Varicose Veins: Managing Recurrence and Long-Term Follow-Up

Varicose veins are permanently dilated, superficial veins. This affliction is a result of venous reflux – the backward flow of blood in a vein, caused by incompetent (faulty) vein valves. There are many reasons why varicose vein occur, but the most predominant cause is a hereditary predisposition. In other words, if others in your family have or had varicose veins, you’re more likely to develop them. Other contributing factors include pregnancy, obesity, menopause, prolonged standing, leg injury, and abdominal straining. The latter is also the reason why varicose veins are common in the homeless and those reliant on a walking stick. This is because walking stick users mainly rely on one leg, and abdominal straining is required to lift oneself up with one leg. Varicose veins are most common in women and the elderly. This is chiefly due to hormonal influences and the loss of vein elasticity associated with aging. Women are at least 3 times more likely to develop the condition because of pregnancy and hormonal changes around menstruation and menopause. When varicose veins originally form, cosmetic, physical, and irritative symptoms usually indicate their presence. Symptoms can include aching legs, leg fatigue, swelling, and night cramps. Visual signs include dilated tortuous veins in the leg, discoloration of the skin, and chronic leg ulcers.

Definition and Causes

Successful treatment of ulceration necessitates a management plan for the underlying venous disease.

Patients with a healed venous ulcer have a high risk of ulcer recurrence, and it has been shown that ongoing treatment of the superficial vein reflux can reduce the rate of ulcer recurrence. Randomized trials have also shown that treatment of the saphenous veins by either surgery or endovenous techniques can reduce ulcer recurrence, but these trials enrolled only a small minority of patients with venous ulcers.

If left untreated, venous disease can lead to the development of leg skin changes and ultimately venous ulcers. The pattern is one of a recurrent and remitting condition with ulceration episodes. A recent population-based study has shown that the rate of venous ulcer development in patients with superficial vein reflux is of the order of 1% per patient year. This is a higher rate than previously suspected.

Varicose veins and venous leg symptoms are progressive and frequently get worse over time. The rate of progression is variable and difficult to predict for an individual patient. Wearing compression stockings can improve symptoms and may prevent progression of the venous disease and the development of skin changes.

Venous leg symptoms that are likely to be due to varicose veins or to the skin changes of chronic venous insufficiency affect around 25-30% of adults. The most common symptoms are aching, discomfort, and tiredness of the legs. These symptoms usually worsen throughout the day, especially in hot weather. Sometimes leg symptoms can be severe enough to interfere with work and leisure activities.

Presence of peripheral superficial varicose veins is very common. They have been estimated to affect 10-15% of men and 20-25% of women. Varicose veins are rarely a cause of serious health problems, but they can be very symptomatic and may have a significant impact on quality of life.

Importance of Managing Recurrence

There are two important stages in the management of recurrent varicose veins. The first is in the immediate post-treatment period where there is often extensive bruising and the symptoms worsen before improving. The patient needs to be reassured that this is part of the healing process and is a consequence of the trapped blood being reabsorbed. In the past, patients have been unwilling to tolerate this and have frequently requested early stripping of the treated leg, often exacerbating the problem as the new incisions produce further hemosiderin deposition.

Recurrence of varicose veins is a virtually universal phenomenon. Its long-term management comprises nearly 90% of a phlebologist’s practice. This should not be an unsuccessful search for a “cure,” but rather symptom control of a chronic disease. The ideal appearance of varicose eczema or a venous ulcer should prompt an earlier and simpler intervention to obliterate the skin changes by eradicating the underlying reflux. This concept, that the long-term consequences of venous reflux should be treated earlier to avoid progression to more advanced CEAP classes, is widely accepted.

Treatment Options for Varicose Veins

These can be done in a clinic and do not require a stay in the hospital or time off work. Elastic support hose is the most common non-surgical approach to the treatment of varicose veins. The hose squeezes the legs and helps improve blood flow in the veins. It also helps to keep new varicose veins from forming. Another treatment involving injection is considered the most effective varicose vein treatment, but these injections can only treat secondary varicose veins and not primary. The treatment is not suitable for everyone and is not suitable for veins that would be best treated with surgical ligation or other varicose vein surgery. It is also not suitable for those who have had blood clots, as these may be dislodged by the injections.

There are two types of treatment options: those which are invasive, containing surgery, and those which are non-surgical. The choice will depend on how severe your varicose veins are. Non-surgical treatments are usually used for patients with less severe varicose veins, but can also be used as a follow-up treatment once you have had surgery on your more severe varicose veins to prevent new veins from appearing.

Non-Surgical Treatments

Elastic compression can be considered as a form of self-help or adjunctive treatment for people with varicose veins. It has been shown to give subjective improvement in leg symptoms and mild objective improvement in venous blood flow. Its effects on reversing venous hypertension and improving skin changes are less clear. Randomised controlled trials have not been performed for elastic compression, and due to the inconvenience and cosmetic disfigurement, regular use of compression stockings is not acceptable to many patients.

Non-surgical treatments have been used for many years to treat varicose veins. Many of the new techniques evolve from the traditional surgical operations, and the more recent investigational procedures are minimally invasive. Non-surgical methods are usually effective as a first line of intervention for people with relatively few symptoms from varicose veins. In addition, some people may choose a non-surgical treatment after a surgical operation has proved ineffective. This most commonly applies to recurrent veins after a surgical operation; repetition of the high tie and strip operation gives an inferior result and is often associated with a higher incidence of complications than the first operation.

Surgical Treatments

Ligation and stripping of the saphenofemoral junction with ablation of the greater saphenous vein is still the commonest saphenous intervention, although increasing use of tumescent local anesthesia and endovenous techniques using laser or radiofrequency energy has mathematical modeling evidence for cost effectiveness. A recent multi-center trial has shown in patients with predominantly truncal reflux; laser therapy is as effective as surgery in terms of occlusion rates and improvement in disease-specific quality of life scores, but with less postoperative pain and a quicker return to normal activities. In the UK, NICE has issued guidelines that both surgery and endovenous methods should be offered to patients in whom an above the knee, greater or small saphenous trunk is to be treated, taking into consideration the patients’ needs and concerns, and only to providers undertaking appropriate training and in units capable of managing complications.

Surgically stripping out the veins from the leg was first described by Babcock in 1907. The procedure was refined and popularized in the 1940s, but two key issues were recognized—firstly, a segmental approach was adopted rather than complete removal of all saphenous trunks, and secondly there was no way of dealing with isolated refluxing veins less than 5mm in diameter. Various attempts at treating the saphenous trunks resulted in less morbidity, although equivocal long-term outcomes. These included high ligation and partial stripping, ambulatory phlebectomy, and more recently, ablative techniques using either laser or radiofrequency energy delivered through a sheath in the vein.

Strategies for Long-Term Follow-Up

Monitoring for the recurrence of varicose veins can be challenging due to the insidious nature of the condition and the fact that symptoms occur at different rates. The term recurrence loosely refers to any appearance of varicose veins after the initial treatment. It is essential that a baseline clinical picture is documented after the treatment, so any change can be identified. At The Whiteley Clinic, we use a combination of the Venous Clinical Severity Score and digital photographs to document a patient’s clinical state. Any change or development of symptoms suggestive of a recurrence should prompt a venous duplex scan. This is an ultrasound test, which gives information about blood flow in the veins. A duplex scan is very effective for finding the cause of varicose veins and it can be repeated as often as needed. It will often show if there is a problem with the valves in the vein, which would suggest that treatment might be effective for preventing progression of the condition. Often, just reassurance that there is not a surgical problem and conservative management of symptoms can be all that is required. However, if there is a good indication for treatment, early intervention can prevent progression of the condition and development of more severe symptoms.

Monitoring for Recurrence

Patients with a past history of varicose veins have a 60% chance of developing a new vein problem. There is a strong propensity for veins to return over time. By five years following any treatment, 40-80% of patients have at least some return of their varicose veins. The most common cause of recurrence is regrowth of the treated veins, rather than the development of new problem veins. Recurrence can also occur from progression of pre-existing vein problems that were insufficiently treated in the first instance. New vein problems can also develop in patients who had successful treatment. Recurrence can range from mild to very severe and can happen at any point in time following treatment. It is generally unpredictable and there is no precise way of determining if or when it will occur. For these reasons, it is important for all patients to remain vigilant of their leg veins indefinitely. A transient sensation of heaviness, aching or swelling of the legs is often the first sign of recurring vein problems. Any such symptoms should prompt patients to inspect their leg veins, looking for signs of bulging surface veins or hidden varicose veins deeper in the leg. Patients who have had treatment for severe or complicated varicose veins, or those with a strong family history of vein problems, are at higher risk of recurrence and should be extra careful to monitor their veins proactively. High-resolution ultrasound can detect potential or actual problems with the leg veins and can be useful for monitoring in patients at high risk of recurrence or those with unexplained leg symptoms. Ultrasound is often more readily available than it was in the past and offers access to non-invasive vein imaging with fast results and relatively low cost.

Lifestyle Recommendations

Venous symptomatology is associated with occupation. Some studies indicate that “prolonged standing” or “heavy manual work” are risk factors for the development of varicose veins, 31, 33 but others have found no association. 12, 14, 29 Interest has centered on nursing and the wearing of nursing uniforms, and two small studies suggest that nurses have a higher prevalence of varicose veins than the general population, 40 or other healthcare workers. 41. Temporal effects, with the wearing of white stockings linked to varicose veins in those nurses who had not previously worn a uniform. 42 The evidence is not consistent and does not enable the rationalization of nursing as a “definite” risk factor. Heavy lifting and shift work have also been linked to increased prevalence of varicose veins in international studies of energy corresponding to heaviness or achiness in the leg. This occurs in up to two-thirds of those with varicose veins and often limits normal activity. Symptoms are thought to be worse at the end of the day or after prolonged sitting or standing. In severe cases, symptoms can lead to a feeling of leg swelling that may progress to chronic venous insufficiency or skin changes between the ankle and mid-calf culminating in venous ulcers. In severe cases, symptoms can lead to a feeling of leg swelling that may progress to chronic venous insufficiency or skin changes between the ankle and mid-calf culminating in venous ulcers.

Three recent studies have suggested that weight and obesity are not associated with a substantial risk of developing new varicose veins. 6-8 Overall, the corpus of evidence available on the link between weight and varicose veins is inconsistent and does not suggest a strong causal relationship.

Importance of Regular Check-ups

Patients should be aware that the superficial venous system is a progressive disease and new problems may develop over time. In much the same way that regular dental check-ups aim to prevent the occurrence of new cavities, regular venous check-ups seek to prevent the occurrence of new varicose veins and thereby reduce the likelihood of needing more treatment. Emerging problems such as the development of skin changes or swelling due to deep vein reflux can often be improved if they are detected at an early stage. This is important because advanced skin changes are often irreversible and can lead to the development of a venous ulcer.

Important treatment of varicose veins may have been completed many years ago, but the superficial venous system remains abnormal, predisposing the patient to recurrent symptoms and chronic venous disease. Consequently, even if the leg feels entirely better after treatment, taking part in regular exercise and occasional use of compression stockings may be beneficial in preventing the return of varicose veins. Unfortunately, recurrence is inevitable unless patients continue regular follow-up with their vein specialist. Check-up intervals will vary depending on the individual patient’s circumstances and the presence of any current symptoms. For those patients in whom recurrence would have serious implications (e.g. leg ulceration), it is conceivable that regular surveillance and periodic prophylactic treatment with further foam sclerotherapy or RFA may be an appropriate strategy to prevent clinical deterioration.

Tips for Preventing Varicose Vein Recurrence

A healthy diet and weight management are also very important. Maintaining a diet that is high in fiber is very beneficial, as constipation can lead to an increase in pressure in the abdomen. This can, in turn, lead to an increase in pressure on the leg veins, which may result in varicose vein recurrence. In more severe cases, this pressure can cause the development of varicose veins in the abdomen and pelvis. This is known as pelvic congestion syndrome and is more common in women, particularly those who have had children. Weight management is also important. Studies have shown that even a modest weight loss can reduce the symptoms of varicose veins. This is due to a reduction in the pressure on the leg veins.

Exercise is very important. It is useful to engage in activities that use the calf muscle because this helps the veins and circulation in the leg. Walking is the best in this regard, and swimming is another good exercise for the legs. Running is also fine. On the other hand, cycling is less effective for improving circulation because it does not involve the calf muscle. Any vigorous exercise is good for people with varicose veins, as this will help to raise the calf muscle. When the legs are at rest, the calf muscle is inactive and this reduced activity can lead to a decrease in the effectiveness of the calf muscle pump. Regular periods of rest with the legs raised are also beneficial. This is to reduce the pressure in the leg veins that builds up during the day. The aim should be to elevate the legs above the level of the heart for 10-20 minutes, 3-4 times per day. This can be a useful aid to the prevention of long-term problems.

Exercise and Physical Activity

The focus of this section is to provide supportive evidence and rationale for regular physical activity as a means to prevent varicose vein symptoms and reduce the risk of varicose vein recurrence. Our primary concern was the potential limiting effect of chronic venous insufficiency and varicose veins on physical activity, meaning we needed to provide clarification of the cause and effect of varicose veins in relation to the functional limitation. Ultimately, the goal of using exercise as a means of preventing varicose vein recurrence is to not exacerbate symptoms while maintaining or improving overall health and function. By the end of this section, it should be evident to the reader that the therapeutic dependence of exercise replaces the use of standing as a means of alleviating symptoms associated with varicose veins.

Healthy Diet and Weight Management

A balanced diet is essential to ensure sustained weight loss and enable weight maintenance. Dieting alone will result in reduced muscle mass and fat loss, but also muscle loss, with a weight regain fat-rich weight. In general, a low-calorie diet will result in around 60-70% of the weight loss from adipose tissue and 30-40% from lean tissue. A healthy diet improves healing, immunity, and prevents recurrence of problems with varicose veins. It is essential to maintain a BMI within the normal range for both overweight patients and after weight loss from obese patients. Recommendations for weight loss in obese patients are weight losses of 0.5 to 1 kg per week. This is achieved through a negative energy balance of 500-1000 kcal per day. This can rarely be achieved through exercise alone and by reducing calorie intake. A negative energy balance up to 500 calories per day can be achieved through dietary modification. Low-fat, reduced-calorie diets are effective in overweight and obese patients. They can achieve weight loss of 3-6 kg in a year, which will decrease venous and inflammatory issues. High-protein, low-carbohydrate diets have increased in popularity. A study on obese patients with type 2 diabetes showed that a high-protein, low-carbohydrate diet had improved several low-grade inflammatory markers. Sugar content and simple carbohydrate intake are also important considerations in a dietary plan. It has been shown that increased sugar-sweetened beverage consumption is associated with increased visceral and liver fat. Sugary drinks have also increased plasma triglyceride and uric acid levels. Uric acid is an established marker for refined sugar and simple carbohydrate intake and has a positive correlation with gout, hypertension, and chronic kidney disease.

Avoiding Prolonged Sitting or Standing

The tips below are taken from the National Institute for Health and Clinical Excellence (NICE, UK) Varicose Veins: Understanding NICE guidance, information for the public, and the American College of Phlebology. These guidelines are based on the best available evidence. Measures aimed at preventing varicose vein recurrence are essentially the same as those for preventing the development of new varicose veins.

For patients with persistent or recurrent symptoms, it is important for their doctor to assess the underlying cause and severity of their varicose veins in order to recommend the most appropriate treatment. Patients who have previously undergone saphenous vein surgery, but whose symptoms have returned, may want to consider their treatment options in the context of the long-term results. An ultrasound examination of the leg veins would provide a clear diagnosis of the underlying problem. Treatment may involve repeat surgery, though increasingly non-surgical treatments such as ultrasound-guided foam sclerotherapy are being used with good results and much less discomfort.

Varicose vein recurrence is a common concern for many patients following their treatment. Symptoms often return within a few years, though they may not be as severe. Varicose veins that are not symptomatic may not require any further treatment. However, if symptoms begin to interfere with your quality of life, you may want to consider further treatment to seal or remove the abnormal veins.

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