Varicose Veins

Varicose veins are dilated (enlarged), elongated and tortuous sections of veins which are located just under the surface of the skin – usually on the legs. They are often easily visible, as they look thick and knobbly and generally blue or dark purple in colour. They may be less obvious if you are overweight, as they are hidden by fatty tissue under the skin.

Spider veins and reticular veins can often occur alongside varicose veins or can occur on their own.

Varicose Veins

About 3 in 10 adults develop varicose veins at some time in their life. More women develop varicose veins than men. Most people with varicose veins do not have an underlying disease and they usually occur for no apparent reason. Varicose veins do not cause symptoms or complications in most cases, although some people find them unsightly.

Arteries bring blood from the heart to the organs and tissues in your body, veins take the blood back to the heart.

Veins contain one-way valves to prevent the blood from flowing back. When the valves become faulty the blood can travel back toward the feet. This causes the veins that are near to the surface of the skin to enlarge and result in what is commonly called varicose veins. These can range from small dilated veins to large bunch of grape-like structures in the calf.

Varicose veins are a slowly progressive disease which if left untreated can lead to marked skin damage or ulceration near the ankle.

Up to 30% of the adult population have varicose veins and heredity is a primary cause.

Environmental factors also play a large part, for example, prolonged standing in various occupations and our Western diet with high fat, refined sugar and low fibre content may also contribute.

Varicose veins become more frequent in advancing age but can appear at any time in life. Hormonal changes in puberty, pregnancy and the menopause may influence the course of the disease, though 60-70% of varicose veins during pregnancy will disappear within a few months of delivery.

Varicose veins may cause feelings of fatigue, heaviness, aching, burning, throbbing, itching and cramps in the legs. These symptoms are often accompanied by swelling of the ankle. Spider veins can also produce the same symptoms. These symptoms are usually worse during warm weather or when you have been standing up for long periods of time.

Most people with varicose veins do not develop complications. Complications develop in a small number of cases when veins are left untreated. However, it is impossible to predict who will develop complications. The complications are due to chronic high venous pressure in the varicose veins resulting in changes to the skin around the ankle.

If complications do develop, it is typically several years after the varicose veins first appear. The visible size of the varicose veins is not predictive whether complications will develop.

Possible complications include:

  • Inflammation of the vein (thrombophlebitis).
  • Swelling of the foot or lower leg.
  • Skin changes over the prominent veins. The possible skin changes are: discolouration, eczema, skin ulcers, or lipodermatosclerosis (hardening of the fat layer under the skin, causing areas of thickened, red skin).
  • Varicose veins near the surface of skin can sometimes bleed due to minor trauma to the overlying skin.
  • To ease unpleasant symptoms, like pain, cramps or discomfort,
  • To treat complications, such as skin discolouration, ankle swelling, bleeding, thrombophlebitis or leg ulcer,
  • To rid your legs of unsightly veins!Get them looking like they were before.

Investigations

Duplex ultrasound scan is a non-invasive and pain free investigation. It is the gold standard investigation for venous diseases. It allows assessment the condition of both deep and superficial veins. It is often the only investigation required in majority of patients with varicose veins as it is able to provide adequate information to allow decision making on treatment. With colour duplex ultrasound imaging, all veins and arteries can be visualized so that the direction of the blood flow can be demonstrated and measured. In patients with varicose veins, it will demonstrate incompetent valves and reversal of blood flowing toward the feet. A venous mapping and report are then produced to indicate all incompetent veins and where they arise from. This will assist surgeon to decide how to best manage your varicose veins.

Magnetic Resonance Venography (MRV) is Magnetic Resonance Imaging (MRI) of veins. It is a radiation-free scanning technique that uses radio waves and magnetic fields to produce detailed three-dimensional images of the body. It is a very sensitive test for deep and superficial venous disease in the lower legs and in the pelvis, where other imaging methods (eg duplex ultrasound scan) cannot reach. MRV is particularly useful for investigating nonvascular causes for leg pain and oedema. In addition, non-contrast imaging techniques are available with MRV, making MRV the preferred technique in patients with renal impairment or contrast allergy.

CT venography is also useful for evaluation and visualization of the anatomical structure of venous system varicose veins and venous malformations. CT venography has advantages of speed and spatial resolution in comparison with MRV. Many patients who are not candidates for MRV by virtue of pacemakers or other MRI incompatible devices, or claustrophobia, can be examined with CT venography. CT venography always requires the use of intravenous contrast and radiation exposure which are the main limitations of this technique.It is especially useful when:

  1. Veins in the pelvis and abdomen are suspected to be abnormal, for example- DVT, iliac vein compression
  2. There is suspicion of congenital venous abnormalities

Varicose Veins Treatment Singapore

Endovenous Thermal Ablation is also known as ‘Laser Therapy’ or ‘Radiofrequency Ablation. It is a new, minimally invasive procedure which has essential taken the place of traditional “vein stripping surgery’. The aim of this treatment is to destroy the vein from the inside using heat. The procedure can be performed under local anaesthesia, sedation or general anaesthetic.The procedure involves passing a laser fibre or radiofrequency probe, under ultrasound guidance, along the vein from the knee or calf towards the groin to treat large varicose veins in the thigh. This is followed by infiltrating large volume of weak anaesthetic fluid around and along the targeted vein (Tumescent anaesthesia). This is used to provide a heat sink to prevent thermal injury to the tissue around the veinand to reduce pain along the treated vein. Heat will then be generated from laser fibre tip or radiofrequency probe in the varicose vein. The laser fibre or radiofrequency probe is withdrawn gradually to heat up, destroy and close off the course of the targeted vein. The treated varicose veins will be left in place to scar and eventually absorbed by the body. This procedure is associated with much less bleeding and bruising as compared with vein stripping surgery. Endovenous thermal ablation procedure also results in less pain and allows a faster return to normal activities.

How long does the procedure take?

Endovenous thermal ablation typically takes 1hour or less for one leg. The procedure is often performed in association with microphlebectomy to remove the larger branch varicosities. This may require an additional 30 to 40 minutes.

What are the risks and potential complications of the procedure?

Your doctor will discuss the specific risks and potential benefits of the recommended procedure with you. This is generally a safe procedure. However, as with any surgical procedure, there are potential risks. Complications after endovenous thermal ablation may include bleeding, bruising, inflammation (Thrombophlebitis), pain along the site of ablation, infection, deep vein thrombosis and injury of the nerves that run along with the treated veins.

  1. Mechanico-chemical sclerotherapy (Clarivein)A minimally invasive key-hole treatment for main feeding varicose veins in which the internal lining of the vein is destroyed by a rotating wire with concurrent injection of sclerosant via a single pin hole. This is a non-thermal technique without requirement of tumescent anaesthesia. There is no risk of thermal injury or nerve injury which is especially suitable for lesser saphenous vein and below knee long saphenous vein reflux whereby there is higher risk of nerve injury with thermal ablation technique.

    This procedure can be performed under local anaesthetic as a day-case and is associated with lesser pain and bruising as compared to endovenous thermal ablation (laser therapy or radiofrequency therapy).

    Short to medium term result of Clarivein treatment is excellent.

    ClariVein® infusion catheter is introduced percutaneously into the vein under ultrasound guidance. The catheter tip is positioned near the saphenofemoral junction. No tumescent anaesthesia required.

    The motorized handle rotates the catheter tip during pullback, creating vessel spasm to block forward flow and concentrate the targeted infusion of liquid sclerosant.

  2. VenaSeal Glue AblationVenaSeal glue ablation is a new minimally invasive, non-thermal procedure without the requirement of tumescent anaesthesia. It involves the application of a Medical Grade “Superglue” to permanently seal off the diseased vein.

A micophlebectomy is a minimally invasive surgery which deals with the removal of a large or medium-sized varicose vein protruding under your skin through tiny incisions. The access points are 2-3mm and do not usually require any stitches, just a little piece of adhesive tape. A small vein hook is passed through this incision to elevate and hook the vein. This may be done in conjunction with the primary procedure or done at a later date.

Ultrasound imaging is also used to map the veins before an operation. This enables the veins to be removed through the smallest possible incisions.

Vein Hooks

Ultrasound-guided foam sclerotherapy is generally reserved for larger veins. Injection of liquid sclerosant into larger vein is likely to be diluted by the blood inside the vein and thus reduces the effectiveness of sclerotherapy. Mixing liquid sclerosant and air to form a foam has been shown to be much more effective in treating these veins. When foam sclerosant is injected into a vein, the foam pushes all of the blood out of the vein. The foam allows better contact of sclerosant with the inside of the vein walls and stays in the vein longer to destroy the vein. The vein will then shrink into a fibrous cord and subsequently absorbed by the body. In our clinic, this technique is mainly reserved for patients with recurrent varicose veins and residual veins after vein stripping surgeryand endovenous ablation procedures. Ultrasound is routinely used in this procedure to guide the injection and to ensure accurate placement of needle.

Ultrasound guided foam sclerotherapy can be performed as an outpatient procedure so that you can carry on life as normal. There is little or no discomfort and only minimal bruising compared to other treatments, especially surgery.

Large varicose veins especially those with large diameter and tortuous may sometimes need to be surgically removed by ligation and stripping. Vein ligation and stripping is done under general or spinal anaesthesia. It is carried out operating theatre with overnight stay in hospital.For removal of long saphenous vein, two incisions will be made, about 3-4cm long in your groin and the second one about 1cm in the leg.The vein will be divided and tied off (this is called ligation) through the cut in your groin to stop blood flowing through it. A thin flexible wire is then used to carefully pull (strip) out the varicose vein through the cut in the leg.

  • Compression stockings or bandagingThe gold standard for conservative treatment of patients with varicose veins or chronic venous insufficiency are medical grade graduated compression stockings and compression bandaging (for patients with venous ulcers). They are able to improve symptoms as a result venous reflux. Compression stockings or bandaging are specially designed to steadily squeeze your legs to improve your circulation. They are often tightest at the ankle and get gradually looser as they go further up your leg. This encourages your blood to flow upwards towards your heart. Reduction of hydrostatic pressure by decreased blood pooling in the leg will effectively minimize vein related symptoms. Compression stockings or bandaging have also been shown to improve calf muscle function. The effective pressure of compression at the ankle should be between 30 – 40 mmHg. However, compliance is crucial as the effects of compression will only last as long as you wear them.

    The stockings need to be properly measured and fitted for knee length, thigh length or pantyhose length as guided but doctor. Some patients may require custom made stockings if their leg size did not fit the standard off the shelf stockings. We take great care in getting the right size of stockings with optimal compression pressure for our patients in order to achieve the maximum benefits of stocking. Wrongly measured and fitted stockings can potentially result in discomfort, pain, skin ulceration or foot swelling. Our stockings also come in different colour, fabric and style, giving patients a wider choice and greater satisfaction.

  • Weight Loss
    Weight loss will lead to decrease in resistance of venous return to the heart and thus decrease venous pressure in the legs.
  • Leg Elevation
    Elevating the legs above the heart will improve venous drainage from the legs. Reduction of venous pressure in the legs by reduction of blood pooling in the legs will help to improve symptoms from venous reflux.
  • Exercise
    During exercise, the calf muscle pump will be activated, pushing blood in the deep veins towards the heart. Reduction of blood pooling in the legs will lead to decreased in venous pressure.
  • Medications
    1. Micronised purified flavonoid fraction (Daflon) has been shown to be effective in treating chronic venous insufficiency related symptoms (eg oedema, fatigue, night cramps and heaviness). It has also been shown to be effective in helping venous ulcers to heal.
    2. Pentoxifylline has been demonstrated to be an effective adjunct in venous ulcer healing when used in conjunction with compression therapy.

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