Varicose Veins Causes, Diagnosis and Treatment by Dr. Shoaib Padaria

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Dr. Saba: Good evening friends. I am Dr. Saba Shaikh. We will be discussing about a very common condition called varicose veins. So, we have a leading speaker here with us, Dr. Padaria Padaria, who has been doing this surgery since past 15 years. He is considered to be as a pioneer of treating varicose veins with laser treatment. So we will ask him about varicose veins and he will give us detail information about that. So Sir, tell us what are varicose veins?

Dr. Padaria: You know, Dr. Saba, varicose veins is a very, very common condition; it is defined as large tortuous veins which are seen commonly in the legs. In many patients, these veins and this condition is seen silently but as it progresses it can be a cause of concern in many people. You will be surprised to know that varicose veins is quite prevalent in the population. By the age of 50 years, almost 40% of men and 20% of woman will have some form of varicose veins. Not only that, you will be surprised to know that varicose veins are twice as common as peripheral vascular disease or coronary artery disease and even more common than cancers. So by and large, varicose veins is a very, very common condition in the population.

Dr. Saba: But how do varicose veins occur?

Dr. Padaria: So, in order for us to determine why varicose veins occur, we must know something about the veins of the legs. You know, in the legs, the bad blood or the blood without oxygen returns back to the heart mainly by the deep veins of the legs and 80% of the blood comes back through the deep veins about 20% of the blood comes back through the skin veins called the superficial veins. And these superficial veins are mainly two veins, one in front of the leg which is called the great saphenous vein and one behind the leg which is called the short saphenous vein and these two skin veins carry blood up towards the heart. Now, since the blood is flowing against gravity, there are a series of valves along the lengths of the veins which ensure that the blood only goes upwards towards the heart and doesn’t come back to the legs and these valves are essential to ensure that blood goes back up towards the heart. In some people, these valves are weak or they damaged and when these valves get damaged, now what happens is the blood instead of going upwards starts coming downwards in the wrong direction, and over a period of time, these veins get dilated, they become tortuous,  they become engorged and they give rise to what are called varicose veins. So as you will see in the picture here, a straight skin vein gradually dilates because of leakage of blood and becomes a tortuous varicose vein.

Dr. Saba: Can you tell us what are the causes of varicose veins?

Dr. Padaria: There are many, many reasons why varicose veins can occur and the common causes are increasing age, with increasing age the valves tend to get weaker and more varicose veins will occur. It’s known that varicose veins are more common in woman than in men, in fact 3 times more common. With repeated pregnancies, you will find that more varicose veins tend to occur. People who are obese, overweight also tend to have weakened valves leading to varicose veins. People who have sedentary jobs like standing for prolonged period, such as liftmen or waiters in restaurants or people who sit for long periods of time, like people who work at desk jobs for example computer people, they can also develop varicose veins, and so there are multiple reasons why varicose veins can occur. Now once varicose veins occur, different type of symptoms occur in these patients and these symptoms are such that sometimes these symptoms occur in people with minor veins and sometimes they can occur in people with large veins. Sometimes large veins can give rise to no symptoms at all, so it’s very, very subjective. The various types of symptoms are heaviness in the legs, fatigue in the legs, swelling around the ankles, scratching or what is called pruritus, ankle oedema, night cramps, restless leg syndrome, etc, multiple symptoms can occur, all of which are nonspecific.

Dr. Saba: Okay, so what happens when you neglect the varicose veins?

Dr. Padaria: So what happens is that over a period of time, these varicose veins will gradually increase in size and small spider veins and reticular veins will become larger in size, which are called varicose veins. Later on, because of pressure in these veins, little blood will start leaking out into the skin, you will start getting skin pigmentation. The skin starts becoming dry, you start getting scratching in these areas, and finally the skin will rupture and this will give rise to venous ulcers, which is the final stage of varicose veins.

Dr. Saba: So what is the ideal time for treating these varicose veins?

Dr. Padaria: When you see a patient who comes to you with significant symptoms like leg aches, leg pains, night cramps, all of which are not relieved either by wearing compression stockings or by taking medications, that is the time to treat varicose veins. When a patient comes with very large varicose veins, which are larger than 5 mm in diameter, this is the right time to treat varicose veins. Why? Because these large veins contains stagnant blood, this blood can clot and this clot can break off and go into the heart and cause a condition called pulmonary embolism which can lead to death. This clot can go into the deep veins of the leg and can cause a condition called deep vein thrombosis. Apart from that, when you have pigmentation of skin around the ankle, development of ulcers, or if a vein bleeds giving rise to bleeding in the area then this is the right time to treat varicose veins.

Dr. Saba: Okay. So, what are the different treatments available for varicose veins?

Dr. Padaria: Initially, when a patient comes to you with varicose veins and he has mild or moderate varicose veins, we must concentrate on conservative medical line of treatment that consists of giving special type of elastic stockings, which are graduated compression stockings. In patients who have varicose veins up to the knee, we give knee length stockings; patients who have veins up to the groin, we give thigh length stockings. Apart from that, there are certain medications which we give to almost all patients of varicose veins and the standard drug which is given is a drug called Daflon MPFF. Daflon, basically is the only drug in the world which has been shown in multicentre trials to be effective for patients with varicose veins. It’s an anti-inflammatory drug, it’s not a pain killer, it decreases the swelling because of varicose veins, it decreases the pain and fatigue because of varicose veins and gives rise to a lot of relief of symptoms. Once you have treated with compression stockings and along with the Daflon and there is no great relief then there are other treatment methods which are available. For example, in the past, we used to do a major surgery called ligation and stripping, in which the valve in the groin was ligated or tied off by the surgery and the entire vein was stripped off by dong a surgery. It was a major surgery, lasting a few hours, patients used to stay in hospital for a few days and recovery used to be a prolonged period of time. And therefore, nowadays this basic technique has been given up. The other technique which is used commonly is something called sclerotherapy. Sclerotherapy is when we inject a tiny acidic solution into the veins and this acidic solution injected via a needle helps to damage the inner lining of the veins and close the veins. However, we must understand that sclerotherapy can only be used for mild-to-moderate degree of varicose veins, it can’t be used for large varicose veins. The standard method of treatment, nowadays worldwide, what we consider the gold standard is now laser treatment of varicose veins.

Dr. Saba: So how is a laser treatment performed?

Dr. Padaria: So, as I said that currently, all the major societies in the world have come to a conclusion that if you want to offer definitive and permanent treatment for varicose veins, the treatment should be laser treatment. Why? Because there are certain advantages, it is offering better results, lesser complications, and much lesser rates of recurrence of varicose veins than other treatment options. Now, the laser machine which is available for laser treatment is basically a portable machine and it generates what we call laser energy. This laser energy is transmitted via a laser fibre and this laser fibre tip generates heat and it is the heat energy which you insert into the vein, which basically helps to weld the vein from inside like doing a welding process and blocks the vein off. Let me show you how the laser treatment is actually done. We were fortunate that we introduced laser treatment of varicose veins in India, in 2003, we were the first centre in the country to do so and since then, in the last 15 years, we have performed more than 12,000 cases. This is the largest series in the country and one of the largest series in the world. When we do laser treatment, the entire procedure is done under ultrasound guidance, and doing ultrasound or sonography, we first map the entire vein of the leg you know and chart it out, so we know where the vein actually is. Once we identify the vein which is there below the knee joint then we want to enter the vein with a needle. On the skin, we give a little bit of local anaesthesia and use a long needle to enter the vein just like we do angiography. So here, you can see that the needle is entering the vein under ultrasound guidance and when you aspirate from the needle and the blood comes out, you know that now you are inside the vein. Through this needle, you would insert a thin laser wire and this wire will go inside the vein, and as you can see here, it will go into the deep vein across the junction. A sheath is then put over the wire and the laser fibre is then advanced so that it is near the groin area of the superficial vein.

Now, as you can see here, this is where the laser fibre is advanced and once you start pulling back the laser fibre, the vein gets actually closed off. At the end of the procedure, you take off the needle and the wire and what you are left with is a tiny little puncture mark and that’s all that is required there. There is no stitch, no cut at all, a small bandage is put on this, a compression stocking is made to be worn by the patient, the patient gets off the table, walks for half an hour and goes home. So this is basically an outpatient treatment which requires only 10-15 minutes. The patient does not require any rest and most patients can go back to work the same day. Here in this picture, you will see the type of results which are seen. This is as you can see large varicose veins in the leg before the treatment and as you can see the varicose veins have totally disappeared one month after the treatment. Another case when large varicose veins are there in the thigh and as soon as you treat that varicose vein, within matter of 2 or 3 weeks, the veins have totally collapsed. Here you can see large varicose veins in the groin, in the leg, and in the ankle, and 2 months later, the same patient, you will see that no varicose veins are remaining behind. This is the patient, lady patient, who is on the table, not even having got up after the treatment process. These are large varicose veins that you see here and as soon as you close this vein by laser, you can see the veins have all collapsed. This is a football player with large varicose veins in the calf, and immediately after the treatment, the varicose veins have all collapsed. Another patient with tortuous varicose veins here and you can see the varicose veins have disappeared leaving a very good cosmetic appearance of the leg. See these massive varicose veins in the leg, here the idea is not to close these varicose veins but the underlying vein which is causing this leakage. Once you close that, the entire vein, part of the vein is treated by laser, and on table itself, the veins have fully collapsed. This is a lady who was very conscious about these varicose veins on the outer aspect of a thigh and a leg. All we needed to do is close this upper part of the varicose vein, the great saphenous vein with laser and as soon as we did that, the leakage in this vein disappeared and led to a collapse of the entire vein. Similarly, the veins which are behind the knee joint, what we call the short saphenous vein can also be treated. You can see a bunch of varicosities or varicose veins in the calf and they have totally disappeared, nobody can make out this patient ever had varicose veins earlier. We also do a lot of cosmetic work, for example, veins in the hand or veins in the leg which look ugly, they are not really varicose veins but patients don’t like these veins. For example, these are very prominent veins in the legs and you can see here that the size of the vein is markedly decreased, you can’t even see this vein here after laser treatment. Apart from…

Dr. Saba: So, you…

Dr. Padaria: Yes, yes, doctor.

Dr. Saba: You have an excellent result with varicosities treated with laser treatment but what about venous ulcers? How do you treat venous ulcers?

Dr. Padaria: Dr. Saba, an excellent question. You know, venous ulcers or wounds around the ankles are the end result of longstanding varicose veins. When these ulcers occur or these wounds occur, most of these wounds do not heal for many months at a time in spite of regular bandaging and all forms of dressing materials. This is because the leakage of bad blood in that area prevents the fresh blood from coming to the ulcer area and causing the healing of the wound. In order to heal this ulcer, what we need to do is close the leakage of the veins in that area and this is very well achieved by a combination of laser technique and something which we call foam sclerotherapy. So along with the laser treatment of the leaking veins, the tiny varicose veins which are around the ulcer are also closed by injecting foamed sclerosant. Let me give you an idea, one example, of how venous ulcers can be treated. As you can see here, there is a very large wound around the ankle in this area in this patient; this ulcer was there since the last 7 years. When we did a sonography, we found that he had 3 large veins which were leaking around the ulcer area. Using a special laser technique, we closed these veins within a matter of few minutes and then started doing regular dressing in this patient. Within one month of treatment, you can see that the ulcer is partially healed and within 2 months the ulcer totally healed. The patient who had an ulcer for 6-7 years healed fully within just 2 months. Similarly, this is a patient who came to us from Kenya, he is a marathon runner. He had a large varicose ulcer here, which used to come on every time after he ran the marathon. As soon as we closed the varicose veins which were around this area, the ulcer healed very well. This treatment was done 5 years ago, he comes for the Mumbai marathon every year and in spite of running the marathon and training every year, the ulcer has not come back again. This is a large ulcer around the ankle, very deep ulcer, resistant to all form of dressings and you can see, the ulcer has healed very well by a simple laser technique. Here you can see, this is a leg which is almost gangrenous in nature, the leg is swollen, it is black, it’s got an ulcer, it’s got dry bad skin. After laser treatment, not only has the ulcer healed but the swelling has gone, the colour of the leg has changed, and the skin texture has improved tremendously. Again, another case where the ulcer has healed beautifully. And so, ulcers is one area which we can do great work in as far as laser treatment is concerned.

Dr. Saba: So, how do you compare a surgery verses a laser treatment? What are benefits of laser treatment over surgery?

Dr. Padaria: As I said earlier Dr. Saba, in today’s day and age with modern technology, surgery for varicose veins is an outdated procedure. In fact, in western countries, surgery is no longer done and most insurance companies will not even give you clearance for doing a surgery procedure. Why? Because there are many advantages. As we know, surgery requires a hospital procedure while laser is an OPD procedure. Surgery requires general or spinal anaesthesia while laser is done under local anaesthetic. Surgery requires 3-4 hrs of operating time while laser requires only 15-20 minutes. After surgery, the patient needs to rest at least for 1 or 2 weeks, leading to loss of work and loss of pay and income, while in laser, most people can go back to work the very next day. Not only that, the long-term results of surgery show that 15-25% of these patients will come back with varicose veins, while with laser, the chance of recurrence is again is only about 2-4%. In fact, I would like to conclude by saying that laser treatment for varicose veins is a safe, easy, nonsurgical approach for the treatment of varicose veins. It requires no hospitalization, it requires no stitches, and there are no scars. Patient can go home immediately after the procedure, so this basically makes it ideal, day care procedure. There is no prolonged recovery time, majority of patients can go back to their routine activity the very next day, and reported success rates of 95-98% make laser treatment for varicose veins today, the preferred mode of treatment compared to any other procedure.

Dr. Saba: So, as we all have understood that laser is a very effective treatment for varicose veins, but as you have said, 2-4% of chances of recurrences, can you explain that?

Dr. Padaria: Right, so very good question. People say that varicose veins come back again after treatment, but when you close a vein with laser, you are doing welding of that vein, that vein can never open again. So why do varicose veins come back again? Because in the legs, there are many, many veins and many, many valves. In fact, in each leg there are about 150 valves, about 15-20 large veins. If any of these valves later on start leaking then in that vein, you can get new varicose veins. So when we talk about recurrences of varicose veins, it’s always a new vein which has come back, it’s a new varicose vein, it’s not a treated vein which opens.

Dr. Saba: Okay Dr. Padaria, all right. So besides laser, what other modalities do you use to treat varicose veins?

Dr. Padaria: So laser was one method of treatment. Today’s day and age, there are lots of other advanced methods, one is radiofrequency ablation which we also use on a regular basis. Radiofrequency ablation is another technique whereby we generate heat energy but unlike using laser, its radiofrequency waves which develop heat energy and close the veins, also very, very effective. We sometimes for smaller veins use what is called sclerotherapy. Sclerotherapy is injection of an acidic drug, something like Fevicol to inject inside and it helps to close the veins. We nowadays have special glues which are available, which we inject via a needle into the veins and the advantage of glue is that there is no heat involved, it’s a very small procedure taking 5-10 mins, no local anaesthesia to be given. The patient just gets up and walks soon after the procedure. Other advantage of glue is that no stockings are required after the treatment process. There is something also called MOCA or MechanicO Chemical Ablation of varicose veins, these also have been introduced recently into our country. We have not yet had a chance to explore these, but in the near future, these are other modalities which we will be using for treatment of varicose veins.

Dr. Saba: Okay. Can you brief us about the side effects of laser treatment?

Dr. Padaria: In the current scenario, using good aseptic precautions, choosing your patients well, using the best of equipment, I would say the chance of complications of laser treatment are very, very less. Some patients may have some degree of pain after the procedure, and therefore, as a matter of routine we will give all patients 7-10 days of pain killers. However, you must understand that most patients will give up the pain killers after 2-3 days, they just don’t get pain. There is always a chance of infection occurring in these patients and therefore all patients are given antibiotics for 7 days. In the earlier times, 15 years ago, there was a small chance of burn injury occurring because of varicose veins laser treatment. We haven’t seen a burn injury ever in the last 12,000 patients of ours. Apart from that, there are really no other problems which can occur with varicose veins laser therapy.

Dr. Saba: Okay, anything else that you would like to brief us about varicose veins or laser?

Dr. Padaria: So, I would like to say to the population in general, is that varicose veins we consider as a very minor condition, it’s not so. Varicose veins can be a dangerous condition if left alone. It can cause pulmonary embolism and heart attacks, it can cause deep vein thrombosis, it can cause bleeding, and it can cause venous ulcers. It is important to realize that nowadays, new techniques, modern techniques, nonsurgical techniques are available for treatment of varicose veins. So please do not wait for your varicose veins to become large, tortuous, give rise to pigmentation, give rise to ankle swelling, give rise to ulcers, before you come for treatment because when you come late for treatment, your recovery also is going to be prolonged. Come early for treatment and you will have a lovely cosmetic result, nobody will ever know that you ever had any form of varicose veins to begin with.

Dr. Saba: Thank you so much, Dr. Padaria, for all the information and knowledge. Okay, so Dr. Padaria will be available at Currae Hospital in Thane, every Tuesday between 2 to 3 pm. For any further queries or information, please mention your queries in the comment box below. Thank you so much.

Dr. Padaria: Thank you very much.

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