Varicose veins. They creep up on you. With no pain and no symptoms, you may not even notice them at first. But over time they get worse. What was once no more than a bluish shadow under the skin, grows, darkens and bulges out in unsightly lumps. And once developed, they don’t go away.
Varicose veins occur when the valves in the superficial veins of the leg stop functioning properly. The veins work against gravity, to carry blood upwards from the feet and legs to the heart. If the valves do not close completely, some of the blood flows backwards (known as reflux) collecting in the veins, stretching the walls and eventually forms those bulging knots. Although not generally a dangerous condition, they can cause discomfort and people worry about their appearance. Most doctors initially suggest compression stockings, both as a preventive measure and to treat the condition. These very tight stockings compress the legs, and hence the veins, restoring circulation to normal. This can help delay the progression of varicose veins and alleviate symptoms that go with them. However, the Cayman climate makes wearing stockings a less than ideal option. Plus, it’s no long term solution. “If a person is predisposed to varicose veins, they would have to use the compression stockings for life. But who wants to wear them for life? It’s not practical,” says Dr. Schanzer, a new York-based vascular specialist who visits KY Imaging Ltd regularly.
Varicose veins are very common. The American Society of Plastic Surgeons (ASPS) estimates that 50 percent of women over 21 in the United States have spider veins and the National Institutes of Health say varicose veins affect one in two people over the age of 50.
With so many people suffering from this condition, other than wearing stockings for life, what are the options in Cayman?
Prevention is always better than a cure and other than wearing the support stockings, maintaining a healthy lifestyle and keeping fit are some of the best measures one can take to avoid developing these veins, says Dr. Tanja Ebanks, a general surgeon specialising in treatment for varicose veins. By exercising, the muscles are pumping which helps increase venous return to the heart. Obese people, pregnant women and those who stand or sit for long periods of time are particularly at risk, so keep weight in check and keep moving. The group most at risk, however, are those whose parents or siblings are affected. There is no avoiding this, so a balanced diet and exercise are essential.
Some people do not suffer any discomfort from varicose veins, and may feel no need to treat them.
However, they will not go away of their own accord and will worsen over time. Many affected by varicose veins do also suffer from tired, heavy legs and swollen ankles due to the blood not circulating back up the legs. Itchiness, throbbing and cramping are also common symptoms. Left untreated, in the long term, varicose veins can cause thickening and permanent discolouration of the skin on the lower legs and non-healing ulcers. They can also make a person more prone to blood clots in the affected veins and in some cases, can cause massive bleeding if the skin and vein wall just beneath it were damaged.
Treatment options for varicose veins have advanced in leaps and bounds in the past 20 years or so. A number of options are now available, which broadly fall into two categories: removing the vein or collapsing the vein.
Vein stripping, which involves removing the whole vein from ankle to groin, was once upon a time the only option available. It is a fairly invasive procedure,
which is considered somewhat outdated in North America. “Stripping requires a general anaesthetic. Post operative recovery can be painful and it can be a week or two before normal life can be resumed,” says S
chanzer. Although the procedure is rarely carried out in the US now, it is still used in some situations in Europe.
An ambulatory phlebectomy is a far less invasive means of removing varicosities. It can be performed under local anaesthetic and entails making tiny incisions through which the affected veins are pulled out and snipped off. The procedure is painless and the recovery is much faster. This is a good option when the affected veins are branches coming off the main saphenous vein.
A number of different methods achieve the same basic result: to irritate the inner surface of the vein which causes it to collapse, shrink and eventually be re-absorbed by the body. This type of endovenous ablation is now commonly used as an alternative to vein stripping.
“Endovenous thermal ablation is used when the main saphenous vein is the culprit,” explains Schanzer. In the procedure, the surgeon inserts a thin catheter into the vein and applies heat through the tip of the catheter to scar and collapse the vein. This can be done with a laser or using radio frequency, although only the laser version is available on island. “Neither procedure has a clear advantage over the other, although if anything the laser treatment has slightly wider appeal. Some surgeons may have a preference just because they are more familiar with, or more comfortable using one or other method,” says Dr. Ebanks, who offers Endovenous Laster Treatment (EVLT) along with a number of other treatments through Chrissie Tomlinson Memorial Hospital. “This type of treatment has become the gold standard in the US as it is less invasive, better tolerated, there is a quicker return to normal activities, less pain and bruising following the procedure and it can be done under local anaesthesia only,” says Ebanks.
An alternative way to ablate the veins is with sclerotherapy, which means injecting them with an irritating solution. This causes the veins to shrink and over the course of several weeks will be re-absorbed by the body. This is a simple and painless procedure that can be used on the larger spider veins as well as smaller varicose veins. Ebanks warns, however, that it can take several weeks for the full effects to show.
A cutting edge new treatment, using foam rather than liquid, may make it possible to treat the larger veins in this way, although at this stage foam sclerotherapy is still experimental says Schanzer.
Choosing the right treatment
With so many options it can be hard to know which treatment to choose. Ideally, talk to a doctor who offers several treatment options so that you know you are getting the right treatment for you, rather than the only treatment they offer.
It is not simply a matter of which options you think sounds best. “
Before obtaining treatment it is very important to know if they are localized or if they are the result of the major saphenous veins being defective. In order to differentiate these two possibilities it is essential to perform an ultrasound-Doppler test,” explains Schanzer.
If the affected veins are localized, sclerotherapy alone may be sufficient, but if the root of the problem lies in the main vein, a combination of treatments may be necessary. Thermal ablation would first be used to close off the vein. “In about 60% of all cases, this by itself eliminates the varicosities. In the remaining 40% of patients, a second stage procedure (microphlebectomy or sclerotherapy) will be necessary for the complete elimination of the varicosities,” says Schanzer. The second procedure is usually performed four to six after the laser procedure.
The procedures are expensive (averaging $5000 per leg) but if the doctor and the insurance company are satisfied that the varicose veins are symptomatic, these procedures may be covered.
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