Treatment of varicose veins by surgery and sclerotherapy by a consultant surgeon
will I manage in the days following my operation?
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.
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.
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.
treatments are there for varicose veins?
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.Are special tests needed before treatment of varicose veins?
Special tests aim to show whether there are important “leaky valves” allowing blood to flow the wrong way in the veins (reflux), and so putting a head of pressure on them. These leaky valves are commonest in the groin (at the upper end of the long saphenous vein) and behind the knee (at the upper end of the short saphenous vein). Varicose veins which are under pressure from leaky valves are best dealt with by an operation rather than by injection treatment, for a good prospect of a long term cure.
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.
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.
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.
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.
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.
depends on whether you are able to have surgery as a day case.
happens before the operation?
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.
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.
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.
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.
How will I manage in the days following my operation?
After two or three hours on the ward you should feel fit enough to go home. Before you leave the ward staff will check your leg. They will give you a note for your general practitioner, and some painkillers to take with you. You will also be provided with an advice sheet. Your bandages will be removed the next day and a special support stocking is worn.
You will usually be able to get up within a few hours of the operation. The bandages on your leg will be changed on the day after operation for a special support stocking. You will be able to go home the day after the operation when the nurses feel that you are sufficiently well and mobile.
What about my wounds?
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.
Will my legs be bruised?
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.
Will I have dressings or stitches?
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.
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.
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.
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.
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.
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.
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.
It is probably best not to fly for approximately one month after the operation. This is particularly important for long haul flights.
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.
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
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.
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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Timothy Magee MD FRCS is a Consultant Vascular and
For further information and consultations please contact
Berkshire Vein Clinic
Royal Berkshire Hospital 0118 3227773