Dr Jason Toniolo

Varicose veins

Varicose veins are enlarged, twisted veins, usually occurring in the legs, due to valve failure in the veins.

These initially pose a cosmetic issue, however, with veins bulging under pressure, they eventually lead to problems with the lower limb.

Causes of varicose veins

Increased risk of increasing age
Obesity – increased pressure on the veins preventing blood from returning to the heart creates engorgement of blood in the veins
Women are more susceptible than men, due to differences in hormones
Pregnancy – most commonly seen to develop during or after pregnancy, due to hormonal changes that relax the vein wall, combined with the increased blood volume that develops and is required to nourish your child
Family history – the condition tends to run in the family

Symptoms and signs:

Swollen, visible veins
Aching, heaviness and ‘tiredness’ in the legs
Itching or skin changes around the veins
Heavy or achy feeling in your feet
Pain is worse after prolonged standing or sitting without movement
Swelling of the legs
Muscle cramps at night

Complications of varicose veins

Clots in the superficial veins (superficial thrombophlebitis) – these can rarely be a cause for pulmonary emboli (clots in the lung)
Bleeding or haemorrhage when the vein sitting under the skin is cut inadvertently
Damage to the skin of the shin region, which leads to thinning and eventual ulceration, which is extremely painful to provide wound care for

treatment options

Medical management:

Compression stockings: Three grades apply compression on the legs. Grade 1 = 18-21mmHg, grade 2 = 23-32mmHg, grade 3 = 34-46mmHg. This compression squeezes the veins under the skin shut so that they cannot bulge under pressure and cause damage and swelling. Grade 2 stockings are used for symptomatic varicose veins.
Natural therapy-based supplements: Micronized purified flavonoid fraction (MPFF) is the natural remedy with the best evidence for managing symptoms. The medication is commonly used in Europe and has the brand name Vasculera.
Exercise and weight loss will help improve circulation in the veins and take pressure off the veins in the waist, improving the venous return
Regular movements of the leg: The calf muscle works as a pump for the deep veins of the leg. Pumping your calf by walking will help reduce the pressure in the veins by increasing the speed at which blood is pumped out of the leg.

Minimally invasive surgery:

Sclerotherapy – multiple injections to kill the veins, see sclerotherapy section
Minimally invasive laser or radiofrequency ablation procedures (often referred to as EVLT – endovenous laser treatment), use heat energy to burn the veins from the inside. Because there is heat energy used, the vein is surrounded by fluid which is injected by a pump and needles into the skin, to ensure the heat doesn’t damage tissue around the vein (insulation)
Glue – Venaseal glue is similar to EVLT in that it is a catheter (long plastic tube) that is passed through the length of the vein. The main difference is that with glue, multiple injections of fluid aren’t required to insulate the vein. The primary downside is that the glue remains in the body forever, and very rarely there have been reportedly allergic reactions that cause large problems for patients.

Traditional open surgery

the main malfunctioning vein is stripped out of the body, using a small cut in the groin and below the knee. Then, smaller varicose veins below the knee are individually plucked through many, tiny 3mm incisions in the skin

Improvements in quality of life from vein surgery

For many patients, the best improvements in quality of life scores are achieved by undertaking a minimally invasive surgical option. Using the venous clinical severity score (VCSS), the average improvement in scores when studied were:

VCSS score with compression garments: 4.6 to 3.5

VCSS score with surgery: 4.8 to 0.6

Because of this improvement in quality of life, the European vascular surgery guidelines on varicose veins have made the formal recommendation that any patient with visible varicose veins should be offered surgery instead of stockings alone due to this quality of life improvements. Unfortunately, medicare has stated that in the public system, only patients with swelling, skin damage, bleeding or superficial vein clots quality of surgery.