Varicose vein surgery

Varicose veins are swollen and enlarged veins that usually occur in the legs and feet. They may be blue or dark purple, and are often lumpy, bulging or twisted in appearance. The veins carry blood towards the heart. They have tiny valves inside them which close to stop blood flowing the wrong way. Sometimes when the valves do not close properly the blood accumulates inside the veins and this causes them to swell.

You may also have 'thread veins' or 'spider veins' which are a network of small dark veins near the surface. These are not true varicose veins.

Varicose veins are very common. Around three in every ten people develop varicose veins. They can be related to pregnancy, being older, being overweight, having a close family member with varicose veins and standing for long periods. However, they do not cause medical problems in most people.

There are a number of symptoms which may suggest you should have treatment for your varicose veins. These include:

• swelling in the affected leg
• heaviness and / or dull, achy feeling in the affected legs at the end of the day, or after physical activity
• itchiness and changes to the colour of the skin of the affected leg

The damaged valves in the veins cannot be cured so the best way to treat the problem is to close off the affected veins or to remove them altogether. The surgeon can use radiofrequency energy or a laser to heat the veins so that they close off. This is known as radiofrequency ablation or laser ablation. Removing the veins completely is called avulsion. Sometimes the surgeon will use ablation and avulsion during the same procedure. The procedure does not affect blood flow because other veins take over this job.

The operation is particularly suitable if the varicose veins cause another problem such as:

• an ulcer (or sore) on the affected leg, or threat of ulceration
• veins have caused bleeding through the skin
• inflammation in the veins
• aching in the veins

Patients will not normally be offered surgery if the varicose veins do not cause other problems.

As with any operation, there are complications associated with a varicose vein surgery

Sometimes a little blood will ooze from the wounds during the first 24-48 hours after surgery. This usually stops on its own.

For this reason, it is best to keep the leg(s) covered with compression bandages. If bleeding a lot, contact you GP immediately or go to accident & emergency

Thrombophlebitis – radiofrequency ablation and laser ablation work by heating the wall of the vein. This will cause inflammation of the vein wall which is known as thrombophlebitis. You may feel the vein that has been treated becomes hard and tender. Varicose veins that are connected to the treated vein may also become hard and lumpy.

Nerve damage – in some patients’ nerves lie next to the veins. These may also become damaged by the heat from the ablation procedures or by the avulsions. Some patients notice small patches of numbness on their skin or a decrease in sensation. This usually improves over time, but it can be permanent. Sometimes patients have pain on the skin where the veins have been treated and is usually relieved by taking simple pain killers.

Bruising – this is very common. There is usually extensive bruising in the leg, particularly down the inside of the thigh after operation. This bruising usually lasts for 3-4 weeks. They will fade with time.

Lump – hard, tender lumps may appear near the scars or in the line of the removed veins. These can appear few days or a week after surgery. You do not need to worry about these lumps. However, see your GP immediately if you also have excess swelling, redness and pain-you may develop a wound infection

Blood clot – sometimes a blood clot may form in the veins which are connected to the vein which has been treated. This type of clot is not usually dangerous, and your body will naturally absorb it in a few weeks.

A deep vein thrombosis (DVT) is a blood clot in the deep veins in the leg. This is a recognised complication of the surgery. If part of the clot breaks away and travels to the lungs this is known as a pulmonary embolism (PE). This can be dangerous. The risks of deep vein thrombosis and / or pulmonary embolism are low, but they can occur.

Recurrence – there is a chance that new varicose veins will form after the surgery.

Wearing compression stockings is a good option for many patients. They encourage blood to flow up through the veins and help to control many of the symptoms. However, they will not change the appearance of the varicose veins or treat the problem and you will need to wear stockings for the rest of your life.

Sclerotherapy is a treatment which involves injecting foam or liquid into the veins under ultrasound guidance. This causes scars to form inside the veins which then close up. Please ask your surgeon if you would like more information about sclerotherapy.

In most cases, a simple examination with an ultrasound machine is all that is required to enable your surgeon to decide what needs to be done, a test called duplex ultrasound scan. This test will be done in the Vascular Laboratory at the University College Hospital.

If your operation is being done under general anaesthetic, we will organise a pre-assessment appointment. This is done by pre-assessment team of nurses and anaesthetists. They will ask you for details of your medical history and carry out any tests we need to make sure you are fit for a general anaesthetic and the operation. Staff in pre-assessment will tell you how to prepare for your operation, when to stop eating and drinking and about the admission process.

Varicose vein surgery is often carried out as day case if you are fit and have a family member or friend who can take you home and be with you overnight. You may however need to remain in hospital overnight if:

• You have a complex surgery
• You have any complex medical problems
• You live alone (This will be discussed with the team looking after you)

Please note, varicose vein surgery is ‘pooled’ (you may be switched from the care of one consultant to another after your initial appointment).This is to maximise theatre use and equalise waiting times.

We’ll ask you to come in the day before or in the morning of surgery. Please bring all of the medications you are currently taking with you.

The surgeon and the anaesthetist (if you are having a general anaesthetic) will meet you and explain your operation and the possible complications and answer any questions you have. If you agree to go ahead with the surgery, you will sign a consent form.

Your veins will be marked with a waterproof pen so it is clear which veins will be removed.

We want to involve you in all the decisions about your care and treatment. If you decide to go ahead with treatment, by law we must ask for your consent and will ask you to sign a consent form. This confirms that you agree to have the procedure and understand what it involves. Staff will explain all the risks, benefits and alternatives before they ask you to sign a consent form. If you are unsure about any aspect of your proposed treatment, please speak with a senior member of staff again.

The procedure usually takes 60 to 90 minutes, but a particularly complicated operation could take longer. Varicose vein surgery can be performed under general anaesthetic (the patient is fully asleep) or under local anaesthetic (where the area is numbed, and the patient is awake) if preferred.

The operation varies from patient to patient, depending on the location of the leaky valves are.

For ablation procedures the surgeon will use ultrasound to locate the superficial truncal vein (one of the large leg veins near the skin). A small tube called a catheter is then placed into the vein and radiofrequency energy or laser bursts are used to close it.

In most cases, the visible varicose veins are removed from the leg through tiny incisions (cuts) about 2-3mm in length. Incisions are placed about 3-5cm apart along the line of the varicose vein. There may be many small incisions if the varicose veins are extensive.

Occasionally, the operation may require a cut in the groin or behind the knee. This will be discussed with you as necessary.

Blood can still flow up the leg along deeper, unaffected veins.

Tiny cuts are then closed with adhesive strips or stitches.

After the surgery, compression bandages are applied to the leg(s) up to the top of your thigh(s) for the first 48 hours. After this time, these are replaced with compression stocking(s). Wear the stocking(s) all day and night for the first week. During the second week, you may leave the stocking(s) off at night, but you still need to wear the stocking(s) during the day. Wearing compression stockings helps minimise pain and swelling, reduce bruising and prevent clots.

You will be taken to theatre recovery unit after your operation for close monitoring, this is where you will wake up. Once fully awake you will then return to day care ward.

Most people describe the leg(s) as stinging or burning when they wake up. It is unusual for the leg(s) to be painful. You should be able to eat and drink again within a few hours.

The incisions, although initially very visible, will settle and become virtually invisible within nine to twelve months. Removal of the veins near the skin means that blood returns to the heart through the deep veins more efficiently than before.

Some patients describe the leg(s) as sore and uncomfortable when they get home. In the first week after the operation, you may need to take pain relief medications such as paracetamol or ibuprofen (if suitable for you). Please have a supply ready at home. Occasionally, when the vein is inflamed (phlebitis), the leg will be painful. The pain may last for up to three weeks in this situation.

For the first week, when you sit keep your legs raised when possible. This helps to drain the excess fluid from the tissues and aids in healing.

The wounds on your leg(s) will be closed with steristrips (strips of medical adhesive tape) to help the edges of the wound close back together. Steristrips usually fall off on their own after about seven to ten days.

Start walking by taking short regular walks (this maybe slightly uncomfortable) and build up gradually returning to your normal daily activities and exercise. Walking helps prevent clots forming in your legs, and it also promotes good circulation. However, avoid running, strenuous activities or heavy lifting for at least 2 weeks. You should avoid standing for a long period of time.

Bathing

You can shower two days after the operation. Sometimes showering immediately after surgery may lead to bleeding from the smaller incisions.

Driving

You will be able to drive two days after the operation provided the leg(s) are not too uncomfortable or causing you pain. If you are unsure, please contact your care insurance company about whether you are required to wait a longer period of time after having a general anaesthetic before driving again.

Returning to work

You should be able to return to work within one week of surgery depending on your job and the complexity of your surgery, that you may need longer. We will give you a sick note to cover this period. You will need to obtain a sick note from your GP if you need longer.

Avoid long flights within a month of major surgery.

Follow-up

Usually there will be no outpatient clinic follow up, unless there is a reason why it is needed in your case.

Please contact your GP if your post-operative pain is not controlled.

The Circulation Foundation is the UK vascular disease charity.

The Vascular Society UK is the society for UK Vascular Surgeons. Their website also has information for patients.

UCLH cannot accept responsibility for information provided by other organisations.

Clinical Nurse Specialist (Monday to Friday 08:00-16:00)
Direct line: 0203 447 5494
Switchboard: 08451 555 000 / 020 3456 7890 ext. 75494
Mobile: 07908 439910

Pathway Co-ordinator (Monday to Friday 09:00-17:00)
uclh.vascularsurgery@nhs.net for any clinic, pre-assessment and theatre appointment
E-mail: uclh.giadmissionsteam@nhs.net

Address: Vascular Surgery Department, 250 Euston Road, London, NW1 2PG