Varicose & Spider Veins

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Many people suffer from venous disease. This can be in the form of spider veins or bulging varicose veins. We understand that you may be very self conscious about your veins and may avoid wearing shorts and skirts as a result. Fortunately these unsightly veins can be improved by treatment of the underlying venous disease. We would like to share with you the current understanding of venous disease and the rationale behind the treatment options.

The anatomy of veins

The treament of spider and varicose veins depend on a sound understanding of the anatomy of the venous system. Veins are blood vessels that carry blood back to the heart. Traditionally veins are classified into three categories: deep, superficial and the perforator system. Deep veins are located deep within the leg, often inside muscles. Superficial veins are located near the skin surface and are above a layer of tissue called the deep fascia. Superficial veins drain into the deep veins through junctions or perforating veins. They are mechanisms in the leg veins to ensure that blood flows upwards towards the heart against gravity, and preventing backward flow towards the feet. Valves within leg veins form an integral part of this flow regulating mechanism. Valves consist of two leaflets (bicuspid) that meet in the middle to prevent backward flow of blood. Valves are found in the superficial veins, they are also found inside the perforating veins and junctions to direct flood flow from superficial veins into deep veins.

367-schema-perforating-vein-small-01 copyAnother way of looking at leg veins is that the veins follow the reverse topography of a tree. Spider veins are like twigs, tributaries are like the main branches and the largest superficial veins are like the trunk. The largest superficial vein in the leg is called the Great Saphenous Vein (GSV). It passes from the inside of the ankle, up the inside of the leg to the groin. It drains into the femoral vein (the larrest deep vein of the leg) at the groin. The Small Saphenous Vein (SSV) is the main vein of the calf, and it drains into the popliteal vein (a deep vein) at the back of the knee. The GSV and the SSV are often referred to as axial or truncal veins. These truncal veins are located in a slightly deeper layer within their own fascial compartments are therefore not visible from the outside. However, it is reflux of these truncal veins that often cause the more superficial veins to become dilated and visible.

How does venous disease manifest?

Abnormal veins are caused by a weakness in the vein wall. When pressure from standing upright and other factors causes the abnormally weak vein wall to expand, the resultant distension of the vein wall is such that the valve leaflets within the vein are no longer able to meet in the middle and therefore are unable to function properly. As the valves stop functioning, “reflux” or “backflow” of blood occurs in the affected vein. A vein showing this backward venous reflux is called “incompetent”.

Abnormal superficial veins are often described according to their morphological or visual appearance. There are three common types of abnormal veins, which are frequently seen in combination. It is important to realise that these abnormal veins are no longer functioning.

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Spider/thread veins (telangiectasia): These are small diameter fine veins within the dermis of the skin and are usually fed by larger reticular veins. They are sometimes extensive and can appear in a formation commonly known as matting.

Feeder veins: These are larger blue veins, which are found slightly deeper below the skin’s surface than spider veins. They are often part of the reticular venous network. Many spider veins are caused by back pressure from these feeder veins. In such cases, it is essential to treat the feeder veins to ensure the successful eradication of spider veins.

Varicose veins: These are the largest in diameter and often form visible bulges on the skin surface.

From the functional point of view and for treatment planning, venous reflux is classified according to the kind of veins that are involved: truncal reflux, tributary reflux and telangiectasia.

Why do these abnormal varicose, feeder and spider veins need to be treated?

As mentioned above, these abnormal veins are no longer functioning in the normal fashion. The backflow of blood (venous reflux) in these abnormal veins allow pressure to increase downstream. This increase in back pressure is called venous hypertension. In the earlier stages of venous disease, there are often little or no symptoms. As venous disease progresses, a variety of symptoms may develop, including heaviness, burning, aching, throbbing, leg cramps, restless legs, and swelling of the ankles. Over time, chronic venous hypertension leads to structural changes in the skin and subcutaneous tissue. These changes include development of a skin rash (stasis dermatitis), swelling of the foot and ankle, dusky discolouration of the skin, matting of veins over the foot and ankle (corona phlebectatica), scarring, and venous ulcers.

Early treatment of abnormal veins can prevent these changes. In addition to these physical changes, abnormal veins are unsightly and patients often feel self-conscious about wearing shorts, skirts and dresses. Treating the abnormal veins will significantly improve symptoms and the appearance for the majority of patients.

Do we need our varicose veins and spider veins?

Varicose, feeder and spider veins are damaged superficial veins that are no longer functioning. These veins are not able to fulfil their purpose in transporting blood upwards against gravity towards the heart. Instead venous reflux places an extra burden on the deep venous system. Redundancy of the venous system means that blood is able to find alternative pathways from the superficial to the deep veins. Removal of the abnormal veins will therefore improve and restore the venous circulation.

Principles of treatment of varicose/reticular/spider veins

All current methods of treatment of abnormal veins involve their permanent removal. Historically abnormal veins were removed by surgical ligation and stripping. However, over the past decade, ablative methods have taken over to become the mainstay and indeed gold standard in the treatment of abnormal veins.

Whilst many patients present with spider veins primarily as a cosmetic concern, it is important to remember that these small veins may be caused by abnormal  larger reticular or varicose veins. It is therefore important to assess whether there is underlying venous reflux that may require treatment.

At Facial Artistry, Dr Jennifer Leung specialises in assessment of the venous anatomy and minimally invasive treatments for venous disease. An assessment of the overall health of the venous system is carried out at the initial consultation. This is as important as the treatment itself. The clinical examination may be assisted by using venous ultrasound Doppler. Duplex ultrasound scanning is usually carried out. This allows a detailed map of your venous anatomy to be understood. The presence and severity of underlying venous reflux can be determined using this detailed ultrasound assessment tool. A management plan can then be formulated based on the site and severity of the underlying venous reflux.

Dr Leung chooses from the following treatments depending the type of venous problems identified by the assessment process:

Based on current best practice, larger diameter veins and truncal reflux (reflux of the axial GSV and SSV) are best treated by EVLA. Tributary reflux is  treated by UGS, whereas smaller veins are treated by direct vision sclerotherapy. Whilst the smaller superficial spider veins are usually more visible and are often what motivate patients to come and see us, it is essential to detect the presence of underlying venous reflux. Adequate treatment of the source of reflux is essential to ensure the best long term outcome is obtained and to mimimise the risk of complications.

Strategy for vein treatment

Based on the findings of the Duplex ultrasound mapping assessment, a management plan can be draw up. The general rule of thumb is that the larger veins are treated first. i.e. truncal (or axial) reflux is treated before tributary reflux and spider veins. Another rule relates to the maximum amount of sclerosant that can be administered in one session, which means that veins of the SSV system or lateral system may have to be treated on a separate occasion from the GSV system. It is for these reasons that the treatment of spider veins and varicose veins may be more complex that what meets the eye and usually require more than one session of treatment.

At Facial Artistry, we insist in delivering the highest standard of evidence-based medical care. Decisions regarding the most appropriate treatment options for your vein problem are made based on the anatomy, degree and severity of venous reflux, rather than just on the visible appearance alone.

What about varicose vein surgery?

Varicose vein surgery (ligation and stripping) is no longer considered the most appropriate treatment for varicose veins. Although varicose vein surgery has been performed for many years and is still commonly used in Australia, such surgery is now considered to be less effective, with a higher recurrence and complication rate compared to ultrasound guided sclerotherapy and endovenous laser ablation.

How much does vein treatments cost?

The cost of vein treatment can vary considerably depending on different factors, such as the extent, distribution and severity of the abnormal veins. It is therefore not possible to give a cost estimate without gaining a proper understanding of the extent of your venous problems.

To request an appointment with Dr Jennifer Leung to discuss your suitability for a vein treatment please email us or call us on 02 6255 8988.