Veins serve to drain deoxygenated blood from the tissues back to the heart so that the blood can be pumped to the lungs for re-oxygenation. As veins drain blood back to the heart, they function as a low pressure and flow system. The vein drainage of the legs occurs via 2 systems – the deep veins and the superficial system. Both these vein systems have to transport blood back to the heart. Deep veins drain more than 75% of the blood from the legs back to the heart. Deep veins are located within the muscles of the legs and are located near the leg arteries. Each time our leg muscles contract, the veins are compressed thus pushing blood upwards (the calf pump system). The superficial veins, on the other hand, drain about 25% of the leg blood flow. They are located in the soft-tissue and fat layers of our calves and thighs. There are 2 main superficial veins – the Great Saphenous Vein (GSV) runs upwards from the ankle on the inner side of our calves and thighs before joining the deep vein system at the groin at the Sapheno- Femoral Junction (SFJ). The Short Saphenous Vein (SSV) runs from the ankle upwards along the back of the calf and joins the deep vein system at the back of the knee at the Sapheno-Popliteal Junction (SPJ).
Normal healthy veins have one-way valves within them that help to maintain continuous blood flow to the heart. These valves can get damaged over time leading to venous reflux disease, a situation in which blood does not flow back to the heart but instead remains engorged in the veins. The valves at the SFJ and SPJ are especially prone to failure and become non-functional and incompetent. Risk factors for development of venous reflux include prior pregnancies especially multiple pregnancies, obesity, prior Deep Venous Thrombosis (DVT) and a positive family history (parents and siblings).
Varicose veins are swollen enlarged veins under the skin and develop as a result of venous reflux disease. These engorged veins are usually the side veins that drain from the main GSV and SSV. They are seen most commonly in the legs over the calf and thigh regions. Some patients present with spider veins, which are mild varicose veins that look like a fine network of red or blue lines just under the skin. Varicose veins can also cause leg swelling around the ankle region and this is especially worse after prolonged periods of standing. Patients also feel an uncomfortable aching pain sensation. In more extreme cases, the skin around the ankle and inner calf region can become darkened or pigmented, itchy and scaly (venous eczema) and develop recurrent skin infections (cellulitis). If left untreated, the skin can break down and non-healing venous ulcers can develop. Sometimes, the engorged varicosities can rupture, resulting in profuse bleeding.
Varicose veins are diagnosed with clinical examination and ultrasound scans. The ultrasound scan is essential, as it will determine the degree and extent of venous reflux of the GSV and SSV. The scans also help determine if the deep veins have reflux disease or DVT.
Conservative non-surgical treatment includes the use of tight compression stockings. The stockings are very useful for alleviating symptoms and for preventing the progression of disease. However, discipline on the part of the pateint is required as stockings can be tight and difficult to put on, especially in our hot local climate. Some patients also find the constant sensation of tight compression in the legs uncomfortable.
Surgery is needed in the following circumstances: persistent symptoms, recurrent episodes of skin infections, the development of skin ulcers, severe pain and swelling. Surgery is also an option for patients who are not able to use compression stockings.
There are 2 surgical options available: 1) Traditional open surgery known as high-tie and vein stripping, and 2) Newer minimally invasive endovenous vein ablation surgery.
Traditional open surgery involves making a skin incision at the groin or back of knee and exposing the GSV and SSV junction before tying off its drainage branches into the deep veins. The vein is then removed by stripping from the thigh down to the knee level. This method requires general anaesthesia,and requires a night’s stay in hospital. Open surgery is often associated with greater pain and a slower process.
Various minimally invasive endovenous techniques are now available to treat varicose veins. These include:
Radio-Frequency Ablation (RFA)
Clarivein Endovenous Treatment
These methods require a small puncture under ultrasound scan and insertion of probes inside the vein to shrink and close off the vein using either heat (RFA) or mechanical/ chemical means (Clarivein). Due to its minimally invasive nature, these endovenous techniques can be done under local anaesthesia and light sedation, usually as a day surgery case with same day discharge. Post-procedure recovery is also much faster with patients returning to their normal daily activities within 1-2 days.
No major surgery
No or minimal visible scars
No general anaesthesia in most cases
Same day admission and discharge
Back to normal activities within 1-2 days