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Varicose Vein - How To Treat It?

Written and reviewed by
MBBS, MS - General Surgery, Fellowship In Advanced Laparoscopic colo-rectal & Robotic Surgery, FICS - General Surgery, Fellowship in Minimal Access Surgery(FMAS) & Reproductive Medicine, Fellowship in Laser Varicose Vein Surgery
General Surgeon, Mumbai  •  25years experience
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I am doctor Dilip S Rajpal. I am a practicing general and laser varicose vein surgeon. Varicose vein is one of the most common diseases which is misdiagnosed and very under diagnosed, varicose vein is a disease in which the veins of the legs become dilated and tortuous, so the patient usually neglect it thinking that it's a very common disease, it's a day-to-day activity and I'm having since childhood, my family has it, my relatives have it and we have a family history that's why the disease is grossly neglected. So people have a lot of questions like how do I inherit it? what is the complication? what is the treatment we can offer and most important is whether it causes any recurrence? so I will explain about everything.

The most important is the risk factor so definitely the aging increases because of age, because of daily wear and tear the veins become damaged and the valves become diseased. It is more common in women than in men because of hormonal issues, because of pregnancy, menopause and even OC (oral contraceptive) pills increase the incidence of varicose veins. Obesity obviously because of increased fat deposit the veins are less supported and as the veins become dilated, tortuous and hence the valves become diseased leading to varicose vein formation. Standing is being the most important reason for this thing.

Today most of the jobs are concerned for long standing that's why the incidences become more and more common So coming to familial component, almost 75% of identical twins will have varicose veins and almost 52% of non identical twins will have varicose veins. If both parents have varicose then almost 90% of the children will have varicose veins. If one of the parents is having it then 62% of women and 25% of men will have varicose veins, so the incidence is that common. Coming to the symptoms, patient usually complains of lot of visibility of veins in the legs then comes a stage of pain, then swelling, then discoloration in the legs and even ulceration. Ulceration being the most deadliest of the complication because these ulcers happen because of increase in the pressure in the veins, so these ulcers although they look very simple, but they ooze a lot and they don't heal, they refuse to heal.

We usually follow CEAP classification, which is clinically, etiological, anatomical and pathological classification. According to that we may grade the patient and according to that the treatment is offered to the patient, now before coming to the treatment I would like to highlight something on the pathophysiology because I give a lot of importance to pathophysiology because since the time patient doesn't understand how does varicose vein happen? so he is not critical and he doesn't take care of it. So varicose vein is one disease which happens only in humans because of our standing job because we stand, so anything in this world will come from above downwards because of gravity but nothing goes on below so our bodies is the one structure in this universe, where actually blood is going from below upwards so when this blood is going from below upwards and person's job is concerned with prolonged standing or family compromise as I just mentioned some of the valves become diseased now when these valves become diseased, blood actually falls down and when the blood falls Down the vein becomes dilated so initially the veins will be visible.

Slowly and steadily what happens the pressure in the brain increases and these are small superficial veins they cannot bear that much of pressure, so the veins start paining, this pain is not a typical pain as in orthopedic diseases, this pain is more of heaviness in the legs and when a patient gets up early in the morning, patient feels very comfortable because he was lying down, all the pressure in the vein decreases, but now as the day is ending patient is working throughout the day vein will become more and more tortuous so it caused a lot of pain, more so in the evening and patient feels we should do massage or something like that, slowly the pressure in the vein further increases which causes the plasma, the white part of the blood to ooze out, so leading to swelling in the legs, slowly and steadily even the red blood cell come out leading to blackish color of the legs if there is blackish discoloration, if the red cell ooze out then there is something called inflammatory mediators get released and patient has feeling of itching and patient scratches and once patients scratches, patient develops this and it never heals.

So as I told the main pathophysiology of the disease is increased pressure in the vein, so the treatment is to decrease the pressure in the vein. Now how will you do that? conservative treatment in the form of bed rest, keeping legs elevated more so in lying down position, once you do that the pressure in the vein decreases but throughout the day you cannot do that so what you can do is you are supposed to wear specially designed stockings. Nowadays very good quality, very fine elastic stockings are available we usually recommend class 2 stockings which gives a pressure almost 20-30 mmHg so once you wear the stockings the pressure in the vein decreases, so obviously the pain, swelling and another complication that also decreases, in fact the ulcer also heals, but the disease is not going to get cured, the disease is going to remain static, the disease will not get prolonged. Now coming to the surgical management, if at all in today the diagnosis is done on the basis of venous Doppler and on the basis of venous Doppler we diagnose what is the size of the saphenofemoral valve, saphenopopliteal valve, ankle perforators.

Today, we ask for even the size in millimeters what is it? because the treatment we are doing more and more non-surgical treatment in the form of endovenous laser ablation, so all that is very helpful. So one is of course, as I told you the treatment, the veins, the valves are diseased so surgically we can either cut the valves at those, we can just disconnect the superficial and the main vessels but this has to be done at multiple levels, so it is painful and this wounds itself doesn't heal because of the pressure in the vein, leg is already swollen and the pressure in the vein was already high. Now coming to endovenous laser ablation what we actually do is, we put in a small needle inside the vein, inside the needle you put in a laser fiber and completely burn out the vein from inside. This complete procedure is doppler guided, so this complete surgery in fact is done under local anesthesia, it is an OPD procedure because we do OPD procedures and patient can immediately walk down and can be resume normal activities very next day, so it causes very very less morbid than today's day. The most important treatment is to decrease the pressure in the superficial vein and that is taken care with the help of endovenous laser ablation. Coming to the recurrence part.

A lot of patients have a question regarding the recurrence now this disease is valve related disease, so any valve which is diseased we have to take care of that, so the valves which are diseased we are ablating with the help of laser we are taking care of that, but tomorrow patient is not going to change his job for a particular disease, some new ones may still get disease. Now many times both the veins i.e. long veins and soft veins, when both are diseased so in such patients we ablate both the veins the chance becomes almost nil, but if at all the one vein is diseased there is always a possibility that the patient may still develop, so in such patients, the already operated once and more than once then we recommend them to wear life long stocking otherwise the stocking is recommended only for 3 months. Now if you compare whether this is laser and open surgery the recurrence rate for both is almost the same; however, in open surgery there is a lot of morbidity, a lot of pain, suffering but in laser ablation, it is OPD procedure, can be done under local anesthesia, the patient can resume work very next day so morbidity is absolutely nil. If you want to get more information then you can go to lybrate page.

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