Q1 “Varicose veins always come back after treatment”
Firstly, there are three ways that veins can recur (come back) after surgery.
The first way is that the initial operation was incomplete and not all of the affected veins were treated. This is very common after treatment by doctors who are not vein specialists and to do not use duplex ultrasound to find out all of the causes of venous reflux. Such doctors often still strip veins and do not check for pelvic venous reflux or for perforator vein reflux in the lower legs – and if they do check and find it, often do not treat it. Therefore if venous reflux is still present in any veins after the operation, recurrent varicose veins are almost guaranteed. Thus varicose veins treated by this sort of doctor will almost certainly come back after treatment.
The second way is that the correct veins are identified and treated but using techniques that do not permanently stop the venous reflux in that vein. Many doctors still strip veins despite research from The Whiteley Clinic in the UK which showed in 2007, that when the Great Saphenous Vein (GSV) is tied and stripped away, it is found to be growing back again in 23% of people at one year. Subsequent research by the same clinic has shown the vein is re-growing in 82% of people at five years.
As the new veins that grow after stripping do not have valves in them, they always reflux. This means that when these veins re-grow, the same varicose veins usually come back again. Although the new endovenous techniques, when used properly, have much better results, it does depend on the correct technique being used in the correct vein and the technique being performed optimally. Clinics that specialise in vein treatments with doctors that spend the majority if not all of their time perfecting their vein techniques tend to get far better results than doctors who only perform vein surgery occasionally and who are only trained in one or two techniques.
The third and final way that veins can recur after surgery is due to the natural deterioration in the venous system with time. We know from population studies that approximately 3 to 4% of people who come from vein forming families will develop new varicose veins every year. Therefore it is not surprising that even if perfect surgery is performed on patients with varicose veins, 3 to 4% of them will develop new varicose veins, in different veins from those that were treated, each year.
Therefore in summary, the risk of veins coming back again varies widely and depends to a very large extent on the expertise of the doctor responsible for the investigation and treatment of varicose veins. In non-specialist practices where duplex ultrasound is either not used or only used in a limited fashion, and the veins are then stripped or inappropriate endovenous techniques are used, the recurrence rates are going to be very high and veins will indeed appear to come back very regularly after treatment.
In specialist vein clinics where trained staff perform duplex ultrasonography full-time every day, working hand in glove with doctors and surgeons who are trained in all the new endovenous techniques and thus have a wide selection of treatments to choose from, then the treated veins should not recur and the only risk that varicose veins will come back again should be 3 to 4% per year. In such cases, when these recurrent varicose veins are scanned, these should always be new varicose veins and should not be found to be arising from the veins that were previously treated.
Q2 “Varicose veins are only cosmetic and can be safely left alone”
The first and most important thing to understand is what is meant by “varicose veins” in this statement. When people say “varicose veins are only cosmetic” they are talking about the veins they can see on the surface. Dilated and lumpy veins only appear in 20% of people – whereas 40% of people have underlying venous reflux disease (otherwise known as venous incompetence or “hidden varicose veins“). Therefore from this fact alone it is obvious that whereas half the people with a problem are being told that they are “only cosmetic”, the other half of the people suffering with this condition do not even know that they have it. As in these people there is nothing to see, half the people with venous reflux (“hidden varicose veins”) have a problem with no cosmetic impact at all.
Before the 1980s, it was felt that if the valves did not work in the deep veins resulting in deep venous reflux, then this was a medical problem which could result in leg ulcers. It was also felt at this time that if the valves did not work in the superficial veins, this would lead to dilated veins on the surface (“varicose veins“) which would clearly be cosmetic only. However both of these thoughts were wrong.
In 1985, Mr S Darke from Bournemouth in the UK showed that if people with leg ulcers were scanned with venous duplex ultrasonography, it was found that approximately half of them only had reflux in their superficial veins.
This was a major discovery with two important conclusions. Firstly it meant that the old idea that visible varicose veins due to superficial vein problems with were only cosmetic was wrong. Secondly it also meant that as we can treat the superficial veins, a large number of leg ulcers are also treatable by varicose vein surgery.
Therefore this myth is incorrect and quite insidious. It is often used to put people off seeking proper investigation and treatment. This is a great disservice in a large number of people who, if they believe the myth and do not seek medical help for their varicose veins, may go on to develop the complications of long-term venous reflux such as superficial thrombophlebitis (clots in the superficial veins), venous eczema, swelling of the ankles, skin discolouration around the lower legs and even venous leg ulcers.
Q3 “If your varicose veins are not painful they do not need treatment”
Q4 “Thread veins (AKA "spider veins" "broken capillaries") on the legs can easily be treated by cosmetic treatments alone”
Thread veins on the face are at a level above the heart and the skin is exposed every day to sunlight. Therefore direct treatment with lasers, IPL and electrolysis can be very effective as the skin is able to cope with thermal damage and the veins are not being filled by gravity. However thread veins on the face should not be injected with sclerotherapy as there is a risk of the sclerotherapy draining through the orbital veins and into the venous drainage of the brain. This could cause a “stroke like” problem called “cavernous sinus thrombosis”.
Thread veins on the legs are completely different. The skin on the legs is often hidden away from the sun and is therefore much more likely to scar with laser treatment. In addition, these veins are below the heart and there is a large effect of gravity in their formation. Research from New Zealand in 2001 suggested that 89% of thread veins of the legs are fed by deeper hidden varicose veins that need treatment before the visible thread veins can be successfully treated.
Therefore thread veins on the legs should be treated firstly by investigating if there are hidden varicose veins causing them. This should be done using duplex ultrasound scanning but, if this is not available, then the minimal investigation would be examination with a hand held Doppler. Only if these tests show that are no hidden varicose veins feeding the thread veins should treatment then be started. The optimal treatment for thread veins of the legs is microsclerotherapy injections. These not only treat the thread veins successfully but also other veins in the same network. Lasers, IPL and electrolysis rarely get as good results on thread veins of the legs.
Thread veins of the legs should not be treated as a simple cosmetic or aesthetic condition and should only be treated by those trained in Phlebology. In all cases, a duplex ultrasound scan at best or a hand held Doppler at worst should be performed to identify any underlying hidden varicose veins. These will be present in almost 9/10 cases and will necessitate treatment of the underlying varicose veins before microsclerotherapy can be successfully performed. Blind treatment of thread veins on the legs without a scan is unlikely to produce a good or lasting result.
Q5 “You should wait until you’ve had your family before having varicose veins surgery”
Before venous duplex ultrasonography was available, doctors had to guess which veins might be causing the problem, using only clinical examination (which has been shown to be very inaccurate) and having only open surgery as an option to tie and strip the veins, it was not surprising that recurrence rates after varicose vein surgery were very high. These high recurrence rates would be expected as a clinical examination alone often meant that refluxing veins missed and were left behind, and tying with or without stripping allowed the veins to grow back again.
With the increased volume of blood in pregnancy, any recurrent varicose veins would become prominent during the pregnancy and therefore an incorrect association was made between pregnancy and the formation of varicose veins. Pregnancy merely causes hidden varicose veins to be prominent enough to become seen.
Therefore as these old techniques have such a high recurrence rate, doctors used a variety of reasons to try to delay people having surgery, so that when they did eventually get round are having surgery, the virtually inevitable recurrence would be delayed.
With the new highly specialised venous duplex ultrasound scans that are available in specialist units that can identify all of the abnormal reflux in the veins of the leg and pelvis, and with the new endovenous techniques that have been perfected over the last decade or more, recurrence rates of the treated veins should be now virtually zero in specialist units and the only varicose veins that should be found in a leg after treatment should be new varicose veins that have occurred – which should only affect 3 to 4% of people per year.
Therefore, provided women are investigated by specialists and have the optimal surgery performed correctly using the latest endovenous techniques, they will actually benefit from having any varicose veins treated before pregnancy, as this will reduce the risks of thrombophlebitis and the discomfort of enlarging varicose veins from the accumulation of blood.
Thus the myth that you should wait until you’ve had your family before having your veins operated on is it now exactly the wrong way round. Women should actually have their varicose veins treated before they start a family, provided they choose a specialist vein clinic that has venous duplex ultrasound scanning performed by a specialist who does it every day, directing endovenous surgery using the latest techniques by specialists who use the correct protocols to get the best results.
Q6 “Support stockings cure varicose veins”
As far as curing varicose veins is concerned, graduated pressure stockings or support stockings have several excellent roles in venous disease, but do not cure varicose veins, hidden varicose veins nor even stop the deterioration of the veins in venous reflux disease.
Graduated pressure stockings or support stockings are very useful in relieving symptoms due to varicose veins and hidden varicose veins (venous reflux). The symptoms of swollen ankles and aching legs are caused by blood falling down veins when their valves have failed. Wearing properly fitted, medical grade graduated pressure stockings or support stockings, gives excellent support to the lower leg, reduces swelling and reduces the effect of blood falling down the leg by reducing the pressure gradient. This has the result of causing less inflammation in the lower leg and therefore less aching and tiredness in most patients.
In addition, if graduated pressure stockings or support stockings are worn in people with large varicose veins, the large veins are squashed smaller, making the blood flow faster within them (as shown in the image below). This reduces the risk of clots, both thrombophlebitis and in the deep veins, deep-vein thrombosis (DVT).
Therefore properly fitted medical grade graduated pressure stockings or support stockings, have many uses in improving symptoms in patients with varicose veins and hidden varicose veins, and can even transiently cure venous eczema or leg ulcers. However, as they do not make any permanent change to the deep or superficial veins of the leg, as soon as they are taken off, the deterioration continues.
Support stockings cannot be used to cure varicose veins but merely help the patient while definitive treatment is planned.
Q7 “Removing veins during varicose vein surgery puts more strain on other deeper veins”
There is an erroneous concern that by removing or closing a vein, the blood that should be flowing through it has to now be taken by another vein therefore increasing the work and strain on that other vein.
Unfortunately, many non-specialists who regularly see patients with varicose veins do not fully understand how the venous system actually works and often answer this by such platitudes as “there are plenty of other veins that do the job” or “the blood just finds another way back to the heart”. These are both incorrect and do not answer the patients question which may distress the patient further.
To understand what actually happens requires an understanding of venous reflux and this is discussed fully in The College of Phlebology’s book “Understanding venous reflux – the cause of varicose veins and venous leg ulcers“. However to try and give a simple but accurate answer to this question:
Normally blood flows up veins from feet to heart. If a normal vein were to be removed, it would indeed put more blood into other veins and they would indeed have to pump more blood than they normally would.
However in patients with varicose veins or hidden varicose veins, at least one of the veins is not working and is therefore letting blood fall the wrong way down the vein with gravity. This can be likened to lifting a bucket full of blood but having a hole in the bottom of the bucket. The bucket being lifted is like the blood being pumped up the good veins. The blood falling out of the hole as it is lifted is like the blood falling down the incompetent veins that do not have valves.
In the example of a bucket with a hole in it, it would seem obvious that the bigger the hole, the more blood falls out of the bucket as it is lifted and therefore the harder the person has to work to lift (or “pump”) the same amount of blood. This is the same in the leg veins. When someone has venous reflux in varicose veins or hidden varicose veins, the blood falling down the affected veins that do not have valves means that the deep veins that are working, have to pump harder to get the same amount of blood returned to the heart. Thus it is when the varicose veins or hidden varicose veins have not been treated, that the deep veins have to work harder and to pump more blood.
Going back to the analogy with the bucket with a hole in it, if we wanted to make the job of lifting the blood in the bucket more efficient and save muscle energy, we would repair the hole in the bucket making sure that all of the blood that is lifted in the bucket stays in the bucket and therefore is “pumped”. Similarly, by properly treating the varicose veins or hidden varicose veins that are allowing blood to fall the wrong way down the leg, the deep veins would only have to pump blood once towards the heart and therefore would actually work less hard than when they had to pump this normal amount of blood plus all of the blood that was falling back down the varicose veins.
Thus this myth is completely the wrong way round. Treating varicose veins or “hidden varicose veins” actually reduces the strain and work on the deep veins, allowing them to work less hard. This is one of the reasons why legs ache less, venous eczema and ankle swelling disappears and leg ulcers heal after successful varicose vein surgery.