Comprehensive Review of All Aspects of Lower Limb Vein Conditions.
Everyone knows that venous disease is common and important. The Bonn Vein Study is one of the largest and most quoted medical studies looking at how common venous disease is. It looked at over 3000 adults: the participants completed a questionnaire, they were examined carefully and they underwent an ultrasound scan. They were allocated into one of 7 classes. C0 being a completely normal assessment with no signs of vein abnormality all the way to C6 which is an open leg ulcer. There are 3 striking findings from this study. Firstly, fewer than 10% of the participants had completely normal legs, that is no spider veins, no varicose veins and a completely normal venous duplex ultrasound scan. Secondly, nearly one in 5 people had either swelling, varicose eczema or ulceration- that being a significant complication of their veins. Thirdly, over a third of those in this study had superficial venous reflux on ultrasound. So, as you can see, venous disease is very common.
Another important study, the Edinburgh Vein Study looked at over 1500 adults. It too involved a questionnaire, a standardized assessment and classification of venous disease in the legs, as well as a standardised ultrasound scan to detect venous reflux in the leg veins. A follow-up 13 years later included a reclassification to see if there had been any deterioration or progression of the varicose veins or if complications had developed. Nearly half of the participants with venous disease deteriorated over the 13-year period, and almost one-third with varicose veins developed a complication.
These 2 studies, the Bonn Vein Study and the Edinburgh Vein Study confirm that vein conditions are common and that they get worse with time. The latest findings from the Bonn Vein Study strongly suggest that early treatment of varicose veins prevents deterioration and helps avoid complications such as varicose eczema and leg ulcers.
It has been estimated that the National Health Service (in the UK) spends £5bn annually on treating chronic wounds of which £1bn annually is spent treating venous leg ulcers. Leg ulcers and other vein complications such as phlebitis, varicose eczema and thrombosis cause distress, pain, time off work and a considerable economic burden to the NHS, so vein problems are indeed common and very important.
So what is the underlying problem?
Although surface varicose veins are pretty obvious, the cause of varicose veins is deeper under the skin. It is a problem called superficial venous reflux. That is a defect in the one-way valves that keep blood flowing in the correct direction. Venous valves are delicate folds in the lining of the vein that open and close keeping blood flowing in the correct direction. In the legs, healthy vein valves direct blood from the foot upwards back towards the heart. When the one-way valves in the veins do not work properly, gravity can pull the blood downwards in the wrong direction. Whenever fluid flows in the wrong direction in the body, it is called reflux. So, for example, many of you may be familiar with indigestion caused by acid reflux and a hiatus hernia, well, varicose veins and nearly all the common vein conditions such as spider veins, varicose eczema and leg ulcers are caused by reflux in the superficial veins.
The only way to accurately diagnose vein conditions and their underlying cause is with a venous duplex ultrasound scan. This examination is performed with the patient standing and the deep veins, superficial veins and their connections are checked as well as the function of the valves. With a duplex ultrasound scan, problems such as obstruction and blockages as well as reflux and thrombosis can be accurately diagnosed and identified. A duplex ultrasound scan is the only reliable way to accurately diagnose the cause of vein conditions and it provides the information essential to formulate the correct treatment. NICE, the National Institute for Health and Care Excellence provides evidence-based national guidance on health matters and it recommends in its clinical guideline CG168 to use duplex ultrasound to confirm the diagnosis and to plan treatment. In its Quality Standard QS67 it also recommends that successful treatment should abolish reflux and the only way to confirm that this has happened is with a venous duplex ultrasound scan. So as you can see, ultrasound is necessary at all stages of vein diagnosis, treatment and aftercare.
Surprisingly, superficial venous reflux may exist in the absence of visible surface varicose veins. Reflux can cause ache, throbbing, tiredness or even symptoms such as restless legs. Medical problems such as varicose eczema and varicose ulcers can develop without visible varicose veins. As the superficial venous reflux is the underlying cause, and as venous duplex ultrasound is the only way to identify superficial venous reflux reliably, it is clear that everyone with suspected vein problems, including spider veins, varicose eczema, leg ulcers, phlebitis or even deep vein thrombosis must have a venous duplex ultrasound scan to establish an accurate diagnosis.
Before I cover the treatment options for varicose veins and superficial venous reflux, let’s cover the major complications. The medical complications are phlebitis, varicose eczema, leg ulcers and deep vein thrombosis.
Phlebitis. Phlebitis should really be called Superficial Vein Thrombophlebitis. In this condition, thrombus or clot formation is the main concern and threat. In Superficial Vein Thrombophlebitis there is thrombus – or clot – in the superficial vein, and inflammation in the tissue surrounding the vein. Often, a tubular-shaped lump can be felt which is red, tender and painful. The most frequently affected vein is the saphenous vein on the inner part of the thigh or calf. It can also occur in the veins of the arms or neck, usually after intravenous cannulation and drug administration. The important feature in Superficial Vein Thrombophlebitis is the clot formation rather than the inflammation. The clot in the superficial vein can extend into the deep veins causing deep vein thrombosis and possibly pulmonary embolism – a clot in the lungs. The diagnosis of Superficial Vein Thrombophlebitis is established on clinical signs: that is a painful, tender, red lump along the course of a superficial vein and on the basis of an ultrasound scan. Venous Duplex ultrasound should be carried out to confirm the diagnosis as well as to check for deep vein thrombosis in the affected leg and the opposite leg. That is to say, both legs should be examined by ultrasound. Superficial Vein Thrombophlebitis has traditionally been considered a rather trivial condition, with treatment mainly focusing on the relief of symptoms. However, it is now clear that there is a strong association between Superficial Vein Thrombophlebitis and deep vein thrombosis as well as pulmonary embolism and experts agree that blood-thinning medication is often necessary to prevent clot spread. Superficial Vein Thrombophlebitis can sometimes be confused with cellulitis. These conditions, which can be hard to distinguish clinically – that is simply by looking at the leg- have very different treatments. Superficial Vein Thrombophlebitis often requires treatment with blood thinning medication. If not treated properly, the clot can spread and lead to deep vein thrombosis or even death. Cellulitis on the other hand is an infection that requires antibiotics. If cellulitis is not treated properly, the infection can enter the blood stream causing septicaemia, which also can sometimes be fatal. An ultrasound scan is the only way to confidently distinguish these 2 important conditions.
This is a very confusing term. This condition is a complication of superficial venous reflux. It can exist in the absence of varicose veins. Furthermore, it is not a skin condition as the term “varicose eczema” might suggest. In fact, it is a vascular issue and the reaction of the skin is a response to continued damage to the microcirculation. The skin is actually being deprived of nutrients and oxygen and the area becomes vulnerable and may ulcerate. The importance of “varicose eczema” is that it indicates venous reflux or sometimes venous obstruction and if varicose eczema is neglected it may progress to a leg ulcer. Its presence is a warning sign that should not be ignored. The condition should be investigated by a duplex ultrasound scan and then treatment of any reflux. It should not be managed with creams or stockings alone. Steroid creams in particular should be avoided if possible. Steroid creams will give very prompt relief of redness and itch and can be used very briefly if symptoms are very distressing, but if used long term, steroid creams thin the skin and actually cause deterioration. A leg ulcer then becomes much more likely.
Deep Vein Thrombosis
The association between varicose veins and DVT is now very well established. In 2013, a study from Germany looked at 83,000 people over a three-year period and it found that people with varicose veins were approximately 9 times more likely to develop a deep vein thrombosis. A study from Texas in 2012 showed that people undergoing total hip replacement were at an increased of DVT if they had varicose veins. Very importantly – the study also showed that people who had had treatment for their varicose veins and who were undergoing total hip replacement had the same risk of DVT as people who had never had varicose veins. So these results dispel any doubt that might remain that varicose veins are indeed a risk factor for deep vein thrombosis and now there is considerable evidence that this risk is reduced by successful treatment of the varicose veins.
This is a feared complication of venous disease. Approximately 90% of leg ulcers are due to an abnormality of the veins, and the majority of these are due to superficial venous reflux, which can be cured. Most leg ulcers will develop in an area of varicose eczema and so, not only are the majority of leg ulcers treatable and often curable, the majority can be avoided in the first place.
Now to the Treatment of Leg Veins.
In 2013, The National Institute for Health and Care Excellence – NICE- published clinical guideline CG168 and stated that patients with varicose veins should be referred to a vascular service – a team of healthcare professionals who have the skills to undertake a full clinical and duplex ultrasound assessment and who can provide the full range of treatment options. NICE recommends that endothermal ablation should be the first option, ultrasound‑guided foam sclerotherapy the second option and that surgery is now the last resort.
Let’s look at these in turn.
Endothermal Ablation. During endothermal ablation, the veins affected by reflux are treated from the inside with heat energy. I perform this under local anaesthetic under ultrasound guidance. With an ultrasound probe on the skin, the unhealthy vein is located and the skin overlying the vein is numbed with local anaesthetic and then a small needle is inserted into this vein. Through the needle a fine catheter is inserted into the vein and advanced along the vein under the skin and positioned accurately to the site where the superficial vein joins the deep vein, confirmed by ultrasound. The vein is then numbed with a series of local anaesthetic injections, again, guided by ultrasound. Thereafter, the vein is heated from the inside – hence the term endothermal ablation – to a temperature at which the vein is closed and cauterised and the cells of the vein are sterilised. Thereafter, thvein cannot recover, re-open or re-join with the deep veins and the superficial venous reflux is effectively cured. After endothermal ablation the varicose veins disperse, varicose eczema or leg ulceration can heal, and any associated spider veins will also disperse. Large varicose veins can be extracted at the same time, a procedure called Phlebectomy.
Ultrasound Guided Foam Sclerotherapy. Ultrasound Guided Foam Sclerotherapy is appropriate for those people who are not suitable for various reasons for endothermal ablation. Usually, they are not suitable because the vein is tortuous, or there is some other feature on the ultrasound that means that endothermal ablation cannot be performed. Ultrasound Guided Foam Sclerotherapy involves the injection of a prescription medicine called a sclerosant into the vein guided by ultrasound. The sclerosant is prepared and transformed into foam. When injected, the foam sclerosant removes the delicate lining of the vein, called the endothelium and the veins close, over the following weeks.
I use endothermal ablation (either with laser or radiofrequency), together with ultrasound guided foam sclerotherapy and phlebectomy in combination. I perform these 3 treatments for varicose veins under local anaesthetic as a walk-in walk-out procedure and now I never perform surgical stripping. The avoidance of general anaesthetic ensures that these treatments are extremely safe. NICE – the National Institute for Health and Care Excellence – does not comment on the use of local anaesthetic versus general anaesthetic. However, in my opinion, local anaesthetic is much, much safer. Serious complications after endovenous treatments performed in this way are almost completely avoided. Since these endothermal treatments are performed through pinpricks in the skin guided by ultrasound at all times, there is virtually no scarring and complications such as infection and nerve injury are extremely rare compared to surgical stripping. In addition, these treatments can be performed without admission to hospital and after treatment people can return to normal activities such as driving and get back to work very quickly.
The results of endothermal ablation, ultrasound guided foam sclerotherapy and phlebectomy at my clinic are excellent. My clinic complies with NICE Clinical Guideline CG168 and it meets the NICE Quality Standard QS67.
Other endovenous treatments that have been approved by NICE, but which are not yet included in their list of recommendations are Clarivein® and VenaSeal®. I am one of the few specialists in the southwest of England that offers these 2 alternatives in line with NICE Interventional Procedures Guidance. I can advise people as to whether these treatments might be appropriate for them.
Expert consensus confirms that people with spider veins on the legs should be assessed by venous duplex ultrasound in most instances and that where appropriate superficial venous reflux and feeder veins should treated first by endothermal ablation or ultrasound guided foam sclerotherapy. Thereafter, the most effective treatment for thread veins and spider veins on the legs is by direct injection of a prescription medicine called a sclerosant solution – a treatment called microsclerotherapy. This prescription medicine removes the lining of the vein and a healing process ensues so that over the following weeks and months, the spider veins disperse.
True varicose veins on the hand are extremely rare. In the vast majority of cases, the arm and hand veins function normally and they look prominent because the person is either very thin, or because the collagen structures that support the hand veins have lost elasticity. The appearance can be very distressing. I use a combination of sclerotherapy and collagen stimulation that I have developed. The sclerotherapy method I use shrinks the veins and makes them return to a more normal size; and unlike other forms of sclerotherapy, compression gloves or bandages are not required. At the same time, I use a collagen stimulator injection under the skin to restore volume to the back of the hand for a more youthful appearance and to support the hand veins.
So in summary, it is important that leg veins are checked by venous duplex ultrasound and treated in line with guidance from the National Institute of Health and Care Excellence. Furthermore, I believe that local anaesthetic is preferable to general anaesthetic and that endothermal ablation is the number one option. If this is not possible, ultrasound guided foam sclerotherapy should be considered. Venous disease should only be treated by a specialist team who have the necessary skills to undertake diagnosis and treatment. Treatment should be guided by ultrasound before, during and after any intervention.
Spider veins and hand veins can also be effectively and safely treated by sclerotherapy and in the case of hand veins, I have developed a combination therapy which reduces the appearance of hand veins and which stimulates surrounding collagen and supporting collagen formation.
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