VARICOSE VEINS – Surgical Treatment by Dr Peter Bray

Varicose veins are a condition that occurs when the superficial veins no longer function properly for reasons that are poorly understood. The walls of the veins lose their elasticity and become dilated and elongated. The tissues surrounding the veins cannot effectively support the vein, so the vein becomes large and tortuous. Valves inside the veins, which are designed to return the blood back to the heart, become incompetent, and the blood passes backwards down the leg instead of returning to the heart. These changes result in pooling of blood, increased venous pressure and the accumulation of fluid in your legs. This may progress to clotting in the veins, bleeding from superficial veins, thickening of the skin and may eventually lead to ulceration in the lower leg (uncommon in uncomplicated varicose veins).

WHY DO I NEED A VENOUS INCOMPETENCE ULTRASOUND SCAN?:  The accurate diagnosis of your specific varicose vein problem can only be made by a vascular ultrasound test which Dr Bray uses to confirm the most suitable course of action. This is a simple, non invasive test which takes approximately an hour. It enables accurate diagnosis by visualizing the veins and measuring the flow and direction of blood through the veins. This test enables all your abnormalities to be identified so that the appropriate treatment will be recommended. If the main superficial veins are grossly abnormal then surgery is recommended. Sclerotherapy obtains good results when the varicose veins are superficial and the main veins are normal.

WHAT DOES MY OPERATION ENTAIL?:  The most established treatment for long and short saphenous vein incompetence (ie. the two main superficial veins in the leg) is by surgically ligating (tying off) and stripping the abnormal veins. This involves an incision in the groin and avulsion of varicosities down the leg. When the long saphenous vein is ligated and stripped, an incision is made in the groin to ligate (tie-off) the vein. A fine wire is passed along the length of the abnormal vein to the appropriate level where the vein is normal, it is secured in position and the abnormal vein is stripped by pulling the vein out along with the wire. This will cause varying degrees of bruising along the length of the stripped vein due to some oozing from its branches. This is a normal occurrence and the bruising is controlled by surgical technique, bandaging of the leg and the elevation of the foot of the bed. If the short saphenous vein (SSV) is abnormal, the incision is made behind the knee.

The varicose veins are removed through tiny incisions in the leg (stab avulsions). These require no sutures and heal well with the application of adhesive paper strips (steristrips). In most cases the only sutures required will be in the groin or behind the knee depending on your procedure. These are dissolving sutures, so there is no need for removal.

This operation is performed under general anaesthetic and takes approximately 1-2 hours depending on the extent of veins.

Surgical treatment in Hospital can be daunting so we recommend following the links provided for information on What to expect in Hospital, including a detailed description of what you can expect in the days and weeks Post Surgery.

BOOKING INTO HOSPITAL:   Dr Bray chooses to operate at St John of God Hospital Subiaco as they provide high quality care by properly trained nursing staff who constantly manage patients with your condition.  Should there be any issues that are not adequately dealt with by the hospital then these should be referred back to the rooms.

In order to book into these facilities, you will be provided with a pre-admission form to facilitate booking the surgery at the time of your consultation with Dr Bray in our rooms. You will need to have completed pages 1-3 in their entirety. You will have signed the consent form (page 4) with Dr Bray. Following completion of this form, we will organise the date for your operation and confirm it with the hospital.  Our staff can assist with any queries regarding the filling in of the form.

After checking with your health fund, the hospital will be able to give you the details of your fund’s requirements so that you are aware of any costs you may incur during your stay, prior to your admission.

NB:  Please refer to the Estimation of Patient Cost section at the bottom of this page for more detailed information.

RETURN TO WORK OR NORMAL LIFESTYLE:  Depending on your occupation, you may be able to return to work at the end of the first week. You will be the best person to judge this as it depends on how you are progressing and the type of work you do. Most people return to work after 1-2 weeks. However, if you stand on your feet a lot then you may need more time. It may help to wear your support stockings for the first week back at work. Sport or exercise classes can be resumed 4 weeks after surgery. Driving is generally not recommended in the first week and then only if movement of the leg is normal and relatively pain free in the second week onwards. Sit in the car and practise “slamming” on the brake. If this hurts, you are not ready to drive.

FOLLOW-UP CONSULTATION WITH DR BRAY:  Our staff will contact you in the week following your surgery. Should you have any questions or problems however, please do not hesitate to contact our rooms directly on 9287 7400.

Where the vein has been stripped and large varicose veins removed, there will be lumpiness due to some blood filling the space left by removing the veins. This can be tender and varies with the size of the veins removed. It is normal and will disappear spontaneously over 3-4 months. The bandages and stockings are designed to reduce this.

Some varicose veins may remain after surgery and these can be removed by sclerotherapy which is an injection technique performed by a Phlebologist. Dr Bray will make the necessary referral for this if it is required after the effects of the varicose vein surgery have settled down, approx. 2 months following the surgical procedure.

You may notice some numbness or tingling in your legs. This is due to nerve irritation which occurs at the time of surgery. There are some nerves which lie adjacent to the vein and during the procedure they may become irritated. These sensations usually subside within a 2-3 month period.

Usually swelling in the leg is reduced by treatment but swelling may occur due to an aggravation of the lymphatic drainage system. To remedy this, a firm graduated compression stocking should be worn until it settles. This only occurs where there were abnormal lymphatics in the leg prior to surgery.

Other frequently asked questions about Varicose Vein Surgery:

POSSIBLE COMPLICATIONS:  Complications are rare and usually minor following varicose vein surgery. All surgical procedures involve assessing the risks and benefits before making an informed decision to proceed. Everything we do in life involves some degree risk to achieve a goal. We anticipate and prevent complications but sometimes, despite our best intentions, they can occur.  Click here to see a more comprehensive list of possible surgical complications.

NB:  We recommend discussing possible anaesthetic complications with your anaesthetist when he/she sees you on the day of your operation.

WILL THE CIRCULATION BE DAMAGED BY SURGERY?:   Many people are concerned that the removal of a main superficial vein could lead to circulation problems. One of the benefits of the ultrasound test is that it ensures that only truly abnormal veins are removed. These are of no use in maintaining the venous return from the leg as the valves are not working properly and the blood passes back down with pooling in the leg. Hence, by removing this abnormal vein or making it competent, the circulation is in fact improved. The abnormal veins are also unsuitable for use in bypass surgery if it was required later in life. The ultrasound test also checks the main deep veins which are largely responsible for all venous return from the leg. If these are abnormal you will be informed, as this could alter treatment.

ESTIMATION OF PATIENT COST:   Hospital – Medicare does not cover any hospital costs for varicose vein surgery. It is your responsibility to check your level of cover with your health insurance company and the hospital in regard to fees which will be charged for your operation. A phone call to your health insurance company and the hospital admissions office will ensure you are correctly informed of the rebate on the hospital costs. The main costs are for the operating theatre fee and for your hospital bed.

For the Operation – Dr Bray’s surgical fees are currently covered in their entirety by most private health funds if you have private hospital cover and Medicare. Medicare pays 75% of the schedule fee and your fund pays the remaining 25%. Please note that you will receive a separate invoice for anaesthetic fees directly from your anaesthetist. Should a surgical assistant be required, your health fund and Medicare should cover the fee. Please note that by proceeding with this surgery you agree to pay the balance of any fees charged that are not covered by Medicare or your health fund.

More specific details of costs, including the “item number” for the surgery will be provided in your letter confirming the date and time of your admission to hospital.

TRAVEL AFTER VARICOSE VEIN SURGERY:  We strongly advise avoiding airline travel or any form of long distance travel (greater than 2 hours) for at least 4 weeks following varicose vein surgery to reduce the risk of deep venous thrombusis occuring. Travel should be broken down into 1 hour segments and compression stockings worn. Should you have any queries related to travel, please contact our rooms on 9287 7400.

RECURRENT VARICOSE VEINS:  It is possible you may develop further varicose veins in the future as surgery removes the visible varicosities and abnormal veins detected on ultrasound, but is unable to cure the primary problem, which is a weakness in the vein wall. As the vascular ultrasound test can clearly define the existing abnormalities which are subsequently removed, it is now unusual to develop recurrent varicose veins.

If you do develop recurrent varicose veins, it will usually be necessary to have another ultrasound examination to determine the precise abnormality. It should be appreciated that completely new varicose veins can develop with time, as you have a predisposition for this. Superficial veins can be removed by injection. Occasionally, incompetent larger veins may require further surgery.

For the prevention of recurrent varicose veins it is recommended to take leisurely half hour walks (or the equivalent) on a daily basis, gradually increasing your pace and duration of the walk as you become fitter. Again, you are reminded to wear good lace-up walking shoes which in turn promote the efficiency of the calf muscle pump and improve your circulation.

We also strongly recommend managing your weight.  Obesity is recognised to be the commonest cause for recurrent varicose veins. Extra weight will increase the pressure on the walls of your veins and in time may lead to further varicose veins.

© Vascular Solutions 2007