Varicose Veins are largely a hereditary condition in which the veins just under the skin are unusually large, prominent and tortuous. The veins gradually become more distended due to increased pressure caused by defective valves in the vein at the groin or behind the knee. These veins do not provide any important function as the main drainage of blood from the leg is through large veins situated deep in the leg. In varicose veins, blood flows in the wrong direction due to valve defects. Therefore removal of these large varicose veins does not compromise the circulation in any way.
Objective Of Surgery
The objective of surgery is to tie the vein at the site of valve incompetence and remove as much of the dilated vein system as possible.
These are blue/red thread like veins in the skin. They often co-exist with varicose veins. These will not be improved by surgery. They can be treated by injection (or sclerotherapy) or possibly laser treatment. There is a separate information leaflet on this topic available here.
Prior To Surgery
The contraceptive pill or HRT should be stopped for 6 weeks prior to surgery (see below). Scans of the veins may be carried out using ultrasound in the vascular laboratory. This scan is completely painless and without risk as no x-rays are used. You will be preassessed by the day ward team prior to being booked for surgery. At the time, you will be given detailed instructions about the procedure on the morning of surgery and what you should bring with you.
Morning of Surgery
You will be seen by a member of the vascular surgery team in the day ward on the morning of surgery. If you have any additional questions which have not been addressed by the leaflet or in the OPD, you will have an opportunity to ask these at this time. The veins on the legs will be marked - make sure that any veins that are causing you particular concern have been identified. You will walk to the operating theatre with a nurse and be brought inn to have an anaesthetic. When you are asleep in the operating theatre, we will shave the leg and a small area of the groin but if you prefer to get your legs waxed, this should be carried out at least two days prior to surgery. The visible large veins are marked using a skin marker. The anaesthetist will decide on the type of anaesthesia used, i.e. general or spinal/epidural anaesthesia. You should fast, i.e. no food or drink to be taken after midnight on the night prior to surgery.
The operation may be carried out as a day care or in-patient procedure. As surgery is not performed on both legs in one operation, if you have varicose veins in both legs you will need two hospital admissions.
Day Care Surgery
Having fasted from midnight, you come into hospital early in the morning. Surgery is carried out early in the day to enable sufficient recovery to return home in the afternoon. It is better if you do not have to travel more than one hour from the hospital following day care surgery. Make sure to wear track suit bottoms or loose trousers and flat, comfortable shoes as you will have a bulky bandage applied to the leg after surgery.
In-Patients are admitted to hospital on the day prior to or on the day of surgery and usually discharged on the day after surgery. Patients may require blood tests, chest x-ray and/or cardiograph. These will be carried out in the hospital prior to surgery.
In conventional open surgery, the area of the defective valve is exposed through a small (usually 2-3cm) incision in the groin, the junction with the deeper vein is ligated, the troublesome vein is then stripped from the thigh and the remaining varicose veins are then removed piecemeal through small (5mm) incisions. Absorbable (dissolving) sutures are used in the groin and/or behind the knee. The other wounds in the leg are all closed using paper tapes ("Steristrips")
In certain cases, rather than removing the troublesome vein from the thigh, it can be obliterated using radiofrequency energy (similar to the commonly described "laser" technique) avoiding the need for an incision in the groin. In this case, ultrasound is used to guide the puncture the long saphenous vein at the knee below the knee. A radiofrequency catheter is passed from the knee to the groin inside the vein and the area infiltrated with local anaesthetic under pressure. Guided by ultrasound imaging, the physician treats sequential 7 cm segments of vein with a 20-second burst of radiofrequency energy, heating the vein to 120° C and causing the vessel to shrink around the catheter. The catheter is withdrawn until the entire length of the vein has been sealed. this technique may cause less bruising and postoperative pain than conventional surgery.
If you have day care surgery, you are discharged home with a bandage from toe to thigh. An elastic stocking will be provided. On the day after surgery you should remove the bandage and apply the elastic stocking. As the leg is often still tender, application of the stocking will cause a little discomfort.
On removing the bandage, one or more of the steri strips may peel off and there may be slight bleeding, It may be necessary to apply a little pressure and band aid type dressing to control bleeding.
During the week following surgery it is important that an elastic stocking be worn at all times. Stockings can be changed and washed.
There will be discomfort in the leg in the days following surgery. Occasionally the discomfort does not develop for 3-6 days following surgery. Medication for pain will be provided and should be taken as required.
Walking is important. However it is not necessary to walk great distances. We suggest 10-15 minutes walking a couple of times per day starting the day after surgery. Prolonged standing will lead to discomfort and should be avoided if possible.
When sitting put your foot on a stool or chair. It is better to avoid long car journeys for the first couple of days.
You should keep your leg dry for 4-5 days. After 5 days you may shower but should avoid soaking the leg. On the eighth day following surgery you should bathe the leg and peel off the steri strips. Applying a damp cloth may help.
Following removal of the steristrips, olive oil, baby oil or other agents such as Silcock's base should be applied as the skin will tend to be dry. You should continue to wear the stocking during the day but it can be removed at night.
Continue to wear the stocking during the day until the bruising has resolved. This varies from patient to patient and can take from 2 -6 weeks to resolve. You should not wax your legs for 3 to 4 weeks following surgery.
Quite frequently lumps will be evident underneath the skin and these may be quite tender. This is quite normal and may take up to 3 months to resolve completely.
Getting Back To Normal
Recovery varies from person to person but generally speaking, you should be able to get back to your normal routine after 2 weeks.
Work: The time to get back to work and normal activity is best dictated by how your leg feels, some people have much more discomfort than others. The nature of your work will also influence your return. People standing all day would need longer off work than those who have a desk job.Typically we advise people to plan for up to two weeks off work.
Exercise: Returning to exercise routine or swimming depends on the degree of bruising. Exercise such as jogging should be avoided until bruising has subsided. You should return to normal exercise gradually.
Driving: You will be able to drive shortly after surgery but you should not drive until leg movement is pain free.
Holidays and Travel: Short flights of 1-2 hours can be taken within 1-2 weeks. Long flights or sun holidays should not be scheduled until 5-6 weeks after surgery. On a note of general health care elastic stockings should be worn on all long haul flights, aspirin may be taken for 2-3 days before flights. These measures may help prevent blood clots developing in the legs.
Every effort is made to minimise complications from surgery and anaesthesia. However there is no guarantee that the results will be 100% satisfactory. Varicose vein surgery is technically demanding and can take 2 hours or more to complete one leg. This is in order to obtain, as far as possible, the best functional and cosmetic result.
Post operative problems occur as with any operation. These include:
- wound infection (0.2%)
- chest infection (0.1 %)
- reaction to dissolvable stitches (0.1%)
- severe bruising resulting in pain on walking for 2 weeks (0.3%)
- deep venous thrombosis (DVT) can occur after surgery and is symptomatic in up to 2% of patients. While serious complications of these DVTs is rare, it may be necessary to go on blood thinning medication and these clots may rarely travel to the lungs (pulmonary embolus). While pulmonary embolus is rare after varicose veins, fatal pulmonary embolus may occur.
- nerve injury causing temporary (20%) or permanent (5%) numbness. The nerves that supply sensation to the skin run in very close proximity to the veins and are occasionally bruised and damaged at the time of surgery. If a nerve is bruised but not completely disrupted sensation can return to normal and may take up to 6 months. Transient numbness is common , small areas of permanently reduced sensation occur in about 10%, and less than 5% have reduced sensation in larger areas such as the side of the foot. Sometimes, there may be an area of increased sensitivity or hyperasthesia around or instead of the numbness. This numbness and/or altered sensation may be permanent and may interfere wiht normal activities.
- injury to the motor (muscle controlling) nerves can rarely occur. This could cause weakness of the muscles that help move the knee or ankle joint (foot drop). This may occur due to direct injury to the nerves when removing the veins, traction or stretching of the nerves, or compression of the nerves between the bone and operating table or compression bandages. Usually this will recover but permanent motor nerve injury may rarely occur after varicose vein surgery and this could interfere with walking or other activities.
- leg swelling is common in the early period after surgery. Rarely, this swelling may be persistent or even become permanent (lymphoedema). This may require the use of compression stockings or other treatment on a long term basis.
- the major blood vessels of the leg (vein and artery) and located close to the surgical site and very rarely these may be injured. This can be a serious injury when it does occur adn could potentially put the leg at risk
If you have any worries or concerns post surgery please contact the vascular surgical team. We will be happy to answer any queries you may have. We usually review patients 4- 5 weeks post surgery, however if you have no problems and everything is satisfactory then this is not necessary.
Hormonal contraceptives or replacement therapy
Both oestrogen and progesterone use may be associated with an increased tendency to form clots. While this risk is very low in most people, lower limb surgery (including varicose vein surgery further adds to that risk. For this reason, we have adopted the following policy.
Combined (oestrogen/progesterone) or progesterone only pill should be stopped six weeks before surgery. It is important to use an alternative mode of contraception during this time as pregnancy can occur. You should discuss this with your GP.
Implantable devices need not be removed (norplant, mirena coil etc.).
Patients considered to be at particular risk may also be prescribed sub-cutaneous injections of anticoagulant at the time of surgery.
You can resume your regular contraceptive medication after 2 weeks in consultation with your GP.Updated 14/04/2017 Sean Tierney