the calf may be better off with support stockings than an operation. The operation would probably not improve the discomfort and swelling that deep vein thrombosis (DVT) usually causes.
Author: Mr Michael Edwards FRCSEng FRCSEd. Consultant general surgeon
© Dumas Ltd 2006