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| Minimal Invasive Procedure For
Varicose Veins(SEPS) |
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 What
are varicose veins? |
| What
causes it? |
| What
are the symptoms? |
| How
is it diagnosed? |
| What
are the treatment options? |
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Non-surgical
methods |
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Standard
surgical method |
|
Minimally
invasive procedures like SEPS |
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| What
are varicose veins? |
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| The word "varicose" comes
from the Latin root "varix," which means "twisted."
Any vein may become varicose, but the veins most commonly
affected are those in your legs and feet. That's because
standing and walking upright increases the pressure in
the veins in your lower body. |
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| The veins of the legs are divided
into two systems - the deep veins (which run deep to the
leathery layer of fascia surrounding the muscles) and
the superficial veins (which run in the layer of fat just
beneath the skin). The superficial veins are the ones
that you can see (for example, on your foot or around
the ankle) and they are the ones that can become varicose.
It is essential to keep in mind these two different systems
- deep and superficial - in order to understand varicose
veins and their treatment. In a number of places in the
leg, the superficial and deep veins are linked by perforating
veins (or 'perforators'). They are called perforators
because they perforate the leathery fascial layer surrounding
the muscles of the legs. Normally their valves should
allow blood to flow only inwards - from the superficial
veins to the deep veins. If the valves stop working properly,
then blood is pushed out into the superficial veins when
the muscles contract: this is one reason for high pressure
in the superficial veins, and can be a cause of varicose
veins. |
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| The blood in your leg veins must work
against gravity to return to your heart. To help move
blood back to your heart, your leg muscles squeeze the
deep veins of your legs and feet. One-way flaps called
valves in your veins keep blood flowing in the right direction.
When your leg muscles contract, the valves inside your
veins open. When your legs relax, the valves close. This
prevents blood from flowing backward. However, when these
valves do not function properly, the blood pools, pressure
builds up, and the veins become weakened, enlarged, and
twisted. This causes varicose veins to develop. Varicose
veins develop when one has faulty valves in the veins
and weakened vein walls. These veins are twisted, enlarged
veins close to the surface of the skin. They usually develop
in the legs and ankles. |
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| Varicose veins are a common condition,
affecting up to 15 percent of men and up to 25 percent
of women. Treatment may involve self-help measures or
procedures by your doctor to close or remove veins. |
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| Which veins become varicose? |
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| The long saphenous vein (LSV) |
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| This vein and its tributaries are
the ones that most often form varicose veins. The long
saphenous vein is formed from tributaries in the foot,
and is visible in many people when they stand, as the
vein just in front of the bone on the inner side of the
ankle. It runs up the inner side of the calf and the thigh,
and at the groin dives to join the main deep vein (the
femoral vein). |
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| The short saphenous vein (SSV) |
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| This is the other main vein under
the skin of the leg, the tributaries of which can become
varicose, but it is affected much less often than the
LSV. The SSV starts just behind the bone on the outer
side of the ankle, and runs up the middle of the back
of the calf. It usually dives to join the main deep vein
just above and behind the knee (the popliteal vein), but
this varies and before any operation on the SSV it needs
to be checked by a scan. |
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| Perforating veins |
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| In almost any part of the leg, a perforating
vein can develop incompetent valves. This allows blood
to be pumped outwards under pressure into superficial
veins, causing them to become stretched and varicose.
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| Any vein |
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| Any vein under the skin, in any part
of the leg, can become varicose, without valve problems
in the LSV, SSV or perforating veins. These varicose veins
are usually quite small and cause few symptoms. |
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| What
causes it? |
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| Some people may be more likely than
others to develop varicose veins and spider veins because
of inherited characteristics (genetics), the aging process,
or hormone changes. Varicose veins may also result from
conditions that increase pressure on the leg veins, for
example being overweight or pregnant. Though, the most
contributing factor is Hereditary. Women are more likely
to suffer from abnormal leg veins. Hormonal factors can
affect the disease. It is very common for pregnant women
to develop varicose veins during the first trimester.
Pregnancy causes increases in hormone levels and blood
volume, which in turn cause veins to enlarge. In addition,
the enlarged uterus causes increased pressure on the veins.
Varicose veins due to pregnancy often improve within 3
months after delivery. However, with successive pregnancies,
abnormal veins are more likely to remain. Other predisposing
factors include aging, standing occupations, obesity and
leg injury. Varicose veins are present in 20-25% of adult
females and 10-15% of men. This common condition represents
a considerable surgical workload. |
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| What
are the symptoms? |
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| In varicose veins, symptoms are often
worse at the end of the day because more pooling has occurred.
Other things which increase pooling and therefore symptoms
also include prolonged standing and sitting, exposure
to heat (summertime, hot baths) and hormonal factors (pregnancy,
around the time of the menses). |
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| Varicose veins may be associated with
a sensation of heaviness and itching and, in the presence
of deep and superficial reflux, cramps and aching. However,
all too often generalised aches and pains in the leg may
be attributed to visible varicosed veins. Left unchecked,
they tend to increase in size and often lead to progressive
skin and tissue damage resulting in eczema, lipodermatosclerosis
and, in advanced cases, venous ulcers. Lipodermatosclerosis
is the medical term that describes damage both to the
skin and to the fatty layer beneath it ' |
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| Ulcers, when they occur, most often
afflict the elderly, blighting their lives with frequent
visits to their local surgeries or hospital out-patient
departments. Many sufferers complain of aching of the
legs, skin itching, ankle swelling, restless legs, night
cramps and sleep disturbance. |
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| How
is it diagnosed? |
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| Varicose veins are arguably the most
frequently referred general surgical malady presenting
to hospitals. Varicose veins are often caused by an underlying
problem in leg vein. |
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| General examination |
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| First your physician asks you questions
about your general health, medical history, and symptoms.
In addition, your physician conducts a physical exam.
Together these are known as a patient history and exam.
Your physician will examine the texture and color of any
prominent veins. He or she may apply a tourniquet or direct
hand pressure to observe how your veins fill with blood.
So the diagnosis is based primarily on the characteristic
appearance of the legs when the patient is standing or
is seated with the legs dangling. |
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| Duplex ultrasound exam |
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| At times a physician may order a duplex
ultrasound exam of extremity to see blood flow and characterize
the vessels, and to rule out other disorders of the legs.
Duplex ultrasound uses high-frequency waves higher than
human hearing can detect. Your physician uses duplex ultrasound
to measure the speed of blood flow and to see the structure
of your leg veins. The test can take approximately 20
minutes for each leg. |
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| Angiography |
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| Rarely, an angiography of the legs
may be performed to rule out other disorders. |
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| What
are the treatment options? |
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| The surgeon first assesses the patient,
with a detailed history and physical examination, and
confirms the diagnosis and extent by relevant investigations.
Not every person with a varicose needs surgery. One needs
to discuss the reasons for operating and understand the
risks involved. |
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| A large proportion of patients may
wish surgery for cosmetic reasons or due to anxiety that
their disease may progress to chronic venous insufficiency
and ulceration. It should be emphasized that varicose
vein surgery is not curative, and early surgery in uncomplicated
veins will not prevent development of future varicosities.
However, it has been shown, that quality of life is reduced
in patients with varicose veins compared with the general
population, and that this is improved by surgery. |
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| Non-surgical
methods |
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| Varicose veins may sometimes worsen
without treatment. Your physician will first try methods
that don't require surgery to relieve your symptoms. If
you have mild to moderate varicose veins, elevating your
legs can help reduce leg swelling and relieve other symptoms.
Your physician may instruct you to prop your feet up above
the level of your heart 3 or 4 times a day for about 15
minutes at a time. When you need to stand for a long period
of time, you can flex your legs occasionally to allow
the venous pump to keep blood moving toward your heart.
Besides these treatments like compression stockings, sclerotherapy,
laser treatments are offered which are non-surgical and
the first line of action. |
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| Compression Stockings |
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| For more severe varicose veins, your
physician may prescribe compression stockings. Compression
stockings are elastic stockings that squeeze your veins
and stop excess blood from flowing backward. Compression
stockings also can help heal skin sores and prevent them
from returning. |
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| Sclerotherapy |
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 This
form of treatment is a non-surgical procedure in which
a solution is injected into the problem varicose veins
or spider veins in order to cause its disappearance.
A chemical irritant can be injected into veins, although
large veins are difficult to treat using this method,
as the chemical has to physically come in contact with
the lining of the target vein for long enough to destroy
it. Sclerotherapy works by burning the lining of the
vein, which causes the vessel to spasm and block off
with clot. The idea is to make the vein shrivel away
by scarring. Unfortunately, the clot often clears away,
allowing the scarred vessel to open up again.
Endovenous Laser Treatment (EVLT)
EVLT works by heating the inside of the vein, which
causes it to seal shut and disappear. This treatment
requires that a very thin laser fiber be inserted into
the damaged underlying vein. Tiny electrodes at the
tip of the catheter heat the walls of your varicose
vein and destroy the vein tissue. As with chemical sclerotherapy,
your vein is then no longer able to carry blood, breaks
up naturally, and is absorbed by your body.
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| Radiofrequency Occlusion |
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| This method treats the vein by heating
them, causing the vein to contract and then close. |
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| Laser and Pulsed Light Treatments |
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| This form of vein therapy involves
a light beam that is pulsed onto the veins in order to
seal them off, causing them to dissolve. Successful light-based
treatment requires adequate heating of the veins. Several
treatments are usually needed for optimal results. |
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| Ambulatory Phlebectomy |
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| This procedure involves making tiny
punctures or incisions through which the varicose veins
are removed. The incisions are so small no stitches are
required. |
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| Standard
surgical method |
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 The
most common operation performed for varicose veins is
high long saphenous ligation and stripping involving a
groin crease incision.
To perform vein stripping, your physician disconnects
and ties off all major varicose vein branches associated
with the saphenous vein, the main superficial vein in
your leg. Your physician then removes the saphenous vein
from your leg. A procedure, called small incision avulsion,
can be done alone or together with vein stripping. Small
incision avulsion allows your physician to remove varicose
veins from your leg.
In a similar procedure called TIPP (Transilluminated Powered
Phlebectomy), your physician shines an intense light on
your leg to show your veins. Once your physician locates
a varicose vein, he or she passes a suction device through
a tiny incision and suctions out the vein. Although these
procedures sound painful, they cause relatively little
pain and are generally well tolerated. Your vascular surgeon
will advise you regarding which procedure is the best
for your particular situation..
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| Minimally
invasive procedures like SEPS |
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| Introduction |
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| A few years ago, long incisions had
to be made in the calf to gain access to these difficult
veins. The dissection was extensive, the complication
rates high and recovery prolonged, which may go a long
way to explaining the continued reluctance of many surgeons
to treat perforators at all. Perforators can now be treated
using a camera. These are exciting refinements that have
yielded excellent results in this series. SEPS stands
for Subfascial Endoscopic Perforator Surgery. SEPS was
introduced more than 15 years ago as a minimally invasive
alternative to open perforator ligature. This is a specialized
minimally invasive procedure performed on patients who
suffer with leg ulcers due to incompetent perforator veins.
Using tiny incisions and an operating scope, perforator
veins are tied off. This results in ulcer healing in the
vast majority of patients. |
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| SEPS provides excellent visualization
of the anatomy of the subfascial plane. Subfascial means
under the fibrous tissue beneath the skin, and endoscopic
refers to the narrow instrument used to examine the inside
of a cavity in the body. It enables introduction of the
instruments through skin incisions that are distant from
the site of skin changes and carries a low rate of complications.
Hence, SEPS is the procedure of choice in the treatment
of patients with chronic venous insufficiency. |
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| Procedure |
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 Subfacial
Endoscopic Perforator Surgery (SEPS) is a minimally
invasive surgical procedure which the doctors use to
treat the underlying condition that causes venous ulcers.
During the procedure they disconnect the abnormal perforator
veins, which cause ulceration because of improperly
functioning valves. By disconnecting these veins, they
redirect the blood flow to healthy veins. Circulation
in the leg is improved, and the ulcer is healed.
SEPS is usually performed with two ports of entry into
the leg. A special instrument is inserted deep to the
fascia of the leg and a large balloon is inflated with
water to create a working space. The balloon is then
emptied and the space is insufflated with air. The camera
is inserted and the perforator veins can be seen in
the space passing from superficial to deep layers. Another
small incision is made in the calf for passage of another
instrument. The perforator veins are carefully dissected,
clips are applied and the veins are divided if necessary.
Perforating veins are then divided with endoscopic scissors.
Metal clips are placed on the cut ends of the vein to
avoid bleeding. Another option to interrupt the vein
is to use a harmonic scalpel, an instrument that uses
ultrasonic waves to seal the cut end of the veins to
avoid bleeding. All trocars are then removed and the
wounds are closed. The leg is dressed with an ACE wrap.
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| After surgery |
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| After surgery, the limb is elevated
at 30 degrees for 3 hours, after which walking is allowed.
Patients are discharged from the hospital either the same
day or the morning after the procedure. After 10 days
to 2 weeks, patients may return to work. |
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| Recovery |
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| The patient is generally sent home
the same day of surgery and the ACE wrap can be removed
in 48 hours. Recovery from this procedure is rapid with
a return to normal function within a week. Walking is
permitted throughout this recovery period and pain associated
with this procedure is minimal. For those patients who
present with leg ulcers, healing of these ulcers is markedly
accelerated with the reduction of venous pressure subjected
to the skin and ulcer area. |
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| Benefits and drawbacks |
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| Subfascial endoscopic perforating
vein surgery (SEPS) is the treatment of choice. The healing
time with SEPS is substantially decreased when compared
with conventional treatment and carries low complication
and recurrence rates. Conventional surgery of perforating
veins requires long skin incisions in order to ligate
incompetent perforating veins. As the overlying skin is
often atrophic, poorly nourished and frequently affected
with skin necrosis, impaired wound healing and wound infection
pose considerable problem. |
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| Ulcer healing is rapid, and half of
the ulcers can be expected to heal within 8 weeks. The
wound complication rate is only 5%. At 2 years, 80% of
the ulcers stay healed in patients who never had blood
clots in the leg but only 54% of those who had blood clots
in the leg veins before surgery have no ulcers. And above
all minimal hospital stay is required following SEPS. |
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