What are Varicose Veins?

Varicose veins are veins under the skin of the legs which have become widened, bulging, and tortuous. They are very common.

Blood flows down the legs through the arteries, and back up to the heart through the veins. There are two main systems of veins in the legs - the deep veins which carry most of the blood back up the legs to the heart, and the veins under the skin, which are less important and which can form varicose veins. All these veins contain valves which should only allow the blood to flow upwards. If the veins become widened and varicose these valves no longer work properly. Blood can then flow backwards down the veins and produce a head of pressure when standing, walking about, or sitting. Lying down or "putting your foot up" relieves this head of pressure and usually makes the legs feel better. Both symptoms and treatment depend on how badly the valves in the veins are working, although the trouble people get from their varicose veins is very variable.

Varicose veins may appear first in pregnancy. People who are overweight are more likely to get varicose veins and to find symptoms from them troublesome. There is some tendency for bad varicose veins to run in families, but this is by no means always the case. Usually there is no special cause for varicose veins.
Very many people have no symptoms at all from their varicose veins, except for the fact that they are unsightly and embarrassing. Other than cosmetic reasons, the commonest symptoms from varicose veins are aching, discomfort, and heaviness of the legs. Sometimes the ankle can swell, too. These symptoms are not medically serious, but can be treated.
Although varicose veins can get worse, this often happens very slowly.
In a few people the high pressure in the veins causes damage to the skin near the ankle, which can become brown in colour, sometimes with scarred white areas. Eczema (a red skin rash) can develop. If these changes are allowed to progress, or if the skin is injured, an ulcer may result. Skin changes are a good reason for going to see your GP and for referral to surgeon.

Other problems which varicose veins can occasionally produce are phlebitis and bleeding. Phlebitis (sometimes called thrombophlebitis) means inflammation of the veins, and is often accompanied by some thrombosis (clotting of blood) inside the affected veins, which become hard and very painful. This is not the same as deep vein thrombosis and is not usually dangerous. The risk of bleeding as a result of knocking varicose veins worries many people, but this is uncommon. It will always stop with firm pressure and the veins can then be treated to remove the risk of further bleeding.

What treatments are there for varicose veins?

If varicose veins are causing troublesome aching or other symptoms, treatment may well be worthwhile. Surgery can also improve the appearance by removal of the varicose veins.
There are four main methods of treatment – support hosiery, and operation. Foam injection sclerotherapy under ultrasound guidance is gaining popularity. Your surgeon can advise whether your veins are suitable for this treatment.

What evidence is available for the newer treatment for varicose veins?

Download my book chapter on "Innovations in Varicose Vein Treatment".

From: Topical Issues in Vascular Surgery, 2005: ISBN:81-308-0037-3

Editors: RB Galland, TR Magee & MH Lewis

It is always important to consider the pros and cons carefully before deciding on treatment. It may be helpful to talk with your general practitioner, with your family, and perhaps with friends who have had varicose veins treated, as well as getting advice from a specialist.

Being overweight makes varicose vein problems worse and if you are overweight you would be well-advised to diet, or to seek advice from your doctor about how to lose weight. This also applies if you are considering any kind of treatment for your varicose veins.

Specialists use Doppler ultrasound machines to examine blood flow in the veins: these “listen” to the blood flow through the skin.

A small handheld Doppler machine will often provide all the information which is required. More detailed scans using a “duplex” scanner (which produces pictures of the veins as well as blood flow information) are needed in some cases.

Support hosiery

This means support stockings or tights, which can be effective in relieving symptoms of aching and heaviness caused by varicose veins 7. They can be bought from clothing shops or chemists. Stronger support hosiery (“graduated compression stockings”) are even more effective. They are made in above or below knee lengths, and in three different “classes” of compression (Class 1 are a little stronger than ordinary support tights; Class 2 are most often advised by doctors for patients with vein problems; and Class 3 provide very firm compression when there is a particular need).

Graduated compression stockings can be obtained by a doctor’s prescription or specialist referral. Different colours are available in some makes. If worn regularly each day graduated compression stockings need to be renewed very three or four months.

Operations for varicose veins

How can varicose veins be treated by an operation?

A cut is made over the top of the main varicose vein and it is tied off just where it joins the deep vein in the groin.

This cut is closed with absorbable stitches, which are hidden under the skin.

A section of vein under the skin in the thigh is removed by passing a fine wire down it. A small cut of 4-5mm is made either just below or just above the knee. This helps to guard against varicose veins forming again. Blood flows up the network of other veins in the leg after this vein has been removed.

Varicose veins marked before the operation are removed through tiny 3-4mm cuts in the skin. These cuts are so small they do not require stitches or adhesive strips.

Other veins under the skin with important connections to the deep veins may need to be dealt with - in particular one just above and behind the knee. If important veins other than the one on the inner side of the leg need to be tied off, this may require special scans before the operation, and we will explain this to you.

How long will I have to wait for an NHS varicose vein operation?

Surgeons working in the National Health Service do not like to keep people waiting for long periods of time, but have to deal with patients according to their medical priorities.

Delays are caused by heavy demands on staff and resources, and there are particular problems in dealing with varicose veins because large numbers of patients are referred to hospital with varicose veins and operating on them takes quite a long time. This means that there is a limit on the numbers of varicose vein operations which can be done, while dealing at the same time with other conditions which are a serious threat to life or health. Some health authorities have experienced such difficulty in offering treatment to all patients referred with varicose veins that they will not treat people with "cosmetic" varicose veins, and in some parts of the country NHS treatment is not available unless varicose veins are starting to cause skin damage.

What about the anaesthetic?

The anaesthetic is one of the main concerns for all patients, stemming from the fact that many feel they are handing over control to another person. This worry is understandable but modern anaesthetics are very safe, and serious complications are uncommon. The operation is usually conducted under a general anaesthetic, and lasts about one hour for each leg.

If I have an operation, how long will I spend in hospital?

This depends on whether you are able to have surgery as a day case.
Day-case
If you are medically fit and have somebody at home with you then a day case operation may well be possible. If you need an operation to one leg only, then you are more likely to be offered surgery as a day-patient than if you have a lot of varicose veins in both legs. As a day-patient you are able to return home on the day of your operation.
In-patient
If it is thought best that you come into hospital as an in-patient, you will usually be admitted on the day of your operation. You will go home the next morning.

What happens before the operation?

After coming into hospital you will meet the nurses and the consultant anaesthetist. They will ask some basic questions about your health and explain what will happen.

The consultant surgeon will mark your varicose veins with a felt tip pen. Be sure that all the veins you would like dealt with have been marked, and ask about any which have not.

The consent form

The hospital requires you to sign a consent form, as for any operation.

Food

Because an empty stomach is important for a general anaesthetic, you will not be allowed anything to eat or drink immediately before your operation. Information about the length of time without food will be given to you when the operation date is booked.

Shaving

If you are going to have a cut in the groin, this area will need to be shaved, but there will be no need to shave all the pubic hair. The doctors and nurses will advise you whether a shave is needed. Once you are asleep, before the operation begin sit may be necessary to shave an area of a leg or the tummy to allow a sticky pad to be attached. This is for diathermy cautery of any oozing vessels. This pad is removed before you wake up.

After the operation

How much does it hurt afterwards?

Most surgeons inject a long acting local anaesthetic into the groin wound at the end of the operation. People vary a lot in the amount of pain they experience after the operation, though most experience discomfort only. It is more uncomfortable to get up and walk after an operation to both legs than when only one leg has been dealt with. In either case you will be allowed to get up and walk on the day of your operation when the effects of the anaesthetic have worn off.

Painkillers will be prescribed for you to take after the operation. You should ask the nurses for these in hospital, or take them yourself at home if you are uncomfortable. It is important that you should take painkillers if you need them to walk about and to rest with comfort. You should not need them for more than a few days, but the duration of discomfort varies.

Sometimes a little blood will ooze from the wounds during the first 12-24 hours after the operation. The amount is likely to be very small and bleeding usually stops on its own. If necessary, press on the wound for ten minutes with a dressing or a pad of paper tissues. If bleeding continues after doing this twice, phone the ward or your general practitioner.

It is common for the area under the groin wound to feel tender for a few days and thickened for a few weeks. Areas of tender lumpiness may also be felt elsewhere on the legs. This is caused by some bruising under the skin in the places where varicose veins were removed. It is not harmful and will gradually go away, but this may take several weeks.

Some bruising always occurs after varicose vein operations. This is sometimes quite extensive and may take some weeks to settle. In particular it can occur on the inner side of the thigh, where there may be no cuts: this is caused by stripping of the vein under the skin from this area.

Often no dressing is used in the groin, but if a dressing has been used it can generally be taken off 2 -3 days after the operation. From that time the groin wound can be washed normally with soap and water. Avoid talcum powder for the first few days.

Stitches may be placed under the skin in the groin which do not have to be removed: they simply dissolve. The small cuts further down the leg are closed with adhesive strips, and some surgeons use no dressings or stitches at all on the tiny wounds. If any stitches do need to be removed you will be advised about this. If adhesive strips have been used, you may be told not to bath or shower for about ten days, unless you can do so without getting the adhesive strips wet. About ten days after the operation you can remove the strips yourself: this is often easiest in a bath or shower which helps to loosen them.

When adhesive strips are used to close the wounds, it is often not possible to wash off all traces of antiseptic or blood from your legs at the end of the operation. All this will be removed when you bath or shower ten days later.

What about bandages and support stockings?

If you are advised to wear stockings during the days after the operation, these may be worn all the time, but if you find them uncomfortable at night, they can be taken off before you go to bed and then put on again in the morning. They are mainly intended to support the leg while you are up and about during the day. You should get clear advice about when to discard stockings – usually about ten days after the operation.

How far should I walk?

Walking helps to disperse bruising and stops the leg becoming stiff. You can start to walk about as soon after the operation as you are able. Getting up the next day is sometimes a little uncomfortable, particularly where the groin has been operated on. The whole leg may be stiff, and tender to the touch in places. You will not damage any of the wounds by walking. Take painkillers if you need them.

You should aim to take walks every day for the first week or two. For many people this simply means getting back to their active daily routine as rapidly as possible. There is no special advantage in going for a single long walk during the day, although you may walk as far as you wish. Frequent walking is more important than walking a long distance.

When you are not walking about try to put your foot up - either on a couch or on your bed. Avoid standing, or sitting with the foot on the floor as much as you can for about two weeks after the operation.

When will I be fully back to normal?

This varies a lot between different people, and depends on how large and extensive your varicose veins were, which dictates the size of operation you will have had. In particular your recovery will depend on whether you have had an operation on one leg or both legs.

If you have had surgery to one leg only:

You are likely to feel tired for the first two or three days after the operation, and your leg will be stiff after walking long distances for about a week. By two weeks after the operation you are likely to be walking good distances with little discomfort, even though the leg may still be bruised and a little tender.

If you have had surgery to both legs:

You may need to rest two or three times a day for the first few days. It may be two or three weeks after operation before you are walking really comfortably. Your legs may be a little tender and bruised for a month or more.

When can I drive a car?

You can drive as soon as you feel confident that you can make an emergency stop without pain. This is often about a week after surgery. If you have an automatic car and surgery to the left leg then driving may pose little problem! If you are concerned, check with your insurance company.

When can I fly?

It is probably best not to fly for approximately one month after the operation. This is particularly important for long haul flights.

When can I return to work and play sports?

You can return to work and sporting activity as soon after the operation as you feel sufficiently well and comfortable. One week off all work and a clear social diary is essential. If your job involves prolonged standing or driving, then you should not consider going back for at least two weeks. It is unusual to need more than about three weeks off work after surgery.

Avoid violent sports while you are still in support stockings or bandages, and thereafter start with some gradual training, rather than in immediate competition. Do not go swimming until you are out of support stockings and all the wounds are dry.

What problems can occur after the operation?

Serious complications are uncommon after operations for varicose veins. Some bruising is usual, and occasionally the leg becomes very bruised. This bruising may appear during the first few days after the operation: it will all go away over a period of weeks.

1. Aches, twinges, and areas of tenderness may all be felt in the legs for the first few weeks after the operation. These will all settle down, and should not discourage you from becoming fully active as soon as you are able.

2. Lumps under the skin are common and are sometimes tender. They are not dangerous and will gradually be digested by the body, but this can take several weeks. Occasionally they can be quite painful during the first two weeks or more.

3. Infection is an uncommon problem, but can occur, particularly in groin wounds. It usually settles with antibiotic treatment.

4. Rarely, a collection of clear fluid (lymph) can appear as a lump in the groin (or on the lower leg). This almost always settles down without treatment. Less commonly still, a leak of clear lymphatic fluid can occur from a wound, and this may take days or weeks to dry up.

5. All complications in groin wounds are more common in people who are obese, and after operations done following previous surgery in the groin.

6. The scars on your legs are easily noticeable to start with, but will continue to fade for many months after the operation. Very occasionally, some people develop a little brown staining where the veins were removed, or areas of tiny veins appearing in the skin nearby: this is unpredictable and uncommon.

7. Small nerves under the skin can be bruised when removing varicose veins close to them. This is uncommon, but will give an area of numbness on the leg, which settles or gets smaller over some weeks. If varicose veins on the foot are removed, damage to small nerves is a special danger. If a main vein behind the knee needs to be dealt with, then there is a small risk to the nerve which conducts feeling from the skin on the outer part of the lower leg and foot. The risk of nerve damage is increased when surgery is done after previous operations in the area.

8. Deep vein thrombosis causes swelling of the leg and can result in a blood clot passing to the lungs. It is an uncommon complication after varicose vein surgery, but is particularly unlikely if you start moving your legs and walking frequently soon after the operation. Heparin injections are given just before surgery to make the blood clot less than normal: these reduce the risk of thrombosis but increase bruising. If you are taking the contraceptive pill, your risk of thrombosis is increased, and the surgeon will discuss with you the pros and cons of stopping the pill or continuing it and taking special action to reduce your risk of a thrombosis. If you start taking the contraceptive pill while waiting for your operation, let your surgeon know.

9. Any general anaesthetic carries risks, but considerable precautions are taken to keep these risks as low as possible. The risk of death as a result of varicose vein surgery is less than one in a many thousands.

Will my varicose veins come back?

Some people develop new varicose veins during the years after a varicose vein operation, but this is uncommon after thorough surgery. Rarely, varicose veins simply re-grow in the areas which have been dealt with, or else they develop in a different system of veins which was normal at the time of the original operation. If veins develop again they can be dealt with should they be troublesome or unsightly.

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Innovations in Varicose Vein Treatment

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