Varicose veins are veins under the skin of the legs which have become widened, bulging and tortuous. They are very common and do not cause medical problems in most people. Blood flows down the legs through the arteries and back up the legs through the veins. There are two main systems of veins in the legs - the deep veins, veins deep inside the muscles, which are not visible and which carry most of the blood back up the legs to the heart, and the veins under the skin, which are less important and which can form varicose veins. All these veins contain valves which should only allow the blood to flow upwards (see diagram). If the veins become widened and varicose these valves no longer work properly.
Blood can then flow backwards down the veins and produce a head of pressure when standing, walking about or sitting. Lying down or "putting your foot up" relieves this head of pressure and usually makes the legs feel better. Both symptoms and treatment depend on how badly the valves in the veins are working, although the trouble people get from their varicose veins is very variable. In women varicose veins often appear first in pregnancy when hormones relax the walls of the veins and when the womb presses on the veins coming up from the legs. People who are overweight are more likely to get varicose veins and to find symptoms from them troublesome.
There is some tendency for bad varicose veins to run in families, but this is by no means always the case. Usually there is no special cause for varicose veins.
Very many people have no symptoms at all from their varicose veins, except for the fact that they are noticeable and their appearance can be embarrassing. Other than cosmetic embarrassment the commonest symptoms from varicose veins are aching, discomfort and heaviness of the legs, which are usually worse at the end of the day. Sometimes the ankle can swell, too. These symptoms are not medically serious, but can be treated if they are sufficiently troublesome. Although varicose veins can get worse over the years, this often happens very slowly.
In a few people the high pressure in the veins causes damage to the skin near the ankle, which can become brown in colour, sometimes with scarred white areas. Eczema (a red skin rash) can develop. Other problems which varicose veins can occasionally produce are phlebitis and bleeding. Phlebitis (sometimes called thrombophlebitis) means inflammation of the veins and is often accompanied by some thrombosis (clotting of blood) inside the affected veins, which become hard and tender. This is not the same as deep vein thrombosis and is not usually dangerous. It does not mean that the varicose veins necessarily have to be treated.
EVLA is a minimally invasive procedure where laser energy is delivered to the faulty vein that is normally stripped during surgery, causing it to close. There are many veins in the leg, so after treatment the body simply re-routes the blood-flow through other healthy veins.
Blood in the veins normally flows up the legs, back to the heart. It is under low pressure and gravity tends to push it back down the leg. This is normally prevented by one-way valves inside the veins which allow the blood flow up, but prevent it from flowing back the wrong way.
Most varicose veins are caused by a faulty valve in the groin or behind the knee. This faulty valve allows blood to be forced out into the veins under the skin (the superficial veins) from the main veins inside the leg muscles (the deep veins). This leads to the valves in the superficial veins becoming faulty and the increased pressure in the veins causes them to enlarge (dilate) and give rise to varicose veins.
The principle behind EVLA is that the laser is used to obliterate the superficial vein (either the long or short saphenous vein), above or below the knee respectively. This stops the faulty valve in the groin or behind the knee having any effect. It achieves exactly the same as conventional surgery when a wound is made in the groin or behind the knee to put a ligature around the top of the vein which is then removed by stripping. EVLA is therefore used to treat the underlying cause of your varicose veins.
You will be asked a series of questions about any symptoms that your varicose veins are causing and any other health problems that you may have had. We will examine your legs and perform an ultrasound scan, called Doppler ultrasound. This is a form of scan that can check blood flow and direction. It will identify which faulty valves have caused your varicose veins. Scanning takes about 15 minutes per leg. It is done at an initial assessment and is also repeated at the time of EVLA. If the main faulty vein valve is in the groin or behind the knee, your varicose veins should be suitable for EVLA. We do not treat people during pregnancy, and will also take account of other medical conditions.
The procedure begins with an ultrasound scan to mark the vein in your leg to be treated. An injection of local anaesthetic is given to freeze the skin over the vein (at 4 or 5 points along it’s course). A small needle is inserted into the varicose vein (at knee level or upper calf level) and a flexible fine wire is passed up the vein to the junction at the groin or knee crease. You will not feel this. A fine tube is passed over the wire into the vein and the laser fibre is threaded up this tube.
The position of this laser fibre is then checked with ultrasound.
Once the laser fibre is in the right position some more local anaesthetic is injected around the vein to minimise any discomfort when the laser is turned on.
The laser works by shrinking the vein and closing it up from the inside. Lasers are powerful sources of energy and you and the staff will wear protective glasses whilst the laser is being used, only as an extra safety precaution. The laser light is never fired externally.
When the vein has been sealed up, the laser is removed and a graduated compression stocking or bandage is applied to the leg. You should keep this on for 7 days and nights, then during the day for 7 further days.
The EVLA procedure takes about 45 minutes and is performed in a treatment room with you lying on a treatment table.. No general anaesthesia is required, just a local anaesthetic. Your surgeon will insert a thin flexible fibre into the faulty vein.
The laser emits thermal energy that will close the vein from the inside. Only minimal discomfort, if any, should be experienced due to the local anaesthetic that is administered along the length of your vein.
Most patients return to normal activity immediately after EVLA treatment, although a minority may not do so for up to a week.
You can start to walk immediately after the procedure. The whole leg may be stiff and tender to the touch in places. Take painkillers if you need them. You should aim to walk about every half hour or so during the day for the first week or two. For many people this simply means getting back to their active daily routine as rapidly as possible. Avoid standing or sitting with the foot on the floor as much as you can for about two weeks after the operation.
This varies a lot between different people. We encourage you to return to normal activities immediately, although swimming will not be feasible in the first two weeks and we advise against using the gym or running in the first two weeks also, as this allows the treated vein to fully seal and close. Your legs may be a little tender and bruised for a month or more.
You can drive as soon as you feel confident and for most that should be the morning after treatment. We advise against driving home after treatment as your leg will be slightly stiff with the bandage and stocking and may make an emergency stop difficult in the first few hours whilst you get used to it.
When can I return to work and play sports?
You can return to work and sporting activity as soon after the procedure as you feel sufficiently well and comfortable. Avoid violent sports while you are still in support stockings or bandages, and thereafter start with some gradual training, rather than in immediate competition. Do not go swimming until you are out of support stockings and all the wounds are dry.
Not everyone is suitable for EVLA but if you have not had previous surgery for your varicose veins then you will probably be suitable for EVLA. About 70-75% of people with varicose veins are suitable for EVLA.
Besides support stockings (hosiery), the most common form of treatment is surgical ligation and stripping. At least two incisions are required, allowing the surgeon to tie off and pull out the faulty vein. It requires general anaesthesia, hospitalisation, leaves scars and requires 2-4 weeks recovery. Another form of treatment is ultrasound-guided sclerotherapy— the injection of an irritant to close the vein. Although sclerotherapy is effective with larger veins there is a risk of veins coming back.
This is usually undertaken under a full general anaesthetic. When asleep a cut is made over the top of the main varicose vein and it is tied off just where it joins the deep vein in the groin. This cut is closed with stitches, which are hidden under the skin. The main vein under the skin is removed by passing a fine wire down it - either to just below or just above the knee ("stripping" the vein). This helps to guard against varicose veins forming again. Blood flows up the many other veins in the leg after this vein has been removed. Varicose veins marked before the operation are removed through tiny cuts in the skin. These cuts can be closed with stitches or adhesive strips. Other veins under the skin with important connections to the deep veins may need to be dealt with - in particular one just above and behind the knee. If important veins other than the one on the inner side of the leg need to be tied off, this may require special scans before the operation, and we will explain this to you.
This means support stockings or tights, which can be effective in relieving symptoms of aching and heaviness caused by varicose veins. They can be bought from many different outlets. Stronger support hosiery ("graduated compression stockings") are even more effective. Above or below knee lengths are available in three different "Classes" of compression (Class 1 are a little stronger than ordinary support tights; Class 2 are most often advised by doctors for patients with vein problems; and Class 3 provide very firm compression when there is a particular need). Graduated compression stockings can be obtained by a doctor’s prescription, although a wider range (in a variety of colours) is available for purchase from specialist surgical supply outlets. If worn regularly each day graduated compression stockings need to be renewed every three or four months.
This is performed in the outpatient department with the patient able to walk out immediately treatment is completed. A small area of skin is numbed with local anaesthetic at the knee. Using an ultrasound machine to help guide treatment, a small tube is inserted into the vein in the thigh. The leg is then supported in a sling and foam injected to fill the varicose vein. Each injected area will be covered with a pad and a stocking or bandage will then be applied from the foot to the groin. The chemical substance injected into the vein works like a glue. For the glued surfaces to become firmly and permanently fixed, they must be clamped together until the glue has set. In the case of your veins, bandages and stockings act as a "clamp" to hold the vein walls together.
Immediately after treatment patients can walk from the clinic room without any discomfort. The injections of foam are painless. After about 6 weeks the results are assessed. The varicose veins in the calf which are invariably present often shrink considerably with just treatment to the thigh vein. If they persist they may be treated with further foam injections or be removed, after the injection of local anaesthetic into the skin over the veins, through tiny little incisions (multiple phlebectomies). Whichever treatment is used recovery is immediate.
You have a number of options:
If your varicose veins are not suitable for EVLA then surgery remains an option that is open to you. Further information about this is included in the leaflet "INFORMATION ABOUT VARICOSE VEINS" which you can download here.
If you have had an operation in the past then you have a 1 in 3 chance that you will be suitable for laser treatment if you have developed further varicose veins. A lot will depend on the type of operation that was performed. If this did not involve a wound in the groin, or if an operation was done behind the knee then the chances that you can now have laser treatment are increased.
EVLA treatment has been performed for a number of years on thousands of patients. The procedure has proven to be highly effective with high patient satisfaction. There is a low probability that recurrence of the veins will occur.
Whilst EVLA is considered to be a relatively new method of treating varicose veins, in patients who had EVLA more than 5 years ago the results are as good as and probably better than for surgery.
These are very small veins on the surface of the skin that some patients consider unsightly. They may sometimes be the cause of itching and some mild discomfort but often they cause no problems other than their appearance. The best treatment to improve their appearance is microsclerotherapy.
This involves the veins being injected with a solution that will close the vein. Very small needles are used and this should cause little or no discomfort.
Following microsclerotherapy these small veins should be re-absorbed by the body and this may take up to three months or longer. It is possible that new small visible veins will occur in the same area and it is also possible that larger veins can re-appear in the future and further treatment may be needed to close them off again.
EVLA has a number of advantages. These are:
The advantages over conventional surgery are summarised in the following table:
Complications following EVLA are uncommon. Those of which you should be aware are: