PRIMARY VARICOSE VEINS
Uncomplicated varicose veins can be treated at any point of time and treatment should be minimally invasive and cosmetically acceptable. The recommended treatment is endovenous laser ablation or radiofrequency ablation of the major subcutaneous veins (Great or Short Saphenous Veins) with or without additional phlebectomy or sclerotherapy (veins are either removed from the leg via small incision not larger then few millimeters or are injected with a special substance that makes them shrink). Everyone with varicose veins deserves assessment including ultrasound scan and based on the findings he or she can be offered adequate treatment.
Patients with more advanced CVD (significant leg swelling not improving with stockings, skin pigmentation or even skin ulcer) should be treated as soon as possible. Leg ulcers are very difficult to heal and if they do heal they tend to reoccur (in up to 70% of cases they reopen again). The causes for these ulcers may be large primary varicose veins, previous deep vein thrombosis (DVT) or a vein compression (often between an artery and spine). For all patients with advanced CVD there is a realistic chance to improve their quality of life by a key-hole surgery (or mini-invasive surgical procedure under local anesthetic) with no overnight hospital stay. Results of this surgery have proved this is a very safe and reliable treatment.
ADVANCED CHRONIC VENOUS DISEASE
Patients with chronic swelling, skin pigmentation, redness or leg ulcers should seek a vascular specialist as their venous system is not working correctly.
Causes of chronic venous insufficiency are either “faulty valves” (incompetence or reflux) or a “blockage” in the deep veins (obstruction or compression). There are also often both obstruction and reflux found in many patients.
The concept of treatment of chronic venous insufficiency aims to:
- 1. Reduce (eliminate) obstruction
- 2. Reduce (eliminate) reflux (“faulty” valves in the veins)
Diagnosis is made by:
- Ultrasound assessment (by expert technician)
- CT Venogram/ MR Venogram – can give us more details about pelvic veins but up to 50% of blocked veins are underdiagnosed (blockage not seen) due to many issues (shape of the vein, non-contrast blood etc.)
- Formal venogram (or angiogram) – has much better sensitivity rate of underdiagnosed blockages
- IVUS (intravascular ultrasound) – the golden standard (unfortunately not funded and not always available)
The obstruction can be found in the venous system after DVT quite often. This is partially since in some segments of the venous system the vein after DVT often reopens incompletely despite adequate medical management (anticoagulation medication). Typical example is iliac (pelvic) or femoral (groin) veins. Obstruction increases venous pressure (Venous Hypertension) and is responsible for tissue damages.
In many people there is an asymptomatic (‘silent’) blockage waiting for a trigger like heart failure, inflammation, dehydration, etc. to become symptomatic – causing a non-thrombotic obstruction or acute DVT (a theory of a ‘permissive’ iliac vein lesion).
In certain complex situations where both reflux and obstruction play a role we treat one problem first. If the healing is satisfactory then no more intervention is required. If on the other hand, the healing is not as fast as we would have liked, another procedure is considered. It is mostly a combination of key-hole stenting (angioplasty) and phlebectomy (with or without laser surgery) that is usually opted for. In most of cases this is regarded as a day-procedure.
Redressing of the wounds in cooperation with a general practitioner or wound nurse is necessary for a certain period. Elastic compression stockings might not be necessary if the obstruction (and/or reflux) was successfully removed. There is a chance for patients who were wearing stockings to not to wear them afterwards at all. Anticoagulation medication (warfarin, dabigatran, etc.) in some situations is required and also aspirin (or Plavix) can be prescribed due to a previous DVT or stent placement, but in certain cases even those medications might be ceased, and the patient might not take any of them following a successful operation.
Cooperation with hematologists, dermatologists, wound nurses and general practitioners is necessary during and after the treatment of CVD. Patients are also encouraged to look for a second opinion.
Technology is advancing every year and there are a number of new devices available that may change a patient’s quality of life. If a previous physician’s intervention failed several years ago it does not mean that the next intervention will fail again. It might be the right time to discuss your leg problems with a different vascular specialist in Perth and revisit your options.
ACUTE DEEP VEIN THROMBOSIS (DVT) AND ITS CONSEQUENCES
Acute DVT can clot off any vein in the body. If the pelvic vein gets affected the full recovery is seen in only the minority of cases. Calf or thigh veins reopen more frequently by the body’s inner “clot dissolving” mechanism after several weeks. Therefore we advocate an intervention for pelvic vein thrombosis (Iliofemoral DVT) as soon as possible. This window of opportunity is 1-2 weeks and therefore patients have a time to seek adequate medical attention. General practitioner should put the patient on anticoagulation medication and refer them to a physician specialising in venous disease. Treatment method of choice is a pharmaco-mechanical thrombolysis, where a small catheter is placed into a vein and the clot is sprayed with a solution that allows it to dissolve. The clot is then sucked out clearing the vein. In most cases there will be an underlying blockage in the vein which might have triggered the DVT in the first place and this obstruction needs to be repaired by placing a stent in the vein. The stent is a flexible but strong (usually nitinol) spring that will keep the vein open. This procedure also can be done as an outpatient with no hospital stay.