Op. Dr. Orhan Coşkun
Although varicose veins are more of an appearance or symptom of underlying venous insufficiency than a disease itself, we will continue to use the term “varicose vein disease” for practical and understandable purposes.
Venous insufficiency can manifest itself in the early stages with twisted, dilated varicose veins, or later on, it can lead to swelling and eventually prompt the patient to seek medical attention.
Typically, women tend to consult a doctor after visible varicose veins cause aesthetic discomfort, while men often seek medical help when pain and swelling reach a level that interferes with their daily activities. Early diagnosis is crucial to guide patients towards measures that can prevent the disease from developing into a more challenging form and to intervene in its progression.
Even when a diagnosis is made, in many cases, patients resort to temporary measures, using methods such as medication and compression stockings, which may lead them to stay away from a permanent and effective treatment for an extended period. Patients often believe that their diseases will come to an end with the prescribed drug therapy and the use of compression stockings for a specific period. When the outcome does not match their expectations, they may lose hope in the treatment.
Some patients may only seek treatment for visible varicose veins, remaining unaware of the underlying issues. It is crucial for patients to understand that varicose veins are not just an aesthetic problem; they can be a manifestation of a disease that can have significant implications for leg health.
To treat an illness, one must first provide a thorough definition of what the disease is and why it occurred, understanding its course. The method for this is a comprehensive evaluation of the patient from every perspective, involving listening, observing, researching, and decision-making stages.
1- Listening: It involves listening to the patient’s medical history until they come to us. Sometimes, to perceive details that the patient may not find significant but are crucial for us, we need to guide them with some questions. Questions such as when they first felt the discomfort, whether they consulted another doctor, what tests were conducted, what were the results, what treatments were suggested, whether they implemented these treatments, and the outcomes need to be investigated. Occasionally, patients may have undergone treatments that we do not approve of or are not scientifically supported, experienced disappointment, and might be concealing this information from us. However, knowing the ease with which the hopeful patient can be deceived by charlatans, we do not blame them; instead, we approach them with understanding and prefer to focus on our treatment.
Our patients most commonly present with increasing visible varicose veins in the legs, cramps, a feeling of heaviness, swelling in the feet and legs, and itching. In more advanced cases, there may be changes in skin color, significant pain in the legs exacerbated by standing, varicose bleeding from the skin, clotting in superficial or deep veins, and wounds on the inner side of the ankle.
2- Observation: At this stage of the examination, we use a specialized light system called veinlite, which allows us to observe the area of the patient’s complaints and see beneath the skin. For this, we provide the patient with disposable shorts and slippers, asking them to prepare with the affected areas exposed. We examine the patient on the examination table while standing. Conducting varicose vein examinations while the patient is standing is more accurate since varicose veins are more visible in this position. We mark the areas of discomfort reported by the patient and the regions beneath the skin that we identify.
Patients often only notice small superficial varicose veins on the skin, but they are surprised when they see the deeper part beneath the skin.
3- Research Doppler Ultrasonography: Especially for patients with suspected venous insufficiency, advanced varicose veins, and swelling in the legs, it is necessary to examine the deeper veins. The method for this is the examination of these veins using Doppler ultrasonography. Sometimes, our patients may present with previous Doppler ultrasonography reports. We may have already identified these in the initial stages of the examination, but we still conduct our examination to confirm the compatibility of the report with our own results. Additionally, for more advanced reporting, we may refer patients to a radiologist for further evaluation.
How is Doppler Ultrasonography Conducted?
Doppler ultrasonography operates on a principle similar to sonar, using the transmission and reception of sound waves. It does not expose the patient to any radiation, is painless, does not require specific preparation, and does not necessitate fasting. It can be safely used during pregnancy without harm to the baby or mother. It is more accurate to perform the procedure with the patient’s legs exposed while they are standing. Since we spend most of the day standing or sitting, measuring when in this position has become an accepted and accurate approach recently. With Doppler ultrasonography, the structure and diameters of the veins, the presence of blood clots, and whether the venous valves are functioning correctly can be determined. Valves play a crucial role in maintaining vascular health by preventing the backward flow or reflux of blood in the veins. To assess the functioning of the valves, the patient is asked to perform maneuvers that increase intra-abdominal pressure, such as bearing down or holding their breath. If blood flow is refluxing in the opposite direction, the patient is diagnosed with venous insufficiency, also known as venous incompetence. There are four levels of this condition, with levels 3 and above indicating a severe insufficiency that requires treatment.
Doppler Ultrasonography evaluates the Great Saphenous Vein, which drains into the deep vein in the groin area, starting from the inner side of the wrist and continuing from the front of the leg to the inner calf, and the Small Saphenous Vein, which drains into the deep vein behind the knee, starting from the outer side of the ankle (these two are called superficial veins). Deep veins and perforating veins, which connect deep and superficial veins, are also assessed. Blockages, insufficiencies, or enlargements in these veins are identified and reported. Doppler ultrasonography is also used in the treatment and post-treatment follow-ups.
4- Data Evaluation: In the final stage of the examination and assessment of the varicose vein patient, after observing and investigating the causes of the problem, we gain detailed information about the patient’s venous problems and their severity. In a sense, we map the patient’s venous system. At this stage, depending on the level and severity of the problem, we present treatment options and recommendations to the patient. We discuss the advantages and disadvantages of each option and, after determining the most suitable treatment for the patient, proceed to implement the chosen treatment.
