Understanding Varicose Veins
Varicose veins are enlarged, twisted surface veins most commonly affecting the legs. They develop when the one-way valves inside the veins become weak or fail, allowing blood to flow backwards and pool. This leads to increased pressure within the vein, causing it to stretch and become visible beneath the skin.
While some people seek treatment for cosmetic reasons, surgery is usually recommended when symptoms or complications occur.
When Is Surgery Recommended?
Surgery may be advised if you experience:
- Persistent aching, heaviness or throbbing in the legs
- Swelling, particularly at the end of the day
- Itching or skin irritation over the veins
- Skin thickening or pigmentation changes
- Venous eczema or ulceration
- Episodes of bleeding from a vein
- Recurrent superficial thrombophlebitis
Not all varicose veins require surgery. The decision depends on symptoms, examination findings and, importantly, ultrasound results.
The Importance of Venous Duplex Ultrasound
A venous duplex incompetence study is an essential investigation before surgery.
This specialised ultrasound:
- Maps the superficial and deep vein systems
- Identifies which veins are incompetent (leaking)
- Determines whether the long (great) saphenous vein, short (small) saphenous vein, or both are involved
- Excludes deep vein thrombosis
- Guides the surgical plan
Surgery should only target veins proven to be incompetent on duplex scanning. Accurate mapping reduces recurrence and ensures appropriate treatment.
Types of Surgical Treatment
The operation performed depends on which veins are faulty.
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Long (Great) Saphenous Vein Surgery
The long saphenous vein runs from the ankle to the groin.
Ligation at the Saphenofemoral Junction
If duplex ultrasound shows incompetence at the top of the vein, it is tied off (ligated) where it joins the deep vein in the groin. This is called saphenofemoral junction ligation.
This step prevents backward flow from the deep system into the superficial vein.
Stripping of the Long Saphenous Vein
After ligation, part or all of the long saphenous vein may be removed (stripped) through small incisions. A special instrument is passed along the vein to remove it from the thigh or down to the knee.
Stripping reduces the chance of recurrence compared with ligation alone.
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Short (Small) Saphenous Vein Surgery
The short saphenous vein runs along the back of the calf and joins the deep vein behind the knee.
If incompetence is identified on duplex imaging:
- The vein is ligated at the saphenopopliteal junction (behind the knee).
- Stripping of the short saphenous vein may be performed depending on the extent of reflux.
Because of nearby nerves, careful pre-operative mapping is particularly important in this area.
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Multiple Stab Avulsions (Phlebectomies)
Even after stripping, smaller branch veins (tributaries) may remain visible.
These are removed through tiny skin incisions using fine instruments. This technique is called multiple stab avulsion or phlebectomy.
Stab avulsions are often performed at the same time as stripping to improve symptom relief and cosmetic outcome.
What Does the Operation Involve?
- Usually performed as a day procedure
- May be done under general or regional anaesthesia
- Small incisions are made in the groin, behind the knee (if required), and along the leg
- The incompetent vein is ligated and stripped as indicated
- Tributary veins are removed through small puncture incisions
- Dressings and compression bandaging are applied
The procedure typically takes 45–90 minutes, depending on the extent of disease.
Expected Outcomes
Most patients experience:
- Relief of aching and heaviness
- Reduced swelling
- Improvement in skin changes
- Better cosmetic appearance
It is important to understand that surgery treats the affected veins but does not prevent new varicose veins from developing in the future.
After Surgery: What to Expect
Bruising and Discomfort
Bruising along the course of the removed vein is common and may be extensive. It usually settles over 2–4 weeks.
Mild to moderate discomfort is expected and is managed with simple pain relief.
Compression Stockings
You will be advised to wear Grade 2 compression stockings continuously for a specified period (often 1–2 weeks, sometimes longer during the day). These:
- Reduce swelling
- Improve comfort
- Lower the risk of complications
- Support healing
Mobilisation
Early mobilisation is very important.
You should:
- Walk on the day of surgery
- Take frequent short walks
- Avoid prolonged sitting or standing still
Movement improves circulation and reduces the risk of deep vein thrombosis.
Potential Complications
All surgery carries some risk. Possible complications include:
Bruising and Haematoma
Very common but usually settles without intervention.
Recurrence
Varicose veins can recur over time due to:
- New vein incompetence
- Incomplete treatment of reflux
- Progression of underlying venous disease
Duplex-guided surgery reduces this risk.
Deep Vein Thrombosis (DVT)
A blood clot in the deep veins is uncommon but potentially serious. Early mobilisation and compression stockings significantly reduce this risk.
Seek urgent medical attention if you develop:
- Increasing calf pain
- Significant swelling
- Shortness of breath
Numbness
Temporary numbness may occur due to irritation of small skin nerves.
Follow-Up
A follow-up appointment is usually arranged to assess wound healing and recovery. In some cases, repeat duplex ultrasound may be required.
Key Points to Remember
- Venous duplex ultrasound is essential to guide appropriate treatment.
- Ligation alone is often insufficient — stripping reduces recurrence in suitable cases.
- Multiple stab avulsions may be required for remaining tributary veins.
- Early mobilisation and Grade 2 compression stockings are critical after surgery.
- Recurrence is possible, as venous disease is a chronic condition.