What are varicose veins?
Varicose veins are enlarged, bulging, malfunctioning veins close to the surface of the skin. They are twisted and knotted and are often blue or purple in colour, and can appear as "ropes" or "bunches of grapes" under the skin. They are caused by damaged or faulty one-way valves that allow blood to reflux or travel in the wrong direction towards the feet instead of the heart. Varicose veins cause pooling of blood in the lower limbs and are more prominent after long periods of standing, during hot weather, and following exercise. They will reduce in size with rest and leg elevation.
Whilst they have been considered by many to be of cosmetic concern only, this is not true. At least 50% of patients presenting to The Vein Clinic have significant symptoms including pain, aching, swelling, tiredness, and restlessness in their legs. Changes in the skin may occur, comprising redness, eczema, discolouration, pigmentation, skin thickening, and eventual ulceration. More serious complications from varicose veins include superficial and deep vein thrombosis as well as venous leg ulcers. Varicose veins close to the surface of the skin, particularly in elderly patients, may present a bleeding risk as a result of minimal trauma.
Why do I have varicose veins?
Varicose veins occur due to malfunction of the superficial veins near the surface of the skin. Due to reasons not fully understood the delicate one-way valves in the superficial veins often fail as we get older, resulting in a condition known as venous reflux that causes blood to pool in the affected veins. The increased venous pressure in the malfunctioning veins leads to the subsequent development of bulging, tortuous veins beneath the skin otherwise known as varicose veins.
Many people ask what causes varicose veins. The short answer is, if possible, take a look at your parents' legs, because the basis for most varicose veins is genetic or hereditary. If neither of your parents has or has ever had varicose veins, you still have a risk of 25% of developing varicose veins by the age of 50.
If you have varicose veins it is not your fault.
How can I get rid of varicose veins?
If you rest and elevate your legs it may temporarily appear that your varicose veins have resolved, this is only because they have been temporarily decompressed. Once you stand, particularly for long periods, the veins will dilate again and become swollen as blood pools in these non-functioning veins. Conservative measures of weight loss, exercise, high fibre diets, compression stockings, and various medications may improve the symptoms of varicose veins but will not help them go away.
The best way to get rid of varicose veins is to see a vein specialist, i.e. phlebologist, who can accurately diagnose your condition and advise on the most effective treatment options. These commonly include endovenous techniques such as laser ablation, foam sclerotherapy, and ambulatory phlebectomy.
What are the best varicose vein treatments?
The best varicose vein treatments are those that will address your problems with the least amount of discomfort, downtime, and the highest success rates. For the majority of people, this is endovenous laser for the treatment of incompetent surface veins and ultrasound-guided foam sclerotherapy, with or without ambulatory phlebectomy, for the treatment of the branch vessels arising from the incompetent saphenous veins.
In the last 20 years, endovenous laser has emerged as the gold standard treatment for addressing the underlying cause of most varicose veins, which is reflux of the great or small saphenous veins. Treatment of incompetent branch vessels arising from the saphenous veins is now frequently performed with ultrasound-guided foam sclerotherapy rather than stab avulsion phlebectomy. In cases of larger branch vessels that may not close adequately with foam sclerotherapy alone, the minimally invasive procedure of ambulatory phlebectomy may be performed.
At The Vein Clinic, Dr Luke Matar has pioneered and perfected a technique of ultrasound-guided foam phlebectomy (UGFP). In this technique, the veins to be removed are injected under ultrasound with sclerosant foam then subsequently removed via small incisions using ultrasound guidance to ensure a more thorough removal of abnormal veins than occurs with the standard surgical marking and non-guided removal.
Treatment at The Vein Clinic is highly personalised and individualised depending on your particular vein problem. Usually the most effective treatments are obtained by combining a variety of treatment methods to address your problem.
What will happen if I do not treat varicose veins?
Unless they are related to pregnancy, varicose veins will not improve on their own. Lifestyle measures such as weight loss, exercise, and wearing of compression stockings may reduce the symptoms of varicose veins but will do nothing to reverse their cosmetic appearance.
Without definitive treatment, the best one can hope for is stability of the veins. Most patients however will gradually have progression of varicose veins and associated problems of chronic venous insufficiency over time. Common symptoms such as heaviness, ache, pain, tiredness, and restlessness in the legs will tend to progress and are usually worse in hot weather, towards the end of the day, and following long periods of standing or exercise.
Over time, further progression can result in leg swelling, itch, skin discolouration, and eventual skin ulceration. Blood clots related to superficial venous thrombosis may occur and in severe cases can lead to more serious conditions such as deep vein thrombosis and pulmonary embolism.
When should I be concerned about varicose veins?
For many years medical professionals dismissed varicose veins as simply of cosmetic importance but research in the last 20 years has shown they may be medically significant. International societies now recommend patients should seek treatment for varicose veins if they are experiencing any symptoms such as pain, heaviness, aching, itching, and restlessness, or if they are experiencing skin reddening, skin discolouration, ulceration, or hard, lumpy, tender veins. Untreated varicose veins can lead to venous eczema, venous ulcers, and venous thrombosis, all of which can be serious conditions.
If you are experiencing any symptoms from your varicose veins it is recommended you see a dedicated vein specialist for further clinical and ultrasound assessment so that the true extent of your condition and treatment options can be evaluated.
Are varicose veins painful?
Contrary to popular belief, varicose veins are not simply a cosmetic concern and do cause discomfort for a large number of people. Patients attending The Vein Clinic report significant symptoms in approximately 50% of cases and pain and heaviness are often the presenting symptoms. Pain can be relieved by rest and elevation of the legs, wearing compression stockings, taking anti-inflammatory medications and venotonic and venoactive medications.
Ultimately the best results however are obtained from definitive treatment removing the source of reflux and removing or closing the abnormal veins.
Are varicose veins dangerous?
Contrary to the belief held by many doctors and laypeople alike that varicose veins are only a cosmetic issue, they may lead to serious health consequences. Approximately 50% of patients attending The Vein Clinic complain predominantly regarding the appearance of their veins, however at least half of patients presenting for treatment have symptoms such as pain, swelling, heaviness, aching, and restless legs. In addition to these symptoms the skin may become reddened, itchy, discoloured, thickened, and eventually ulcerated. Untreated varicose veins can also lead to superficial venous thrombosis and at times subsequent deep venous thrombosis and even pulmonary embolism. Death from varicose veins has been reported following trauma, with a notable death in Adelaide following a rooster attack.
How do I prevent varicose veins?
The most effective means to prevent varicose veins would be to make sure that neither of your parents suffer from varicose veins as hereditary disposition is the strongest risk factor. Unfortunately this is not a viable option.
The next strongest risk factor for varicose veins in women is multiple pregnancies, and once again, limiting the number of children based on your desire to limit the likelihood of varicose veins again is not practical.
There are however a number of practical things that can be done to prevent progression of varicose veins:
1. Walk 20-30 minutes per day.
2. Maintain a normal healthy weight.
3. Regularly alternate between sitting and standing positions.
4. Avoid constipation by eating a high-fibre diet.
5. Wear graduated compression garments.
6. Use orthotics if suffering from flat feet.
7. Elevate your feet at the end of the day or when symptoms occur.
8. Venotonics and venoactive drugs.
What are venotonics?
Venotonics are a class of compounds that are often used to alleviate the symptoms of venous disease such as heaviness, aching, and itching in the legs. Venotonics are often herbal medications such as butcher's broom extract (Ruscus Aculeatus), horse chestnut seed extract, and diosman lycozoid. There is grade B and C evidence that these substances may assist in symptomatic relief but no evidence of them reversing the physical appearance of varicose veins.
What are venoactive drugs?
Numerous studies have shown a clinical benefit in the use of venoactive drugs to address symptoms of venous insufficiency such as pain, heaviness, swelling, burning, itching, and restlessness. The highest level of evidence exists for micronised purified flavonoid fraction (MPFF) (Daflon 500mg) along with calcium dobesilate and HR-oxerutins. These medications have been shown to reduce oedema as well as leg circumference and improve skin tone and assist with ulcer healing. Unfortunately access to these medications in Australia is difficult.
What are truncal veins?
Phlebologists (vein specialists) refer to the main superficial veins of the leg the Great Saphenous Vein (GSV) and Small Saphenous Veins (SSV) as Truncal veins as they drain the main “trunk “of the leg.
What are tributary veins?
The branch vessels draining to the GSV and SSV are often referred to as tributary veins and it is usually these veins that dilate and protrude leading to the visible varicose veins.
Why is an ultrasound scan important prior to vein treatment?
Ultrasound provides an essential “road map” for the treating doctor to understand the exact nature of your vein dysfunction and plan the most appropriate treatment. Often what is seen on the surface is figuratively speaking the “tip of the iceberg”.
We have seen many patients have unsatisfactory outcomes when treated elsewhere without an ultrasound. Surface sclerotherapy performed without first eliminating venous reflux and “feeder vessels” for example may lead to new vessel growth and a dramatic worsening in cosmetic appearances.
Phlebectomy performed without elimination of underlying reflux (only detectable on ultrasound) similarly will often lead to new vessel proliferation and rapid recurrence of varicose veins.
Can I have my ultrasound scan performed at any clinic ?
Whilst a number of clinics offer vascular ultrasound, few have staff skilled in the performance of the highly specialised venous incompetence studies required to adequately understand the nature of your vein dysfunction and the most appropriate treatment.
It is best to have ultrasound performed at a specialised centre that is accustomed to the assessing patients before, during and after endovenous vein treatments. If we are to treat your veins, we cannot rely on assessments done elsewhere and will require our own detailed ultrasound scan prior your treatment.
Why should I have my scan performed at the Vein Clinic?
In addition to modern high frequency ultrasound, the Vein Clinic is one of the few clinics in Australia to use specialised equipment (venapulse ™) to improve the accuracy of our venous incompetency studies.
Has much changed in vein treatment over the years ?
In the last 15 years a major revolution in the understanding of venous disease has occurred. Much of this new understanding has been driven by the greater use of high frequency ultrasound by properly trained ultrasound practitioners.
The introduction of endovenous laser ablation (EVLA) for treating truncal incompetence has been a major paradigm shift and has shifted thinking and research towards safer and better tolerated ways of treatment. The dark old days of surgical vein stripping are thankfully coming to an end.
I have heard endovenous laser (EVLA) is quite expensive, can I have ultrasound guided sclerotherapy (UGS) instead?
UGS tends to be less than half the cost of ELVA and for that reason has gained popularity as a “catch all” treatment.
At the vein clinic we believe the optimal treatment that gives you the greatest chance of success with the least discomfort is always preferable.
We do not agree with a “one size fits all” approach to UGS and believe that in many instances UGS is not “best practice” for the treatment of primary truncal incompetence. The appropriate choice will be highly dependent on the exact anatomy and size of the veins involved. If we believe UGS is suitable for treating your veins, we will offer this option to you. It is only by undertaking a through clinical evaluation and ultrasound scan that we can appropriately advise you of the treatment options best for your individual circumstances.
Why is EVLA preferred over UGS for larger veins?
Studies have shown that the success of UGS declines rapidly with increasing vein size. Once veins are > 6mm in size, recanalization (re-opening) rates increase dramatically and the chance of long term success decreases. The chances of post treatment complications such as thrombophlebitis and pigmentation also increases dramatically.
If appropriate laser energy is delivered to the wall of the vein with EVLA the chance of success is essentially 100%. This chance of success is virtually independent of vein size. The complications following EVLA are also usually minimal if properly performed.
When may surgery be appropriate?
In very tortuous veins that may not be accessible to a laser fibre, UGS can be considered however surgery may be a better option in such cases if the vein is very large or very superficial.
What are the risk factors for varicose veins?
Genetic Risk of varicose veins if :
- Neither parent has varicose veins – 20%
- One parent has varicose veins – 64%
- Both parents have varicose veins – 90%
- (Cornu-Thenard, A., et al. Importance of the familial factor in varicose disease, J Dermatol Surg Oncol. 1994. 20:318)
Although some studies have estimated that 20% of men and 40% of women will develop venous disease in their lifetime, this data has been refuted and it may simply be that men do not report the signs or symptoms of venous disease to their doctors until it is severe, as advanced chronic venous disease is more common in men.
The incidence of varicose veins increases with age. The risk of varicose veins, spider veins chronic venous insufficiency and ulcers all increase with age. A 70yr old is estimated to have twice the risk of varicose veins compared to a 40 yr old.
(Adhikari A, Criqui MH, Wooll V, Denenberg JO, Fronek A, Langer RD, et al. The epidemiology of chronic venous diseases, Phlebology 2000. 15: 2-18.)
Other Reported Risk Factors
There are other risk factors for varicose veins, but these are not as well-supported by the scientific evidence. (Bergan, JJ, Risk Factors, Manifestations, and Clinical Examination of the Patient with Primary Venous Insufficiency, The Vein Book, 120.)
- Obesity – Many studies claim an increased risk of varicose veins in the obese. However when corrected for age, the evidence is weak. It is of course desirable to maintain a healthy weight, and doing so may slow progression of venous disease but once present, weight loss is unlikely to reverse venous dysfunction.
- Standing occupations – Some have shown that those in standing occupations such as hairdressers have an increased incidence of varicose veins.
- Diet –Venous disease is more prevalent in Western cultures than in cultures which have predominantly fibre-based diets, but many other factors come into play beside diet.
Will I save money having traditional vein surgery instead of laser vein surgery?
Traditional vein surgery for varicose veins which consists of “stripping”, may well result in less out of pocket expense than laser vein surgery which is often referred to as endovenous laser ablation (EVLA). This is because health fund rebates currently only apply to traditional surgery and not laser vein surgery.
Cost savings by having traditional vein surgery however may well be short sighted when one considers the time and income lost by several weeks off work , the inconvenience and added health risk of hospital admission, general anaesthetic and prolonged recovery.
When you weigh this all up, for most people the sensible decision is to spend a little on your health and have the best available treatment rather than an out-dated and inferior treatment. Whilst some initial savings may occur with surgery, in the long run this approach usually end up being more expensive not to mention uncomfortable and inconvenient.
How soon before flying can I have endovenous laser treatment (EVLA)?
If your flight is longer than 4hrs, it is generally recommended you complete your treatment at least 4 weeks prior to travel. In certain circumstances such as unexpected work travel, we can prescribe a blood thinning agent (Clexane) to be taken prior to travel to reduce your risk of venous thrombosis.
Do I need a referral to come to The Vein Clinic?
Yes - to see a specialist, a referral is required to comply with Medicare regulations. As a radiologist, Dr Matar cannot self-refer.
In order to maximise the Medicare benefits available to you for the comprehensive ultrasound assessment and subsequent treatment and follow up scans, we recommend you have your GP fill in our dedicated venous services referral forms.
If you have trouble getting in to see your own GP or do not have a GP, contact us on 9200 3450 to find out how we can assist in this regard.
Why can’t you give me a quote over the phone for the cost of treatment?
The costs will depend on the methods required to treat/remove your abnormal veins, the number of abnormal veins to be treated, the number of treatments required, the time and complexity of each treatment; the amount of consumables needed and will naturally vary significantly from person to person.
Once you have had a thorough ultrasound and clinical examination to identify the extent and nature of your vein problem, we will be in a position to provide a quote for treatment.
Do you “bulk- bill” any vein treatments?
Due to the high overheads in running the vein clinic which is a state of the art assessment and treatment centre for venous disease, it is not financially viable for us to “bulk-bill” treatments as the medicare rebates nowhere meet the cost of providing these services.
Do you provide second opinions on vein treatments I have been recommended elsewhere?
If you have an appropriate referral from a medical doctor for a consultation and scan, we are happy to provide second opinions. If you have had an ultrasound assessment elsewhere we will generally repeat this at a greatly reduced fee to facilitate you getting a comprehensive assessment in order to allow you to make the best treatment decision for you.