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Treatment of varicose veins
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The main purpose of the treatment of varicose veins is to alleviate the symptoms and improve the quality of life of the patient. Other aims to consider are the decrease in the risk of local complications (ulcerations, phlebitis, or bleeding), as well as to treat the obvious aesthetic component.
Non-pharmacological treatment
The main therapeutic recommendations, as regards the prevention and treatment of venous insufficiency and varicose veins, are:
Physical exercise. It is a fundamental activity in the prevention and treatment of varicose vein disease due to the fact that it helps combat causes, such as overweight and sedentarism and, particularly, because with each step, the muscle contraction of the legs pump blood towards the heart, combatting the tendency to accumulate in the veins of the limbs. It is not necessary to carry out an intense physical activity. To walk quickly for 10-15 minutes regularly is more than sufficient.
Rest with the legs raised. Combat the accumulation of fluid produced due to the effect of gravity. During the day, it is sufficient to have short rests (2-3 times) with legs raised. During the night, it would be useful to raise the foot of the bed by about 10 cm. It is not recommended in patients who have heart failure.
Cold. Its effectiveness is due to its anti-inflammatory and vasoconstrictor effect that causes narrowing of the blood vessels and prevents blood from accumulating with such ease. Showers with cold water over the legs are very recommendable, as well as to avoid hot environments and prolonged exposure to the sun.
Compression stockings. Their effectiveness is clearly demonstrated in the prevention and treatment of venous insufficiency and varicose veins, including being superior to pharmacological treatment. Their usefulness is based on the compression force, which is greater in the foot and ankle than in the rest of the leg, having an emptying or draining effect on the leg.
Other treatments, such as physiotherapy, drainage massages (rising from the ankles to the groin), and pressotherapy, which can also be useful.
Pharmacological treatment
There are numerous products for treating venous insufficiency and varicose veins, known as phlebotonics. The large majority are derived from vegetable extracts, such as flavonoids, rutosides, extract of horse chestnut, vine leaves, Ruscus or Ginkgo biloba.
Despite there being many products and form different families, their effectiveness in varicose disease is mild and with a wide individual variability, since there are patients that notice a great effect, such as improving the heaviness, of the swelling feeling, or of tired legs, while others note practically nothing.
It is important to mention that their effectiveness on the varicose veins themselves and the outcome of the disease is practically zero. Thus, they are prescribed in those symptomatic cases, and in time periods of 2-3 months, and then re-assessing the need to continue the treatment depending on the improvement obtained. The preventive administration in asymptomatic varicose veins is not indicative.
Surgical treatment
The surgical treatment of varicose veins has two parts or aims. On the one hand, to correct the problem that causes varicose veins (mainly the reflux due to dysfunction of the venous valves), and on the other hand, to remove the visible veins that have become swollen.
With the aim of correcting the cause, two techniques are used:
- Phlebectomy or stripping. It completely removes the dysfunctioning part of the superficial venous system where the varicose veins originate.
- Haemodynamic surgery or CHIVA strategy. It is different from phlebectomy in that it only disconnects the specific points of the superficial venous system where the reflux occurs and conserves the majority of superficial venous system.
There is insufficient scientific evidence to demonstrate that one technique is clearly better than the other, although the CHIVA strategy is generally less aggressive than phlebectomy. Both techniques usually require an incision of 5-6 cm, normally in the groin (in the case of varicose veins accessory to the internal saphenous vein), or behind the knee (in cases accessory to the external saphenous vein).
Once the cause is corrected, the aforementioned varicose veins are extracted using small incisions following their trajectory.
Both procedures (correction of the cause and extraction of the varicose veins) are usually performed in the same surgical operation. The majority of times it is performed using local or locoregional (intradural) anaesthesia and requires a few days in hospital or sometimes it does not require hospital admission (performed in a Day-Surgery Unit).
Treatment complications
The most significant complications of the treatment are:
- Infection of surgical wound. They are generally rare, although its prevalence increases when there are wounds in the groin and, especially, in overweight patients. It may require antibiotic treatment in tablet form or even a small drainage in the clinic itself. It is rarely serious.
- Haematomas or bleeding. The appearance of small bleeds or small haematomas (bruising) around the wounds is common, and usually disappear spontaneously within a few weeks. Sometimes they require a surgical revision.
- Aesthetic complications. Such as the hyperpigmentation of the wounds, the appearance of new spider veins, or keloid scarring (thickened scars). Although they are obviously associated with the surgical technique, their appearance is very dependent on the individual predisposition of each case.
- Varicophlebitis. They are small clots in superficial veins that can be painful, but are not usually serious. The large majority improve within a few days with anti-inflammatory drug treatment.
- Deep venous thrombosis. It is fairly uncommon (less than 5% of cases). Early and progressive movement in the immediate post-operative period is usually recommended to reduce the risk of this appearing. It requires anticoagulant treatment for a while, but rarely entails any important risk.
- Sensitivity disorders. Generally, numbing or change in sensitivity of a skin area. It usually appears a few days after surgery and disappears spontaneously within weeks. They are rarely permanent.
- Re-appearance of the varicose veins (recurrent varicose veins). Although the prevalence varies depending on the initial type of varicose veins, the surgical technique used, and the characteristics of the patient (overweight, sedentarism…), it is generally estimated to be around 20-30% of the patients operated on in a 5-10 year period. It occurs due to the fact that the body sees the surgery as an aggression that it wants to repair, or because the varicose veins were not removed with the surgery.
New therapies
Radiofrequency. It is performed using a catheter that is inserted inside the distorted vein and generates intense heat (between 80 and 100ºC) for very few seconds. This induces the coagulation and subsequent healing of the vein.
Endovenous Laser. Its function is similar to radiofrequency, and in this case it uses the energy from a fibre laser to coagulate the non-functioning vein.
Foam sclerotherapy. It induces the coagulation of the vein by means of the use of a chemical product (sclerosing agent). The mixture of the product with a gas (normally room air) generates a foam, which on having more volume than the sclerosing fluid, acts more homogeneously and extensively.
Mechanical-chemical ablation. It combines the chemical effect of the sclerosing agent with the mechanical action of an intravenous catheter.
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Substantiated information by:
Esther Armans Moreno
Nursing
Cardiovascular Surgery Department
Xavier Yugueros
Vascular Surgeon
Angiology and Vascular Surgery Service
Published: 19 June 2018
Updated: 19 June 2018
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