Varicose Veins: Exploring Non-Surgical Treatment Alternatives

What are varicose veins?

Global issues are a highly relevant topic that needs to be included when gaining a respected understanding of varicose veins. With the western world’s population demonstrating more obesity and living much longer than previous generations, the number of people suffering from varicose veins is set to escalate. It is also known to impact women more than men due to hormonal influences and multiple pregnancies. Veins often need to be repaired or destroyed where there is damage to the surrounding skin or ulcers have been formed. This helps to lessen the progression of severe varicose vein¬†which can often go untreated because the symptoms do not match the significant appearance. It is clear from the global perspective that the treatment of varicose veins must cater to more than the cosmetic issues.

The onset and progression of varicose veins is a process that takes place over time, often over the course of many years. It is quite common for patients to have family who also suffer from this problem. In some patients, they may begin to see a progression of the same veins their family members had. Veins are blood vessels that carry blood from all the organs of the body back to the heart. The leg veins carry all the blood from the lower limbs which makes the blood against gravity. Deep veins and their function can lead to clotting problems and therefore it is mainly the superficial veins which are removed or destroyed as they do not carry an essential blood supply for the body. All veins have one-way valves which keep the blood flowing upwards. If these valves fail, by genetic influences or damage, the veins will become congested with blood, especially when the patient is standing. At this point, the veins start to bulge and become the varicose veins.

Importance of non-surgical treatment options

Less invasive methods of treatment are rapidly becoming more important for patients and their physicians. Most patients with varicose veins can be managed with simple conservative measures. A minority of patients with severe venous disease will develop serious complications and will require more invasive treatment. It is very important for the physician to have a variety of treatment options available for the full spectrum of the disease. This shift in the treatment paradigm is occurring because patients are becoming more educated about their treatment options, and they are opting for less invasive treatment methods to cure their venous ailments. Physicians who offer minimally invasive treatment options are more likely to attract patients with early venous disease who are symptomatic, and patients with complicated venous disorders. This essay will briefly discuss less invasive methods of treating varicose veins, and will also outline some of the more serious complications of venous disease that require more invasive treatment.

Non-Surgical Treatment Alternatives

A number of lifestyle changes can improve the symptoms of varicose veins or help prevent them from developing. Engaging in regular, moderate exercise is possibly the best thing you can do to help prevent varicose veins from getting worse. Exercise helps improve your circulation and muscle strength in your legs. Good circulation will help to reduce and prevent any further varicose veins. Losing weight and not sitting or standing for long periods can also help improve your leg symptoms. When sitting, avoid crossing your legs and try to elevate your legs for a few minutes every hour. If you have to stand for long periods try to shift your weight from one leg to the other every five minutes. This will help prevent too much pressure on the one leg. High heels will not cause varicose veins, but can make the condition worse. Changing to lower heeled shoes can be beneficial. This way, lifestyle changes are quite simple yet very effective ways to reduce and prevent varicose veins. However, it will take a few months to a year to notice dramatic changes.

Compression stockings are the primary non-surgical treatment for varicose veins. They improve the symptoms of varicose veins by providing a gradual compression up the leg. This compression helps prevent blood from flowing backwards and also reduces swelling in the veins. Improvement in the symptoms from compression stockings can be seen in as little as a few days. However, since they are tight and can be difficult to put on, many patients do not like wearing them. It is important to continue using the stockings, even if you do not notice an improvement, as it can take up to several months to see any changes. If the varicose veins are not causing much problems, or if other surgery is too risky, compression stockings may be the only treatment that is used.

Compression stockings

The positive effects of compression stockings can be achieved in about 60% of people with varicose veins, depending on compliance. The benefits of compression will be lost when they are taken off, so it is important to put the stocking on first thing in the morning and remove it just before going to bed. Many patients do not wear the stockings during hot weather, but a compromise can be wearing them just for the working day. Compliance can be improved with the use of stocking aids. Unfortunately, some patients find the stockings either too difficult to put on or uncomfortable to wear, in which case alternative treatments should be considered.

It is important for the compression on the stockings to be measured at the highest pressure around the ankle, with the pressure reducing as it goes higher up the leg. Strong compression at the top of the stocking can cause additional problems and increase the size of varicose veins in the groin/pelvis. Support socks and tights are essentially lightweight compression stockings and are useful for mild symptoms both during the day and during long flights.

Compression stockings exert steady pressure on the veins, thus preventing blood from pooling. They are a reasonable, low-cost initial approach to controlling mild varicose veins and can be useful following any of the other treatments. They come in different styles, ranging from below the knee to the top of the thigh. Stockings that go above the knee are more practical in shifting blood to the deeper veins, helping to prevent pooling.

Lifestyle changes

Varicose veins are said to be more common in those who stand for long periods of time. Research has suggested this is the case because the calf muscles do not contract effectively when the person is standing. The objective of regular exercise is to improve the calf muscle pump and the return of blood from the legs. This will help to prevent the pooling of blood in the veins, making them swell. The best exercises are the ones that involve the calf muscles and the thigh muscles. Walking is a good exercise and is likely to be beneficial. Swimming is probably the best form of exercise for the condition, as the water exerts pressure on the body which will help to improve circulation. High-impact sports should be avoided, as they put too much strain on the joints. Step/bounce exercises should also be avoided, as it has been suggested time and time again that it will increase the pressure in the veins.

Lifestyle changes are often recommended as a treatment for varicose veins. These usually have no harmful side effects, and their beneficial effect will be felt throughout the whole body. The aim is to relieve the symptoms caused by the veins and to prevent their further progression. Over time, with the correct conservative treatment, varicose veins should improve, though it is generally slower to see an improvement than it would be with invasive treatment. If the veins have reached an advanced state, it’s possible that these methods may not help to improve them a great deal.

Sclerotherapy

The chemical of choice is normally a detergent type solution called sodium tetradecyl sulphate or a salt solution. A smaller gauge needle and a smaller syringe is used, normally 2-5ml in size. This is inserted into the vein and the chemical is injected as the needle is withdrawn so the entire length of the vein is treated. The aim is to cause endothelial destruction but without causing deep vein thrombosis or injury to surrounding tissues. The process is painful and any patients with needle phobias may not tolerate the procedure. The vein to be treated should be isolated with a tourniquet or using ultrasound before injection. This is to confirm that reflux in the vein is responsible for symptoms and to prevent accidental injection of the chemicals into non-varicose or deep veins. Many veins may require multiple sessions of treatment. The number of veins injected in one session varies, depending on the size and location of the veins. This may be 1-2 or even 10-20 in more severe cases, although only part of a large vein may be injected at once. After each session, an elastic bandage or compression stocking is worn for 5-7 days to prevent recurrence. Veins will fade over a few weeks to months after treatment, the pre-treated symptoms may initially improve before becoming worse, and the area may be discolored for a few months. The price of sclerotherapy is approximately $150 per session but varies depending on the amount of veins to be treated.

Endovenous laser treatment

The machines used to perform ELT generate energy at relatively high voltages, creating heat to close the vein. During the procedure, the vein is visualized using ultrasound and punctured with a needle through which the fiber is advanced. A local anesthetic is placed around the vein to be treated, preventing discomfort when the energy is applied. The most common side effect of ELT is some mild to moderate discomfort in the treated leg, which usually responds well to common analgesics. Other side effects that are less common include numbness or tingling involving the treated vein, mild phlebitis, and extremely rare skin burns. Most patients only experience the above side effects for a few days to weeks, and serious complications following ELT are exceedingly rare. Unlike more invasive surgical options such as ligation and vein stripping, ELT is considered to be somewhat less effective at closing the treated vein but does not carry the same risk of nerve damage, infection, or severe chronic pain in a small percentage of patients. Randomized trials comparing ELT to both vein stripping and to more conservative forms of treatment have demonstrated better improvement in quality of life and less pain with walking at 6 months after the procedure. A preliminary report has also suggested that further treatment of incompetent veins in the same limb increases the effectiveness of symptom improvement with EVLT, though more definitive studies are needed to confirm this.

Benefits and Risks of Non-Surgical Treatment

Patients considering different management options should be aware of the potential benefits and risks involved in these decisions. This section aims to outline the expected outcome of various treatment alternatives and the potential risks involved, taking into account a full discussion of all available treatment modalities is beyond the scope of this guideline. The suggested interventions throughout this and other sections are evidence-based recommendations, rather than an exhaustive list of all recognized techniques.

Have been suggested as the primary treatment for both symptomatic and asymptomatic varicose veins, in particular those defined as small to moderate in size (diameters of less than 10mm). The National Institute for Clinical Excellence (NICE) guidelines for varicose veins suggest early medical management interventions, such as compression stockings, should be trialed for a period of at least 6 months before considering further treatment. This guidance is based on new evidence of the relative safety and effectiveness of newer techniques. These conservative measures may also be continued in the long-term for patients who are not suitable for further interventions due to co-morbidities or for those who choose not to undergo a surgical or procedural intervention.

Benefits of non-surgical treatment alternatives

The greatest determining factor in the decision to use non-surgical treatment is the fear of complications from surgery. This is frequently unwarranted, given the safety and success of vein surgery when performed by a skilled surgeon for the appropriate patient and condition. However, consideration of complications and potential worsening of the condition is not uncommon for people weighing the treatment options. The current awareness of deep vein thrombosis and pulmonary embolism due to the widely publicized use of blood thinning medication and compression stockings after surgery has imposed a more fearful perception of vein surgery onto the patient. The rate of blood clot-related complications after varicose vein surgery can be as high as 16%, although the majority of these are only minor and temporary. Any mention of a statistically higher chance of experiencing a DVT (deep vein thrombosis) than the general public has a great impact on a patient with a history of or family history of DVT and its more severe consequence, pulmonary embolism.

The commitment to non-surgical treatment is usually an easy one for most people with varicose veins. The ease of using external compression through compression stockings or bandages, and the various forms of sclerotherapy means very little change to a person’s lifestyle and work activities. Surgery, involving time off work and regular physical activities, is generally more inconvenient for the patient. Treating smaller varicose veins and spider veins usually result in the patient having an extended period of time wearing compression stockings after vein surgery or sclerotherapy. A person with a history of multiple and/or larger varicose veins is more likely to choose non-surgical treatment as a first approach, with surgery being a fall-back option. This decision can be influenced by recent improvements in ultrasound-guided sclerotherapy and endovenous therapy. With minimally invasive techniques replacing surgery for a variety of other conditions, in the future they may become the standard approach for any person with venous disease requiring treatment.

Potential risks and complications

Hyperpigmentation: Hyperpigmentation is the dark staining of the skin in the areas where the varicose veins have been injected. This can give a mottled appearance to the leg. It is a common problem and occurs in up to 20% of patients. The staining can fade with time, but it may be permanent. It is more likely to occur in patients with dark skin. Hemosiderin, a brownish pigment caused by the breakdown of blood in the tissues, is thought to be the underlying cause, although in many cases the exact mechanism is not clear. Hyperpigmentation can be treated with laser or IPL therapy, but this is relatively expensive and is not always effective.

Allergic Reactions: Some patients have an allergic reaction to the sclerosant. This can cause redness and swelling at the injection site. These allergic reactions are usually mild and can be treated with anti-allergy medications. In rare cases, the allergic reaction is more severe and generalized, causing hives or asthma. This type of reaction is more common with sclerosing agents.

Non-surgical treatment techniques are safe and effective. They generally cause few problems. However, there are a number of potential risks and complications that you should be aware of:

Choosing the Right Treatment Option

During the information gathering phase, patients should consider the rate of success and possibility of recurrence of each treatment option. Measures with higher rates of success will be more likely to provide patients with long-term relief of their symptoms.

Low-impact options such as prescription stockings or exercise may be best for those who suffer from, or are at risk for developing varicose veins but currently have no symptoms of them. Sclerotherapy is an option for most people with few medical problems, while it may not be the best procedure for those who are known to have inflammatory conditions or allergies to sclerotic agents. For more severe symptoms, patients may consider more invasive operations such as phlebectomy or endovenous ablation.

Varicose vein sufferers should weigh out the options for non-surgical treatments to evaluate which option is best for them. They should consider their individual lifestyles, any previous medical history, and their current state of health. It is also important to consider the cost of treatments.

Factors to consider

Treatment options are numerous and vary depending on the severity of the disease. C1 and 2 patients having no venous reflux or skin changes may not be offered any treatment at all. These patients and C3 patients with only skin changes are usually offered compression therapy, and C5 and 6 with severe skin changes or patients with active ulcers are usually offered some form of ablation therapy. Other options include foam sclerotherapy and ambulatory phlebectomy. It is unlikely that a patient will be offered a specific treatment unless they themselves ask about it. This again emphasizes the importance of patients having varied knowledge of treatment options.

The objective of teaching patients about treatment options is that they may choose the one that is most appropriate for their needs. However, what is deemed appropriate or suitable varies widely between individuals. In consideration of this, two things must occur. First, the physician must offer his best judgment on what treatment is most appropriate for the patient’s condition. Second, the patient must improve their understanding of their treatment options and, using their knowledge of their own personal values and preferences, determine which option is the best fit for them. This process, known as shared decision making, is most easily done when the risks and benefits of each treatment option are known. However, before you head to your physician’s office to start weighing out treatment options, you must first consider the severity of your condition and your own willingness to undergo treatment.

Consultation with a healthcare professional

A consultation with a healthcare professional is a crucial step in determining the most appropriate management for varicose veins. The family physician may check for underlying primary vein problems and refer the patient to a vascular specialist. The specialist will provide a comprehensive evaluation of the patient’s venous system. This often involves a detailed venous ultrasound examination as the most appropriate way of assessing the deeper venous system, which is the most important system involved in varicose vein problems. Ultrasonography is also used to plan for any intervention. The ultrasound examination is bulk billed to Medicare. At the completion of the assessment, the doctor should be able to discuss with the patient the various conservative, noninvasive, minimally invasive, or surgical treatment options that are available and the likelihood of their success, taking into account the various factors relevant to the patient’s own condition.

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