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Varicose veins literally mean grossly dilated, tortuous knotted veins. It can occur at different places in the body. The commonest is the varicosity of the lower limbs. Next is the Haemorrhoids (Piles) which are the commonest cause of rectal bleeding. Varicosity of the lower end of the esophagus or the upper end of Stomach (Esophageal Varices) produces vomiting of blood in chronic (alcoholic) liver diseases, which may become fatal. There may be swelling of the scrotum and the spermatic cord with a feel of a bunch of round worms in the scrotum, Varicocoele, which is one of the causes of sub fertility in the male. There can be bleeding from the urethra in Prostatic Disease due to Vesical Piles. Dilated tortuous veins of the vaginal wall are called Vaginal Varices which is one of the causes of severe vaginal bleeding after delivery.

Varicose Veins of the Lower limbs
 

They are ugly looking tortuous dilated knotted veins seen on either sides of the leg which remain harmless for quite a long time. In the early phases treatment is given for cosmetic reasons, but later it becomes very distressing by discoloration, edema of legs, Eczema, recurrent ulcerations around the foot and ankle joints. Finally it produces painful non healing ulcers in the foot and ankle region.

Varicose veins are classified into 3 major groups

  1.  Varicosity of the Long Saphenous Vein.
  2.  Varicosity of the Short Saphenous Vein.
  3.  A third group of atypical Varicose Veins occur in a small group of people.
 

Normal vein with Unidirectional valve   Unidirectional valve       Prevents blood from      falling down

Varicose vein with damaged valves. Because of incompetence of the valve Blood is falling down

The veins of the legs are divided into two systems – the deep veins (which run deep to the leathery layer of fascia surrounding the muscles) and the superficial veins (which run in the layer of fat just beneath the skin). The superficial veins are the ones that you can see on your foot or around the ankle and they are the ones that can become varicose veins.

Perforators

In a number of places in the leg, the superficial and deep veins are linked by perforating veins (‘perforators’). They are called perforators because they perforate the leathery fascial layer surrounding the muscles of the legs. Normally their valves should allow blood to flow only inwards – from the superficial veins to the deep veins. If the valves stop working properly, then blood is pushed out into the superficial veins when the muscles contract: this is one of the  reasons for high pressure in the superficial veins, and can be a cause of varicose veins

Valves in the veins

There are delicate valves located at half to one centimeter distance through out the length of veins which helps to pump the venous blood towards the heart against the gravitational force just like the ‘Foot Valve’ of the water pump. They are unidirectional valves which prevent the back flow. The incompetence of these valves is the basic pathology of varicose veins.

The muscle pump

The Calf muscle acts as the booster central pump to lift forcibly the venous blood from the Deep Veins to the heart. (Peripheral Heart)
 

Calf muscle is relaxed                   The venous Valves remain closed

Calf muscle is contracted Venous Valves open up and blood is pumped up

Where do the varicose veins develop?

It occurs in the Superficial Systems; namely the Long Saphenous & Short Saphenous Veins and in the Perforator Veins. There are net working tributaries to these veins and as such any vein is likely to develop varicosity.

What is the cause of Varicose Veins?

Damage or malformations or congenital absence of the valves are responsible for the development of the disease. Persistently increased intravenous pressure damages the venous walls and results in stretching, loss of elasticity

What are the predisposing factors?

Age: As age advances the frequency of the disease increases
Sex: Most commonly seen the female population
Racial
Hereditary Factors
Hormonal: Female hormone
Pregnancy: Pressure of gravid uterus on the major veins in the abdomen
Secondary to Diseases: Fibroid Uterus, Lower abdominal tumors
Secondary to Deep Vein Thrombosis
Chronic Constipation
Occupational: Standing for long standing

Symptoms

Pain: Dull aching pain in the lower leg is the commonest early symptom
Swelling of the feet: Oedema of the feet especially on standing for long time or by evening is the next common sign
Bleeding
Itching
Discoloration: Blackish discoloration around the ankle joints and lower leg
Eczematous Change around the ankle and foot
Hyperlipodermatosclerosis: Thickening of the skin with depigmentation or hyper pigmentation
Ulcer Formation: Initially small ulcers develop and heal spontaneously over a period of time
Giant Ulcers: Later small ulcers refuse to heal and proceed to progressive skin erosion resulting in very large non healing ulcers

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Investigations

In addition to the routine investigations, the specific investigation is a Color Doppler Scan of the Lower Limb Venous System. The main purpose is to rule out any thrombosis Clotting of blood) in the Deep Vein.

Treatment of Varicose Veins

Though physicians administer certain medicines for the symptomatic relief, the definitive treatment is Surgery. There different modalities in the procedure and they briefly summarized below.

1) Surgery:

1. This is the conventional treatment directed towards the ablation of the diseased veins by dissection ie, Ligation of the feeding vessels at the inguinal region followed by Stripping of the superficial vein.

2. Multiple subfascial ligation by different techniques/invasive as well as minimally invasive techniques.

3. Valvoplasty: Reconstructing artificial valves in the veins, a very tedious as well as expensive procedure.

2) Minimally invasive Procedures

(a) Electrodesiccation: This is the process of passing electric current through a probe to  ......destroy the vessel wall.
(b) Radiofrequency ablation
(c) Endo venous Laser Ablation (ELT)
(d) Sclerotherapy

Sclerotherapy /Foam Sclerotherapy

The oldest, simplest and the cheapest method of treating varicose veins, the most accepted and promising method of treatment by constant innovations in the technique. It takes hardly 10 to 15 minutes for the completion of the procedure.

What is Sclerotherapy?

In all minimally invasive procedures, the principle involved is basically the same. In electro desiccation a wave of electric current is used to destroy the inner lining of the vessel wall. In Radiofrequency it is again the radiofrequency waves that are modulating the destruction process by mechanical damage. In Laser therapy (ELT) laser beam administered through a special probe produces thermal burns on the vessel wall, Likewise in Sclerotherapy a chemical substance that is injected at selected sites produces chemical burns.

How does the Sclerosant Act?

The Sclerosant produces chemical burns of the endothelium, Due to the severe inflammation of the vessel will the vessel wall will stick together and get fibrosed.

About Sclerotherapy

Phenol in almond oil injected through a special cannula was the original method of Sclerotherapy. This is no more used. The sclerosing agents currently used are Sodium Tetradecyl Sulfate (STS), Polidocanol (POL) and Ethanolamine. Method of administration and the strength/dilution of the sclerosant depends on the size of vein, the site injection and above all the experience of the surgeon. The solution is injected at multiple sites in varying dilutions. No anesthesia is required. No hospital stay is usually required Pain at injection site is variable . In smaller veins there will be some pain but in larger veins it is practically painless. If the drug extravasates, there is will excruciating pain and subsequent tissue necrosis will develop. The procedure has to be done by a Surgeon well experienced in the technique. There should be all facilities to combat any untoward reactions of the drug,, though extremely rare. Crepe bandage is applied over the injected sites., assuring compression of veins. The patient can walk about after the procedure. In fact, they should be encouraged to walk about following surgery. In rare occasions, two or more sittings may be required to effect complete occlusion of the vessels. Revascularization and recanalisation of the veins contribute to recurrence. The Newer technique is the Foam Sclerotherapy, which has got added benefits over the conventional Sclerotherapy. The overall cure rate is more than 90% in all available literature. The success rate in operative procedure is limited to 80%.

In what all conditions Sclerotherapy is advocated.

In all stages of the disease Sclerotherapy can be done.
In some literature it is stated to be good only in smaller size veins and midsized veins. The statement is absolutely wrong; it is very effective in large sized veins as well.
This can be done in cases of recurrence after surgery
In patients who are otherwise unfit for surgical procedure.

Where not to be done?

a. If there is Deep Vein Thrombosis
b. If the patient is allergic/sensitive to the drug
c. In pregnant and lactating women

What are the precautions after the procedure?

The procedure is done preferably on one limb at a time.

After the injection the patient can go home and take rest. To avoid swelling of the limbs, it is preferable to keep the limb elevated
.
It is also advisable to use crepe bandage to the limb for at least 10 days to help the veins remain collapsed and stick together.

Any Side effects?

Side effects, if at all, are very mild. Some patients may complain of some heaviness of head, and dryness of mouth.

Some may complain of itching over the injection site.

After a few days there may be some swelling of the lower limbs, pain, bleb formation, redness, indurations and /or discoloration at the injection site.

In case of extravasation of fluid it can cause excruciating pain locally.

Local Hirsutism has been observed in a few patients

Advantages!!

Very safe procedure
Very Simple
Economical
Enhanced success rate over other procedures
No hospital stay
Can go back to normal activities earlier than all other techniques
Safe for very aged patients otherwise unfit for surgery

Disadvantages**

Allergic/ Hypersensitivity reactions
Recurrence of new Varices or recanalisation
Local reactions, tissue necrosis, itching
Extremely very rare chance of Deep Vein Thrombosis

Conclusion

A very safe promising technique
The most cost effective technique
All critics are well wishers


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