Leg vein problems mainly encompass varicose veins and deep vein thrombosis, both of which can be fairly distressing conditions. However, active treatment is not always necessary for varicose veins unless it is for cosmetic reasons or when they cause sufficient discomfort or produce complications. On the other hand, deep vein thrombosis needs to be diagnosed and treated at the earliest, so as to prevent the clot in the vein from breaking off and lodging in a blood vessel in the lungs, leading to the much dreaded and potentially life-threatening complication known as pulmonary embolism.
Varicose Veins Treatment
Varicose veins are twisted, dilated and visibly prominent veins that are most commonly seen on the surface of the legs. It occur due to venous insufficiency, where the one-way valves in the veins that normally allow blood to move towards the heart are damaged, thus causing blood to flow back into the legs. Varicose veins are usually diagnosed by the typical appearance. To determine the position and extent of valve damage, ultrasound of the veins may be done, with Doppler ultrasound providing more specific information. This is usually necessary when active surgical or non-surgical treatment is being contemplated.
Treatment for varicose veins is not always necessary. In many cases, treatment is sought for cosmetic reasons. At other times, treatment may be indicated due to the presence of symptoms such as pain or swelling, or because of the severity of the problem causing complications such as ulcers. Varicose veins may be treated by non-surgical or surgical methods. The type of method best suited for an individual will depend upon the age of the patient, size of the varicose veins, location of the veins, and the presence of symptoms or complications.
Varicose Veins Non-Surgical Measures
Lifestyle changes are advisable both to improve the condition and prevent it from worsening any further. These measures include :
- Avoiding standing or sitting for long periods of time.
- Elevation of the leg while sitting or lying down.
- Losing weight if obese.
- Regular exercise such as walking.
Another very effective and widely used non-surgical measure is the use of compression stockings. These specially designed stockings help to reduce the amount of blood in the veins and aid in moving the blood towards the heart. Compressive stockings may give symptomatic relief for pain and swelling of the legs. The relief may only be temporary if used for a short time since blood will flow back into the veins once the compression stockings are removed. There are many different types of compression stockings and they are best used as advised by the doctor.
Varicose Veins Surgery
Vein Ligation and Stripping
Varicose vein surgery involves ligation and stripping of the varicose veins. The varicose veins are tied (ligated) and removed through small incisions in the skin. Eventually, the deep veins of the legs take over the function of the superficial veins that have been removed. This surgery is performed under general anesthesia. The recovery period after surgery may be between 1 to 4 weeks. This procedure is usually performed for treatment of very large varicose veins or in those patients with severe pain or ulcers.
This procedure is done by injection of a liquid into the vein. The chemical solutions most commonly used are hypertonic saline and sodium tetradecyl sulfate. These sclerozing agents damage the inner lining of the vein and close it by triggering edema and clot formation. The damaged vein turns into scar tissue which gradually disappears. Successive treatments may be needed on the same vein.
- Sclerotherapy does not require anesthesia and can be done at the doctor’s office. The patient may resume normal activity immediately.
- Sclerotherapy is normally performed when lifestyle changes and compression stockings are ineffective. It is usually most effective for treatment of spider veins and small varicose veins.
- Sclerotherapy may produce complications such as dark discoloration or hyperpigmentation of the injected area, ulcer around the injected site, or formation of new spider veins near the treated site.
Endovenous Laser Treatment
In this procedure, a fine laser is passed inside the varicose vein, thus damaging it and causing it to close.
Radiofrequency ablation uses a high frequency electric current to heat the wall of the varicose vein. This damages the vein thereby causing it to close. It is done under local anesthesia.
Also known as micro-incision or stab phlebectomy, this is usually performed as an outpatient procedure under local anesthesia. Tiny incisions are made on the leg and the varicose veins are hooked out and removed through these incisions.
Transilluminated Powered Phlebectomy
This procedure for minimal invasive varicose vein surgery requires less time to perform and may give good cosmetic results with fewer complications. A tiny light source inserted under the skin provides better visibility of the varicose veins and a powered phlebotomy device is used to remove the varicose veins. The procedure may be done under local anesthesia.
Deep Vein Thrombosis Treatment
Deep vein thrombosis (DVT) is a condition that occurs due to a single blood clot or multiple clots developing in the deep veins of the leg. Prolonged immobilization is the most important factor leading to DVT. Early diagnosis and treatment is of paramount importance in this condition so as to prevent the development of pulmonary embolism which is potentially fatal.
DVT may be diagnosed based on the clinical history and physical examination. An ultrasound can not only diagnose the condition, it can also help to detect the site and size of the clot. The D-dimer blood test may indicate the presence of a blood clot. A CT scan or MRI scan can also help to detect a clot. Venography is rarely done nowadays for diagnosis of DVT.
The aim of treatment should be to :
- prevent the blood clot from increasing in side,
- reduce the risk of further clots, and
- avoid dislodgement of the clot and the possible development of pulmonary embolism.
Since a small clot below the knee is less likely to embolize, it may not need any active treatment except management of the underlying cause. Monitoring of serial ultrasounds and careful observation should be done to see that the DVT is not extending above the knee.
Anticoagulants or blood thinners cannot dissolve existing clots but help prevent the formation of new clots and also prevent the existing clots from increasing in size. Anticoagulation therapy (warfarin and heparin) is the treatment of choice for treatment of DVT above the knee provided that there are no contraindications. Contraindications may include :
- recent surgery
- bleeding disorders
- potential bleeding lesions such as active peptic ulcer
- pregnancy (warfarin)
Warfarin therapy is usually continued for 3 to 6 months. Regular monitoring with blood tests such as INR (international normalized ratio) will indicate the effectiveness of warfarin therapy. In some patients warfarin is continued for more than 12 months, while in others it may be continued for life, especially where the cause is not known or there is a risk of recurrent clots. The risk of bleeding increases when a person is on anticoagulant therapy.
Heparin injections may be started immediately. It can be given as low molecular weight heparin (enoxaparin) injections and treatment continued on an outpatient basis. The patient needs to be hospitalized if intravenous heparin is given. Warfarin, though being the drug of choice, takes a few days to be fully effective. It is given orally and is usually started along with heparin. Heparin injections are continued till warfarin reaches its therapeutic level.
DVT Non-Surgical Measures
Lifestyle changes are similar to the measures employed for varicose veins.
- Avoid sitting and standing for long periods without walking around or doing lower calf muscle exercises.
- Lose weight if obese.
- Stop cigarette smoking.
- Graduated compression stockings may be used to prevent or reduce leg swelling caused by DVT due to a complication known as post-thrombotic syndrome or post-phlebitis syndrome. These stockings are usually worn for at least 12 months following an episode of DVT.
Read more or watch the video on how to improve leg circulation.
Surgery may be indicated if medication is not achieving the desired results. Surgical procedures may include
- placing a filter in the large veins,
- injection of a thrombolytic or clot-busting drug, or
- surgical removal of a large blood clot
Vena Cava Filter
The inferior vena cava (IVC) is the large vein that carries blood from the lower parts of the body back to the heart. The blood is then pumped by the heart to the lungs. A filter may be placed in the inferior vena cava to prevent clots from reaching the heart or lungs but it cannot stop the formation of new clots. In fact, these filters may sometimes be the source of new clots.
Clot Busting Drugs
These drugs help to dissolve large clots rapidly. Clot-busting drugs such as streptokinase or alteplase may be used in some cases where there is severe DVT or pulmonary embolism. Thrombolytics are not used routinely as it may cause severe bleeding and is therefore only used in life-threatening situations.
Clot Removal Surgery
Surgical removal of a large blood clot is known as an embolectomy. A large blood clot in the iliac vein of the pelvis and the femoral vein of the leg can cause a condition known as phlegmasia cerulea dolens, where there may be severe obstruction to the blood flow. Removal of the clot is essential in this case and an embolectomy may be done.