Dr Arvind Kohli
Acute and chronic venous diseases are among the most common ailments affecting the population. Symptoms necessitating evaluation for the treatment of venous disease include achiness, tiredness or heaviness in the leg, swelling, throbbing pain, burning pain, leg cramping, restless legs, stasis dermatitis and venours stasis ulcers.
Minimally invasive surgery is revolutionizing the treatment of venous disease and its associated symptoms, allowing extensive surgeries with long recovery times to become a thing of the past.
Varicose Veins
Varicose veins are the most common indication of superficial venous disease. It is important to have a thorough knowledge of the anatomy of the veins in order to understand and discribe the clinical symptoms of varicose veins.
Saphenous varicosis
Saphenofemoral Incompetence : the venous return begins at the 1st valve located in front of the aperture where the saphenous vein enters the deep venous system (Groin)
* Incomplete saphenous varicosis : saphenous vein insufficiency with sufficient cross and return venous flow from another vessel.
* Branch varicosis (flow over an incompetent lateral branch).
* Perforans varicosis (flow over incompetent perforating veins).
Reticular varicosis winding subcutaneous veins that do not belong to the main stem neither to the branches, less than 3 mm in diameter
Spider veins Intradermal vein ectasia
Treatment of venous diseases
Compression therapy
Leg bandaging has been carried out for thousands of years, possibly as part of a ritual, and was confirmed as a medicinal strategy in Ancient Greece. Compressing leather boots have been used for therapeutic purposes since the Middle Ages, and elastic fabric and rubberstockings since the 19th century. Indications were based on clinical experience of efficacy and were much the same as they are today; oedema, varicose veins and skin lesions. A wide range of mechanisms of action was offered, based on the pathophysiological conditions of the time; constriction of the veins, improved valve function, reduced volume of blood in the veins and improved pumping action, amongst others.The reduction of oedema, an improvement in inflammatory skin changes and the healing of ulcers are clinically feasible on a regular basis. The successful treatment of such pathological states, which can be determined objectively, coupled with the beneficial effect on symptoms, quality of life and even on the prognosis of certain diseases, has been confirmed in clinical studies. Bandaging has always been an art. Many methods for applying bandages were thus developed and enthusiastically encouraged but their effects in certain indications were not compared until recently. Medical compression stockings (MCS) are becoming increasingly popular due to improved compression levels, reproducible efficacy, ease of use, long-lasting effect and excellent tolerance.
Surgery
In previous years, vein stripping and perforator ligation was regarded as the only viable option for the treatment of venous disease. This procedure was extremely invasive and generally required patients to abstain from activities for five to 10 days following surgery. Often, it took up to six weeks for patients to return to optimal functioning, and the chance of patients developing recurrent disease was as high as 40%.
LASER Treatment (EVLT) Through the use of new, minimally invasive techniques such as endovenous laser ablation, which requires little to no down time, more patients have been able to benefit from treatment for venous disease.
Endovenous laser ablation is utilized for the treatment of lower-extremity venous disease and can be performed in an outpatient setting without the use of general anaesthesia. This has enabled its use to treat various patient populations-such as the elderly- who were previously not considered appropriate candidates for treatment. Patients who were often excluded from treatment of venous disease due to age or the presence of comorbid medical conditions now have an option, because endovenous laser ablation does not require the use of general anaesthesia, these patients can now benefit, even in the presence of other medical concerns. “During endovenous laser ablation, an IV is placed in the diseased vein. Using ultrasound guidance placement of the IV is confirmed, and a laser fiber is safely positioned within the IV. This laser fiber is used to seal the vein that is causing a patient’s symptoms. When this occurs, blood flowing through the abnormal vein is rerouted back through the patients’ normal venous pathways. Results are often seen within the first week following surgery, and research has shown that fewer than 5% of patients have recurrent venous disease following an endovenous laser ablation procedure.
After the diseased vein has been treated with endovenous laser ablation, varicose veins, retricular veins and spider veins branching from the diseased vein can be treated with sclerotherapy injections.
Venous stasis ulcers can profoundly affect a patient’s quality of life, causing pain and requiring multiple physician appointments, dressings and wound-healing modalities. The presence of venous stasis ulcers can interfere with daily activities, including work, exercise and sleeping. Many patients live with venous stasis ulcers, thinking the condition is incurable, without realizing they could be the result of an underlying disease. Many patients with venous stasis ulcers experience significant improvements after endovenous laser ablation that were not achieved using conventional surgery.
As a result, physicians are gaining a better understanding of venous disease as a whole and its associated symptoms.
Foam sceleortherapy
Foam sclerotherapy consists of injection of small amounts of a sclerosing agent that has been transformed from liquid to foam by a exchange of air and liquid agent between two syringes connected by a small three-way valve. Foam works better than liquid in scelertheray of varicose veins. With traditional liquid sclertherapy once the sclerosing liquid is injected in a vein, it quickly dilutes with blood, resulting in decreased concentration of sclerosing agent within the lumen of the target vein. Therefore, an effective concentration of sclerosant is not staying in touch with the inner surface of the vein for a sufficient amount of time in many cases. Foam displaces the blood and remains in contact with the inner layer of injected veins for a longer and more effective period. This makes foam sclerotherapy a much more effective treatment than liquid sclerotherapy. Furthermore, with foam there is much less post treatment local pain, discomfort, and pigmentation of the overlying skin. In summary, foam is much more effective and associated with fewer side effects in the treatment of varicose veins.
Self Care
There are a few home-based treatments for varicose veins. These treatments include elevating the legs above the heart for at least 10 to 15 minutes, three to four times per day to allow the pooled blood to drain. Compression stockings help the blood flow back up from the legs. These can be worn all day. Calf exercises are recommended to strengthen the cardiovascular system and promote good blood flow back to heart. Weight loss is strongly recommended if you are overweight. Excess weight puts strain on the veins and lead to incompetence of vein valves. Avoid standing or sitting for too long because this impedes blood flow to the heart. Avoid wearing clothes that are tight because this, too, can restrict blood flow. Care should be taken not to get ulcers in the legs and if at all they develop prompt management is advised.
(The author is Heart Surgeon GMC Jammu)
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