The aim of vein surgery is to treat venous diseases. In fact, in over 90% of cases, this disease is Chronic Venous Insufficiency (CVI) in the lower limbs, which causes varicose veins. Varicose veins are the result of a dilation and lengthening of superficial veins, which strains their walls and causes a blood reflux when a person is stood up.
Veins in the lower limbs
There are two venous networks.
The network of deep veins, found within the muscles and connected to the arteries, carries out 90% of venous return.
The ancillary network of superficial veins, which drains the skin and subcutaneous tissue, carries out just 10% of venous return. The latter features two main draining veins in each leg.
The long saphenous vein or great saphenous vein runs along the inner leg and thigh, from the ankle to the fold of the groin, where it arches to join the deep venous network.
The short saphenous vein or small saphenous vein is found in the posterior leg; it begins at the ankle and arches at the knee joint (popliteal fossa).
Perforator veins act as a kind of ladder, connecting the two networks through the muscles.
The veins in the lower limbs are equipped with valves, which direct the blood flow upwards from below and from the surface towards the deeper network. These valves also prevent blood reflux.
The venous system ensures blood returns to the heart. This process is reliant on a number of mechanisms.
- Firm pressure on the sole of the foot and on the superficial veins of the sole.
- Contraction of the calf muscles, “the second heart”.
- Respiration, as intrathoracic pressure becomes negative during expiration.
- The cardiac pump
- And finally, the valves which prevent reflux.
Venous pressure in the ankle is 10 mmHg when laid down and 80 mmHg when stood up. When valves are damaged, downwards blood reflux occurs, which then dilates and strains superficial veins.
1. The true causes of varicose veins are still unknown. However, they are five times more common in developed countries.
In contrast, predisposing factors have been identified:
- Heredity. There is a 20% risk of having varicose veins if neither parent has them. This risk is 50% if one parent is affected and 90% if both parents suffer from varicose veins.
- Age. Varicose veins are three times more common at the age of 70 than at 30. 70% of varicose veins occur after the age of 60.
- Gender. Varicose veins are more common amongst women.
Other contributing factors include:
- Obesity and/or rapid weight gain leading to a sedentary lifestyle and muscle loss.
- Standing or sitting for long periods of time at work, particularly in warm and humid environments that involve staying in the same spot (sales assistants, waiting staff, cabin crew).
- Certain sports
- Static foot disorders: flat or arched feet.
- Pregnancy and its associated hormonal changes, and compression of veins in the pelvic cavity.
Other related factors: chronic constipation; overly tight clothing; unsuitable footwear (excessively high heels or lined boots); some lifestyle habits such as smoking, alcohol consumption or eating excessively spicy foods; and heat-related damage (saunas, hammams, hot wax hair removal, prolonged sun exposure).
2. Often, there are few or no symptoms.
Clinical signs are more common in summer and during menstruation. Symptoms include heavy legs, above all at the end of the day, oedema of the ankle, tingling, itchiness, cramps, particularly at night, and even a burning sensation in the legs. Phlebalgia (pain in the veins) and a real venous claudication may also occur.
Aesthetic issues are sometimes the most prominent symptom.
Pelvic venous insufficiency can also occur. This is associated with pelvic congestion syndrome which causes pain and heaviness in the pelvis, dyspareunia, urinary urgency and vulvar varicosities or varicose veins in the upper thigh.
Diagnosis is largely clinical and allows the disease to be classified (CEAP). It involves a series of thorough questions regarding previous family history, contributing factors, the different problems experienced by the patient and the associated pathologies. There will also be a full, one-on-one examination of the front, back and side, first in a standing position and then laid down, for which the patient must remove their clothes from the waist down.
Paraclinical examinations are mainly carried out using a Doppler ultrasound test. In the event of pelvic insufficiency, a phlebo-MRI will be requested.
4. Without treatment, complications may occur, which may include:
- Dermatitis: stasis or atopic.
- Hypodermitis: red patches, inflammation, pain.
- Varicose eczema with lesions caused by scratching.
- Ulcers: loss of soft tissue, somewhat painful, an open sore which occurs on the medial malleolus and exposes the dermis.
Haemorrhages due to the rupture of a varicose dilation.
Or even thrombosis. This refers to phlebitis in the superficial veins which causes acute, localised pain, with a cord-like, red and inflamed vein.
5. Varicose vein treatment.
TREATMENT IS ALWAYS MEDICAL
Some lifestyle and dietary rules must be followed. Feet must be raised in bed, legs should be washed using cold water, maximum heel height of 5 cm, use of insoles if necessary.
Tight clothing must not be worn. Take care with heat, tobacco, alcohol, etc. Choose sports such as walking, jogging, swimming, cycling or aquabiking.
An appropriate compression sock, stocking or tight must be warn and, sometimes, manual lymphatic drainage massages are required. A prescription for veinotonic medication may also be helpful for use as a short-term analgesic.
Surgery depends on the stage of the disease and on the area.
There are a number of surgical techniques ranging from the classic crossectomy and stripping of veins to phlebectomies and to the ligation of perforator veins using thermal vein-stripping techniques. Sclerotherapy can also be beneficial, both on its own or alongside surgery. For pelvic varicose veins, an embolisation may be carried out percutaneously.
Using an endovenous laser or radiofrequency, heat is used to destroy the vein. This gives immediate positive results in over 90% of occlusions.
The procedure can be performed under local anaesthesia. It is relatively painless and allows for an earlier return to work. Postoperative compression is required.
Crossectomy and stripping
This is mostly used on large, truncal varicose veins with a diameter of over 9 mm and multiple instances of tortuosity, and/or if there is significant blood reflux with ostial incontinence of the anterior saphenous vein. It is also used to treat post-sclerosis relapse cases. It is carried out as an outpatient procedure or with a short hospital stay, under general or local/regional anaesthesia.
After preoperative marking, the saphenous vein is disconnected from the deep network (crossectomy); then, stripping of the vein takes place. A postoperative compression garment must be worn for one month after the operation.
The patient will be able to walk the following day but will be unable to do sport. Sick leave is usually between 8 to 15 days. Postoperative haematomas and pain are variable, and complications are rare.
This is a technique which is carried out via ultrasound using sclerosing foam or sclerosing products. Depending on the case, it can be used on its own or alongside surgery. Multiple sessions will usually be required. It is contraindicated in the presence of complications or in the event that varicose veins are too large.
A phlebectomy is used alongside stripping to treat collateral varicose veins and non-systematised networks, or as a standalone treatment to treat isolated or non-systematised varicose veins.
Embolisation of pelvic varicose veins
This treatment is carried out percutaneously under local anaesthesia. It is indicated to treat pelvic congestion syndrome.
Varicose veins are a common disease of chronic progression which requires comprehensive care. The contributing factors must always be considered for a successful treatment result.
The choice of surgical treatment requires expertise, taking into account all the various parameters, and knowledge of all the techniques. Finally, it is important for postoperative follow-up care to be arranged.
MUCH LESS FREQUENTLY:
Vein surgery may sometimes relate to other pathologies, such as deep vein thrombosis or oncology, or other parts of the body, such as the upper limbs.