Lower limbs’ varicous veins:
Medical therapy? Surgical therapy?
Do nothing at all??

Introduction:

The lower limbs’ varices are a pathology known since the ancient times and they have always been object of attention and care.

In the ancient Egypt phlebology was already well advanced. Then Euscalpium, the son of the king of Thessaly, and also Hippocrates, defined the Father of the Medicine, they all took care of varicose diseases. In particular Hippocrates, in his Corpus Ippocraticum, had predicted an entire section dedicated to the varicose disease!

But also the very modern surgical technique, such as the outpatient phlebectomy was described as a surgical technique.

Aulus Cornelius Celsius described the operation on the varices in his work Artes: incision on the skin, isolation of the vein, lifting through a hook, and in the end the ligature of the treated vein. Some other times the vein was cauterized.

The technique was not successful especially for the lack of the anaesthesia.

The famous leader Caius Marius, affected by a moderate serious form of bilateral varices of the lower limbs, was convinced to be submitted to this surgical operation.

He tolerated impassive the operation on the first limb, by the time to treat the second one he said that the results was not worth so much pain!

Instead in the I century A.D. Galenus was used to face the problem of the varices ripping them with hooks and then treat the ulcers with a good wine!

You can see how this problem has always been worthy of attention.

But since the end of the nineteenth century, with the famous doctor Trendelemburg, the modern phlebology probably started both for surgery and accessories techniques, as sclerotherapy, till the advent in those last years, of the endovascular Laser that allows very good and lasting results with an almost void surgical commitment.

From what the appearance of varices depends on?

The world Organization of sanity provides us with a very accurate definition of varices: “Saccular dilatations of the veins that often assume a tortuous course”.

The most famous are the ones of the lower limbs and the ones of the hemorrhoidal plexus, the so called hemorrhoids.

The causes that can bring to the appearance of the varices are various: familiarity, gender, age, some jobs can be pre-existing cause, but in the primitive varices is not possible to recognize one and a unique etiological cause.

On the contrary, the secondary varices recognize an uncontrollable cause: for example a phlebothrombosis, a closing of the deep circle.

So, some superficial veins expand, they become more tortuous and swollen during the upright position for the major pressure of the inside.

Expanding, the valves in their inside are not able to work correctly, fatherly increasing the venous reflux and making the pathology worse by the time goes by.

The vicious circle is established provoking those symptoms and signs known with the name of Varicose Syndrome.

Modest venous exhaustation.

Serious varicosity.

The veins that mostly interest the varicose process are the saphenas, internal and external.

But also all of their collaterals and the so called perforating can be damaged.

What is it useful to make a diagnosis and then set up the treatment?

The anamnesis and the clinic exam are still very important to make a diagnosis and set up an eventual treatment. If the vascular surgeon decides that a surgical treatment is needed, then a venous echocolourdoppler of the lower limbs can be very useful.

This exam based on ultra sounded technology allows confirming the indications of the surgical operation and it also allows the surgeon to write a map of the varices.

I personally believe that the surgeon who operates should personally execute the preliminary exam before the operation…

or at least he should arrange an assistant he knows very well and he is close to.

In this way the mapping of the varices was born and it always comes before any operation on the veins of the lower limbs. Through the echocolourdoppler all the veins that need to be treated are signed with a marker, understanding with a great precision all the refluxes and comprehending intimately where eventually cut during the operation or also before the sclerotherapy. Now it has become an exam executed practically always before any operation on the lower limbs’ veins.

This exam also allowed diagnosing numerous cases in which the saphena was not damaged and so it has not to be taken away or in which it is damaged only on a short stretches, cases in which the so called short stripping is executed.

The phlebography is now an exam only executed in some selected cases.

For example for recurrence varices, or in particular varices where there is a diagnostic doubt, or in cases in which there can be doubts to face a case of secondary varices.

Which treatment is more suitable in case of secondary varices of the lower limbs?

With reference to this it is important to me to say that, even if every patient is however a particular case and subjected to an absolute personalized therapy, the general indications respect well determined standards.

I personally always start the surgical operations of the cases of the big saphena’s varices with a reflux of the clear femoral safenous orifice and with an incontinence of the big saphena during its course.

Reading the response of your pre operation echocolourdoppler, you can simply understand the indications of the operation.

Instead in case of the important varicose veins, but in absence of a safenous-femoral reflux, and with a sane saphena (case that happens very often) the treatment depends on the cases: we can think about a surgical operation with a local anaesthesia, such as the outpatient phlebectomy, but sometime a sclerosing therapy can be advised.

This therapy is advisable for big veins also, when there are some refluxes that cause a notable local hypertension, especially with the new method that exploits the sleromousse.

Some other times, there are particular motivations that go against any invasive therapy.

Too old patients, with general complications, cardiopath, serious nephropath or with local complications, can have conservative treatment.

This does not mean that the patient has to be left alone: all the aids have to be put into effect to reduce the complications to a minimum.

Essentially these are:

·elastic accurate constriction, with last generation elastic socks, possibly tights, but also shorter socks up to the thigh or also up to the calf, according to the cases

·active walking, with very long walks

·avoid the upright position, motionless (as in the case of the strainers or surgeons)

·rise of the bed from the feet’s side (I advice to put two bricks under the feet of the bed which is better than placing a pillow under the mattress).

For what reason do I have to treat a pathology that essentially does not bother me right now?

Because, probably, if I do not do anything, I will have complications that will bother me later on my life.

You can not die for varices, but by the time will go by be sure that your sins will find you out:

·in case of an abdominal or orthopaedic operation, the risk of varicophlebitis will increase exponentially

·if you have to stay in bed for some disease, the reduction of legs’ movement increases exponentially the risk of phlebitis

·after a certain limit, the venous insufficient will get worse and the signs of this misbalance will start to appear at the ankles: first the tickle with a local eczema, then the cutaneous dyschromias while the epidermis becomes dark brown, and in the end the skin will break.

The varicose ulcers have been luckily often seen for years.

Today the major knowledge and the prevention allow getting to these limits only in rare cases.

News:
Those past years, for the whole medicine, were foreboding of great improvements and especially in the “Hydraulic” medicine.
By the way we can remember the great improvements reached in the therapy of the coronary syndrome.

Also in phlebology we made big steps forward:

·sclerosing therapy through scleromousse

Through this technique is possible to sclerose big veins with much reduced dosages, with an unthinkable efficiency and with very low collateral effects.

·saphenectomy through endovascular Laser.

This surgical method allows treating some cases of the varices of the big saphena absolutely outpatientially, with local anaesthesia and with a very precocious recovery of the normal activities.
How much time do I need to get back to my normal occupations after an operation of saphenectomy?
It is always a surgical operation: basically ten days are sufficient for a total recovery.
The complications are always possible, a wound difficult to heal, a local pain difficult to solve, a painful haematoma… but the operation is done, in my opinion, especially to prevent complications during the time and for this reason it is also worth to suffer a bit from some little momentary trouble.

In my experience major complications are very very rare.

Conclusions:
As you could see the therapeutic possibilities exist: the advice I feel like giving to all the patients affected from varices is, before all, not to listen to the advice of non expert people (friends, hairdressers, bakers, taxi drivers.. very experts in their jobs but not in varices!).
Addressing to your own doctor is the first step in order to have the best advice.
If your doctor decides to deepen in the diagnostic course, then address to a good specialist who will advice you for the best.