Vein Care Center Vienna

The Sievering Clinic is a specialty clinic offering state-of-the-art treatment modalities for venous disorders. Headed by Dr Philippe Bull, specialist in vascular surgery, the clinic provides both cosmetic and surgical intervention for vein problems.

It is estimated that 35-60 % of the population suffer of some form of venous disorder. If you think you might be one of them, let the professional staff at the Sievering Vein Care Centre complete a comprehensive medical evaluation for you. If you have a venous disorder, they will help assess and develop a treatment plan specific to your need.

Whether your interest in cosmetic treatment of spider veins or whether you suffer from extensive varicose veins, our Vein Care Centre offers a wide range of options including all traditional vein procedure treatments as well as foam sclerotherapy and endovenous procedure.

Persons suffering from chronic venous disease can access specialists to treat their symptoms. The Vein Care Centre follows a multi-specialized team approach comprising vascular surgeons and angiologists in providing and managing care, including a dedicated follow-up of patients to be certain that our treatment achieves expected results.

The all-in-One Vein Care Centre with modern facilities

Our advantages

• Latest technologies
• Minimally invasive procedures
• Excellent clinical and aesthetic results
• Personalized care
• Highly specialized professionals
• Quick recovery
• Pleasant and friendly environment
• Affordable prices
• Private atmosphere
• Personalized treatment plan

Diagnosis and treatments

• Duplexsonography
• Plethysmography
• Ultrasound-Dopplersonography
• Phlebodynamometry
• Sclerotherapy
• Microphlebectomy
• Endoluminal Laserablation
• Radiofrequency ablation
• Endoscopic surgery
• Phlebography

Clinical treatment for varicose veins

Varicose veins are not only an aesthetic problem; they also cause fatigue, leg cramps, skin rashes and inflammation of the veins.

Treatments

Follow-up care

Vein exercise

 

In order to provide our patients with the highest quality surgical care available, our practice is limited on the assessment and treatment of general surgical conditions. If you do not have a family doctor, we will gladly refer you for your non-surgical needs.

 

For your information:

This page has been provided for your information and to answer common questions. This website has been prepared to answer questions about a variety of circulatory problems, ranging from cosmetic blemishes through to more serious underlying circulatory problems. The site is intended to be a simple guide, answering commonly asked questions. It does not replace a formal consultation with a vascular or vein specialist, who will be in a better position to answer your questions fully.

 

 

Diagnosis

At the Sievering Clinic we are committed to providing personalized and compassionate service to all our patients and offer state-of-the-art surgical techniques.

 

Our diagnosis services include:

Venous Assessment

Non-invasive Diagnosis

Service Order

Requests for any of these services are accepted on the order of a physician and the patient’s request. As part of the consult, a complete history, physical, interview, and ultrasound Doppler with venous mapping will be ordered and performed. Referrals are accepted by either phone call or fax. The physician’s office should fax the venous consult order, and our staff will arrange for all the rest.

 

To provide our patients with the highest quality surgical care available, our practice is limited to the evaluation and treatment of general surgical conditions. If you do not have a primary care physician, we will gladly refer you to someone for your non-surgical needs.

 

Venous Assessment

Inspection is the most important since it may reveal ulceration, spider veins, skin alteration (white atrophy), fungal involvement like inter-digital mycosis, acrocyanosis, eczematous lesions, micro-ulcers, stasis dermatitis, flat angiomata, prominent varicose veins, scars from a prior surgical operation, or evidence of previous sclerosant injections. Measuring and photographing lesions is recommended because patients undergoing treatment for varicose and spider veins often forget the original appearance of their legs and feet and may report that pre-existing lesions were caused by treatment

Normal veins typically are visibly distended at the foot and ankle and occasionally in the popliteal fossa. For other regions of the leg, visible distension of superficial veins usually implies disease. Translucent skin may allow normal veins to be visible as bluish sub-dermal reticular pattern, but dilated veins above the ankle usually are evidence of venous pathology.

Discoloured skin often is a sign of chronic venous stasis, particularly if it is localized along the medial ankle and the medial aspect of the lower leg. Non-healing ulcers in this area are most likely due to underlying venous stasis. Skin changes or ulcerations that are localized only to the lateral aspect of the ankle are more likely to be related to prior trauma or to arterial insufficiency than to pure venous insufficiency.

Palpation

The entire surface of the skin is lightly palpated with the fingertips because dilated veins may be palpable even where they are not readily observed. Palpation helps to locate both normal and abnormal veins. After light palpation to identify superficial vascular abnormalities, deeper palpation helps to elucidate the causes and sources of the superficial problems.

Percussion

Venous percussion is useful to determine whether 2 venous segments are directly interconnected. Percussion can be used to trace the course of veins already detected on palpation, to discover varicose veins that could not be palpated, and to assess the relationships between the various varicose vein networks. Percussion can be used to elucidate the course of any significant superficial vein.

Perthes Manoeuvre

The Perthes Manoeuvre is a traditional technique intended to distinguish antegrade flow from retrograde flow in superficial varicose veins. Antegrade flow in a variceal system indicates that the system is a bypass pathway around deep venous obstruction. This is critically important because, if deep veins are not patent, superficial varicose veins are an important pathway for venous return and must not be sclerosed or surgically removed.

Trendelenburg Test

The Trendelenburg Test can often be used to distinguish patients with superficial venous reflux from those with incompetent deep venous valves.

 

Non-invasive Diagnosis

Non-invasive diagnostic methods for venous disease were developed for screening, for quantifying lesions, and for hemodynamic studies. Both the general practitioner and the specialist must, at their different levels, know the significance of the various vascular tests, their indications and limitations, so they can avoid having to prescribe unnecessarily invasive and costly tests.

Because venous disease is so manifold it is somewhat more difficult to evaluate than arterial disease and requires experience and closer evaluation. This means venous tests are much more operator-dependent and require specific clinical skills, particularly in the evaluation of CVI. CVI can be the result of obstruction to venous outflow or reflux, or to a combination of the two. Clinical examination and diagnostic techniques therefore aim to establish which conditions are present. The anatomical location of the alterations must be found and the reflux and/or obstruction must be identified.

 

There are many simple, rapid and efficient tests available, with good cost-benefit ratios. The diagnostic procedures listed summarily below reflect those set out in the Procedure Operative per Indagini Diagnostiche Vascolari (Operating Procedures for Vascular Diagnostic Investigations) published by the Italian Society for Vascular Investigation, and accepted by the Italian College of Phlebology.

 

Main investigational techniques

• Ultrasound
• Continuous-wave (CW) Doppler
• Duplex scan
• Echo(color) Doppler (ECD)

 

Radiographic imaging

• angio-computed tomography (CT) scans
• angio-magnetic resonance (MR) scans

 

Plethysmography

• Quantitative photoplethysmography
• Phlebography (venography)

 

Diagnostic process

The aim of the investigation is to check whether there is venous reflux or superficial and/or deep venous thrombosis. Depending on the findings, the diagnostic pathways divide. The deep venous circulation should always be examined.

 

Ultrasound examination is useful to demonstrate reflux, identify its origin and follow its axis cranio-caudally.

After clinical examination, the main screening method for CVI should be CW Doppler.

Echo- Doppler and echo color-Doppler should be used to establish the location and the morphology of the problem, and preoperatively.

Phlebography is only needed for a small number of patients who have anatomical anomalies or malformations, or when surgery or endovascular therapy on the deep venous system is indicated. Grade B Plethysmography should be considered as an additional quantitative test. Grade B Investigations of the microcirculation are only indicated in selected patients, mainly for research purposes.

 

Doppler Auscultation

The physical examination as described thus far cannot differentiate dilated veins of normal function from true varicosities that carry venous blood in a retrograde direction. Doppler examination is an adjunct to the physical examination that can directly show whether flow in a suspect vein is antegrade, retrograde, or to-and-fro.

When used as part of the physical examination, a Doppler transducer is positioned along the axis of a vein with the probe at an angle of 45° to the skin. Gentle tapping on the underlying vessel produces a strong Doppler signal and confirms the correct positioning of the transducer.

An augmentation manoeuvre is performed by compressing and then releasing the underlying veins and muscles below the level of the probe. Compression causes forward flow in the direction of the valves. Release of compression causes backward flow through incompetent valves, but no Doppler signal is noted if the valves are competent and the blood cannot flow backwards.

These compression-decompression manoeuvres are repeated while gradually ascending the limb to a level where the reflux can no longer be appreciated.

Each superficially visible or palpable is investigated in this way. If no visible or palpable dilated varicose veins exist, the presence or absence of retrograde flow is documented at the top, middle, and bottom of long and short saphenous veins on each leg.

Doppler flow assessment adds a great deal of information to the physical examination findings, but patients with significant varicosities should also be evaluated by duplex ultrasonography, which combines Doppler flow detection with 2-dimensional ultrasound imaging.

 

Ultrasound Investigation

Imaging Studies

The goal of imaging studies is to identify and map all areas of acute or chronic obstruction and all areas of reflux within the deep and superficial venous systems.

 

Ultrasound

Successful imaging of the deep venous system requires a thorough knowledge of venous anatomy and physiology and a meticulous attention to detail.

 

The most useful modalities available for venous imaging are contrast venography, magnetic resonance imaging (MRI), and colour-flow duplex ultrasonography.

 

Duplex ultrasonography is the standard imaging modality for diagnosis of varicose insufficiency syndromes and for treatment planning and preoperative mapping.

 

Two-dimensional ultrasonography forms an anatomic picture based on the time delay of ultrasonic pulses reflected from deep structures. Structures that absorb, transmit, or scatter ultrasonic waves appear as dark areas; structures that reflect the waves back to the transducer appear as white areas in the image. Vessel walls reflect ultrasound; blood flowing in a vessel absorbs and scatters ultrasound in all directions. The normal vessel appears as a dark-filled white-walled structure.

 

Duplex ultrasonography is a combination of anatomic imaging by 2-dimensional ultrasound and flow detection by Doppler-shift. With duplex ultrasonography, after the 2-dimensional anatomic image is displayed, a particular spot in the image can be selected for Doppler-shift measurement of flow direction and velocity.

 

Colour-flow imaging (sometimes called triplex ultrasonography) is a special type of 2-dimensional ultrasonography that uses Doppler flow information to colorize areas of the image in which flow has been detected. Vessels in which blood is flowing are coloured red for flow in one direction and blue for flow in the other, with a graduated colour scale to reflect the speed of the flow. Modern colour-flow duplex ultrasonography equipment can provide flow information in conjunction with surprisingly high-resolution views of both deep and superficial venous systems. Structural details that can be observed include the most delicate venous valves, small perforating veins, reticular veins as small as 1 mm in diameter, and (using special 13-MHz probes) even tiny lymphatic channels.

 

Magnetic resonance venography (MRV) is the most sensitive and most specific test for deep and superficial venous disease in the lower legs and in the pelvis, where other modalities cannot reach. MRV is particularly useful because unsuspected nonvascular causes for leg pain and oedema may often be observed on the MRV scan when the clinical presentation erroneously suggests venous insufficiency or venous obstruction.

 

Direct contrast venography is the most labour-intensive and invasive imaging technique. In most centres it has been replaced by duplex ultrasonography for routine evaluation of venous disease, but the technique remains extremely useful for difficult or confusing cases.

An intravenous catheter is placed in a dorsal vein of the foot, and radiographic contrast material is infused into the vein. If deep vein imaging is desired, a superficial tourniquet is placed around the leg to occlude the superficial veins and force contrast into the deep veins more quickly.

 

Assessment of reflux by direct contrast venography is a difficult procedure that requires passing a catheter from ankle to groin with selective introduction of contrast material into each vein segment.

Nearly 15% of patients undergoing venography for detection of deep venous thrombosis (DVT) develop new thrombosis after contrast venography. The incidence of contrast-induced DVT in patients who undergo venography for diagnosis and mapping of varicose veins is not known.

 

Other Tests

Physiologic tests of venous function are important adjuncts to anatomic imaging of venous disease. The physiologic parameters most often measured are the venous refilling time (VRT), the maximum venous outflow (MVO), and the calf muscle pump ejection fraction (MPEF).

 

The venous refilling time is the time necessary for the lower leg to become suffused with blood after the calf muscle pump has emptied the lower leg as thoroughly as possible.

When perfectly healthy patients are in a sitting position, venous refilling of the lower leg occurs only through arterial inflow and requires at least 2 minutes.

In patients with mild and asymptomatic venous insufficiency, some venous refilling occurs by means of reflux across leaky valves. These asymptomatic patients have a VRT that is 40-120 seconds.

In patients with significant venous insufficiency, venous refilling occurs through high-volume reflux and is fairly rapid. These patients have an abnormally fast VRT of 20-40 seconds, reflecting retrograde venous flow through failed valves in superficial and/or perforating veins. This degree of reflux may or may not be associated with the typical symptoms of venous insufficiency. Such patients often report nocturnal leg cramps, restless legs, leg soreness, burning leg pain, and premature leg fatigue.

A venous refilling time of less than 20 seconds is markedly abnormal and is due to high volumes of retrograde venous flow. High-volume reflux may occur via the superficial veins, the large perforators, or the deep veins. This degree of reflux is nearly always symptomatic. If the refilling time is shorter than 10 seconds, venous ulcerations are so common as to be considered virtually inevitable.

 

The MVO measurement is used to detect obstruction to venous outflow from the lower leg, regardless of cause. It is a measure of the speed with which blood can flow out of a maximally congested lower leg when an occluding thigh tourniquet is suddenly removed.

The advantage of MVO testing is that it is a functional test rather than an anatomic one, and it is sensitive to significant intrinsic or extrinsic venous obstruction from any cause at almost any level. It can detect obstructing thrombus in the calf veins, the iliac veins, and the vena cava, where ultrasonography and venography are insensitive. It also detects venous obstruction due to extravascular hematomas, tumours, and other extrinsic disease processes.

The disadvantage of the test is that it is sensitive only for significant venous obstruction and does not detect partially obstructing thrombus. It is not useful for detection of venous insufficiency states. A normal MVO absolutely does not rule out deep vein thrombosis.

 

The MPEF test is used to detect failure of the calf muscle pump to expel blood from the lower leg.

MPEF results are highly repeatable but require a skilled operator to obtain clean meaningful tracings. The patient is asked to perform 10-20 tiptoes or dorsiflexion at the ankle, and the change in some physical parameter that reflects calf blood volume is recorded as the calf muscle is pumped.

In patients without varicose veins, 10-20 tiptoes or ankle dorsiflexion cause the venous capacitance circuit of the calf to be emptied.

In patients with muscle pump failure, severe proximal obstruction, or severe deep vein insufficiency, tiptoes or ankle dorsiflexion have little or no effect on the amount of blood remaining within the calf.

 

Treatments

At the Sievering Clinic we are committed to providing personalized and compassionate service to all our patients and offer state-of-the-art surgical techniques.

 

 

Our treatment services include:

Non-invasive Treatments

Minimally invasive Treatments

Surgical Treatments

Instructions for Varicose Vein Surgery

A simple outpatient procedure

The Vein Care Centre is a one-stop medical service centre that specializes in the management of all stages of vein disorder; from diagnosis to laser elimination of spider veins to non-surgical treatment of the more serious varicose veins.

 

Some of our treatment methods

• Micro-Sclerotherapy with Transillumination
• Mini-ambulatory Phlebectomy
• Intense Pulse Light
• Polaris Laser
• Veinwave
• Endovenous Laser Ablation of truncal veins
• Sclerotherapy

Varicose veins

Presently, the common clinical problem of varicose veins can be addressed using a variety of techniques. Treatments range from the standard surgical therapy of high ligation and stripping of the greater saphenous and tributaries to sclerotherapy, laser vein ablation, and vein closure devices. As the technique has evolved over time, microphlebectomy has been used to remove varicosities below the knee, and the greater saphenous is stripped from the groin to the knee.

 

Guidelines for reducing some effects of varicose veins:

• Raise your legs whenever possible with your feet above the level of your heart.
• Exercise every day.

Walking, cycling, climbing stairs and swimming are excellent ways to keep your calf muscles in motion.

• When sitting for prolonged periods, move your legs frequently. Moving your ankles and flexing calf muscles will help keep blood moving in your legs. Avoid sitting for extended periods.
• Wear compression stockings

Graduated compression provides external pressure (like e.g. the valves in the veins) to aid in blood return to the heart. Compression stockings provide an effective non-operative option for symptom control. Compression is required for most vein surgery recovery.

 

 

Non-invasive Treatments

Compression stockings

Compression stockings are a simple non-invasive treatment for varicose veins, chronic venous insufficiency, and lymphedema. The most effective option to prevent and treat lower limb varicose veins is to wear graduated compression stockings (GCSs). These stockings are called graduated because the pressure is higher at the ankle level and gradually decreased towards the heart.

Chronic venous insufficiency (CVI) in the lower limb is most commonly due to varicose veins, which appear as dilated, elongated, or tortuous superficial veins. Despite the considerable number of studies conducted on the aetiology of varicose veins, the reason is not known. However, it is generally recognized that occupation and posture are the major associated factors and contribute significantly to the effects of raised venous pressure and incompetence of primary structures in the vein wall and valves.

People who spend most of their working day in a standing or sedentary position (eg, police officers, teachers, sales assistants) are considered to be at a high risk for varicose vein development. The development of varicose veins usually occurs in the superficial venous system of the lower limbs, especially in the long saphenous veins (LSVs) and their tributaries. The short saphenous vein (SSVs) behind the knee and its tributaries can also become varicose, but this occurs less often. The reported incidence of varicose veins in adults varies from 7% to 40% in men and from 14% to 51% in women. If the condition cannot be prevented or treated in a timely manner, varicose veins can lead to more serious morbidities and medical complications.

The treatment compresses superficial veins to promote the flow of blood through the leg veins and prevent the accumulation of fluid (oedema) in the tissues of the legs.

To be effective, compression stockings must be worn regularly.

Compression stockings, which are made from an elastic fabric, fit most tightly around the ankles and gradually become looser farther up the leg. The treatment compresses superficial veins to promote the flow of blood through the leg veins and prevent the accumulation of fluid what we call oedema in the tissues of the legs.

 

Compression stockings are commonly used to treat or prevent:

• Chronic venous insufficiency (CVI);
• Varicose veins;
• Lymphoedema; and
• Deep vein thrombosis.

 

Indications

Compression stockings are recommended or prescribed for moderate to severe CVI, following a procedure to treat varicose veins, or for lymphoedema in the leg.

Although many compression stockings are sold without a prescription, they should not be used without medical advice.

 

Pre-treatment Guidelines

Patients with CVI or lymphedema may require bed rest for 2 to 7 days to reduce oedema (swelling) as much as possible. If the patient has infected leg ulcers, antibiotics may be prescribed. Ulcers (sores) are cleaned and dressed daily as needed.

When swelling has decreased and any ulcers have healed, the patient is fitted with compression stockings.

 

Who is eligible?

Patients with impaired arterial circulation in the legs should not use compression stockings.

 

Risk factors for possible complications

Many patients have difficulty adjusting to compression stockings. They require daily use to be fully effective, yet they may initially cause great discomfort when they press against existing or recently healed ulcers. However, most patients can tolerate compression stockings by wearing the stockings briefly at first and gradually increasing the duration of wear.

 

What to expect

Patients are told they will need to wear the stockings at all times during the day and are therefore usually given two pairs of compression stockings to be able to wash them. The patient should put on the stockings in the morning before getting out of bed and wear them all day until bedtime.

Special devices can ease the process of putting on compression stockings.

 

Post-treatment Guidelines and Care

Compression stockings generally have to be replaced every 3 to 6 months.

Patients with CVI or severe varicose veins should be prepared to use compression stockings for the rest of their lives.

 

Unna Boots

First described by Unna in 1854, the Unna boot now is the mainstay of treatment for people with venous ulcers. Unna boots are rolled bandages that contain a combination of calamine lotion, glycerine, zinc oxide, and gelatine.

 

Minimally invasive Treatments

 

Transcutaneous Laser and intense-pulsed-light (IPL) Therapy

Transcutaneous laser and intense-pulsed-light (IPL) therapy has proven effective for the tiniest surface vessels (eg, those found on the face), but this modality is not generally useful as primary therapy for treatment of spider veins of the lower extremity. This is true for several reasons.

 

Because of the physics of light absorption, delivering an ablative dose of thermal energy to the vessel without damaging the overlying skin is difficult.

The degree of patient-to-patient variability of light absorption in the skin is high.

Even an experienced practitioner may inadvertently cause painful skin burns that can lead to permanent hyperpigmentation or hypopigmentation.

For most patients, the laser pulses are significantly more painful than the 30-gauge needles used for microsclerotherapy.

Most spider veins have associated feeding vessels that must be treated by some other means before the tiny surface vessels are amenable to laser or IPL treatment.

 

After treatment the areas treated become reddened and there is a feeling of sunburn for a couple of hours. On occasion it is possible to produce a bruise if one of the smaller veins ruptures but parameters can be altered to stop this recurring. This will fade as with normal bruising. There is a slight possibility of a blister forming but it is very superficial and will heal with no scarring. Local swelling of the face is a possibility but this subsides spontaneously within a few days. Ice packs can be applied to reduce swelling and soothe the thermal affect. Make-up can be applied immediately post treatment.

 

IPL (Intensive Pulsed Light) is a very successful way of eradicating facial veins and reducing redness. Three or four sessions are usually required at three-week intervals. If a good moisturiser and strong sun block are applied whenever exposed to sunshine (including day to day activities, not only when sunbathing) then the likelihood of recurrence is greatly reduced.

Sclerotherapy

Sclerotherapy remains the “gold standard” in the treatment of telangiectasia or spider veins. Spider veins are tiny veins, visible through the skin. This technique involves injecting a sclerosing agent into a small varicose vein or spider vein. The sclerosing agent irritates the wall of the abnormal vessel, causing it to collapse and seal off.

 

Ultrasound Guided Foam Sclerotherapy

This method is used as an alternative to surgery for large varicose veins. The main surface of vein is injected with special foam under ultrasound guidance. The foam destroys the lining of the vein and a firm bandage is applied to the leg. This type of injection is suitable for treating the main surface veins as well as varicose veins. The procedure does not require an operating theatre and is usually carried out in a consulting room or treatment room. The injection causes only trivial discomfort.

 

Advantage

Stripping of the vein is avoided and there is little or no discomfort after treatment. There is less bruising than following surgery. There is no need for general anaesthetic, incisions in the leg or an operating theatre. Re-treatment for further varicose veins is simple. The cost of treatment is much less than for surgical treatment or for either VNUS Closure or Laser treatment.

 

Disadvantage

The treatment produces mild discomfort in the leg, which may last for 2 – 4 weeks. It also produces mild bruising, which may last for several months following treatment. The final outcome may take several months to evolve following treatment, and this is longer than would be taken following surgery. The long-term outcome of this procedure has not been established.

 

Pre-Sclerotherapy Instructions

When you have decided to have sclerotherapy there are considerations that will make your treatment more successful and decrease potential side effects.

Please review the following, and remember: you must bring your compression stockings to each sclerotherapy session.

 

Please review the following procedure guidelines before your treatment day:

• You will need to bring your compression stockings to wear after the sclerotherapy session;
• Compression stockings are an essential part of the treatment. If you do not have compression stockings, please contact the clinic prior to your sclerotherapy appointment;
• Do not take aspirin, Ibuprofen, or arthritis medication for at least 48 hours before treatment;
• Avoid alcoholic beverages for 48 hours before treatment;
• Do not shave your legs, nor use creams or oils on them
• Shower using antibacterial soap on the day of treatment;
• Please remember to bring your compression stockings with you to each session of your sclerotherapy, Your session will be rescheduled if you don’t;
• Please call 0676 3288777, 24 hours in advance to cancel a session.

When scheduling your procedure, keep in mind that your legs may be bruised or slightly discoloured for some weeks afterward. You probably won’t be comfortable wearing shorts, a swimsuit or a mini skirt until after your legs have cleared up a bit.

 

Where your treatment will be performed

Sclerotherapy of spider veins is a relatively simple procedure that requires no anaesthesia, so it will be performed in an outpatient setting, in our consultation office.

 

The procedure: A typical sclerotherapy session is relatively quick, lasting only about 15 to 45 minutes.

After changing into shorts, your legs may be photographed for your medical records.

You will be asked to lie down on the examination table and the skin over your spider veins will be cleaned with an antiseptic solution. Using one hand to stretch the skin taut, your doctor will begin injecting the sclerosing agent into the affected veins. Bright, indirect light and magnification help ensure that the process is completed with maximum precision. Approximately one injection is administered for every inch of spider vein – anywhere from five to 40 injections per spider vein treatment session. A cotton ball and compression tape is applied to each area of the leg as it is finished.

 

During the procedure, you may listen to music, read, or just talk to your practitioner.

You will be asked to shift positions a few times during the process.

As the procedure continues, you will feel small needle sticks and possibly a mild burning sensation. However, the needle used is so thin and the sclerosing solution is so mild that pain is usually minimal.

 

Post-sclerotherapy Instructions

Since injection therapy for your varicose veins has been arranged please read the following carefully:

 

After your treatment

Patients who have had sclerotherapy have reported little discomfort and are generally pleased with the results. Careful attention to post-procedure care is very important in minimizing complications and maximizing your cosmetic results.

 

Following each session:

Immediately after each session, compression stocking must be worn. The stockings should be worn 24 hours a day for 3 days. Wear your compression stockings for an additional 2-3 weeks following treatment, putting them on in the morning and removing at night. Fading should continue over the next 2-6 weeks.

 

• Walk at least 1 hour a day. Avoid standing for long periods of time.
• Avoid strenuous activity, high impact aerobics, or weight lifting for 3-4 days after treatment.
• Avoid hot baths for 2 weeks. Take cool showers to help keep veins closed.

 

Additional considerations:

1. Compression

• Compression of the sclerosed vein with graduated compression stockings should be maintained after treatment as outlined above. Compression serves a number of purposes:
• Compression helps decrease the likelihood of blood re-entering the vein, especially if compression is maintained over 
2-3 weeks.
• The pressure helps seal the irritated vascular lumen.
• Compression reduces the risk of ‘blood clot’ formation, and reduces incidence of hyperpigmentation, and matting 
after sclerotherapy.

 

2. Discomfort

• Wear compression stockings as prescribed. This alone may eliminate discomfort. Walking will also help, and when needed, topical ointments or mild pain medication may be used (non-aspirin Diclofenac type medication).

 

3. Bruising

• Fair-skinned people tend to bruise more than do dark skinned people.
• Clots sometimes develop at the site of injection. Although not a major cause for concern, removal of these clots may 
be necessary within a couple of weeks to allow the healing process to progress normally.

 

4. Itching/Swelling at injection site

• A small percentage of people may develop an allergic reaction to the sclerosing agents. This occurrence usually resolves 
with time but occasionally antihistamines may be used.

 

5. Tape Blister or Ulceration

• Occasionally a blister type hive may arise at the site of tape dressing or at the site of some leakage of medication. This potential side effect can be unpredictable, but usually resolves within a couple of weeks using topical treatment such as zinc oxide.

 

6. When should I return for evaluation or additional treatment?

• You should wait 4-8 weeks between sessions to achieve maximum fading. Ask your doctor or nurse.

 

Microsclerotherapy

Microsclerotherapy is a technique used for the removal of surface and spider veins. It involves injections with a very fine needle of a sclerosing agent, which has an irritant effect on the lining of the veins causing the walls of the veins to stick together. Blood stops flowing through the veins, which are then absorbed by the body’s natural defence mechanisms over a period of three months. The blood is then directed back to the deeper venous system.

 

The procedures are carried out by specialist nurses under the supervision of experienced vascular surgeons who are ultimately responsible for the treatments.

 

Bruising can last anything from two weeks to three months depending on the size of the blood vessels treated. Due to bruising following injections the treated areas can look worse before they improve and it is necessary to be patient to obtain a good result. Occasionally thicker bruises in larger veins, which can remain for several months, may cause brown discolouration of the skin. This could take up to a year to fade. High compression stockings are worn for up to three days to help reduce the amount of bruising. It is usually advisable to leave a two-week period between treatments on the same area to allow bruising to settle.

 

Certain areas are more susceptible to swelling, particularly the ankle and knee areas. It is also possible for some larger veins to develop a small degree of thrombophlebitis were the vessel can feel hard, warm and a little sore. These symptoms resolve spontaneously and only simple analgesia may be required. Larger veins may require strong compression for a little longer to help minimize this problem.

 

Fifty per cent of vessels treated at any one session usually disappear. At least eighty percent of all vessels treated during the course of microsclerotherapy can be expected to be eradicated. Unfortunately there are always a few exceptions.

 

It is possible to drive immediately after a treatment and a brisk walk of 20 minutes is beneficial. Normal exercise can be resumed after 24 hours, including swimming. Air travel may be undertaken straight away but it is advisable to drink plenty of water and to wear class 11 compression stockings on journeys over six hours. As a general rule standing still should be avoided and feet kept elevated whilst sitting.

 

Patients find that over time a few more thread veins may appear and it is common for an annual or bi-annual ‘tidy-up’ visit.

 

If you have questions about this information, please contact us.

 

 

Endovenous  Laser Ablation (EVLA, ELVeS, EVLT)

Lasers have been used for numerous medical applications throughout the body. Recently, a novel technique utilizing laser energy delivered “endovenously” (directly inside the vein) has been developed to treat varicose veins. The use of lasers has become an accepted alternative to surgical stripping to remove varicose veins. A 980 nm diode laser is used to deliver the laser energy via a small laser fibre. The procedure, termed the Endovenous Laser Procedure (EVLP, ELVeS), or Laser ablation (EVLA) is performed under local anaesthesia. A tiny laser fibre is first inserted into the diseased vein through a tiny needle (venipuncture) in the skin similar to blood sampling in a laboratory. After he Laser has been positioned energy is then delivered through the fibre, which causes the vein to close as the fibre is gradually removed.

 

EVLA is optimal for treatment of:

• Greater saphenous vein
• Small saphenous vein
• Branch varicosities
• Reticular veins
• Spider veins
• Telangiectasia
• Venous ulcers

 

Endovenous Treatment of Sapheneus Veins

The treatment of venous incompetence of the lower limbs by endovenous laser under ultrasound guidance is easy to perform in either treatment room or operating theatre setting.

Using only local anaesthesia it provides a minimally invasive, less traumatic and cosmetically optimal solution to this condition.

 

This endovascular technique leaves no scars and minimises the risk of infection and post-operative pain. Excellent clinical and aesthetic results have been observed with greatly reduced procedure costs.

How EVLA works: Following percutaneous entry into the greater saphenous vein, a fine ELVeS laser fibre is inserted into an introducer sheath and advanced towards the sapheno-femoral junction. Once in position (confirmed by ultrasound and the laser aiming beam), the near infrared laser energy is delivered in short pulses, causing thermal damage and contraction of the vein wall. Due to the application of tumescent local anaesthesia damage of surrounding structures is inhibited.

The laser treatment is performed along the entire vessel length. The irreversible thermal damage induced by the laser energy then leads to a complete occlusion of the vein.

The complete procedure takes about 30-45 minutes; the patients can return to normal activities immediately, with the exception of vigorous gym workouts.

 

Endovenous Treatment of Branch varicosities and reticular veins

Branch varicosities and reticular veins can also be treated under direct visualization by a similar endovascular technique.

 

This method is faster and more efficient than conventional treatments. The procedure is well tolerated with rapid patient recovery.

Experiences in more than 1000 patients have proved a high success rate in vessel closure. Positive patient feedback has been reported 2 additionally attributed to the fact that side effects as skin blanching or pigmental disorders are a non-issue.

The endovenous treatment can also be performed on patients taking anti-coagulants or with impaired circulation.

 

Transcuteneous Treatments of Spider Veins and Telangiectasia

Anaesthetic Telangiectasia and Spider Veins are frequently observed in patients presenting varicose veins. These tiny veins can be treated transcutaneous with the same laser system combined with the ELVeS focusing hand-piece.

The near infrared laser energy is well absorbed by haemoglobin and easily penetrates to underlying tissue with low absorption in the dermis.

The surface tissue is unaffected by the laser energy as it is defocused at this level and anaesthesia is not necessary. Vessels up to 1.5 mm in diameter can be successfully treated by this technique.

 

Wound Healing for Venous Ulcer

Laser light is well known to have beneficial effects on healing wounds. The treatment of wounds with the ELVeS wound healing hand-piece encourages the wound healing process, significantly reducing the healing time.

Low-level laser energy is applied to the wound in criss-cross pattern to ensure complete exposure. This photo-stimulation effect is specifically noticeable in treatment of diabetic foot ulcers.

The laser treatment induces a positive effect in conditions of reduced microcirculation and results in the stimulation and proliferation of the patient’s own cells.

ELVeST is also useful in the management of wound care and constitutes an alternative treatment that is free of side effects.

 

 

Radiofrequency Ablation (VNUS)

Radiofrequency Ablation (VNUS) is a relatively new thermal ablation technique that uses a specially developed proprietary RF catheter placed inside the vein. A cut down, stab incision with vein exteriorization, or a Seldinger over-the-wire technique is used to place an introducer sheath into the truncal varix to be ablated. A special RF ablation catheter is passed through he sheath and along the vein until the active tip is at the saphenofemoral junction just distal to the sub-terminal valve. Position of the tip is confirmed by ultrasonography. Tumescent volumes of local anaesthetic are injected in quantities sufficient to separate the vessel from the overlying skin and other delicate tissues along its entire length. Metal fingers at the tip of the RF catheter are deployed until they make contact with the vessel endothelium. RF energy is delivered through the metal catheter fingers and passes through the surrounding tissues; tissue heating occurs both in and around the vessel to be treated. Thermal sensors record the temperature within the vessel. Energy is delivered until the tissue temperature is just sufficient to ensure endothelial ablation. The RF catheter is withdrawn a short distance, and the process is repeated all along the length of the vein to be treated.

 

Subfascial Endoscopic Perforator Surgery (SEPS)

Minimally invasive endoscopic approach for ligation (“clipping”) of abnormal perforator veins underneath the muscle fascia in the legs. This is done by making small incisions in the calf region for placement of the scope. Sutures are placed under the skin so scarring is minimal. Recovery time is minimal as well.

 

Surgical Treatments

Surgical techniques to treat varicose veins include ligation (tying off of a vein), stripping (removal of a long segment of vein) and ambulatory phlebectomy, which allows for the removal of large surface veins through very small incisions that do not need stitches. Surgery is usually performed using local anaesthesia but may be performed using spinal or general anaesthesia in some centre. Most patients return home the same day as the procedure. Surgery is generally used to treat large varicose veins in advanced disease.

 

Phlebectomy

Ambulatory Phlebectomy

This procedure may be used to remove varicose veins that are too large for sclerotherapy but too small for the TriVex system. It involves vein removal through tiny incisions. It is often used in conjunction with sclerotherapy to reduce the pressure in the smaller spider veins for a more pleasing cosmetic outcome.

 

Transilluminated Powered Phlebectomy

Transilluminated Powered Phlebectomy is a minimally invasive approach to vein removal. This procedure is performed in the operating room, under tumescent anaesthesia. The TriVex system requires few small incisions, and is a more complete approach to vein cluster removal. The surgeon passes a light source through a small incision allowing visualization of the veins. A scoping device is passed through a second small incision, which actually removes the abnormal vein. Patients are discharged the same day with a brief recovery period.

 

Surgery of the perforating veins

The perforating veins supply blood through the muscular fascia to the superficial and deep venous systems. These veins are numerous, from 80 to 140 per leg, their diameters not exceeding 2 mm. The valves are normally in the sub-aponeurotic area. The best way of identifying incompetent perforating veins in the leg is still undecided. Echo-Doppler scans seem the most reliable, though the examination procedure is still debated. A reflux is defined as pathological if it lasts more than 1 s and the calibre of the perforating vein is more than 2 mm.

The severity of the CVI in relation to incompetent perforating veins is based on the number of perforating veins involved and whether more than one system is affected.

Elimination of the incompetent perforating veins in combination with drainage of the varicose veins and restoration of the saphenous return in patients with severe CVI is an important therapeutic approach for trophic disorders of the skin.

The indication for surgical treatment is elective in patients with incompetent perforating veins of the leg and active or healed ulcers (CEAP classes C5-C6).

 

Treatment of perforating veins due to superficial vein inadequacies is reserved for cases with symptomatic cutaneous dystrophy (CEAP class C4).

 

There are 2 main surgical procedures for perforating veins:

• the traditional supra and subfascial approach;
• subfascial, by endoscopy

 

The traditional methods (according to Linton, Cockett, Felder, De Palma) give broadly similar results, with 9-16.7% of patients having recurring ulcers when followed up for 5-10 years. The more recent endoscopic approach for perforating veins may employ a single access (1 trochar) or 2 (operating and optical trochars). A number of studies report 0-10% of recurrent ulcers at five-year follow-up.

Endoscopic surgery is often combined with high ligation and saphenous stripping.

 

Recommendations

In patients with post-thrombotic syndrome it is important to treat the incompetent perforating veins, with sclerotherapy, traditional surgical techniques or endoscopy. For varicose veins with no specific cause it is essential to distinguish the hemodynamic role of the perforating veins of the thigh (Dodd perforating veins) and the Boyd perforating veins. When these are incompetent they must always be closed or removed. For any other perforating veins in the leg, the clinical aspects and the radiological findings must be taken into account.

 

Vein Ligation and Stripping (Babcock procedure)

This procedure is performed in the operating room. It involves tying off the affected vein through small incisions, and then stripping the vein from the leg. This technique is typically used for removal of the saphenous vein from the leg. Patients are discharged the same day with a brief recovery period.

 

Instructions for Varicose Vein Surgery

Before your Operation

Your surgeon may suggest that if you are taking the oral contraceptive pill, it should be stopped one month before the operation. This is to reduce the risk of thrombosis. However, it is very important that you think about other contraceptive methods. Alternatively, he may give you an injection to thin the blood before the operation. You may be called for a pre-admission visit about one week before your actual date to make sure you are fit for the operation. The operation is usually performed as a day-case. However, if you are having both legs operated upon, or if you have any medical problems, it is usual to remain in hospital overnight.

 

Coming into Clinic

You will be asked to come in either the day before if its in the hospital, or in the morning of your operation if its performed in the out-patient clinic. Please bring with you any medicines you are taking and show them to the doctor. You will be received in the ward by a nurse who will note your personal details. You will also be visited by the surgeon who is to perform your operation, who will mark the position of the veins, and the doctor who will give your anaesthetic if you are having the procedure performed with spinal anaesthesia. Many people are concerned about anaesthetics, so please ask the anaesthetist if you have any specific worries so that he may reassure you. All of these professionals are ready to answer any questions you may have, so please ask.

 

The Operation

This is performed under spinal (epidural) or local anaesthetic. The most common operation is where a cut is made in the groin over the top of the main varicose vein (Stripping). If you are having an endovenous ablation there will be no incision. This is then tied off where it meets the deeper veins. If possible, the main varicose vein on the inner aspect of the leg is then stripped out. Blood can still flow up the leg along deeper, unaffected veins. The cut in the groin is closed with a stitch, usually hidden under the skin. The other veins marked before the operation are then pulled out of tiny cuts. (Some surgeons may use injections for this part of the operation.) These are then closed with adhesive strips or stitches. Some other veins may be affected, especially one behind the knee. Special scans may be needed before the operation, and this will be explained to you. A dressing will be placed on the cut in the groin, and your leg will be bandaged up to the top of the thigh. The bandages put on at the operation will stay on your leg until you are advised to remove them by your specialist.

 

Going home

For the first week sit with the feet elevated so that your heels are higher than your hips to aid the drainage of excess fluid from the tissues and assist healing. Three times a day take a short walk (a few hundred yards will do, but more if you wish) to avoid stiffness of the muscles and joints. Slight discomfort is normal. Occasionally, severe local twinges of pain may occur in some patients and may persist for some months. In the first week after the operation you may need to take a mild painkiller such as paracetamol to relieve discomfort. You should not get the adhesive strips on your leg wet for the first 7-10 days. Care will be needed when washing. You should wear the stocking bandage day and night for the first week, after which you may leave it off at night. You will need to wear it during the day for about six weeks. Shower or bath in the usual way, after removing the stocking bandage. The transparent dressings are waterproof and will not come off.

 

What next?

You will be given an appointment 10 days to 2 weeks after surgery to attend your GP’s surgery for removal of the dressings and stitches if there are any to remove. You should avoid driving for about one week from the operation because, in an emergency, your response time may be prolonged. It is essential that you are able to perform an emergency stop without pain. If in doubt, delay driving until you are happy. Swimming and cycling are allowed after the dressings have been removed.

 

Complications to look out for

Sometimes a little blood will ooze from the wounds during the first 12-24 hours. This usually stops on its own. If necessary, press on the wound for ten minutes. If bleeding continues after doing this twice, phone your general practitioner or the ward. Occasionally hard, tender lumps appear near the operation scars or in the line of the removed veins. These can appear even some weeks after the operation and need not be a cause of concern. However, if they are accompanied by excess swelling, redness and much pain they may represent a wound infection and you should see your surgeon. Rarely there is numbness around the wound or ankle. This is unavoidable and is due to pulling on nerves during the operation. It usually settles after some weeks or months. The scars on your legs will continue to fade for many months.

 

Return to normal activity

You can return to work when you feel sufficiently well and comfortable, generally about a week to 10 days. If you have had both legs operated at the same time and you have a number of scars on each leg, it will probably be three to four weeks before you are able to undertake most normal activities. If you have a job that involves much standing and your varicose veins were particularly severe, you may need up to six weeks off work. Your general practitioner will advise you about returning to work in the light of your progress after the operation. You will have been warned that not every visible vein will disappear as a result of your operation and there is a chance that in the future, further varicose veins may develop, as you are clearly disposed to them. The taking of regular exercise, the avoidance of becoming overweight, and the wearing of light support tights or stockings will all help prevent you being troubled by varicose veins in the future.

 

Bleeding Varicose Veins

Our skin

As a response to repeated contact or outside pressure our skin reacts by producing callus, an especially toughened area of skin, most often found on hands or feet. This is a complete normal reaction. Under pressure from inside, however, skin reacts in opposite with a thinning of the dermal layer, a so-called atrophy. This can also be seen under cortisone treatment. Such anomalies are readily identified in the clinical examination. Indeed, when a lower limb is raised, a true depression is formed in this area. Conversely, when the subject is erect, the incompetent vein is subjected to tension by blood due to reflux and a protruding ampullar dilatation covered with thin skin known as a “varicose pearl” can be identified.

 

Bleeding

After time skin over varicose veins will get thinner and a bluish dark vein can be seen through the skin. Trauma or sheering may cause skin rupture and dramatic bleeding (bleeding varices) can result. In terms of aetiology, primary varicose veins most often are the main cause of such bleeding, but episodes of bleeding can occur due to congenital venous malformations, in particular with a dominant arteriovenous shunt. Bleeding occurs less often in a pre-existing ulcer, and it is the inflammatory or infectious process, which erodes the vascular wall.

Clinically, varicose haemorrhage almost always occurs in a subject in erect posture and who presents with varicose veins of several years’ duration and that have produced skin changes possibly including a venous ulcer. A context of minor, unremarkable trauma is often found. If the patient has not been told what measures to take, he or she may remain in a vertical position and bleeding continues, and can even result in death. Such episodes of haemorrhages have a recurrent feature if their cause is not treated.

 

What to do if varicose veins bleed

If bleeding occurs while standing, the blood flow is too high for coagulation to process and bleeding persists. Immediate treatment is simple. The patient should be made to lie down with the affected limb raised, a foam cushion is placed over the area where the bleeding occurred, and then compression with a bandage is applied. The patient is allowed to get up after a few hours of compression therapy, under a doctor’s supervision.

At first treatment is limited to sclerotherapy started locally by injecting the sclerosing agent into telangiectasias, “varicose pearls” and especially tributary varicose veins. Such local sclerotherapy can be supplemented by endovenous laser treatment of the large saphenous vessels and their branches. In post-thrombotic syndromes, local sclerotherapy can be considered, but it should always be supplemented by continuous compression therapy. Venous malformations require a thorough clinical evaluation and treatment in specialized multidisciplinary centres.

Preventive therapy consists of covering the skin area with a gel or foam pad with whenever an examination reveals the existence of a lesion likely to produce a varicose haemorrhage.

 

Remember

Superficial varicose veins can sometimes cause minor problems like bruising or bleeding if you scratch or cut the skin over a larger vein. Small blood clots may occasionally form in the surface veins (superficial phlebitis). Most of these problems can be safely treated at home.

 

If you bump your leg so hard that you know it is likely to bruise, elevate your leg and apply ice or a cold pack as soon as you can for the next hour or two. This may help reduce the amount of bleeding under the skin and minimize bruising.

 

If you cut or scratch the skin over a vein, it may bleed a lot. Elevate your leg and apply firm pressure with a clean bandage over the site of the bleeding. Continue to apply pressure for a full 15 minutes. Do not check to see if the bleeding has stopped sooner. If the bleeding hasn’t stopped after 15 minutes, apply pressure again for another 15 minutes. You can repeat this up to three times for a total of 45 minutes.

 

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Deep Vein Thrombosis

A Deep Vein Thrombosis (DVT) is a clotting of the blood in any of the deep veins – usually in the calf. If a clot develops, it usually makes its presence known by an intense pain in the affected calf. Medical attention should be sought immediately if this occurs, especially after a long journey. In some cases this can be fatal, if the clot breaks off and makes its way to the lungs where it can then affect the lung’s ability to take in oxygen. A DVT can occur some days or even weeks after a trip.

 

Is a deep vein thrombosis serious?

When a blood clot forms in a leg vein it usually remains stuck to the vein wall. The symptoms tend to settle gradually, but there are 2 main possible complications.

 

What is Travel Related Deep Vein Thrombosis?

“Economy Class Syndrome” is a term used to describe the swollen and aching legs that air or some car travellers observe during long trips. It may be associated with a serious leg condition called deep vein thrombosis (DVT) through venous obstruction.

Each year, DVT occurs in about one in every 1,000 people in the general population and in up to one-third of people who have had major surgery. Scientific study to quantify the risk of DVT posed by air travel – although it is suspected to be small in most people – is on-going.

While the problem is often associated with air travel, the risk is equally reported among those travelling by car, coach and train.

 

Who is at risk?

Most cases have at least 3 predisposing risk factors – the risk increases as risk factors increase. Very little established research exists in relation to travel. However we do have a wealth of information from hospital research specific to DVT. We already know that the following factors increase the risk of travel related DVT:

• Immobility for an extended period of time;
• Over 40 years of age;
• Who have had blood clots already;
• Suffering from or who have had treatment for cancer;
• Who have had recent surgery especially on the hips or knees;
• Existing clotting abnormality or inherited clotting tendency;
• Overweight and obesity;
• Chronic illnesses;
• Hormones or the oral contraceptive pill;
• Varicose veins;
• Pregnancy or 2 months post-partum;
• Being treated for heart failure and circulation problems;

 

How is DVT diagnosed?

DVT/PE is undiagnosed and misdiagnosed more often than not. Diagnosis usually involves a special type of ultrasound scan of the leg called a duplex ultrasound. If this test does not show a DVT but the doctor still suspects a DVT based on the symptoms, then further tests such as venography may be carried out. Venography uses an X-ray image to track the distribution of a special dye injected into the deep veins of the leg.

 

What are the symptoms of DVT?

• Leg symptoms (Deep Vein Thrombosis, DVT) may appear during flight or in the next few days.
• Sudden swelling in one lower leg. (A little swelling in both legs is normal in flight.). Cramp or tenderness in one lower leg
• Bruise or swelling behind knee
• Chest symptoms (Pulmonary Embolism, PE) usually appear 2-4 days or more after the initial blood clot, which you may not have noticed:
  • Shortness of breath
  • Rapid breathing, panting
  • Cramp in your side, painful breathing
  • Chest pain accompanied by shoulder pain
  • Fever
  • Coughing up blood
  • Fainting (often the first sign, especially in older people)

Phlebitis (fle-BYE-tis) is a condition where the veins close to the surface of the body (superficial veins) are inflamed thus becoming swollen and reddened. The inflammation causes a blood clot to form in the vein, and usually occurs in leg veins, but it may occur in an arm following improper injections. The thrombus in the vein causes pain and irritation; it may hinder blood flow in the veins. Phlebitis occurs in the surface (superficial) and thrombosis in the deep veins.

Superficial phlebitis affects veins on the skin surface. The condition is rarely serious and, with proper care, usually resolves rapidly. Sometimes people with superficial phlebitis also get deep vein thrombophlebitis, so a medical evaluation is necessary.

Deep vein thrombosis affects the larger blood vessels deep in the legs. Large blood clots can form, which may break off and travel to the lungs. This is a serious condition called pulmonary embolism. This situation is rare in superficial thrombophlebitis

 

Causes

Phlebitis occurs in people with poor blood circulation or in veins damaged from intravenous drug use or an intravenous catheter. It can be a complication due to a medical or surgical procedure. Since Phlebitis is often caused by an injury to a vein, one is more likely to get phlebitis in veins where the blood flows more slowly than normal, such as varicose veins. A clot, called a thrombus, can form and adhere to the vein wall. Since there are no muscles to push the clot, it stays stuck inside the vein and blocks blood flow.

Phlebitis can also be a complication resulting from connective tissue disorders such as lupus erythematosous, or of pancreatic, breast, or ovarian cancers.

 

Some risk factors for phlebitis include the following:

• Prolonged inactivity – Staying in bed or sitting for many hours, as in a car or on an airplane, creating stagnant or slow flow of blood from the legs in a dependent position (This pooling of blood in the legs leads to thrombus formation.)
• Sedentary lifestyle – Not getting any exercise
• Overweight and obesity
• Cigarette smoking
• Certain medical conditions, such as cancer or blood disorders, that increase the clotting potential of the blood
• Injury to your arms or legs
• Hormone replacement therapy or birth control pills
• Pregnancy
• Varicose veins

 

Symptoms and Complications

The area around the vein is red, swollen, and often painful. Because the blood in the vein tends to clot, the vein feels hard, not soft like a normal vein. The vein can feel hard down its entire length.

 

Superficial phlebitis

There is usually a slow onset of a painful tender red area along a superficial vein under the skin. A long, thin red area may be seen as the inflammation follows a superficial vein.

This area may feel hard, warm, and tender. The skin around the vein may be itchy and swollen.

Symptoms may be worse when the leg is lowered, especially when first getting out of bed in the morning.

Sometimes phlebitis may occur where a peripheral intravenous line was started. The surrounding area is swollen and may be sore and tender along the vein.

If an infection is present, symptoms may include redness, fever, pain, swelling, or breakdown of the skin.

 

Deep vein thrombosis (DVT)

This can be similar in presentation to superficial phlebitis, but some people may have no symptoms.

One may have pain and swelling throughout the entire limb. For example, one side of the lower leg may swell for no apparent reason.

Some people also get fever from a superimposed bacterial infection and skin discoloration and/or ulcers if the condition becomes chronic and inadequately treated earlier.

 

When to Seek Medical Care

Call your health care provider if you have signs and symptoms of swelling, pain, and inflamed superficial veins on the arms or legs. If you are not better in a week or two, get re-evaluated to make sure you don’t have a more serious condition.

Deep vein thrombophlebitis requires immediate medical care. If you have any of these signs and symptoms, go to a hospital emergency department for evaluation:

 

• High fever with any symptoms in an arm or leg
• Lumps in a leg
• Severe pain and swelling in an arm or leg
• New, unexplained significant shortness of breath, which could be the first tip-off that a blood clot has already travelled to your lung

 

Making the Diagnosis

Your health care provider can tell that someone has phlebitis by examining the veins. An ultrasound scan may be performed to see if the phlebitis has spread into a deep vein. Ultrasound can detect clots or blockage of blood flow, especially in larger, more proximal (upper leg) veins. A small hand-held instrument (probe) is pressed against your skin to help identify blood clots and where the obstruction is. This is a painless, non-invasive test.

Occasionally a venogram is needed to identify blood clots in the smaller, more distal veins. This is an invasive procedure that requires injecting x-ray dye or contrast material into a vein on the foot, and then an x-ray is taken of the flow of the dye up the leg.

 

Treatment and Prevention

Phlebitis usually improves on its own in a few days, although it may take a few weeks for the lumps and pain to disappear. Phlebitis in the superficial veins is rarely serious and usually responds to pain control, elevation, and warm compresses for 1-2 weeks.

 

Treatment usually consists of warm soaks, rest, and a non-steroidal anti-inflammatory drug such as aspirin (acetylsalicylic acid, ASA) or ibuprofen. Wearing elastic compression stockings also can help. The doctor might also remove the blood clot under local anaesthetic.

 

Doctors might do emergency surgery for phlebitis in the groin. Since this is the point where a superficial vein joins a deep vein, the blood clot could extend into a deep vein. Tying off the superficial vein under a local anaesthetic can prevent this from happening.

 

To prevent phlebitis, avoid smoking and participate in moderate physical activity to maintain muscle tone and promote circulation.

An anti-inflammatory drug, such as aspirin or ibuprofen, can help lessen the pain and inflammation.

If you increase your walking, you increase blood flow. This helps prevent blood clots from developing.

Prescription leg compression stockings (knee or thigh high) improve your blood flow and may help to relieve your pain and swelling.

Avoid bed rest for prolonged periods. It can make your symptoms worse.

If you have deep vein thrombophlebitis, you will probably need to stay in the hospital for a few days for diagnosis and treatment to ensure that no complications occur.

 

Medical Treatment

If your evaluation shows superficial phlebitis and you are otherwise healthy, you can go home. You will need to use compression stockings, heparin-containing ointments and anti-inflammatory medications to control your symptoms. Additional management involves elevation of the arm/leg and application of warm compresses. Only a few cases require antibiotics.

If you have a history of deep vein thrombophlebitis, or if the phlebitis might possibly spread to the deep veins, you will need to take a blood thinner (anticoagulant). The duration of anticoagulant treatment is usually between 3-6 months.

If you have signs of infection, you will need to take an antibiotic.

If the phlebitis has progressed to involve the deep veins, then it is a serious condition that often requires hospital admission for treatment and further evaluation. If you have a swollen limb contact your doctor immediately.

 

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More information about Phlebitis and its prognosis.

 

Post-Thrombotic Syndrome

The post-thrombotic syndrome consists of clinical features following thrombosis of deep venous veins of the limb (DVT). Patterns of post-thrombotic changes remain difficult to predict and once established, difficult to contain and reverse. Due to increased obesity and decreased physical activity this intent is increasing in number.

 

The course of the disease can be divided into an acute phase with a duration of about 7 to 10 days, the sub-acute phase following thrombosis lasting from the second to the fourth week and the phase of the post-thrombotic syndrome which will generally appear 10 to 15 years after the first event.

 

Following a thrombotic event of the extremity, 3 clinical stages can be observed which may be followed by intervening quiescent intervals.

 

Stage I, or the early phase, is characterized by the residual obstructive process following acute venous occlusion. This can be manifested by either a bursting type of pain (venous claudication) or oedema of the leg. A thrombotic process can involve the calf veins, thigh veins, pelvic veins, or any combination of the three.

During the healing process following DVT the occluded vein will go through a process of recanalization and collateralization. Concomitant with the presence of blood clot, fibrinolytic factors are then activated which will dissolve the thrombus to a certain extent after which blood flow can be re-established.

 

The extent of venous recanalization can be quantified radiological. In 35.5% of the patients there is complete recanalization, in 53.4% partial and in 11.1% no recanalization. At nearly all sites of venous occlusion collaterals generally can be found.

A hemodynamically relevant occlusion causes an increase in venous pressure which increase as the damaged valves loses more of their function as the vein distends. Doppler ultrasound examination shows an absence of respiratory modulation as well as a high-frequency continuous signal, which disappears as soon as collateral function is optimal.

 

Specific clinical syndromes develop depending on the venous pump system involved. The venous pump system consists of the calf muscle pump and the thigh pump. These serve to propel blood upward. Involvement of any one or more of the 3 in the thrombotic processes can result in a relative obstruction with a specific pattern of clinical symptoms.

 

Optimally, the venous thrombotic process should be treated during this early phase to prevent the subsequent events, which may render the process irreversible. The second stage of the post-thrombotic syndrome consists of the development of fat sclerosis (lipodermatosclerosis). At this stage, the process becomes progressively irreversible as the extravasation of fibrin into the interstitial space results in progressive fibrosis and sclerosis. This results in damage to the skin and subcutaneous tissues, which render the process irreversible. Specific treatment, while still introducible at this stage, can halt the progress of the syndrome, but rarely results in complete reversal.

Spider Veins

Thread veins, or dermal flares, are very fine dilated veins situated just beneath the surface of the skin. Heredity, as with larger varicose veins, is an influencing factor as are hormonal surges as at the onset of periods and during pregnancy. In some patients they are associated with varicose veins but in other people they occur without any problems associated with their deeper veins. It is essential that patients with dermal flares undergo a venous assessment to make sure that there is no underlying condition causing them. Treating surface veins in the presence of varicose veins, even though they are not visible, results in them not disappearing or returning quickly giving an unsatisfactory result.

 

Mild to severe pain can be associated with dermal flares as well as fatigue, aching and throbbing. This can quite often be cyclical in women and related to their periods. Such symptoms that present with larger varicose veins do not always disappear following surgery but do diminish with subsequent sclerotherapy treatment for thread veins. The best form of treatment for these small veins is microsclerotherapy.

 

 

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Varicose Veins

Varicose veins and spider veins are visible surface manifestations of abnormal, dilated blood vessels. Varicose veins occur when healthy vein walls become weak and swell, causing blood to back up and pool inside the vein. Varicose veins are also related to increased pressure in the leg veins or defective valves in the veins. They may appear as swollen, twisted clusters of blue or purple veins and are sometimes surrounded by thin red capillaries known as spider veins.

 

Mild forms of venous insufficiency are merely uncomfortable, annoying, or cosmetically disfiguring, but severe venous disease can produce serious systemic consequences and can lead to loss of life or limb. Most patients with venous insufficiency have subjective symptoms that may include pain, soreness, burning, aching, throbbing, cramping, muscle fatigue, and restless legs. Over time, chronic venous insufficiency leads to cutaneous and soft tissue breakdown that can be debilitating.

Varicose veins are very common ailment. They affect around 60% of the population at some time in their lives. They are swollen veins (usually on the legs) that look lumpy and bluish through the skin.

 

What causes varicose veins?

Blood is pumped from your heart to your legs through arteries. Once it has supplied oxygen and nutrients to the legs, blood returns to your heart through your veins. To do this from your legs, blood in your veins must flow upwards, against gravity. The muscles in your legs help this flow. Each time your calf and thigh muscles contract when you are walking, veins deep inside your leg are squeezed. One-way valves inside your veins help prevent the blood from flowing backwards. Walls become weak and swell, causing blood to back up and pool inside the vein. Varicose veins are also related to increased pressure in the leg veins or defective valves in the veins. They may appear as swollen, twisted clusters of blue or purple veins and are sometimes surrounded by thin red capillaries known as spider veins.

 

The reason varicose veins develop is not fully understood. One of the basic problems is not only a damage to the valves but a lost of vein wall elasticity. In time the vein will dilate and the valves are no longer effective in hindering a back-flow of blood. This means that blood can’t travel up the veins as easily, and is more likely to pool. It is possible that people inherit a tendency for weak venous walls and valves. Alternatively, the vein walls may become weak following an inflammation or thrombosis, which will cause bulging of the vein with time and so damage to the valves.

There is a greater risk of getting varicose veins during pregnancy, because of the higher pressure exercised on the pelvic venous veins and increased in hormonal activity. Adding to this if one is overweight will further increase the pressure in the abdomen and so in the veins. Many other factors have been blamed for varicose veins, such as standing for long periods, crossing your legs while sitting, smoking and poor diet. However, there isn’t reliable scientific evidence to support these theories.

What are the symptoms?

The symptoms from varicose veins don’t necessarily match their size, and sometimes there are no symptoms at all apart from the veins being unsightly. Most people will not have symptoms but may be concerned about the appearance of the veins.

 

If symptoms occur, they may include:

• Swollen legs
• Muscle cramps, soreness or aching in the legs
• Tiredness, burning, throbbing, tingling or heaviness in the legs
• Soreness behind the knee
• Itching around the vein
• Brown discoloration of the skin, especially around the ankles

 

Symptoms often worsen after prolonged standing or sitting. In women, symptoms may be worse during menstruation or pregnancy. Occasionally varicose veins can form a painful blood clot, referred to as superficial phlebitis (inflammation of a vein).

 

Chronic non-healing leg ulcers, bleeding from varicose veins, and recurrent phlebitis are serious problems that are caused by venous insufficiency and can be relieved by the correction of venous insufficiency.

 

More severe symptoms are usually associated with the complications of varicose veins. In some cases, varicose veins can be harmful to your health because they may be associated with the development of:

• Chronic venous insufficiency

the poor flow of blood in the veins can interfere with the way the skin exchanges oxygen, nutrients and waste products with the blood. When this happens over a long period of time, it is called venous insufficiency, which can cause a number of problems including the following:

• Varicose eczema

brown or purple discolouration of the skin that can become permanent;

• Venous stasis ulcers

ulcers (open sores) that result when the enlarged vein does not provide enough drainage of fluid from the skin. As a result, an ulcer may form.

• Fungal and bacterial infections

may occur as the result of skin problems caused by fluid retention (oedema) in the leg. These infections also increase the risk of tissue infection (cellulitis).

• Phlebitis

veins close to the surface of the skin can become painful and reddened due to inflammation or blockage of the vein. This is different to the more dangerous blockage of the deeper veins, known as deep vein thrombosis (DVT).

• Thrombosis

blood clots that form in the dilated vein;

• Bleeding

varicose veins near to the surface can bleed if the leg is cut or bumped. This bleeding might become a medical emergency if it can’t be stopped. If a varicose vein in your leg is bleeding, you need to lie down, raise your leg and apply pressure directly to the bleeding area. Then seek medical help.

• Skin changes

The first sign of venous insufficiency is the formation of oedema and bothersome skin alteration.

 

Complications are more common when varicose veins are the result of a problem or disease in the deep veins or in the perforating veins, which connect the deep and superficial veins. These underlying conditions may include deep vein thrombosis or chronic venous insufficiency. Having varicose veins does not mean that you will definitely get complications or chronic venous insufficiency. And although they won’t usually get better without treatment, varicose veins only get worse slowly.

 

Contributing factors

Multiple factors can cause the development of varicose veins:

• Age

the development of varicose and/or “spider” veins can occur at any age, however, they most commonly begin between the ages of 18 and 35 years, and peaks between 50 and 60 years.

• Heredity

there is a significant relationship between heredity and the development of varicose and “spider” veins. If your mother or father has varicose or “spider” veins, there is a greater chance that you will develop these abnormal veins.

• Gender

approximately four females are affected to every one male.

• Pregnancy

Approximately 8 to 20% of pregnant women will develop varicose veins, however, some may disappear shortly after delivery. Both hormonal changes during pregnancy and compression of veins by the enlarged uterus can contribute to varicose or “spider” veins.

• Lifestyle or Occupation

People who are involved in prolonged periods of sitting or standing are at increased risk for developing varicose veins. Blood tends to collect in the veins putting pressure on the valves, thus causing the vein to distend.

 

Diagnosis

Varicose veins are easily visible. To work out the position and extent of valve weakness, there are a number of tests a doctor might do.

• A Doppler Test is a technique that uses sound waves (ultrasound) to give information about the direction of blood flow in a vein and whether valves are working properly.
• Colour Duplex Ultrasound Imaging is used to look for any abnormalities in the vein structure.
• The Trendelenburg Test involves lying down and lifting one leg up in the air. The doctor uses a hand or a tourniquet to temporarily block off the blood flow in your veins. When you stand up again, the doctor can watch your varicose veins refilling with blood; this gives an indication of which part of the leg veins have faulty valves.

 

Call your doctor if:

• Varicose veins make walking or standing painful
• A sore or tender lump develops on or near a varicose vein
• You have swelling in the feet or ankles
• Your leg suddenly becomes swollen and painful
• Skin over a varicose vein bleeds on its own or when injured
• You have any other symptoms that cause concern

 

Treatments

Compression stockings

These may relieve the swelling and aching of your legs but do not prevent more varicose veins from developing. They need to be worn during the day and are taken off at night. Graduated compression stockings are tightest at the ankle and get gradually looser further up the leg. These help the blood to flow up towards the heart.

Compression stockings are available in various sizes and pressures and it is very important that they fit you properly. They are made to fit your calf diameter, not foot size. Your GP or pharmacist can provide advice.

Some people find compression stockings difficult to put on. There are tools available to help, or you could ask for help from a partner or friend. Stockings can be uncomfortable, especially in hot weather. But there is no point in wearing them rolled down.

 

Injection Sclerotherapy

Small varicose veins can be injected with a chemical that damages the vein walls. As a result scar tissue forms, which closes off the affected vein. Other stronger veins take over and the treated vein, which is no longer filled with blood, becomes less visible.

For larger veins, foam is sometimes injected instead of a liquid (this is called foam sclerotherapy), using ultrasound to guide the injection. Foam sclerotherapy is a new technique, and in a small number of people it can cause complications including blood clots in other leg veins, temporary vision problems, headaches and fainting. Your doctor will give you more information and advise whether foam sclerotherapy is a suitable treatment for you.

For best results, you should wear a compression bandage for between three and six weeks after injection sclerotherapy. Injection sclerotherapy can be an alternative to surgery, but varicose veins may come back and nearby veins may become varicose. Often, several injections are needed. One possible side effect of this treatment is skin discolouration. Your doctor will give you more information.

 

Varicose Vein Surgery

This involves removing the affected superficial veins. There are many variations of operation, depending on which veins need treatment. The most common is called ligation and stripping. For more information, please see the separate BUPA health fact sheet, Varicose vein surgery.

 

New approaches

Minimally invasive techniques such as laser, microwave and radiofrequency treatments are being provided at some hospitals. One of these is endovenous ligation treatment (EVLT), where a fine laser probe is passed inside a vein. This heats the vein and causes it to close up.

 

Prevention

Anyone can develop varicose veins, so it may not always be possible to prevent them. Although there are no scientifically proven ways to prevent varicose veins, the following suggestions may be useful:

• avoid standing still for long periods of time;
• take regular exercise, such as walking;
• maintain a healthy weight;
• wear properly fitted compression stockings to prevent further deterioration of existing varicose veins.

 

Links

TheVeinClinic.Info

www.dr-bull.com

The Circulation Foundation 
www.circulationfoundation.org.uk

 

Sources

Varicose Veins – Clinical Evidence 
www.clinicalevidence.com 


Surgical treatments of varicose veins- Royal College of Surgeons 
www.edu.rcsed.ac.uk

 

More information on functional testing for venous disease

If you have questions about this information, please don’t hesitate to contact us.

 

Varicose Veins Care

Tips to relief symptoms of varicose veins

1. Avoid standing for long periods of time. This will reduce pressure on the valves in the veins in your legs. If you are pregnant of if your occupation puts a lot of stress on your legs, wear support stockings.
2. While standing get on your tiptoes by lifting your heels off the floor. Do this twenty times, relax for a few minutes, and then repeat. This exercise will strengthen your calf muscles and promote circulation.
3. Your job or hobby may be the cause of your varicose veins. If you have to stand or sit too long in one position, this may cause circulatory problems. Crossing your legs may greatly enhance your problem, too. Try changing your work or sitting conditions and take the mini-breaks mentioned above. Varicose veins did not happen overnight and alleviating them will take time, too. Be patient.
4. Heat dilates blood vessels so the veins are more visible after hot showers or baths. Try cool, quick showers morning and evenings instead of hot soaks. Cold compresses can also temporarily hide veins.
5. Elevating your feet whenever possible will reduce the pressure in your legs. Use a recliner when reading or watching TV, or if you read in bed, elevate your feet with cushions or pillows.
6. Weight may also be a problem. Exercise and dietary changes to lose weight will be very beneficial to relieving varicose veins.
7. Jump rope to strengthen the leg muscles and blood vessels. Begin slowly to build up tolerance; jump one minute per session and slowly build up to 5 minutes.
8. Rubbing your legs with some sort of soothing lotion such as St John’s Wort oil, lanolin, or massage oil will relax the leg muscles and improve circulation. Gently massaging with an upward motion with your palms or fingertips and occasionally squeezing your legs will help force blood out of the veins in your legs and back to the heart.

 

Changes to make

1. Dietary

Constipation is one of the leading causes of varicose veins. Although it may initially be hard to see the connection, let us explain. Constipation may restrict the blood as it returns to the torso through the deep veins in the legs. Straining to have a bowel movement closes off the veins. As the blood backs up it takes another course through superficial veins, thus the blue streaks in the legs. As part of our recommended wellness program, we suggest a diet low in fats and refined carbohydrates, and high in fruits, vegetables and whole grains. This diet promotes health for the entire body, and, in the case of constipation, the high-fibre diet promotes regularity.

2. Eat more ginger, garlic and onions. These foods help break down the fibrin surrounding the varicose veins. People with varicose veins have a decreased ability to break down this substance.
3. Some people recommend going on a juice diet one day a week to improve regularity.
4. As part of dietary changes a program to lose weight will greatly help prevent or ease varicose vein problems. Carrying too much weight creates extra pressure on your heart and interferes with circulation.

 

Supplements

As with so many diseases, there are underlying nutritional problems, that, if corrected, may well alleviate or eliminate the disease.

 

Exercise

As with any wellness program, exercise is an important component. Exercise helps promote circulation and improves muscle tone. People with varicose veins need to have moderate exercise as opposed to more strenuous forms, such as high- impact aerobics, jogging, strenuous cycling or other activities that increase the blood pressure in the veins. Walking, 
weight training, low-impact aerobics and swimming are a few of the preferred means of exercise, but anything that helps shift your weight or standing or sitting position will help. If you have a bad problem, take short breaks several times a day and walk around and stretch.

 

As we age we lose muscle tone and the skin loses its elasticity. Veins that are undergoing pressure from some of the factors mentioned above will have a tendency to bulge out and become noticeable varicose veins. Any form of exercise that will strengthen the legs will help relieve varicose veins. Consistent exercise over several months will generally reduce the 
throbbing and aching often associated with varicose veins.

 

1. Ankle turns: Lift your feet off the floor and move your toes in a circle, one foot moving clockwise and the other foot 
moving counter clockwise. Change direction and repeat.
2. Foot lifts: Place your heels on the floor and bring your toes up as high as you can. Then put both feet back flat on the floor. 
Then pull your heels up while keeping the balls of your feet on the floor.
3. Knee lifts: While keeping your knee bent, raise your leg while tensing your thigh muscle. Repeat 20 to 30 times, alternating legs.
4. Shoulder rolls: Raise your shoulders and then move them forward, downward and then backward in a smooth circular movement.
5. Arm bends: Start with your elbows on the armrests and your hands pointed forward so that your lower and upper arms make a 
90-degree angle. Take turns moving your left and then your right hand toward your chest and back, and continue for 30 seconds.
6. Knee to chest: Bend slightly forward. Fold your hands together around your left knee and pull it toward your chest. 
Hold this position for 15 seconds and let your knee drop slowly. Change legs and repeat.
7. Forward bends: Place both feet on the floor and pull your abdomen in. Bend slowly forward and “walk” your fingers along your shins to your ankles. Hold for 15 seconds and sit up slowly.
8. Upper-body stretch: Stretch both arms over your head. With your right hand, grab your left wrist and pull it slowly to the right. Hold for 15 seconds and change arms.
9. Shoulder stretch: With your right hand, grab your left elbow and pull your outstretched left arm slowly toward your right shoulder. Hold for 15 seconds and change arms.
10. Neck roll: Relax your shoulders, let your head drop to your right shoulder and roll your head slowly to the front and then to your left side. Repeat five times.

 

Clothing

Clothing that is too tight, including shoes or boots, will restrict circulation and may be the cause of your varicose veins by not allowing the blood to properly flow through your body. Snug fitting girdles, pantyhose, belts, and boots and shoes, especially high-heels, cut off circulation, thus forcing blood to seek alternative routes or causing back-pressure on the veins. Support hose, on the other hand, helps promote circulation. Make sure it is the kind that is tighter at the ankles, gradually decreasing the pressure, as they get higher up the leg. If you can’t find a good over-the-counter brand, they can be medically prescribed.

 

Venous Exercise

Don’t exercise in vain – Fitness for your veins

Although venous insufficiency is largely hereditary it is important to keep your veins fit to avoid complications of varicose veins. And this is quite literally true: the walls of your veins remain elastic if the muscles surrounding them are exercised regularly. This does not mean that you have to be a professional sportsman or sportswoman. A few minutes of targeted venous exercises every day are enough to give your legs a good chance against pronounced venous weakness. If you already have diseased veins and wear compression stockings, it is important to wear them even while performing exercises.

 

Compression stockings support the affected veins and, by applying mechanical pressure, ensure the necessary return flow of blood in the veins from the legs back to the heart. And this is necessary not only for everyday living but also in sport. Particularly for women, it may be of interest to know that compressions tights exert a massage effect during sport on the problem areas of the bottom and thighs, which leads to firming of the tissues. In addition, toning of the muscles in general is promoted by the fact that during sporting activity you are working against the resistance of the stocking.

 

People with spider veins and mild to moderate varicose veins can in principle practice any type of exercise. One exception is extreme bodybuilding, as this puts an additional strain on the veins. Particular suitable sports include hiking, power walking (also Nordic walking with poles), cycling, cross-country skiing, inline skating (here poles can be used to simulate the skating technique from cross-country skiing), aqua jogging, swimming, dancing, golf, fitness training on endurance equipment (e.g. stepper, cross trainer, bicycle ergometer) or special vein exercises.

 

People with pronounced varicose veins, a history of thrombosis (venous occlusion) or phlebitis (inflammation of the veins) must be more cautious in choosing their exercise. Sports that can be considered particularly suitable are power walking, hiking, cycling, golf, dancing, swimming, aqua-aerobics or aqua jogging and in the winter cross-country skiing. All kinds of sports involving the development of high strength and abrupt stopping movements must be avoided. These include bodybuilding but also jogging, high-impact aerobics, badminton, handball or football. Skiing and snowboarding are also unsuitable.

Those who want to relax in the sauna after sporting activity should keep in mind that the feet should be kept up in the sauna and restroom, and that the legs should be thoroughly showered with cold water after each visit to the sauna. For patients with deep vein thrombosis, however, the sauna is to be avoided.

 

Exercise program

Standing position:

Put on socks over your compression stocking or compression bandage and hold the loops of the rubber straps in both hands.

Carry out all exercises in a comfortable position, making sure that your back is straight. Start with a low strap tension.

Take the vein exerciser under the sole of your foot and stretch the straps.

Point the toe downwards and then pull it back towards your body, creating a rocking movement.

After ten rocking movements for correct stretching of the tendons and muscles, you can increase the strap tension continuously until you obtain a feeling of tension.

 

Exercises in the sitting position:

Ten rocking movements for stretching, then increase the strap tension until you obtain a feeling of tension; hold this position for about ten seconds, then reduce the tension again.

With your foot extended, circle several times. Assist the circular movement by pulling on the right or left strap. Place the foot on the floor in front of the chair, and then raise the heel and toe alternately. Slowly increase the tension on the straps in the course of the exercise.

Place the foot about 30 cm in front of the chair, on the heel. Raise the forefoot, then bend and stretch the toes alternately.

Sitting on the chair, flex and extend the knee joint against the tension of the straps.

 

Exercises lying down:

Lie on your back and raise your extended leg; rock the foot against the strap tension in this position.

Lie on your back, raise your leg and flex and extend your knee joint against the strap tension in this position.

Push down your toes and heels alternately against the tension of the straps. The effect of this exercise can be increased by resting on a base (newspaper, book).

Stretch and bend the leg against the tension of the straps.

Move the foot out to the side against the strap tension, down to the floor, pull it in towards the body, down to the floor again, gradually increasing the tension on the straps.

 

 

Venous Reflux

When our venous valves are working effectively, every muscle movement of the leg causes blood to be pumped inward and upward past a series of cups. In motion, the normal pressure in the venous system of the lower leg is nearly zero. Immediately after ambulation, the early standing pressure in the normal leg remains low. Arterial inflow fills the leg veins slowly, and the only source of venous pressure is the hydrostatic pressure of a column of blood as high as the nearest competent valve. After prolonged standing, the veins are completely filled, and all the venous valves float open. At this time, high hydrostatic venous pressure results from the unbroken column of fluid that extends from the head to the foot.

Failed valves cause the column of standing blood in the vein to remain high even when during ambulation. The hydrostatic pressure increased during and immediately after ambulation.

 

High venous pressure is directly responsible for many aspects of venous insufficiency syndrome, including oedema, tissue protein deposition, perivascular fibrin cuffing, red cell extravasation, impaired arterial inflow, and other locally mediated disturbances.

Not all of the complications of venous insufficiency are related to venous hypertension, and not all patients with venous hypertension develop ulceration. Some patients with venous ulceration do not have marked venous hypertension.

 

 

Venous Ulcers

Chronic venous insufficiency (CVI) with ulceration is a common condition affecting 2-5% of the population. Ulcers are wounds or open sores that will not heal or keep returning. Historically, CVI was known as post-phlebitic syndrome and post-thrombotic syndrome, both of which refer to the aetiology of most cases. However, these names have been abandoned because they fail to recognize another common cause of the disease, the congenital absence of venous valves.

 

What are the symptoms of venous ulcers?

Ulcers may or may not be painful. The patient generally has a swollen leg and may feel burning or itching. There may also be a rash, redness, brown discoloration or dry, scaly skin.

 

What are the types of leg and foot ulcers?

The three most common types of leg and foot ulcers include:

• Venous stasis ulcers
• Arterial (ischemic ulcers)
• Neurotrophic (diabetic)

 

Ulcers are typically defined by the appearance of the ulcer, the ulcer location, and the way the borders and surrounding skin of the ulcer look.

 

Venous stasis ulcers

Appearance

Typically, these lesions occur around the inner side just above the ankle, where venous pressure is greatest due to the presence of large communicating veins. The base of a venous ulcer is usually red. It may also be covered with yellow fibrous tissue or there may be a green or yellow discharge if the ulcer is infected. Fluid drainage can be significant with this type of ulcer.

 

The borders of a venous ulcer are usually irregularly shaped and the surrounding skin is often discoloured and swollen. It may even feel warm or hot. The skin may appear shiny and tight, depending on the amount of oedema (swelling). The skin may also have brown or purple discoloration about the lower leg, known as “stasis skin changes.”

 

Causes

Ulcers occur in people with poor blood circulation or in veins damaged from thrombosis. It can be a complication due to a medical or surgical procedure or following thrombosis.

Venous stasis ulcers are common in patients who have a history of leg swelling, long standing varicose veins, or a history of blood clots in either the superficial or the deep veins of the legs. Ulcers may affect one or both legs.

 

Venous ulcers affect 500,000 to 600,000 people in the United States every year and account for 80 to 90% of all leg ulcers.

 

Risk Factors

Some risk factors for venous ulcers include the following:

• Prolonged inactivity – Staying in bed or sitting for many hours, as in a car or on an airplane, creating stagnant or slow flow of blood from the legs in a dependent position (This pooling of blood in the legs leads to thrombus formation.)
• Sedentary lifestyle – Not getting any exercise
• Overweight and obesity
• Cigarette smoking
• Certain medical conditions, such as cancer or blood disorders, that increase the clotting potential of the blood
• Injury to your arms or legs
• Hormone replacement therapy or birth control pills
• Pregnancy
• Varicose veins
• Age: Incidence of CVI rises substantially with age
• Family history: History of deep vein thrombosis (DVT), which renders venous valves incompetent, causing backflow and increased venous pressure, is a risk factor.
• Diseases like diabetes and polyneuropathy

 

Prevention

How can ulcers be prevented?

Controlling risk factors can help you prevent ulcers from developing or getting worse. Here are some ways to reduce your risk factors:

 

• Keep your skin moist
• Wear compression stockings
• Control your blood cholesterol and triglyceride levels by making dietary changes and taking medications as prescribed
• Limit your intake of sodium (salt)
• Manage your diabetes and other health conditions, if applicable
• Exercise – start a walking program after speaking with your doctor
• Lose weight if you are overweight
• Quit smoking

 

Diagnosis

How are leg ulcers diagnosed?

First, the patient’s medical history is evaluated. Lack of appropriate clinical assessment of patients with limb ulceration in the community has often led to long periods of ineffective and often inappropriate treatment. It is therefore advisable that diagnosis of ulcers should be based on a thorough clinical history and physical examination, as well as appropriate laboratory tests and haemodynamic assessment. This will assist identification of both the underlying cause and any associated diseases and will influence decisions about prognosis, referral, investigation and management. If the practitioner is unable to conduct a physical examination, they must refer the patient to an appropriately trained professional.

 

Following may be indicative of venous disease

• Family history
• Varicose veins (record whether or not treated)
• Proven deep vein thrombosis in the affected leg
• Phlebitis in the affected leg
• Suspected deep vein thrombosis (for example, a swollen leg after surgery, pregnancy, trauma or a period of enforced bed rest)
• Surgery or fractures to the leg
• Episodes of chest pain, haemoptysis, or history of a pulmonary embolus

 

Ulcer stages

Stage I

Non-blanchable defined area of persistent erythema of intact light toned skin. In darker skin tones, the area may appear with persistent red, blue or purple hues. Observable pressure alteration of intact skin whose indicators are compared to an adjacent or opposite area on the body may include one or more of the following:

• Skin temperature (warmth or coolness)
• Tissue consistency (firm or boggy)
• Sensation (pain or itching)

 

Stage II

Partial thickness skin loss involving epidermis and/or dermis. This superficial ulcer presents clinically as an abrasion, blister or shallow crater.

 

Stage III

Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. This ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.

 

Stage IV

Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures (e.g., tendon, joint capsule).

 

Treatments

Each patient’s treatment plan is individualized, based on the patient’s health, medical condition and ability to care for the wound.

 

Treatment options for all ulcers may include:

• Antibiotics, if an infection is present
• Anti-platelet or anti-clotting medications to prevent a blood clot
• Topical wound care therapies
• Compression garments
• Prosthetics or orthotics, available to restore or enhance normal lifestyle function

 

Non-surgical treatments for CVI include the following:

Dressings

It is of the outmost importance to keep the wound clean and moist.

The type of dressing prescribed for ulcers is determined by the type of ulcer and the appearance at the base of the ulcer.

 

Types of dressings include:

• Moist to moist dressings
• Hydrogels/hydrocolloids
• Alginate dressings
• Collagen wound dressings
• Debriding agents
• Antimicrobial dressings
• Composite dressings
• Synthetic skin substitutes

 

Leg elevation

By keeping the legs elevated, venous flow is augmented by gravity, lowering venous pressures and ameliorating oedema. While sitting, the legs should be above the thighs. Supine, the legs should be above the level of the heart.

 

Compression stockings

Venous ulcers are treated with compression of the leg to minimize oedema or swelling due to venous hypertension. Compression treatments include wearing compression stockings, multilayer compression wraps, or wrapping an ACE bandage or dressing from the toes or foot to the area below the knee. The type of compression treatment prescribed is determined by the physician based on the characteristics of the ulcer base and amount of drainage from the ulcer.

 

Unna boots

First described by Unna in 1854, the Unna boot now is the mainstay of treatment for people with venous ulcers. Unna boots are rolled bandages that contain a combination of calamine lotion, glycerine, zinc oxide, and gelatine.

 

Vacuum-assisted wound closure (VAC)

Negative topical pressure, the general category to which the trademarked VAC therapy belongs, is not a new concept in wound therapy. It is also called subatmospheric pressure therapy, vacuum sealing, vacuum pack therapy, and sealing aspirative therapy. The VAC therapy system is trademarked by Kinetic Concepts, Inc., or KCI . It was first reported on in 1997 by a German surgeon.

The aim of the procedure is to use negative pressure to create suction, which drains the wound of exudate (i.e., fluid, cells, and cellular waste that has escaped from blood vessels and seeped into tissue) and influences the shape and growth of the surface tissues in a way that helps healing. During the procedure, a piece of foam is placed directly over the wound, and a drain tube is placed over the foam. A large piece of transparent tape is placed over the whole area, including the healthy tissue, to secure the foam and drain. The tube is connected to a vacuum source, and fluid is drawn from the wound through the foam into a disposable canister. Thus, the entire wound area is subjected to negative pressure. The device can be programmed to provide varying degrees of pressure either continuously or intermittently. It has an alarm to alert the provider or patient if the pressure seal breaks or the canister is full.

VAC therapy may be used for patients with chronic and acute wounds; subacute wounds (dehisced incisions); chronic, diabetic wounds or pressure ulcers; meshed grafts (before and after); or flaps. It should not be used for patients with fistulae to organs/body cavities, necrotic tissue that has not been debrided, untreated osteomyelitis, wound malignancy, wounds that require haemostasis, or on patients who are taking anticoagulants. The VAC system should not be placed on exposed blood vessels or organs or where there is active bleeding.

It may be considered for patients with a chronic cutaneous ulcer when all of the following criteria are met:

• Present for at least 30 days
• Failure of the ulcer to heal despite an adequate wound therapy program consisting of all of the following:
• Debridement of necrotic tissue if present
• Stage III or IV stasis ulcers
• Leg elevation and ambulation for venous insufficiency ulcers
• It is also used following anti-reflux surgery or sclerotherapy of the venous system
• Dressing are changed at 2-4 days intervals

 

Injection sclerotherapy

Injection of sclerosing agent directly into veins usually is reserved for telangiectatic lesions rather than CVI.

 

Surgical therapy

Chronic venous insufficiency (CVI) and its complications of chronic pain, intractable ulceration, and infection are important conditions to treat by modern surgical techniques. Approximately 8% of patients require surgical intervention for CVI. Surgical treatment is reserved for those with discomfort or ulcers refractory to medical management.

The decision to operate on a patient with venous obstruction in the deep veins should be made only after a careful assessment of symptom severity and direct measurement of both arm and foot venous pressures. Venography alone is not sufficient because many patients with occlusive disease have extensive collateral circulation, rendering them less symptomatic. Clot lysis (eg, tissue plasminogen activator [TPA], urokinase) and thrombectomy have been tried but have largely been abandoned owing to extremely high recurrence rates.

 

Following surgical procedure are performed:

• Leg vein and perforator ligation
• Subfascial endoscopic perforator surgery (SEPS) is gaining in popularity as a means of treating CVI. Endoscopic techniques are used to find and ligate perforating veins. Preliminary reports are encouraging. Ulcers treated with SEPS heal 4 times faster than ulcers treated conventionally. In addition, morbidity of SEPS is significantly lower than traditional operations. Long-term results are pending.
• Endoscopic fasciotomy and subfascial perforator division
• A new possibility is endovenous laser treatment of perforating veins. The light phaser is introduced into the vein under the ulcer. This method is only performed by our group and is under clinical study at present

 

Complications of Surgery

Haematoma, sural or saphenous nerve damage, and infection are possible complications of venous surgery.

 

Wound Care at Home

Patients are given instructions to care for their wounds at home. These instructions include:

Keeping the wound clean

Changing the dressing as directed

Taking prescribed medications as directed

Drinking plenty of fluids

Following a healthy diet, as recommended, including plenty of fruits and vegetables

Exercising regularly, as directed by a physician

Wearing appropriate shoes

Wearing compression wraps, if appropriate, as directed

 

Foot and skin care guidelines

The treatment of all ulcers begins with careful skin and foot care.

Inspecting your feet and skin is very important, especially for people with diabetes.

Detecting and treating foot and skin sores early can help you prevent infection and prevent the sore from getting worse.

 

• Gently wash the affected area on your leg and your feet every day with mild soap and lukewarm water. Washing helps loosen and remove dead skin and other debris or drainage from the ulcer.
• Gently and thoroughly dry your skin and feet, including between the toes. Do not rub your skin or area between the toes.
• Every day, examine your legs as well as the tops and bottoms of your feet and the areas between your toes. Look for any blisters, cuts, cracks, scratches or other sores. Also check for redness, increased warmth, ingrown toenails, corns and calluses. Use a mirror to view the leg or foot if necessary, or have a family member look at the area for you.
• Once or twice a day, apply a lanolin-based cream to your legs and soles and top of your feet to prevent dry skin and cracking. Do not apply lotion between your toes or on areas where there is an open sore or cut. If the skin is extremely dry, use the moisturizing cream more often.
• Care for your toenails regularly. Cut your toenails after bathing, when they are soft. Cut toenails straight across and smooth with an emery board.
• Do not self-treat corns, calluses or other foot problems. Go to a podiatrist to treat these conditions.
• Don’t wait to treat a minor foot or skin problem. Follow your doctor’s guidelines.