What is an Abdominal Aortic Aneurysm?

An aneurysm is an abnormal dilatation of a blood vessel. The commonest site to develop an aneurysm is the aorta, at the back of the abdomen just below the kidneys. This is called the infrarenal aorta and an aneurysm in this area is called an abdominal aortic aneurysm and often referred to as an AAA.
AAAs gradually grow at a rate of around 1 to 5 mm per year. The bigger they get, the more likely they are to burst. Ruptured AAA is a common cause of sudden death. Males are 8 times more the faster the grow, & likely to be affected than females, and 1 in 20 men over the age of 65 have an AAA. However females with an aneurysm are more prone to rupture than their male counterparts.

Why do Aneurysms Develop?

The main risk factors for developing an aortic aneurysm are age, male gender, smoking and family history. The aneurysm wall becomes inflamed and the normal cells and proteins which make up the artery wall break down and weaken. The risk of rupture rises sharply once the aneurysm diameter exceeds 6cm, therefore repair is advised for aneurysms over 5.5cm in all but very unfit patients. Most AAAs are asymptomatic until they burst. Screening programs reduce deaths due to aneurysm rupture. Many AAAs are detected by accident during tests for other problems.

How are AAAs diagnosed?

Physical examination is unreliable to detect and measure AAAs. Ultrasound is highly accurate, and is used to diagnose and monitor aneurysm growth. Once an aneurysm had reached 5.5cm and repair is required, CT scanning is vital to define aneurysm anatomy and determine how best to repair it.

Aneurysm Surgery

There are two ways to repair an abdominal aortic aneurysm: open repair and endovascular (key-hole) repair using a stent-graft.

Open Aneurysm Repair

Open repair comprises replacement of the aneurysmal aorta with an artificial graft sutured into place just below the renal arteries. This is a major abdominal operation with significant risks involved. The risk depends on the extent of the aneurysm, and the age and fitness of the patient. Despite these concerns, the long term outlook after open repair is good and open aortic reconstruction is a very durable procedure that lasts for years without further intervention.

Endovascular aneurysm repair

Endovascular Aneurysm Repair (EVAR) allows a stent-graft to be delivered inside the aneurysm via the femoral artery, then expanded and fixed in position under Xray guidance. The whole procedure can be achieved via small groin incisions. Recovery is much quicker than for open repair and less fit patients can be treated. The risk of severe complications is also much lower. Endovascular repair can be used for planned and emergency operations where the aneurysm has already ruptured. Blood loss is much lower and transfusion less likely to be required.

Complex endovascular aneurysm repair (fenestrated and branched stent-grafts)

Not all patients are suitable for endovascular repair. The shape and extent of the aneurysm mean some patients will require open surgery rather than a key-hole operation. Advances in stent-graft technology however are increasing the proportion of patients who can receive minimally invasive treatment. For example, fenestrated stent-grafts allow aneurysms which extend very close to the kidneys to receive key-hole surgery. Similarly, branched stent-graft devices allow treatment of aneurysms that extend deep into the pelvis involving arteries which supply the pelvic organs. Until recently, many such patients would have been unsuitable for such treatment and would have had to have open surgery for their aneurysms

What is an Aneurysm?

An aneurysm is an abnormal dilatation of a blood vessel. Aneurysms cause problems either by bursting causing major bleeding, or by blocking, starving the organs downstream of their blood supply. The two commonest sites for aneurysms are the infrarenal aorta (at the back of the abdomen just below the kidneys) and the popliteal artery which is behind the knee. Aneurysms can however occur in almost any artery in the body.

Where do Aneurysms form?

Some types of aneurysms are much more common than others. The most frequently seen kinds are described in detail in their sections of the website (please see Conditions Treated, Prevented and Cured). Aneurysms also occur in the brain, and may cause brain haemorrhages and strokes. These aneurysms are not related to peripheral aneurysms, and are usually treated by neurosurgeons and neuroradiologists.

What is atherosclerosis ?

Atherosclerosis is a disease affecting blood vessels and means literally "hardening of the arteries". Large and medium sized arteries are most commonly affected. The inside wall of the artery becomes furred up with deposits of cholesterol and calcium causing the blood vessel to become narrowed or blocked. These deposits are called atherosclerotic plaque. Atherosclerosis is a multifocal condition. A patient with hardening of the arteries developing in one area of the body, for example the heart, is highly likely to have the same condition present in arteries elsewhere in the body. For this reason, someone who has a heart attack due to atherosclerosis is at elevated risk of having a stroke due to the same underlying condition affecting the brain arteries.

How does atherosclerosis cause problems ?

The consequence of atherosclerosis depends on which arteries are affected by the hardening process. Atherosclerosis in the heart causes angina and heart attacks. Atherosclerosis in the arteries supplying the brain causes strokes. Hardened arteries in the limbs cause pain on walking (intermittent claudication). These conditions are explained in their sections of the website (see Conditions Treated, Prevented and Cured).

Risk factors for atherosclerosis

Fixed risk factors

These are of limited interest since no-one can alter their age, the population into which they were born or the age at which a parent had a heart attack or stroke. Vascular disease in any one arterial territory is an important risk factor for adverse events in others. Patients surviving strokes are more likely to die of a heart attack than another stroke. Similarly, intermittent claudication is a major risk factor for stroke and ischaemic heart disease. Strokes and intermittent claudication are both explained in their sections of the website (see Conditions treated, Prevented and Cured).

What is an Aortic Dissection?

The aorta is the main blood vessel that carries high pressure blood out of the heart. It gives off branches to the head and neck and arms then arches over the back of the chest alongside the backbone down into the abdomen, giving off further branches to the internal organs. The aorta is a tough tube made of smooth muscle cells and elastic proteins. It is lined by a special layer called the tunica intima. Aortic dissections are a result of the internal layer of intima tearing and separating from the outer layers. This forms a flap of tissue inside the aorta. The tear usually starts high in the chest just where the aorta arches over to travel down the body. The acute tear may be extremely painful, felt in the chest and back as a searing sensation, sometimes mistaken for a heart attack. Not all dissections are painful, sometimes a dissection is detected in a patient who has no recollection of any painful attacks.

What problems can an aortic dissection cause?

Aortic dissections cause two main problems. First, the torn lining may form a flap of tissue which blocks the flow of blood into the branches of the aorta. The consequences of this depend on which branch is affected. For example, if an artery to the head and neck is blocked, major stroke may result. If the artery involved is supplying a kidney, renal failure may be precipitated. The second problem is a longer term issue. The segment of aorta which has lost its normal lining is weakened, and in time may balloon out and form an aneurysm. An aneurysm is an abnormal bulging of a blood vessel that is prone to bursting. For these reasons, it is always worth considering treating aortic dissections.

How are aortic dissections treated?

All patients with aortic dissections need very careful control of blood pressure as this reduces the risk of long term complications of the condition. More than one type of blood pressure medication may be needed, and beta blocker tablets are nearly always included in the treatment. Some patients with aortic dissection benefit from endovascular treatment with aortic stent-grafting. This procedure is a key-hole operation to place a tough new lining inside the torn aorta to prevent progression of the condition and protect against aneurysm formation. This is also known as thoracic endografting. The graft is placed via the femoral artery in the groin or via the iliac artery in the lower abdomen and manipulated to the correct position under X-ray control. This is usually done under epidural anaesthetic without the need for general anaesthetic, so even quite unfit patients can benefit.

What is a carotid body tumour ?

Carotid body tumours are growths that arise in the neck alongside the carotid artery and jugular vein. They are also known as chemodectomas, and are rare but well recognised. The normal carotid body is a tiny structure made of a bundle of cells which monitor oxygen concentration, carbon dioxide content and acidity of the blood travelling to the brain. It is situated on the wall of the main carotid artery as it divides into the two smaller arteries which carry blood to the brain, skull and face. The carotid body has a very rich blood supply.

Carotid body tumours develop from these cells. The tumour gradually expands and tends to splay wide the two main branches of the carotid artery. As it gets bigger, the patient becomes aware of a lump in the neck. This is usually painless but can cause discomfort, voice hoarseness and damage to the surrounding nerves.

About 5 to 10% of tumours affect both sides unless the individual affected comes from a family with a history of carotid body tumours in which case the likelihood of both sides being involved goes up to 30%. Around one in ten carotid body tumours are malignant, that is they contain cancerous cells.

How is a carotid body tumour diagnosed?

A combination of duplex (doppler-ultrasound) scanning, CT scanning and MRI scanning may all be used to establish a diagnosis of a carotid body tumour.

These tests are helpful in distinguishing a carotid body tumour from other lumps that can arise in the neck. The main condition which may mimic a carotid body tumour is a related condition called a paraganglioma which is a tumour arising from one of the nerves running alongside the blood vessels in the neck. These are easier to remove than carotid body tumours since they are less stuck to the carotid arteries and have a lower blood supply. Other possible causes are lymph nodes, neurofibromas and branchial cysts.

When should a carotid body be removed? Carotid body tumours slowly but inevitably enlarge if left untreated and may eventually block major blood vessels in the neck. The bigger they grow, the more likely they are to turn malignant, and the more difficult becomes the operation. For this reason it is advisable to remove carotid body tumours even when relatively small. The exception to this is tiny growths detected in a family with a history of the condition. These lumps may be impalpable and only detected on ultrasound, and they can safely be left and monitored with regular scans until they reach an operable size How is a carotid body tumour removed? Carotid body tumours are best treated by surgical removal. This requires a general anaesthetic. The carotid arteries are exposed then the tumour gently separated from the surrounding structures until it can safely be removed.

Carotid body tumours have a very rich blood supply, and are usually stuck to the major blood vessels in the neck as well as surrounding nerves. On occasions, if the carotid artery has been invaded by the tumour, it is necessary to reconstruct the carotid artery to preserve the blood flow to the brain. For these reasons it is essential that the operation be performed by an experienced carotid surgeon who is familiar with operating on the carotid arteries.

What are "diabetic feet"?

Diabetic patients are prone to foot deformities leading to ulceration and infection of the foot which may progress to tissue necrosis requiring amputation. This is due to a combination of vascular disease and neuropathy.

Why do diabetic patients develop foot problems?

Diabetes impairs the function of the nerves and blood vessels supplying the feet. This makes them prone to small cuts and pressure ulcers which allow infection to enter and spread through the foot.
Sensory neuropathy robs the diabetic foot of the protective mechanism of pain allowing ulceration to develop in response to minor trauma or rubbing.
Motor neuropathy causes wasting of the small intrinsic muscles of the foot with collapse of the longitudinal and transverse arches. Abnormal pressure areas then develop which progress to ulceration.
Atherosclerosis in diabetics develops at a much younger age and is more extensive and distal. It is not uncommon for a diabetic to have a critically ischaemic foot in the presence of a normal popliteal pulse due to occlusion of the crural arteries. In addition to disease of the major arteries, the capillary basement membranes thicken, impairing oxygen diffusion to the tissues of the foot.

How are diabetic foot problems treated and avoided? Management is aimed at prevention by careful foot care. Good diabetic control helps reduce the severity of foot complications. There is no specific treatment for neuropathy. Localised infections should be treated with debridement (surgical removal of infected tissue) Plain X-rays may show evidence of osteomyelitis (bone infection) and MRI is an accurate way of defining the extent of infection in the foot.
The outcome for patients with diabetic foot problems is greatly improved by multidisciplinary team-working including diabetes specialist, vascular surgeon, radiologist, and microbiologist. After treatment, ongoing care with a specialist podiatrist and surgical appliance technician to ensure good footwear are beneficial.

Procedures to improve blood flow for diabetic feet

It is crucial to maximise the blood flow into the foot. Angioplasty works quite well for the larger arteries but is less reliable for the small arteries around the ankle. Here, bypasses using microsurgical techniques are highly effective at promoting blood flow into the foot to aid healing of wounds.

Intermittent Claudication

Intermittent claudication is the tight cramp like pain felt typically in the calf muscle on walking when the blood supply to the lower limb is limited. The word is derived from the Latin verb, claudere, to limp. The severity of the claudication is defined by the distance walked before onset of the pain. On resting or slowing down, the pain passes off within a few minutes. Walking up hill, carrying a heavy bag or rushing all shorten the claudication distance.

Although unpleasant, intermittent claudication is a relatively benign condition as far as the leg is concerned. Most patients either stay the same or improve and only a small minority (5%) progress to critical limb ischaemia. Diabetics and patients who continue to smoke have a worse prognosis.

Are there other conditions that resemble intermittent claudication?

Other conditions may mimic intermittent claudication. The main culprit is spinal claudication due to congestion of the spinal canal. This is usually a result of wear and tear of the lumbar spine. The pain of spinal claudication resembles intermittent claudication but the onset is variable; patients have good days and bad days. This is never so with vascular claudication which is very consistent. The pain of spinal claudication extends beyond the calf muscle up the back of the thigh and round on to the shin. There is often a history of back problems and straight leg raising may be limited.

How is intermittent claudication treated?

The priority with intermittent claudication is to recognise it as a warning sign of potential hardening of the arteries elsewhere in the body, and address this before intervening with the legs.

Risk factor modification

In many respects the true significance of intermittent claudication is not the symptom but the risk of death from other aspects of vascular disease. Claudicants have a mortality around three times that of age-matched controls, mainly due to coronary heart disease strokes and aneurysms. Attention to vascular risk factors including smoking, hypertension, antiplatelet and statin therapy is therefore of paramount importance. Modification of vascular risk factors is explained in more detail in the section of the website devoted to atherosclerosis (please see Conditions Treated, Prevented and Cured)

Exercise

Many patients can cure their intermittent claudication by walking as much as possible. "Walking through the pain", i.e. continuing to walk as long as possible after the pain starts encourages collateral blood vessels to open up. Patients effectively do their own bypass. Simply advising patients to walk achieves limited benefit but supervised exercised programs are highly effective.

Drugs

Pletal (generic name cilostazol) is a very interesting drug which is very helpful for some patients who have intermittent claudication. Walking distance can be improved significantly. Cilostazol also seems to benefit some patients with more severely impaired limb circulation, and may have beneficial effects after angioplasty, though it was not designed primarily for this purpose. It is likely that this drug will be used more widely in the future. Not everyone can take cilostazol since it is contraindicated in some cardiac disorders.

Angioplasty and stenting

Angioplasty is most effective for stenoses or short blockages high up in the legs. Blockages lower down can also be treated, but the risks are somewhat higher and the benefits less certain.
Angioplasty and stenting are described in the Techniques and Services section of the website.

Surgery

The value of exercise therapy and the effectiveness of angioplasty have greatly reduced the number of patients who end up requiring operations for intermittent claudication. In selected patients however, surgery is highly effective and durable. This is particularly so for blockages and narrownings of the common femoral artery in the groin which is easily accessible surgically and not readily treated with angioplasty. Here a localised endarterectomy to remove the block may be the best treatment. Other surgical techniques are effective to remove or bypass blockages or the iliac and femoral arteries. Bypasses extending below the knee are rarely used to treat claudication, but are used frequently to treat more severe forms of leg ischaemia.

Leg Ulcers?

There are other less common causes but the vast majority of leg ulcers are due to one or a combination of these three problems. The "mixed" ulcers (i.e. due to more than one factor) are more difficult to cure and are more likely to recur.
If an ulcer is very painful, especially if the pain is worse at night and relieved by hanging the leg down, it is likely there is an underlying arterial problem limiting the flow of blood into the leg. By contrast, legs with chronic venous insufficiency feel more comfortable elevated up on a stool or in bed. Neuropathic ulcers are usually painless.
Treatment of a leg ulcer requires more than dressings, but also correction of the underlying cause.

How Is The Cause Of An Ulcer Established?

Clinical assessment by a vascular surgeon is required to confirm the underlying cause of a leg ulcer. Duplex scanning of the arteries and veins in the affected limb are usually accurate ways of establishing whether there is a disorder of the circulation underlying the ulcer.

Treatment Of Ulcers Due To Artery Blockages

An ulcer that is caused by diseased arteries is usually very painful. Ulcerated legs with poor artery blood flow are referred to as being critically ischaemic (i.e.short of blood). Treatment options for this condition are explained in detail in the section of the website devoted to Critical Limb Ischaemia (see Conditions Treated, Prevented and Cured).

Treatment Of Ulcers Due To Problem Veins

Leg ulcers are most commonly due to varieties of varicose veins. In some cases they result from previous deep vein thrombosis. Venous ulcers usually improve rapidly with compression bandaging treatment. This is applied by a specialist nurse and improves the blood flow through the tissues to promote healing of the ulcer.

What is lower limb ischaemia?

Lower limb ischaemia is impaired blood flow into the leg. Mild impairment may not cause any symptoms. More significant limitation of blood flow allows enough blood into the leg at rest, but not enough during exercise; this causes intermittent claudication, a painful cramping pain in the muscles on walking. Severely restricted arterial blood flow causes pain at rest and progresses to ulcers and gangrene.

Removal of the gallbladder is not associated with any impairment of digestion in most people.

Classification of chronic lower limb ischaemia

Lower limb ischaemia is classified according to severity (La Fontaine classification)

  • Asymptomatic
  • Intermittent Claudication
  • Rest pain
  • Ulceration/gangrene

Causes of lower limb ischaemia

Atherosclerosis (hardening of the arteries) accounts for the vast majority of lower limb ischaemia in the west. Presentation of limb ischaemia in a younger adult should prompt a search for causes of accelerated atherosclerosis and consideration of less common causes of lower limb ischaemia. These include:

Atherosclerosis, intermittent claudication, critical limb ischaemia, aortic dissection and aortic aneurysms are all discussed in their own sections of the website (see Conditions Treated, Prevented and Cured).

Thoracic surgery

Cardiothoracic surgery refers to operations on organs in the chest, including the heart, lungs and esophagus. Examples of thoracic surgery include coronary artery bypass surgery, heart transplant, lung transplant and removal of parts of the lung affected by cancer. Specialized thoracic surgeons treat lung and esophageal cancer while specialized cardiac surgeons treat the heart.

Thoracic surgery is frequently used to assess or repair lungs affected by cancer, trauma or pulmonary disease. For lung cancer, your surgeon would remove nodules, tumors and lymph nodes to diagnose, stage and treat the disease. Thoracic surgery to treat lung cancer may be performed using one of the following procedures:

  • Wedge resection: Removing the tumor and tissue surrounding the cancer
  • Anatomical segmental resection: Removing the tumor, the blood vessels, the lymphatic drainage and the lung segment where the tumor is located
  • Lobectomy resection: Removing the entire lobe of the lung with cancer, including the lymph nodes
  • Pneumonectomy: Removing the whole lung with the lymph nodes
  • Pleurectomy: Removing the inner lining of the chest cavity

Thoracic surgery procedures may be performed with either minimally invasive techniques or traditional open surgery methods.

Problems that may result from carotid artery disease.

Asymptomatic: CT and MRI scanning often reveal evidence of multiple small strokes with no history of preceding symptoms. These patients may have no obvious symptoms like mini-stroles, but over time may develop impaired brain function which may progress to a form of dementia (so-called multi-infarct dementia).

Amaurosis Fugax: Small blood clots from the carotid artery may flow through the circulation to the retinal artery in the eye cause the characteristic symptom of a greying-out of the vision in one eye. Patients often describe it as a curtain coming down. The vision returns to normal within a few minutes.

A transient ischaemic attack (TIA) is a small stroke that resolves within 24 hours.

Strokes result from blockages is middle cerebral artery in the brain and cause paralysis on the opposite side to the damaged artery. Strokes lasting less than 3 weeks are said to be transient strokes. Persistent deficits after 3 weeks are established strokes and subsequent recovery may be good, moderate or poor. These clinical distinctions are important since prognosis after carotid surgery is related to the presenting symptom.

What is a popliteal aneurysm?

The popliteal artery is behind the knee joint and carries blood from the upper to lower part of the leg. A popliteal aneurysm is an abnormal bulging of the popliteal artery.

A popliteal artery is usually considered aneurysmal if its diameter exceeds 2cm.

Who gets popliteal aneurysms ?

The risk factors are the same as for other arterial aneurysms, namely family history, smoking, blood pressure etc. In particular, if someone has an aneurysm at another site, popliteal aneurysms are also often seen.

What problems do popliteal aneurysms cause ?

With most aneurysms, the main risk is of the aneurysms bursting and causing massive bleeding. Popliteal aneurysms are different, in that the main problem is not rupture, but rather blockage of the aneurysms causing severe shortage of blood supply to the lower leg and foot. This results from blood clot which gradually builds up on the inside wall of the aneurysm. This is called mural thrombus which, over time, causes severe damage to the arteries lower in the leg and foot. If left too late the problem may be difficult to salvage and there is a high risk of amputations. For this reason popliteal aneurysms should be treated.

Thoracic Aneurysm

What is a thoracic aneurysm?

A thoracic aneurysm is an abnormal bulging of the aorta in the chest. The aorta is the main blood vessel carrying blood out of the heart, sending branches to head and neck and arms before arching over and down the body to supply the internal organs and lower limbs. Thoracic aneurysms are not as common as aneurysms of the lower aorta, but they tend to be more complicated to treat.

Types of thoracic aneurysm

Thoracic aneurysms are classified depending on whether they arise in the ascending or descending thoracic aorta, and on which aortic branches are involved. Aneurysms affecting the ascending aorta may also involve the aortic valve which controls the flow of blood leaving the heart. Generally speaking, the more branches that are involved, and the closer to the aortic valve the aneurysm extends, the more complicated it is to treat.

Treatment of thoracic aneurysms

Ask the doctor, hospital, or facility how much you'll have to pay for the surgery and any care afterward.
Make sure you know if you're an inpatient or outpatient because what you pay may be different.
Check with any other insurance you may have (like a Medicare Supplement Insurance (Medigap) policy, Medicaid, or coverage from your or your spouse's employer) to see what it will pay. If you belong to a Medicare health plan, contact your plan for more information.

Thoracic Aneurysm

What is a thoracic aneurysm?

A thoracic aneurysm is an abnormal bulging of the aorta in the chest. The aorta is the main blood vessel carrying blood out of the heart, sending branches to head and neck and arms before arching over and down the body to supply the internal organs and lower limbs. Thoracic aneurysms are not as common as aneurysms of the lower aorta, but they tend to be more complicated to treat.

Types of thoracic aneurysm

Thoracic aneurysms are classified depending on whether they arise in the ascending or descending thoracic aorta, and on which aortic branches are involved. Aneurysms affecting the ascending aorta may also involve the aortic valve which controls the flow of blood leaving the heart. Generally speaking, the more branches that are involved, and the closer to the aortic valve the aneurysm extends, the more complicated it is to treat.

Treatment of thoracic aneurysms

Ask the doctor, hospital, or facility how much you'll have to pay for the surgery and any care afterward.
Make sure you know if you're an inpatient or outpatient because what you pay may be different.
Check with any other insurance you may have (like a Medicare Supplement Insurance (Medigap) policy, Medicaid, or coverage from your or your spouse's employer) to see what it will pay. If you belong to a Medicare health plan, contact your plan for more information.

What are thread veins ?

Thread veins are purple coloured prominent veins in the skin seen most commonly in the legs. They are harmless but are sometimes uncomfortable and may be very unsightly. They can be very easily treated by sclerotherapy (injection). This is done under bright light and low magnification using tiny needles which are barely felt.

Investigation of thread veins

Before treating thread veins it is necessary to make sure there is no underlying problem affecting the major veins in the leg. A duplex scan (doppler-ultrasound) is usually arranged for this. If a larger vein is malfunctioning, this should be corrected before embarking on treatment of thread veins. These techniques are explained in the Services and Treatments section of the website (see Laser treatment of varicose veins for varicose veins).

Sclerotherapy (injections) for thread veins

Microinjections of thread veins are not painful, the injections are barely felt. The technique works by sticking the walls of the veins together thus obliterating them. The compression applied after the injection is an important part of the treatment. This takes the form of an elastic stocking or tubigrip which is worn for 48 to 72 hours, or longer for larger or more extensive veins.
The cosmetic results of microsclerotherapy for thread veins are usually very good. However some patients may react to the injection and develop an ulcer or scab at the sight of the injection. This is uncommon, but a test injection is always performed before treating larger areas.
Milder skin reactions may also be seen. These take the form of brown staining of the skin at the sight of the injection.

What are Varicose veins ?

Varicose veins are dilated tortuous superficial veins occurring usually in the lower limb. They are common and run in families and tend to affect women more than men.

What causes varicose veins?

Varicose veins are causes by the development of faulty valves in the veins of the leg. In health there are two vein systems in the lower limb: deep and superficial.

The deep veins run alongside the arteries between the muscles and bones. Muscular activity compresses the deep veins driving blood up into the heart (the so called muscle pump). Reflux is prevented by competent valves ensuring blood flows upwards towards the heart.

The superficial veins are just beneath the skin.. There are two main superficial veins, the long and short saphenous veins which drain into the deep system through valves in the groin, behind the knee and at various other so-called perforator sites. Valves in the veins and at the junctions ensure that blood flows in the correct direction back towards the heart.

The commonest cause of varicose veins is the development of incompetence of the valves at the groin or behind the knee. These are called the saphenofemoral and popliteal junctions. This allows blood to reflux from the deep system into the superficial system causing dilatation and tortuousity of the veins under the skin, hence the development of varicose veins.

Clinical features of varicose veins

Characteristic discomfort due to varicose veins is an aching sensation exacerbated by standing for long periods and eased by elevating the leg. This may be associated with swelling of the leg. Varicose veins may be painless but cause considerable distress due to their appearance. Chronic high pressure in the veins causes skin changes including thread veins and brown pigmentation (lipodermatosclerosis). If left untreated, the condition may progress to severe skin changes and ulceration of the leg around the ankle.

How are varicose veins assessed?

Varicose veins are usually obvious to the naked eye. However, as described above, the visible veins are a result of faulty valves elsewhere in the leg. Treating the visible veins without addressing the underlying defective valves would produce a bad result; the problem would simply recur in another part of the leg. By contrast, if all the damaged valves are treated, the varicose veins can be very effectively removed with a very low likelihood of recurrence in the future.

The best test to investigate varicose veins is a doppler-ultrasound (duplex) scan. This is a painless test done by passing an ultrasound probe over the surface of the skin lubricated by jelly. The veins under the skin can be visualised and the direction of blood flow through the valves recorded. A detailed picture of the anatomy and function of all the main veins in the leg is established and helps determine which of the methods of vein treatment is best suited to each individual case

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