Treatment of varicose veins according to their size

A varicose vein is a localized and permanent dilatation of a vein. In this article we will focus on varicose veins of the lower limbs which are the most frequent.

This abnormal dilatation is produced by the weakness of the vein wall, which usually has hereditary causes, and can be made more serious by excessive time in static standing (standing for a long time without walking). They are more common in certain professions and due to lack of physical activity.

Varicose veins are much more evident in the legs or lower limbs, precisely because gravity causes venous blood to accumulate in the legs due to their weight. Varicose veins can cause variable symptoms, finding in our offices patients with few varicose veins and intense discomfort (pain, heaviness, itching …), compared to patients who come with varicose veins of large caliber or even with venous ulcers that have had little symptomatology.

Varicose veins are treated in different ways depending on whether the vein is dispensable or not, as well as its size.

Treatments for varicose veins

Teleangiectasias or spider veins: The most common varicose veins are teleangiectasias or spider veins, which are small red, blue or purplish veins located very close to the surface of the skin, creating an aesthetic problem but has no impact on blood return in the strict sense.

The most effective treatment at present to treat these unsightly varicose veins is still injected sclerosis (with polidocanol or chromed glycerin), although laser sclerosis, preferably neodymium-yag, can be an alternative. In the legs or lower limbs it is usually less effective and requires more sessions, but in turn is a more respectful technique with the skin.

Variculas or reticular varicose veins: If we slightly increase the size of the varicose vein, we find ourselves with variculas or reticular varicose veins, which can cause symptoms of heaviness and may even favor flaccidity or even orange peel (commonly known as cellulite). They are perceived as blue veins that can cause slight bulging through the skin.

The most effective treatment for the elimination of reticular varicose veins is foam sclerosis. Sclerosis, both direct and with foam, is a treatment that is performed in the doctor’s office and does not require hospitalization or anesthesia.

The injected drug damages or burns the venous vessel, which is then reabsorbed by the body. The main precaution in this type of treatment is to warn the patient that it is a treatment with slow results, where several months may pass from the injection of the drug until the total disappearance of the venous vessels.

This period is the time necessary for the reabsorption of the disappearing venous tissue, which occurs with a slight inflammation. This is why, during the first weeks after a sclerosis session, the legs may have an unsightly appearance that recovers by itself. For this reason, we recommend performing these treatments in autumn or winter.

This is the explanation why the treatment is also scheduled in several sessions, since the tolerance to the treatment depends on the amount of drug injected, and should not exceed a certain amount.

This does not mean that the treatment should be prolonged for many months, but that the appearance of the legs will improve for months after the sclerosis sessions have been completed.

The time between sclerosis sessions will depend on the amount of drug injected in each session and the patient’s tolerance, generally recommended between one and three weeks.

To facilitate the reabsorption of the venous tissue it is mandatory to follow the indications given in consultation, which basically include the use of compression stockings and the application of creams that accelerate the process. During this period of time, the skin over the treated veins may show hyperpigmentation, i.e. it may darken slightly or moderately.

This hyperpigmentation is transitory and disappears progressively, although, in certain types of skin, it may be advisable to apply creams that inhibit the formation of melanin, depigmentation or pulsed light treatments after sclerosis to achieve an adequate aesthetic result more quickly.

3.- Truncular varicose veins (internal and external saphenous). When varicose veins are thicker, surgery may be indicated. This indication appears when the dilated veins are truncal veins, such as the internal saphenous vein or the external saphenous vein, especially when they are diseased from its inception, which is what we call saphenous arch. Varicose veins derived from the internal saphenous vein are usually located along its course, on the anterior and internal aspect of the thigh and leg.

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The internal saphenous vein, despite being a larger caliber vein, is dispensable. In fact, it is a vein that surgeons use to perform arterial bypass when we want to revascularize another organ such as the heart. When the internal saphenous insufficiency is sufficiently severe, it should be eliminated.

In cases of internal saphenous vein involvement, a conventional internal saphenectomy can be performed, which is still a widely applied technique with very satisfactory results. This surgery is usually performed under spinal anesthesia (i.e. puncturing the back and leaving the patient asleep from the waist to the feet) or general anesthesia if the patient prefers. An incision of about 4-5cm is made in the inguinal crease and one and a half centimeters in the inner aspect of the ankle, completely extracting the vein thanks to intravascular phleboextractors. A careful surgical technique that reduces the occurrence of postoperative discomfort.

The patient remains hospitalized for about 6-12 hours after surgery, although it takes about three weeks for the patient to walk freely again. During these three weeks, it is necessary to follow a schedule in which we alternate periods of rest with the leg elevated with short periods of 5 to 10 minutes walking, always with the compression stocking.

Alternative treatments that allow the elimination of varicose veins without the need to remove it: internal saphenous saphenous sclerosis.

Currently there are other techniques that allow the elimination of varicose veins of the internal saphenous vein without removing it, but burning the vein inside the body to cause its subsequent reabsorption by the body. This procedure is called internal saphenous sclerosis, similar to sclerosis for smaller veins, but with techniques that burn the vein from the inside and more precisely to avoid damaging deeper veins.

For the internal saphenous vein, this treatment can be performed by introducing a catheter into the vein through a puncture made slightly below the knee. Once this catheter is introduced and placed under ultrasound control, the vein is burned by laser or radiofrequency energy. In this way we avoid surgical wounds.

The techniques of saphenectomy or saphenosclerosis with laser or radiofrequency must also be performed under anesthesia and sedation, because during the laser or radiofrequency treatment pain may occur.

The patient remains hospitalized for 3-6 hours after surgery, although it takes about two weeks to walk freely again. During these two weeks it is recommended to follow a program that alternates periods of rest with the leg elevated with short periods of walking, avoiding standing without walking, always with the compression stocking on.

Alternative to conventional treatments: Venaseal

The newest technique for the treatment of internal saphenous vein varicose veins consists of sealing with Venaseal biological glue. This surgery does not require wounds, being the least painful procedure and with the fastest recovery. It is recommended for patients who cannot tolerate anesthesia or cannot interrupt their professional activity. Once a catheter is introduced and placed under ultrasound control, a biocompatible glue is injected to seal the internal saphenous vein completely.

The advantages of this treatment are that it does not require anesthesia, does not require hospitalization, does not require subsequent rest and has almost no postoperative discomfort. The disadvantage is that being a new technique, we do not scientifically know its long-term results, although everything suggests that its results will be similar to laser or radiofrequency.

Varicose veins derived from the external saphenous vein are usually located along its course, on the back of the knee. The external saphenous vein is smaller than the internal saphenous vein and of course is dispensable. The same techniques apply as for the internal saphenous vein.

The most classic technique that we usually recommend is the conventional external saphenectomy, which consists of making a wound in the posterior aspect of the knee of about 4 cm to section the vein. This surgery can be performed under local anesthesia.

The patient remains hospitalized for 3-6 hours after surgery, although it takes about 10-14 days to walk freely again, and during these two weeks it is recommended to avoid standing without walking, always with the compression sock on. The surgical wound remains in the popliteal crease, almost imperceptible, so it is not usually compensated to perform saphenosclerosis techniques.

Radiofrequency or laser saphenosclerosis, as well as occlusion with Venaseal biological glue, can also be applied in the territory of the external saphenous vein under ultrasound control with good results.