Operation for varicose veins

What do I need treatment for?

As your vascular surgeon has explained to you, you suffer from varicose veins of your legs, which are widened and buldging veins caused by weakening of their wall and by failure of their valves to close properly and direct blood flow one-way towards the heart.

The aim of surgery is to reduce the excess pressure in the veins under the skin. Surgery is effective in controlling symptoms and preventing skin complications as well as the appearance of new varicose veins.

You will usually be a candidate for this operation:

• If the skin of the lower leg has changed colour, has become thickened or has developed eczema, especially with sores (leg ulcers)
• If a varicose vein has bled through the skin
• If you have had an episode of thrombophlebitis, i.e. redness, pain and inflammation over a vein
• If you have symptoms, such as burning, itching or a heavy leg
• If the veins are a cosmetic problem to you

Small varices not causing symptoms do not necessarily need to be treated.

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Before the treatment

Before the operation is performed, certain investigations and tests need to be done. These usually include: blood tests, chest x-ray, electrocardiography and examination by a cardiologist. These investigations will be done a few days before or on the day of admission. Also, duplex ultrasonography of the leg veins may be performed for mapping of the damaged veins and their connections.

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Coming into hospital

When you are admitted, it will be quite useful to bring with you all medications you are on. Your medical history will be recorded. Later, your vascular surgeon and the anaesthetist who will put you to sleep will visit. They will explain certain aspects of the procedure and of the immediate postoperative care. You will be asked to sign a form confirming that you understand why the procedure needs to be performed, the risks of the procedure and that you agree to the surgery.

Your vascular surgeon will visit you immediately before the procedure to mark up your veins with a waterproof pen, agreeing with you which veins will be removed. You should ensure that all your varicose veins are marked.

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The anaesthetic

The first part of any operation is the administration of anaesthesia. Through an IV in your arm, you will be receining fluids and medications during and after the procedure until you are able to drink. Your anaesthesia may be general (by receiving the anaesthetic, which will put you to sleep within a few seconds), regional (spinal) or more rarely local.

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The operation

The operation varies a little from case to case depending upon which veins have leaking valves. Most commonly, the long (or greater) saphenous vein (LSV), which is the main superficial vein in the leg, is affected. To perform long saphenous vein stripping, the surgeon first makes a small (3-4 cm) incision in the groin area and usually another incision in the calf below the knee. Then, he/she disconnects and ties off the junction of the LSV to the femoral vein and all the major branches associated with the LSV, and removes it from your leg by stripping it with a special wire (stripper). Less commonly, the short (or lesser) saphenous vein is affected and it is tied off and disconnected from its junction to the popliteal vein via a small incision behind the knee.

Finally, vein avulsions, or phlebectomies, can be done alone or together with LSV stripping. These are performed through tiny incisions about 2-3mm in length, which are placed about 3-5cm apart along the line of the varicose vein. There may be a large number of tiny incisions if the varicose veins are extensive. The larger incisions are closed with stitches, but the tiny ones do not need to be stitched. The leg is bandaged firmly from toes to groin at the end of the operation.

After the late 90’s, some new methods have been developed, which are also performed via skin incisions in the leg. They differ in that the LSV is not stripped, but thermally ablated in its place using a thin flexible tube (called a catheter) inserted into the vein. Tiny electrodes at the tip of the catheter heat the walls of the vein and destroy its tissue. The vein is no longer able to carry blood and is eventually absorbed by the body. Ablation methods are radiofrequency closure (RFC) and endovenous laser therapy (EVLT). These methods have some limitations.

Although these procedures sound painful, they cause relatively little pain and are generally very well tolerated.

Your vascular surgeon will advise you regarding which procedure is the best for your particular situation.

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What can I expect after the operation?

Following the operation you will probably stay in the theatre recovery area until you are fully awake, and then you will be transferred back to the ward.

You may have a stinging or burning feeling in your leg when you wake up, but no significant pain is expected. Ask the nursing staff for pain relief if you need. It is rare to feel sick following this type of surgery, and you should be able to have something to drink and eat a few hours later.

We will encourage you to get up and walk as much as possible a few hours after the operation. Some of the smaller incisions may bleed a little over the first 24-48 hours. This is easily controlled with bandages or stockings. It is common that you develop some bruising in the thigh and calf, which will disappear completely within the next few weeks.

Removal of the superficial veins means that blood returns to the heart through the deep veins more efficiently than before the operation.

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Are there any complications?

Complications are uncommon following varicose vein surgery.

• Chest infections may occur after any operation especially in smokers. Antibiotics or physiotherapy may be required then
• Infection of the wound in the groin can occur but isn’t severe and settles down with antibiotics
• Damage to a skin nerve is uncommon, however, it may occur. This will cause reduced feeling to the touch or numbness over a skin area, and may be quite annoying initially, but settles down with the time and only rarely remains a problem
• Deep venous thrombosis (DVT) is very rare with the precautions we take today, and especially with the early postoperative ambulation
• Appearance of new varicose veins following a well performed procedure may occur in 25-30% of the cases in a period of 10 years. Occasionally, a new procedure may be required
• Appearance of some new spider veins is not uncommon following varicose vein surgery

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Going home and aftercare

You will usually be discharged the day of the operation or the following day, after removal of the bandages and application of a thigh-long antiembolism stocking. Some bruising in the leg is almost unavoidable to occur, but will disappear completely within 3-4 weeks. The stocking helps you feel the leg more comfortable, and the surgeon will advise you how long to wear it for.

The leg will be a little uncomfortable over the next few days, and you may need mild pain relief. This discomfort is due to the bruising, i.e. the inflammatory reaction to the blood which occurs following surgery, and gradually resolves.

Your surgeon will recommend that you walk for at least 1 hour every day, avoid standing and keep the leg elevated when you don’t walk. He/she will also tell you when you may wash the wounds, when the stitches will be removed and when you may return to your work.

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Can removal of my varicose veins be harmful?

Varicose veins, as well as spider veins, are damaged veins, which do not function properly. Their removal is not only harmless, but it improves the venous circulation in the leg. From the moment varicose veins appeared, the nearby healthy veins have taken over their work, i.e. to return of blood to the heart.

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What can I do to help myself?

After going home, try to resume your normal activities as soon as possible, but avoid standing. The more you exercise your leg the more discomfort you may have, but the quicker it will return to normal.

Increase physical exercise and reduce your weight.

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