What are normal veins?
Veins are a type of blood vessel that brings blood back from the tissues of the body to the heart. The veins in your legs, therefore, carry blood up the legs towards the heart.
There are two main types of veins:
- Superficial veins are those that you can see or feel (if your skin is dark) just under the skin.
They are more prominent when they are under pressure, which is why an armband helps doctors find the veins in your arm before they give injections or take a blood sample. The veins in your legs are also more prominent when you stand up, because they have to work harder to return blood against gravity.
- Deep veins are further from the skin surface. In the legs, they are within the muscle of the leg and can not be seen.
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How do veins in the leg return blood against gravity?
The veins of the leg still need to carry the blood upwards when we are standing. In order to do this, they contain one-way valves to stop the blood falling back down.
The muscles of the leg also help the veins by squeezing blood forwards. When we walk, the muscles in the calf squeeze the deep veins in them, which increases the bloodflow up out of the leg. This also reduces the blood pressure in the veins.
The deep veins and superficial veins are connected and so the benefits of this squeezing are felt in all the veins in the leg.
Standing still has the opposite effect; the muscles are not moving and the deep veins aren't squeezing, so blood 'pools' in the veins.
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What can go wrong with veins?
There are several things that can go wrong with veins:
- Varicose veins;
- Phlebitis;
- Deep vein thrombosis;
- Venous insufficiency.
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What are varicose veins?
Varicose veins are superficial veins that have become dilated and irregular. There are several reasons for this occurring:
- The veins might be 'weak' to start with;
- There might be a reduced number of valves in the veins;
- The superficial veins might be exposed to abnormally high pressures from the deep veins.
Many of these factors 'run' in families.
If a vein has become varicose, the valves in the superficial veins do not work and the bloodflow follows gravity, which is down the leg when you are standing. This is why the pain and swelling that result from varicose veins are often worse after a you have been standing or at the end of the day.
It will help relieve the symptoms of varicose veins if you:
Raise (elevate) your legs whenever possible;
Walk frequently;
Avoiding long periods of standing;
Lose weight if you are overweight, which will reduce the pressure in the leg veins.
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Elastic support stockings for varicose veins
Elastic support stockings compress the varicose veins and reduce the flow down them, improving the circulation. It is important that you don't use these stockings if you have bad arterial disease in the legs - if in doubt, ask your doctor.
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Surgery for varicose veins
Varicose veins are very common and, with the help of the measures described above, many people do not need surgical treatment. If your symptoms are severe and your deep veins are working well, the varicose veins can be removed surgically.
A small number of patients with varicose veins develop red, flaky and itchy skin with brown staining. If this occurs, the above measures should be taken to help the venous circulation. If the problem persists, then surgery might help. In a small number of these severe cases, an ulcer can form on the leg if there is no treatment at all. Again, the above measures (plus surgery in some cases) will prevent ulcers, or help heal ulcers that are already present. See below for more information on operations for varicose veins.
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What is phlebitis?
Phlebitis is a bloodclot (called thrombosis) that has formed in the superficial veins, which can cause the veins to become inflamed. The vein is red, swollen and painful but the condition usually resolves over one to two weeks. It can help to use painkillers, a supportive bandage or tubigrip. If it is severe and extensive, do go to see your general practitioner for advice.
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What is a deep vein thrombosis (DVT)?
If the deep veins develop a thrombosis, this is called a deep vein thrombosis. This causes the leg to swell and become painful. It is important to have this correctly diagnosed, because treatment to stop the clot enlarging might be necessary. This involves thinning the blood with heparin and warfarin.
After a deep vein thrombosis, the deep veins of the leg can be damaged by the clot and stop working normally; this causes venous insufficiency (see below).
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What is venous insufficiency?
If the system of veins in the leg fails to work normally, the pressure in the leg veins rises. This can damage the circulation in the lower leg, particularly around the ankle, which can lead to swelling, discomfort, changes in the skin and eventually ulceration.
Reasons for this can include having varicose veins, a previous history of deep vein thrombosis, or problems with the valves without the other disorders ('primary failure' of the valves in the veins).
The simple measures described above (using elastic stockings, walking, avoiding standing, elevating your legs and controlling your weight) are all very important in the management of venous insufficiency.
Surgery on the veins can help, particularly if the problem is mainly in the superficial veins. This can be assessed by a scan of the veins in the leg, which is easy to do and painless.
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Surgery for varicose veins
Varicose veins are dilated superficial veins under the skin of the leg. These abnormal veins are common, cause a number of symptoms and can be removed without affecting the function of the other veins in the leg. Commonly, the vein in the groin or behind the knee has a valve that no longer works, which causes back pressure on the varicose veins. The operation, therefore, involves tying off the vein in the groin or knee and then removing the varicose veins through a series of small (two to five mm) cuts (incisions) in the skin of the leg.
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Complications that are specific to surgery for varicose veins
Removing varicose veins inevitably produces some bruising and soreness. The severity of this depends on how many veins are removed. It can sometimes take several weeks for all the bruising to completely settle down. Small nerves next to the veins can be disturbed, leading to patches of numbness in the lower leg and foot in 10 to 20% of patients. This slowly resolves but is occasionally permanent. A thrombosis can occur in the deeper veins of the leg; this occurs in one to two per cent of patients.
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Before the operation
This operation can either be a 'day case' or involve an overnight stay. You should have nothing to eat for at least six hours before the operation, which is done under general anaesthetic. The ward staff will give you the necessary help in preparing for the operation. The varicose veins will be highlighted with a marker pen. A premedication ('premed') to help you relax might be given, depending on the preference of your anaesthetist. The actual operation will take approx. 30 to 60 min but you might be in the operating department for longer, because all patients spend a minimum of half an hour in the recovery room.
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After the operation
When you return to the ward, you might feel drowsy, but you should not feel any pain or sickness. If you do, tell the nurse who is looking after you and you will be given a painkiller or something for sickness. Your leg will be bandaged firmly to help reduce bruising. For the first four to six hours, you should remain in bed. Later, when the nursing staff are happy with your progress, you will be able to first sit up and later get out of bed. Once you have woken sufficiently, you can start drinking again and you may have something light to eat.
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After you leave the hospital
You might leave hospital after a day-case operation or after an overnight stay. You will have either a seven-day or an overnight bandage on your leg(s). The overnight bandage is changed for a support stocking the day after the operation. The seven-day bandage is used to reduce bruising and swelling; it is water resistant to some extent, allowing a shower to be taken after three days - providing the exposure to water is kept to a minimum.
If there is some bleeding through the bandages, do not worry. If this happens, elevate the leg(s), apply some pressure for 10 to 20 min and it will stop. If you are concerned, call the day-time telephone number given to you, or call your general practitioner (GP).
The small cuts on the leg will usually be closed with tape rather than stitches. A cut at the top of the leg will be closed with dissolvable stitches. Rarely, there might be some stitches to remove, and the ward nursing staff will arrange for the district or practice nurse to do this five to seven days after the operation.
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Later on
If you are working, you will probably need to arrange to have 7–14 days off work; return to work when you feel comfortable;
Avoid driving for 7 to 10 days;
We encourage you to do some walking, and to keep as active as possible in order to keep the blood circulating in the leg(s);
Avoid standing for long periods;
Avoid crossing your legs;
Elevate the legs when you are resting;
You may resume having sexual intercourse when it is comfortable, which is usually after approx. one to two weeks.
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