Varicose veins – or chronic venous insufficiency (CVI) – is common in the general population.
By definition, a varicose vein is a tortuous and dilated palpable vein in the lower limb caused by reversed blood flow or reflux. This leads to difficulty for blood to return from the leg to the heart, hence it accumulates in the leg, causing various symptoms.
Varicose veins is two times more prevalent than coronary artery disease and five times more prevalent than peripheral arterial disease. It is more common among females.
They are not commonly presented to a medical practitioner because the initial symptom is mild and does not always lead to major health complication.
Symptoms of venous reflux disease include heaviness and fatigue after prolonged standing and walking. Occasionally, the patient will experience aching sensation, pain or night cramps. Foot and leg swelling are more severe manifestations of CVI.
As the disease progresses, dark pigmentation and hardening of skin will be seen (lipodermatosclerosis). Very soon, this will lead to burning and itching skin. Non-healing ankle ulcer will be seen at a very late stage.
Diagnosis is mainly clinical. Ultrasound examination is the main mode of investigation to identify pathological vein and cause of reflux. This is important in planning a proper treatment and getting good outcome after treatment.
Intervention
Lifestyle management, leg rest and skin care are important interventions to delay disease progression.
Venoactive medication is effective in relieving the symptoms and reducing leg swelling. Under medical supervision, venoactive medication is safe for long term consumption.
Compression stocking has been the mainstay of treatment for decades. However, its role has been replaced since the advent of endovenous treatment for venous reflux disease, which is now popular and easily available.
The more definitive method of treatment relies on identifying and treating the pathological vein that leads to the problems. This can be achieved by conventional surgical treatment or minimally invasive endovenous procedure.
Options of surgical treatment of varicose veins includes ligation or stripping of the diseased truncal vein, multiple phlebectomies (excision) of varicose veins and perforator vein ligation.
There is a very low risk of post-surgical pain, and the recurrence rate of reflux disease can be as high as 20%. Minimally invasive endovenous treatment has been available since the 1990s and it is evolving.
The earliest form of endovenous treatment includes thermal ablation like radiofrequency ablation and laser therapy. Later, sclerosant and mechanochemical ablation was also introduced. Endovenous glue application is the most recent technique introduced.
These treatment modalities have become less invasive and less painful. This greatly reduced the requirement for need of general anaesthesia to carry out the procedure.
Nowadays, most of these minimal invasive procedures can be done safely as daycare surgery under local anesthesia.
According to a survey, the outcome of the minimally invasive treatment is not inferior to conventional surgery. The vein closure rate is about 90-92% for radiofrequency ablation or laser therapy, and near 95% for endovenous glue application.
There is also less bruises and lower inflammation rate in the latest method leading to early recovery and rapid return to work. The patient’s satisfaction rate with the procedure is greatly improved as reported by the survey.
With the aforementioned result, endovenous minimal invasive treatment has become the treatment modality of choice in the modern era.
It has replaced conservative treatment as the first line treatment in venous reflux disease and is strongly recommended in most clinical practice guideline worldwide.
Dr Tan Kia Lean is the consultant vascular and endovascular surgeon at Ara Damansara Medical Centre in Shah Alam, Selangor.
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