Vascular Disease

Veins (vessels that carry de-oxygenated blood) from most areas of the body contain oneway flap valves that are designed to assist in the unidirectional flow of blood towards the heart. When one or more of these valves becomes incompetent (‘‘leaky’’), some blood is able to flow retrograde (away from the heart) and tends to overfill and distend branches of superficial veins under the skin. Over a period of time, this additional pressure causes the veins to stretch and bulge. These often unsightly blue and twisted vessel are called varicose veins. They can cause the skin to itch (pruritis); the legs to swell; and the feet to be uncomfortable with a throbbing, heavy sensation. Approximately 10 to 20 percent of adults suffer from varicose veins, with a preponderance of women affected (nearly 70 percent of all patients with varicosities).

Varicose veins are most commonly experienced in the back of the calf or on the inside of the leg between the groin and the ankle, but they may occur in almost any part of the body. Varices can cause enlargement of veins around the anus (hemorrhoids), the esophagus (esophageal varices) and the testicle (varicocele).

The legs consist of two systems of veins. The first are the deep veins, which carry about 90 percent of the blood. The others are surface veins that are visible just underneath the skin and are less well supported. At all of these sites there is a major junction at which superficial veins (those subject to varicose veins) flow into the important deep veins of the leg, with a oneway valve to control flow at the junction.

Normally, blood is pumped upwards through the leg into the abdomen and back to the heart, and the valves in the veins prevent the blood from flowing back down the leg. Sometimes, however, these valves become defective, resulting in the pooling of blood and the back-flow of blood down the leg and causing the formation of superficial veins that become swollen and distorted.

Causes: nonmodifiable. Causes and risk factors for varicose veins include:

• • Age. Incidence increases with age, and may approach 50 percent of people older than fifty years of age.
• • Sex. Women are affected more often than men, and the increased weight of the uterus during pregnancy may compress the iliac veins and cause an increased backpressure in the veins leading to varicosity.
• • Heredity. There is a strong familial predisposition, and this may be the most important risk of all.
• • Surgery. Any surgery performed near the hips can make vein problems more likely.
• • Congestive heart failure. CHF and thrombus obstruction can also promote the development of varicose veins.
• • Arterial-venous fistula. This is an abnormal connection between the arterial and venous system.

Modifiable causes and risk factors include:

• • Posture. Standing erect can increase the pressure in the veins several-fold (compared to lying down). It is unlikely that standing actually causes varicose veins, however, people who spend a great deal of time on their feet are certainly more likely to notice, and experience discomfort from, their veins.
• • Obesity. Being overweight can increase intra-abdominal pressure, impeding blood flow in the veins or decreasing the support of the veins themselves.
• • Pregnancy. The extra weight of the fetus/ uterus can increase intra-abdominal pressure, impeding the return of blood flow from the leg. Additionally, hormonal changes that occur during pregnancy may contribute to weakened support of the superficial venous system.
• • Thrombophlebitis. Past history of inflammation of a vein before a blood clot forms can damage or destroy the valves in the venous system, rendering them incompetent.

Diagnosis. For successful operative treatment, a detailed understanding of the abnormal varicose veins is required. For most primary (previously unoperated) cases, a clinical examination by an experienced surgeon will establish the cause (and therefore the treatment) of the varicose veins. Most surgeons would supplement the clinical examination by using a handheld ultrasound probe or an outpatient duplex scan, both of which provide a rapid and extremely useful method of identifying sites of faulty venous valves.

A duplex scan is a more elaborate ultrasound scanner, capable of producing both the visual image and information on the direction of blood flow within the venous system. This scan produces a more detailed ‘‘roadmap’’ of superficial and deep veins in the leg and aids in the planning of more complex varicose vein surgery. A venogram (an X-ray of the vein) has traditionally been used in the diagnosis of venous system abnormalities. This test requires the injection of a radio-opaque contrast into the venous system of the leg, with subsequent images captured using standard X-ray technology. While this test can provide detailed pictures of anatomy, the dye used can be harmful to veins in and of itself, and as such is reserved for only select cases that can’t be imaged adequately with a Duplex scan. As stated above, it is paramount to have a complete understanding of the anatomy to ensure a successful operation.

Treatment. Varicose veins, particularly minor ones, may not require any treatment. However, it does appear that varicose veins are a progressive disease, and there are some surgeons who advocate for early intervention. As with all surgical procedures, it is important to understand the rationale for invasive treatments and to balance the expected benefits against the obvious disadvantages of having a surgical operation (e.g., inconvenience, post-operative pain, time off work, potential anesthetic and surgical complications).

Surgical treatment of varicose veins may be appropriate for a number of reasons including symptoms such as aching, throbbing or tenderness of the veins; medical complications such as eczema around the ankle (with or without actual skin ulceration) and thrombophlebitis (clotting and acute tender inflammation of the varicose veins); and also for cosmetic reasons—they become ‘‘unsightly’’ for the patient.

Properly fitted elastic stockings may be a useful short- or long-term method of alleviating the majority of symptoms or avoiding complications if either patient or surgeon is keen to avoid surgery. Varicose veins operations take the following forms:

• • Sclerotherapy. This involves the injection of a chemical that intentionally causes the affected vein to thrombose and scar, thereby obliterating the lumen of the vessel. This therapy generally produces the best results for smaller varicosities.
• • Multiple ligation and local excision. The veins are identified preoperatively with a handheld ultrasound or Duplex scan, and the overlying skin is marked with ink. Using these landmarks, the abnormal veins are removed through several small stab incisions. The operation is often largely cosmetic due to the size of veins that can be avulsed (pulled out) through these tiny incisions.
• • Vein stripping. This technique is utilized for the long, straight segments of varicose, superficial veins. This stripping is usually carried out in conjunction with an exploration through a 3 to 4 cm incision in the groin and/ or behind the knee. This results in a more satisfactory result when removal of superficial veins in the thigh can ensure more thorough disconnection of varicose veins lower in the calf and reduce the risk of future recurrence. Additionally, the underlying vein and its connection with the deep veins of the leg are identified. All associated superficial branches are carefully cut and tied, and the superficial vein itself is tied and divided at its junction with the deep vein. This part of the operation is essential, as it corrects the principle underlying pathology of the varicose veins.

A frequent concern is the potential side effects of tying and removing veins from the leg. Varicose vein surgery is limited to the superficial venous systems, collecting blood principally from the skin, and, as such, contributes little overall drainage from the leg. Approximately 90 percent of venous blood in the leg is contained in the deep veins within the leg. Additionally, there is a complex interconnected network of both superficial and deep veins with inherent redundancy, so that blood can travel via alternate routes out of the leg after varicose veins are tied or removed.

Complications of the operation. While the majority of operations carried out for varicose veins are routine, and serious complications are uncommon, no surgical procedure is completely free of risk. Additionally, the concurrence of increased comorbidities in elderly patients increases the possibility of complications. This should be borne in mind when considering the pros and cons of surgical treatment for varicose veins. Complications include the following:

• • Anesthetic complications. Varicose vein surgery is increasingly performed with the usage of local or regional anesthetic, obviating the need for a general anesthetic. However, cardiac and respiratory complications can still occur, and are certainly more common in the elderly and in those with preexisting problems. Abnormal reactions or allergies to anesthetic drugs are uncommon and largely unpredictable.
• • Bleeding. This is one of the more common complications encountered, since the operation deals directly with blood vessels. Significant hemorrhage requiring a blood transfusion is uncommon, but can occur if a major vein is injured or if the patient is on anticoagulant medications (i.e., blood thinners or an antiplatelet agent).
• • Wound infection. Infection can occur following any surgical procedure, but is more common after long procedures, in obese patients, in the presence of contaminated ulcers, or in patients with a depressed immune system.
• • Damage to surrounding anatomical structures. While this is uncommon, there is small risk of damage to the main arteries, veins, and even major nerves of the leg in explorations at the groin and behind the knee. Injury to small, sensory nerve branches in the skin is extremely common and largely unavoidable when veins are stripped or avulsed. This can result in small patches of numbness, burning, or altered skin sensation close to surgical scars or where varicose veins have been avulsed in the calf.
• • Deep vein thrombosis (DVT). Blood clot formation (a DVT) is also an uncommon but serious complication or varicose vein surgery. Clinically significant DVTs occur in the deep venous system, which may be injured or inflamed during varicose vein surgery. A potentially lethal consequence is detachment of a blood clot that then migrates (embolizes) to the heart and lungs (pulmonary embolus). A major pulmonary embolus can result in sudden cardiac arrest and death.