I have often been told by patients that they need surgery to fix their varicose veins. This statement is usually made after the patient has seen either a general practitioner or vascular surgeon. The statement may have been true 20 years ago but has not been correct for the past 20 years since Ultrasound Guided Sclerotherapy (UGS) was first used. UGS is used to treat the underlying incompetent vein that is responsible for the varicose veins that are seen on the surface. More recently, Endovenous Laser Ablation (EVLA) has been used an alternative to UGS to treat the underlying incompetent veins. EVLA is used for the more severe situations and UGS for the less severe cases. These two procedures have now essentially replaced surgery in America and are progressively replacing surgery in the rest of the world.

The reason for these two non–surgical approaches replacing surgery is simple: they have less complications at the time of the procedure and a lower rate of recurrence of varicose veins in subsequent years. Many doctors who have been trained in the traditional surgical technique of vein “stripping” have been slow to adopt these new techniques because of the costs of equipment (ultrasound and laser machines) as well as the time and financial cost of training to be able to perform these new techniques. I believe that to deny patients access to these procedures is bordering on incompetence.

The short answer is a qualified yes.

Varicose Veins: If someone presents with varicose veins I can guarantee that I will get rid of the varicose veins. I can also guarantee that it will be very unlikely that they will ever get any varicose veins related to the underlying vein that I have treated (provided they come in for the scheduled reviews after their initial treatment).

Spider Veins: For cosmetic spider vein concerns I can guarantee that I will significantly improve the current situation.

If a patient has had multiple previous treatments, that have been unsuccessful and have resulted in an even worse situation, then the expected improvement is obviously not as good as if I had the opportunity to treat the legs initially. Of course I cannot guarantee that spider veins or varicose veins will not occur in other areas as this is the result of genetic coding. Treatment of the underlying incompetent veins by Endovenous Laser Ablation or Ultrasound Guided Sclerotherapy does not affect whether veins will occur in other areas.

I have various hurdles that patients must “jump” over before I will treat their spider veins or varicose veins for cosmetic concerns. In a world of increasing concern about physical appearance, I need to be convinced that the cosmetic concerns are reasonable. By this I mean would an average person think it reasonable for the patient to be seeking treatment. I also use the “2 meter rule” whereby if I cannot see any veins standing 2 meters away then I will not treat. Also if a patient has had numerous previous treatments which have resulted in a poor result then I will be reluctant to treat. This situation is like getting lots of poor tradesmen to do a renovation and by the time a skilled tradesman comes along the structure is just too badly damaged to get an acceptable result no matter what the expertise of the tradesman. I also reluctant to treat patients younger than 21 years old because results are generally not as good as for “older” patients and the tolerance of young patients for the discomfort of treatment and side effects is less. Side effects, particularly matting, are more common in younger patients.

I am often asked "Should I get my varicose veins or spider veins treated?" The answer is generally "yes" for someone with cosmetic concerns provided the patient has been fully informed of the risks of treatment and they are realistic in their expectations for treatment. If the cosmetic concerns are minor and the patient is young then I generally advise that they seek treatment when their cosmetic concerns are more significant to justify the cost and risk of treatment. Often a patient will present with large varicose veins that are not really concerning them cosmetically and are not associated with any aching. This situation warrants an assessment of whether the patient has significant risk of complications if the situation is left untreated. This is assessed by making a decision about the relative risk based on the pressure effects into the ankle (and the associated risk of ulceration) and the risk of thrombosis (based on past history and size of varicose veins). For some patients the risk of bleeding is also a consideration.

Obviously the older the patient is then the less likely I am to advise a procedure is appropriate unless there has already been a complication (complications tend to recur). If I am in any doubt whether treatment is in the patients best interests I will suggest a review in 6-12 months to determine the rate of progression.

I am often asked by patients if they are at risk of getting blood clots when they travel on an overseas trip. To clarify what is meant by a blood clot you must first understand that there are 2 types of blood clots: Superficial (that involves the veins just below the skin surface) and Deep (that involves the more significant deeper veins). It is usually involvement of these deeper veins (a Deep Vein Thrombosis or DVT) that can lead to smaller clots travelling to the lung which are called Pulmonary Embolisms (PE’s). A PE can be fatal. Interestingly, clots can also come from clots in the superficial veins so these should not to be thought of as completely harmless clots.

Often this question about flying and clots is asked because the patient has large varicose veins. The simple answer to this question is that, although varicose veins are a risk factor for developing blood clots, a much larger risk factor is the presence of an underlying blood clotting abnormality. A clotting abnormality is found in over half the people who have DVT’s and PE’s. Approximately 4% of the population have a blood clotting abnormality. For those people in the “at risk” group it is important to understand that it is often other risk factors that are added to the clotting abnormality that precipitate a clot. These factors are: being overweight, smoking, excess alcohol, not enough water, no activity and being on the oral contraceptive pill.

There is very little evidence that any specific measures are helpful in preventing varicose veins. However limiting or modifying some of the contributing factors may be helpful in preventing progression of varicose veins. It is likely that exercise, avoiding be overweight and avoiding long periods of standing stationary might be helpful. You should also avoid wearing garments (socks or stockings) that restrict the blood flow from your legs. It may be helpful to avoid constipation and it may also be useful to avoid wearing high heel shoes for prolonged periods of time as these shoes mean the calf muscle is unable to provide an optimal pumping effect. There doesn’t seem to be much evidence that crossing your legs has any effect on varicose veins.

Spider veins are invariably treated with Sclerotherapy whereby a small amount of solution (the sclerosant) is injected into the abnormal veins to close them off. The body then dissolves these treated veins. Laser treatment of spider veins has produced inferior results to Sclerotherapy. As with all medical treatments the skill of the treating doctor is a critical component to achieving a successful result. The Australasian College of Phlebology has a register of doctors credentialed to perform certain procedures. Varicose veins are increasingly being treated less with surgery (“vein stripping”) and more with the “non-surgical” procedures of Ultrasound Guided Sclerotherapy (UGS) and Endovenous Laser Ablation (ELA). Some Phlebologists still perform adjunctive surgery (ambulatory phlebectomies) in association with one of the non-surgical techniques. Whether UGS or ELA is used depends on many factors with the most important being the size of the vein being treated. The larger the veins are more likely to be treated with ELA.

Compression stockings

These come in a variety of compression strengths ranging from support pantyhose to Class 3 medical compression stockings. In between are the compression stockings that are useful in the prevention of DVT’s when flying and the anti-embolism stockings that are often work in hospital. After Sclerotherapy it is usual for a Class 2 stocking to be worn from 3 days to 2 weeks depending on which vein was treated. As an adjunct to wearing stockings it is important to do as much walking as is possible.

Endovenous techniques (radiofrequency and laser)

In many countries Endovenous Laser Ablation (ELA) is replacing, or has replaced, the traditional surgical “stripping” of veins. The reasons for this are that ELA can be done as an office procedure (walk-in, walk-out) and has less risk than surgery. It also does not have the recovery time associated with surgery. The long term results of ELA are excellent. Importantly the recurrence rate of new varicose veins after surgery, which is often very concerning for patients, is avoided by performing ELA. The technique of ELA consists of placing a small laser fibre up the middle of the vein. This fibre is then very slowly withdrawn from and the laser energy from the tip of the fibre then heat seals as it is withdrawn. The laser is introduced via a 3-4 mm cut (done under local anaesthetic) and the procedure itself is also done under local anaesthetic. Normal walking is possible straight away as the local anaesthetic is not into the muscles but only placed around the vein being treated. The actual laser treatment is painless although some patients report a buzzing sensation.

Interestingly there is no dictionary definition of what constitutes a varicose vein but it is generally accepted that if a vein is “raised” above the surface then it is a varicose vein. What is critical in the management of varicose veins is the determination of the underlying anatomy. Almost all significant varicose veins are associated with an underlying vein that has valves that do not work and allow back pressure (with standing and gravity). This back pressure “forces” its way to the skin as varicose veins. The best and least invasive way to determine the state of the underlying anatomy is to have a Duplex Ultrasound examination. This examination gives a clear understanding of which veins are working (competent valves) and which veins have valves that are not working (incompetent valves / veins). It is only with this information that the treatment options be considered. There are many doctors who can look at veins but the special interest group called Phlebologists are playing an increasing role in assessment and management of all vein conditions.

Spider veins are NOT dangerous and present a cosmetic concern although they can occasionally be associated with some minor aching particularly after prolonged standing. Varicose veins on the other hand can be associated with Deep Vein Thrombosis, Pulmonary Embolism, ulceration of the skin (usually around the ankles), cellulitis (if the damaged skin gets infected) and significant bleeding episodes if the varicose vein is traumatised and bursts. For many people though varicose veins are small and not associated with much in the way of symptoms and the risk of the aforementioned problems is low.

Varicose veins can be associated with a range of symptoms including aching, throbbing, swelling around the ankles, dermatitis (and itching) and discoloration of the skin around the ankles. In severe cases the skin can ulcerate around the ankles. Interestingly varicose veins can also be associated with leg cramps and restless legs (at night) although the mechanism for these two symptoms is not clear. Importantly the presence or absence of aching is NOT a good guide as to the severity of veins. Sadly often the first problem that some people have is the appearance of an ulcer in a leg that had previously had no aching. This means that it is important to assess the severity of the situation by means other than the severity of the aching.